Ymca Medical Clearance Form printable pdf download

Medical Clearance Form

Date: _____________________________________________________

Physician’s Name: __________________________________________

Client’s Name: __________________________________________

Physician’s Phone: ________________________________________

Client’s Phone: _________________________________________

Physician’s Fax: ____________________________________________

Client’s DOB: ____________________________

Dear Doctor _____________________________________________,

Your patient __________________________________has requested to participate in LIVESTRONG at the YMCA: A Cancer Survivor

Exercise Program at the Fond du Lac Family YMCA. At the start of this program your client will participate in a

fitness assessment, including the 6 minute walk test, one repetition max test for upper and lower body, and balance

and flexibility test. Following the fitness assessment, your patient will partake in cardiorespiratory fitness, muscular

strength and endurance, and flexibility and balance activities. A specific, individualized exercise program will be

created for the participant based on the needs, interests and any recommendations you might have. The

LIVESTRONG program is designed to start easy and become progressively more difficult over a 12 week period. All

fitness assessments and exercise activities will be administered by qualified personnel trained in conducting

exercise test and exercise programs.

Based on the LIVESTRONG at the YMCA intake form, your patient has indicated a diagnosed medical condition,

coronary risk factor, and/or health condition that require a physician’s clearance prior to participation in the

LIVESTRONG at the YMCA program.

By completing the form below, you are not assuming any responsibility for our administration of the fitness

assessment or exercise program. If you know of any medical or other reasons why participation in the LIVESTRONG

at the YMCA program would be unwise for your patient, please indicate so on this form.

If you have any questions regarding the LIVESTRONG at the YMCA program, please call program coordinator.

Program Coordinator: Alexandria Berg | P: 920.921.3330 x309 | E: | F: 920.921.3376

Physicians Report

Date: __________________________

My patient, listed above, is:

_______Not cleared to exercise at this time

_______Cleared to exercise with no restrictions

_______Cleared to exercise with the following restrictions and/or recommendations

___________________________________________________________________________________________________________________________________________

Physicians Name: __________________________________ Physicians Signature: __________________________

Fond du Lac Family YMCA | 90 W. Second Street | Fond du Lac, WI | 54935

Ymca Medical Clearance Form