Client Medical Clearance Form
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1
2Pre-Exercise Medical Clearance Form
Dr. _________________
Your patient is interested in undertaking a health and fitness program with Personal Best. An
exercise program will be tailored to suit the health and fitness needs of your patient following an
initial evaluation / consultation. The exercise program may consist of moderate to vigorous
aerobic exercise (walking, cycling, swimming, running) and/or strength training exercises as
appropriate including use of body weight, fitness balls, elastic resistant bands, free weights or
pin-loaded equipment.
Personal Best is a health and fitness consultancy providing professional health and fitness services
to individuals and organisations. Personal Best consultants are all qualified personal trainers with
extensive experience in personal health and fitness for the general population.
It would be appreciated if you could complete the following form and provide approval for this
patient to undertake a graduated health and fitness program. Please complete the form and
return it to the patient. Please circle/ tick the appropriate response and complete additional
details where appropriate.
Patient’s Name:
_________________________________
1. Medical History
a) Does the patient have any form of heart disease?
YES
NO
If YES, please specify: ____________________________________________________
If NO, has the patient ever had any of the following:
i)
chest pain
YES
NO
ii)
breathlessness or upper body discomfort upon
hurrying or with any other form of exercise
YES
NO
iii)
abnormal ECG
YES
NO
iv)
any major heart or cardiovascular investigations
YES
NO
If Yes, please specify: ________________________________________________
b) Has the patient ever had:
i) high blood pressure ?
YES
NO
Present ___
Past but not now ___
ii) diabetes ?
YES
NO
Present ___
Past but not now ___
iii) high cholesterol ?
YES
NO
Present ___
Past but not now ___
iv) any haematological or immune system disorders which may affect their ability to
participate ?
YES
NO
Present ___
Past but not now ___
v) any epilepsy or other neurological disorder?
YES
NO
Present ___
Past but not now ___
vi) any other major illness or disease that may limit their ability to participate?
(e.g asthma, arthritis, back pain)
YES
NO
Present ___
Past but not now ___
Websites/ Personal Best/ Downloads/ Client Documents/ Client Medical Clearance Letter
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