Medical Clearance Form


Medical Clearance Form
Dear Doctor:
Your patient _____________________________________________ wishes to take part in an exercise program
and/or fitness assessment. The exercise program may include progressive resistance training, flexibility
exercises, and a cardiovascular program; increasing in duration and intensity over time. The fitness assessment
may include a sub-maximal cardiovascular fitness test and measurements of body composition, flexibility, and
muscular strength and endurance. After completing a readiness questionnaire and discussing their medical
condition(s) we agreed to seek your advise in setting limitations to their program. By completing this form, you
are not assuming any responsibility for our exercise and assessment program. Please identify any
recommendations or restrictions for your patient's fitness program below (Physician's Recommendations).
Patient's Consent and Authorization
I consent to and authorize __________________________________________ to release to The Salvation
Army Kroc Center, health information concerning my ability to participate in an exercise program and/or fitness
assessment. I understand this consent is revocable except to the extent action has already been taken.
Authorization is not valid beyond one year from date of signature. Further disclosure or release of my health
information is prohibited without specific written consent of person to whom it pertains.
Member's signature
Trainer's signature
Physician's Recommendations
I am not aware of any contraindications toward participation in a fitness program.
I believe the applicant can participate, but urge caution because:
The applicant should not engage in the following activities:
I recommend the applicant not participate in the above fitness program.
Physician's signature
Physician's name (print)
State & Zip


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Parent category: Medical