Medical Clearance Form printable pdf download

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

Date

Trainer's signature

Date:

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

Date

Physician's name (print)

Phone

Fax

Address

City

State & Zip

Medical Clearance Form