Heart Health Program Medical Clearance Form

Medical Clearance

Heart Health Program

MEDICAL CLEARANCE FORM

Dear Doctor,

The Heart Health Program is a free 12 month physical activity and education program provided by the Department

of Veterans’ Affairs. The goal of the program is to assist participants develop healthier lifestyles through physical

activity and health education.

Written medical clearance is necessary for your patient to participate in the program. The medical clearance must

specify if there are any restrictions and exercise limitations that may need to be taken into account.

Participants will exercise either in a gym as part of a supervised group or an individual unsupervised exercise

program developed by an exercise physiologist. Activities may include weight training, walking, swimming, bike

riding. The program includes educational sessions covering diet, nutrition, alcohol, diabetes, goal setting, stress

management, sleep and back care. Your patient will visit you every 3 months to monitor clinical endpoints such as

blood pressure and weight.

I

,...................................................................................................................................................................................................................................

(name of medical practitioner)

......................................................................................................................................................................................................................................

(practitioner address)

give medical clearance for

.................................................................................................................................................................................

(name of participant)

DOB

to participate in the Heart Health Program that is expected to commence in the next 12 weeks

............./............../.............

Participant’s Details:

Participant’s Current Medications

Blood pressure:

Cholesterol: mmol/L

HDL

TC

Trig.

LDL

Blood glucose:

mmol/L

Weight:

kg

Height:

cm

Hip:

cm

Waist:

cm

Smoking Status:

No

Yes

No. / day

1