Healthy Lifestyle Medical Clearance Form
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2Healthy Lifestyle
MEDICAL CLEARANCE FORM
(to be used for courses that require medical clearance prior to enrolment)
PARTICIPANT’S CONSENT FORM
Please complete before seeking Doctor’s consent
I (please print name) .................................................................................. wish to enrol in one of the exercise classes offered by
Healthy Lifestyle and am willing to take responsibility for myself during any courses I attend.
I will inform the leader should there be any change in my health or medication that could preclude me taking part in the following
Healthy Lifestyle program
(Please insert the full title and level of course you are attending) …………………………………………………………………….
Signed.......................................................................................... Date .............................................................
DOCTOR TO COMPLETE – GENERAL HEALTH
To the Doctor:
Healthy Lifestyle Unit of Northern Sydney Health considers the safety of participants to be of paramount
first
second
importance. Please complete
this general health information section and then
complete the section specific to the
class(es) your patient would like to attend.
A. Is your patient able to participate in a group class without the assistance of a carer?
YES or NO
B. Does your patient have any of the following pre-existing conditions?
Cardiovascular disease
Respiratory Conditions
Neurological Conditions
Muscular Skeletal conditions
High Blood Pressure
Asthma
Mild Stroke
Osteoporosis
Arrhythmia
Emphysema
Parkinson’s disease
Osteoarthritis
Pacemaker
COPD
Multiple Sclerosis
Rheumatoid arthritis
Angina
Foot problems
Other (please specify)
Other (please specify)
Other (please specify)
Joint replacement
.........................................
.........................................
Other (please specify)
.........................................
.........................................................
Other
(Please specify) eg Depression .........................................................................................
DOCTOR TO COMPLETE – WARM WATER AQUA CLASSES
To the Doctor:
Healthy Lifestyle offers a number of aquafitness programs which are particularly beneficial because the water
supports the body and lessens the stress on people who are overweight, less active, have joint problems or are recovering from an
injury.
Most of these classes are conducted in hydrotherapy or heated pools where the temperature ranges from 30°C to 34°C. Exercise in
warm water can be tiring and, in the interests of safety, we require participants to have the approval of their doctor.
A. Aside from the conditions listed in the General Health section above, please consider the following conditions
when authorising your patient’s participation in warm water aqua classes:
Hypertension, especially if on vaso-dilating drugs.
Cardiac function, eg cardiomyopathy, valvular disease or ischaemic heart disease
Respiratory conditions including post-myoneural conditions affecting respiratory capacity.
Extreme old age.
B. Contraindications: Patients with the following conditions SHOULD NOT attend warm water aqua classes:
Pregnancy
Incontinence (urinary or faecal)
Infections (urinary or vaginal)
Skin conditions (eg tinea)
C. Consent: Having read the information above, I consider that this patient is fit and able to attend warm water aqua
classes and is unlikely to have a health related event as a consequence.
Referring doctor (please print): _________________________________________
Phone: __________________
Signature: __________________________________________________
Date _____________________
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