Physician Clearance Form printable pdf download

Physician Clearance Form

St. Mary Wellness Center

Langhorne, PA 19047

Tel: 215- 710-6861

Fax: 215-710-6931

** PHYSICIAN CLEARANCE FORM**

I hereby acknowledge that I have examined__________________________________________

within the past _______ month (s), and have found him/her to be capable of taking the active components of the Fitness

Assessment, as described briefly below, and proceeding with an exercise program based on those tests and conforming to

American College of Sports Medicine guidelines. Skip to next section if not applicable.

I would suggest that the following test items be omitted or the following programming precautions be taken:

1.________________________________________________________________________________________________

_________________________________________________________________________________________________

2.________________________________________________________________________________________________

_________________________________________________________________________________________________

3.________________________________________________________________________________________________

_________________________________________________________________________________________________

PHYSICIAN SIGNATURE____________________________ DATE_______/_______/_______

PHONE # (_____)___________________

PHYSICIAN NAME ( PLEASE PRINT)___________________________________

**ACTIVE TEST COMPONENTS CENTER**

Maximal/submaximal VO2 volume of oxygen uptake.

1.)

Submaximal strength evaluation involving all major muscle groups.

2.)

Flexibility measure of hamstrings and lower back.

3.)

Note: For a detailed explanation of the components, please contact our fitness instructors at 215-710-6861

FORMS/CLEARANCE/pf

Physician Clearance Form