CardioCoach PRO User Manual | Page 104
SAMPLE Medical Clearance Form
Dear Doctor:
During application for enrollment at the Fitness Center, your patient
_________________________ completed a Health History and Activity Profile Form.
Information on this form indicates your patient will require a physician’s clearance form.
The patient has indicated the following health risk(s):
__________________________________________________________________
__________________________________________________________________
__________________________________________________________________
The patient’s exercise program will take place in the Fitness Center located in
________________________ and will be administered by qualified personnel trained in
conducting exercise programs. If you know of any medical, or other reasons why
participation in the Fitness Center by the applicant would be unwise, please indicate so on
this form. By completing the form below you are not assuming any responsibility for our
administration of the exercise program.
PHYSICIAN REPORT
Please check one
:
¨ I know of no reason why the applicant may not participate.
¨ I believe the applicant can participate but I urge caution because (please list
limitations):
________________________________________________________________________________
________________________________________________________________________________
¨ The applicant should not engage in the following activities:
________________________________________________________________________________
________________________________________________________________________________
¨ I recommend that the participant NOT participate.
Information other than what is requested is also greatly appreciated. Thank you in advance for your
recommendations and support of this individual.
__________________________________________________________________
__________________________________________________________________
Physician Signature____________________________________________________ Date___________________
Address_______________________________________________________ Phone_________________________
City and State___________________________________________________ Zip____________________
Please return Medical Clearance Form to:
Fitness Center
Address
Phone
FAX
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