MEDICAL CLEARANCE FORM
Name of Patient_____________________________________________________ Date _______________
Your patient wishes to take part in an exercise program and/or fitness assessment at or with
__________________________ . After initial screening it has been determined that this individual requires physician
consent prior to engaging in the exercise program and/or fitness assessments due to ______________________________
The participant will engage in the following exercise programming and/or fitness assessments:
Exercise Programming Fitness Assessments
___Muscular Strength ___Muscular Strength
___Flexibility ___Muscular Endurance
___Muscular Endurance ___Flexibility
___Cardiorespiratory Fitness ___Body Composition
___Other* ___Cardiorespiratory Fitness
*Explain: ____________________________________________________________________________
____________________________________________________________________________
Physician’s Recommendations
Please indicate below for which of the following your patient is cleared to participate
Muscular Strength & Endurance Training and Assessment
___ Yes with no limitations ___Yes with limitations below ___No cannot participate
Limitations/ recommendations: ___________________________________________________________________________
______________________________________________________________________________________________________
Cardiorespiratory Fitness and Assessment
___ Yes with no limitations ___Yes with limitations below ___No cannot participate
Limitations/ recommendations: ___________________________________________________________________________
______________________________________________________________________________________________________
Flexibility Training and Assessment
___ Yes with no limitations ___Yes with limitations below ___No cannot participate
Limitations/ recommendations: ___________________________________________________________________________
______________________________________________________________________________________________________
___________________________________________ ____________
Signature of Physician/Primary Care Provider Date
___________________________________________ Please return this form to:
Printed Name of Physician/Medical Group
____________________________________________________
Street Address
____________________________________________________
City State Zip