Name_________________________________
Date____________________
Person to Contact in case of an Emergency________________________________
Phone number where that person can be reached____________________________
For most people, physical activity should not pose any problem or hazard.
The following questions
are designed to identify the small number of person for whom physical
activity might be inappropriate
or those who should have medical advice concerning the type of activity
most suitable for them.
Have you seen a doctor in the last year? Yes__ No__
If yes, Why? ________________________________________________________________________
Have you had a physical exam by a medical doctor in the last year? Yes__
No__
When? _____
Doctor’s Name __________________________________
Doctor’s Phone __________________________________
Do you have any known medical condition that my prevent you from participating
in physical activity?
For example, congeniatl heart disease, heart murmurs, high blood pressure,
diabletes, musculoskeletal
problem, fainting spells, dizziness or asthma?
If so, please describe
Are you currently taking any medications (prescriptions or over the
counter? Yes__ No__
If so, please list the medication and reason for taking
Are you aware of any physical reason would prevent you from participating
in physical activiy?
Yes__ No__, If yes, please list
I, ______________________________________, certify that I understand
the foregoing questions and my
answers are true and complete. I also understand that this information
is being provided as part of my initial
consultation and may not be periodically updated.
I, ______________________________________, assume the risk for any changes
in my medical condition
that might affect my ability to exercise.
Signature_______________________________________ Date_____________________
Parent or Guardian if under 18
If you answered
yes to one or more questions and you have not seen a doctor about the
condition(s), consult
with your doctor before beginning and exercise program and obtain a
completed Physician’s Clearance form.
Explain to your doctor that you plan to undergo an exercise program
that may include, but not limited to,
cardiovascular training.
I, ___________________________________, acknowledge that I have read
the foregoing statements
and understand the content thereof.
Signature_____________________________, Date__________________________
Parent or Guardian (if under 18)______________________________________________
