International Sports Sciences Association
This form is adapted from ISSA client assessment materials
Medical Release Form
PLEASE COMPLETE THE FOLLOWING INFORMATION
It is my understanding that will be participating in a fitness evaluation and exercise program. This patient is permitted to participate in the following activities. (Please check all that apply.)
1. Comprehensive physical fitness assessment including:
submaximal aerobic capacity test for cardiovascular endurance
resting heart rate, resting blood pressure
body composition analysis
flexibility
baseline upper and lower body strength measures
baseline upper and lower body endurance measures
Other
2. Exercise/rehabilitation program including:
resistance exercise program
cardiovascular exercise program
nutritional recommendations
Other
Please check the appropriate response:
This patient may participate with no restrictions.
This patient may participate with the following limitations:
This patient may not participate. (If checked, the individual will not be accepted.)
Other
Diagnosis/Recommendations/Comments:
SIGNATURE
PHYSICIAN NAME (please print)
First Name
Last Name
PHYSICIAN SIGNATURE
DATE
-
Month
-
Day
Year
Date
PARTICIPANT NAME (please print)
First Name
Last Name
PARTICIPANT SIGNATURE
DATE
-
Month
-
Day
Year
Date
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