Medical Clearance Form 1 - Free Download
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App-VIIE Medical Clearance Form 10-09 1 Revised 10/09
MEDICAL CLEARANCE FORM
Your patient has applied for enrollment in a fitness testing
and/or a structured exercise program at their worksite. As a participant in this program, she/he may be
participating in the activities named below. Under the American College of Sports Medicine guidelines,
medical clearance has been requested for the following reasons:
Fitness Testing: The purpose of fitness testing is to assess cardiorespiratory fitness, muscular strength and
endurance, body composition, and flexibility. The cardiorespiratory test is a submaximal test utilizing a
cycle ergometer, bench stepping, a treadmill walk/run test, or similar test. Muscular strength and
endurance tests require body calisthenics and/or use of exercise equipment such as a bench press. Body
composition analysis is performed via skinfold calipers, bioelectric impedance, and/or tape measurement.
Flexibility testing utilizes active movements as the straight leg raising test and sit and reach test.
Structured Exercise Program: The purpose of an exercise program is to develop and maintain
cardiorespiratory fitness, muscular strength and endurance, body composition, and flexibility. A structured
exercise program is given to each participant based on needs and interests and physician recommendations.
All exercise programs include warm-up, exercise at target heart rate, and cool-down (except for muscular
strength and endurance training, in which target heart rate is not a factor). The programs may involve
walking/jogging/running, swimming, cycling, rhythmic aerobic exercise (low-moderate-high impact
classes), calisthenics, and/or strength training. All programs are designed to place a gradually increasing
workload on the body in order to improve overall fitness and muscular strength. The rate of progression is
regulated by target heart rate and/or perceived rate of exertion.
All fitness tests and exercise programs are administered by qualified personnel trained in conducting
exercise tests and programs as well as having CPR certification.
To facilitate the review and approval of your patient's application for testing and/or exercise program we
require recent (within 12 months) medical information and your recommendations as requested on the
reverse side of this form. If you have any questions about this process please feel free to call our program
Enclosure: Medical Information and Recommendations Form