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ISSA Medical Release

This medical release form allows a participant to obtain approval from their physician to engage in a fitness evaluation and exercise program. The physician can approve the participant for comprehensive fitness assessments and either a resistance or cardiovascular exercise program without restrictions, or note specific limitations. By signing, the physician verifies the participant's medical clearance and any diagnoses, recommendations, or comments.

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Wendy Amador
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301 views1 page

ISSA Medical Release

This medical release form allows a participant to obtain approval from their physician to engage in a fitness evaluation and exercise program. The physician can approve the participant for comprehensive fitness assessments and either a resistance or cardiovascular exercise program without restrictions, or note specific limitations. By signing, the physician verifies the participant's medical clearance and any diagnoses, recommendations, or comments.

Uploaded by

Wendy Amador
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as PDF, TXT or read online on Scribd
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International Sports Sciences Association

Name of Business Medical Release


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:
r submaximal aerobic capacity test for cardiovascular endurance
r resting heart rate, resting blood pressure
r body composition analysis
r flexibility
r baseline upper and lower body strength measures
r baseline upper and lower body endurance measures
r other: _____________________________
2. Exercise/rehabilitation program including:
r resistance exercise program
r cardiovascular exercise program
r nutritional recommendations
r other: _____________________________

Please check the appropriate response:


r This patient may participate with no restrictions.
r This patient may participate with the following limitations:

r This patient may not participate. (If checked, the individual will not be accepted.)
r Other:

Diagnosis/Recommendations/Comments:

SIGNATURE
Please note: possession of this form
does not indicate certification status
with the ISSA. To confirm active
PHYSICIAN NAME (please print) certification status, please call
1.800.892.4772 (1.805.745.8111
international). Information gathered
from this form is not shared with
PHYSICIAN SIGNATURE DATE ISSA. ISSA is not responsible or
liable for the use or incorporation of
the information contained in or col-
PARTICIPANT NAME (please print) lected from this form. Always con-
sult your doctor concerning your
health, diet, and physical activity.

PARTICIPANT SIGNATURE DATE MedicalRelease_0805

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