If “yes” is the answer to any of the above please have physician complete medical clearance form prior to exercise
If “yes” to two or more of the above please have physician complete medical clearance form prior to exercise
MEDICATIONS/LIMITATIONS/PAST MEDICAL HISTORY
SMOKING/PHYSICAL ACTIVITY/SELF IMAGE
10 = most stressful
I pledge that all the information which I have provided in this form is accurate, to the best of my knowledge, and that I have not willingly excluded any important medical information which could have any bearing on my ability to safely engage in exercise testing and exercise participation.