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Exercise Clearance Form - Free Healthcare Template | ZenBuild | ZenBuild

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Exercise Clearance Form

Screens patients for medical clearance before beginning an exercise or fitness program.

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Exercise Clearance Form

Screens patients for medical clearance before beginning an exercise or fitness program.

Patient Full Name*

Date of Birth*

Has a doctor ever told you that you have a heart condition?*

YesNo

Do you feel pain in your chest during physical activity?*

YesNo

Do you lose balance due to dizziness or ever lose consciousness?*

YesNo

Relevant medical conditions

DiabetesHigh blood pressureAsthmaJoint or bone problemsRecent surgery

Describe the exercise program you intend to start

Patient Signature*

By signing, you agree this constitutes an electronic signature.

Template Details

CategoryHealthcare

IndustryHealthcare

Fields8

Uses0

Views1

healthcareexerciseclearancefitnessscreening