Physician's Exercise Release


I have examined

___________________________________

and have found the following:

____ The above named may participate fully in a progressive physical activity program consisting of cardiovascular, strength and flexibility training without limitiation.

____ The above named may participate in a progressive physical activity program with the following limitations:

Please list any medications that your patient is currently taking that may affect heart rate or blood pressure response to exercise (elevating or suppressing). If none, write "NONE".


Physician's Signature:

___________________________________

Date:

_______________________________