Physician's Exercise Release

I have examined _________________________________________

I 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.

or

____ 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:                   _________________________________________