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: _________________________________________
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