Physician Exercise Release Form

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 name (print clearly)

___________________________ Date: ________
Physician's signature