FIT - FitLab Physican Clearance Form
FIT - FitLab Physican Clearance Form
Patient's Name:
Patient's Name:
*
First
Last
Patient's Date of Birth:
Patient's Date of Birth:
*
/
MM
/
DD
YYYY
Upon current review of the patient's health status, I recommend the following course of action:
*
Upon current review of the patient's health status, I recommend the following course of action:
The participant should avoid engaging in physical activity at this time.
The participant should engage in only a medically supervised physical activity/exercise program involving the supervision of a qualified exercise professional (or other appropriately trained health care professional) and overseen by a physician.
The participant is cleared for intensity and mode appropriate physical activity/exercise training under the supervision of a qualified exercise professional.
The participant is cleared for intensity and mode appropriate physical activity/exercise training with limited supervision (i.e., unrestricted physical activity).
The following should be AVOIDED when prescribing exercise for the aforementioned participant:
The following should be INCLUDED when prescribing exercise for the aforementioned participant:
Name of Physician
Name of Physician
*
First
Last
Physician Address
Physician Address
*
Street Address
Address Line 2
City
State / Province / Region
Postal / Zip Code
Country
United States
United Kingdom
Canada
Australia
Netherlands
France
Germany
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Afghanistan
Albania
Algeria
Andorra
Antigua and Barbuda
Argentina
Armenia
Austria
Azerbaijan
Bahamas
Bahrain
Bangladesh
Barbados
Belarus
Belgium
Belize
Benin
Bermuda
Bhutan
Bolivia
Bosnia and Herzegovina
Botswana
Brazil
Brunei
Bulgaria
Burkina Faso
Burundi
Cambodia
Cameroon
Cape Verde
Cayman Islands
Central African Republic
Chad
Chile
China
Colombia
Comoros
Congo
Costa Rica
Côte d'Ivoire
Croatia
Cuba
Cyprus
Czech Republic
Denmark
Djibouti
Dominica
Dominican Republic
East Timor
Ecuador
Egypt
El Salvador
Equatorial Guinea
Eritrea
Estonia
Ethiopia
Fiji
Finland
Gabon
Gambia
Georgia
Ghana
Gibraltar
Greece
Grenada
Guatemala
Guernsey
Guinea
Guinea-Bissau
Guyana
Haiti
Honduras
Hong Kong
Hungary
Iceland
India
Indonesia
Iran
Iraq
Ireland
Israel
Italy
Jamaica
Japan
Jersey
Jordan
Kazakhstan
Kenya
Kiribati
Kosovo
Kuwait
Kyrgyzstan
Laos
Latvia
Lebanon
Lesotho
Liberia
Libya
Liechtenstein
Lithuania
Luxembourg
Macedonia
Madagascar
Malawi
Malaysia
Maldives
Mali
Malta
Marshall Islands
Mauritania
Mauritius
Mexico
Micronesia
Moldova
Monaco
Mongolia
Montenegro
Morocco
Mozambique
Myanmar
Namibia
Nauru
Nepal
New Zealand
Nicaragua
Niger
Nigeria
Norway
North Korea
Oman
Pakistan
Palau
Palestine
Panama
Papua New Guinea
Paraguay
Peru
Philippines
Poland
Portugal
Puerto Rico
Qatar
Romania
Russia
Rwanda
Saint Kitts and Nevis
Saint Lucia
Saint Vincent and the Grenadines
Samoa
San Marino
Sao Tome and Principe
Saudi Arabia
Senegal
Serbia and Montenegro
Seychelles
Sierra Leone
Singapore
Slovakia
Slovenia
Solomon Islands
Somalia
South Africa
South Korea
Spain
Sri Lanka
Sudan
Suriname
Swaziland
Sweden
Switzerland
Syria
Taiwan
Tajikistan
Tanzania
Thailand
Togo
Tonga
Trinidad and Tobago
Tunisia
Turkey
Turkmenistan
Tuvalu
Uganda
Ukraine
United Arab Emirates
Uruguay
Uzbekistan
Vanuatu
Vatican City
Venezuela
Vietnam
Yemen
Zambia
Zimbabwe
Physician Telephone
Physician Telephone
*
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Date of Medical Clearance:
Date of Medical Clearance:
*
/
MM
/
DD
YYYY
Physician Signature
*
Draw
or
Type
I understand this is a legal representation of my signature. This clearance is valid for a period of six months from the date it is completed and becomes invalid if the medical condition of the named participant changes or worsens.
Clear
Full Name
I understand this is a legal representation of my signature. This clearance is valid for a period of six months from the date it is completed and becomes invalid if the medical condition of the named participant changes or worsens.