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Medical Clearance Form

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Medical Clearance Form
MEDICAL CLEARANCE FORM
Dear Doctor:
has applied for membership at the
UNMC Center for Healthy Living in order to exercise. If they request, the
participant will receive guidance in structuring their activity program.
Staff will work individually with each participant to ensure that they are
familiar with a health-oriented approach to physical activity. However,
the center does not provide medically supervised exercise sessions.
Participants will be expected to exercise independently and accept
responsibility for monitoring their own reaction to physical activity.
The simple fitness testing available at the center is not intended to
be diagnostic in nature and does not have the ability to assess the health
of the cardiovascular system.
Our staff is trained in CPR and the facility is equipped with an
automated external defibrillator (AED) to respond to emergency medical
situations.
If you know of any medical or other reasons why involvement in an
unsupervised physical activity program by the applicant would be unwise,
please indicate so on this form.
If you have any questions, please call Peter Pellerito at
402-559-5253 or e-mail at [email protected]
Completed form can be faxed to 402-559-9609.
Report of Physician
I know of no reason why the applicant may not participate.
I believe the applicant can participate, but I urge caution because
The applicant should not engage in the following activities:
I recommend that the applicant NOT participate.
Physician Signature
Address
Date
Telephone
City and State
Zip
Please attach a note for any comments or instructions.
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