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.