Exercise Clearance Form

Exercise Clearance Form — Form Fields

This healthcare template includes 8 fields. Screens patients for medical clearance before beginning an exercise or fitness program. Free to customize and use on ZenBuild.

• Patient Full Name (text, required)
• Date of Birth (text, required)
• Has a doctor ever told you that you have a heart condition? (multiple choice, required) — options: Yes, No
• Do you feel pain in your chest during physical activity? (multiple choice, required) — options: Yes, No
• Do you lose balance due to dizziness or ever lose consciousness? (multiple choice, required) — options: Yes, No
• Relevant medical conditions (checkboxes, optional) — options: Diabetes, High blood pressure, Asthma, Joint or bone problems, Recent surgery
• Describe the exercise program you intend to start (long text, optional)
• Patient Signature (signature, required)