Medical Release Form
Date:________________________________________
Dear Doctor____________________________________
Your patient, _______________________________________, wishes to start a personalized fitness training program. The activity will involve the following:
- Type:__________________________________________________
- Frequency:____________________________________________
- Duration:______________________________________________
- Intensity:______________________________________________
If your patient is taking medications that will affect the exercise capacity or heart-rate response to exercise, please indicate the manner of the effect (raises or lowers exercise capacity or heart-rate response):
- Type of medication(s):________________________________________________
- Effect(s):______________________________________________________________
Please identify any recommendations or restrictions that are appropriate for your patient in this exercise program:
__________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
Thank you,
Sincerely,
Melanie Meade, CPT/BCS
P O Box 833, Leland, NC 28451
(910)795-6060
fitnessplus20@gmail.com