Medical Clearance Form
Medical Clearance Form
Please provide all the necessary information below to complete this form.
Name
Date of Birth
Address
Phone number
Medical History
Do you have any chronic medical conditions?
Are you currently taking any medications?
Do you have any known allergies?
Have you been hospitalized in the last year?
Physical Examination
Blood Pressure
Heart Rate
Height
Weight
Respiratory Rate
Clearance Determination
Medical Clearance Status
-
Cleared without limitations
-
Cleared with limitations
-
Not cleared for participation
Healthcare Provider Information
Provider Name
License No.
Facility Name
Address
Phone number
By signing below, I certify that the information provided in this medical clearance evaluation is true and accurate to the best of my knowledge.
Date:
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