BUILDING RAPPORT AND THE INITIAL INVESTIGATION STAGE CHAPTER 6 SAMPLE MEDICAL RELEASE FORM Date ______________________
Dear Doctor: Your patient, ____________________________________________________________, wishes to start a personalized training program. The activity will involve the following:
(type, frequency, duration, and intensity of activities)
If your patient is taking medications that will affect his or her 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: _______________________________________________________________________________________________________________________________
___________________________________________________ has my approval to begin an exercise program with the recommendations or restrictions stated above.
