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Persons who are of good health, suspect of their health or are aware of any conditions, physical deficiencies or diseases should always consult a physician before undertaking any eating or exercise program. Barbara Baar, Your Personal Trainer, http://www.tightenandtone.com and Results Unlimited, disclaim any liability or loss in connection with the above content, programs, links or advice given in this newsletter, in this document or any workout that is taken or given from said site. Sample programs should not be considered an exercise program.

Medical Clearance Form

Dear Doctor,
Your patient is interested in taking part in a fitness assessment and fitness program. The assessment* involves sub-maximal measurements of cardio-respiratory fitness, body composition, flexibility, and muscular strength and endurance. All assessment protocols will be administered by personnel qualified in assessment techniques and first aid*. The proposed fitness assessment includes: cardio,strength,flexibility and sport specific drills.*

By completing this form, you are not assuming any responsibility for our assessment. If, however, you know of any reason why the participant should not undertake a basic assessment of fitness, I would be most grateful if you could indicate the reason below.

All information that is obtained is completely confidential and will never be sold or given to any other entity.

Doctor's Name:

Patient's Name:

Date of Birth:

Doctor's Phone:

Patient's Phone:

E-Mail:

I know of no reason why the patient may not participate
Yes
No

I believe the patient can participate, but I urge caution because:

The applicant should not engage in the following activities:

I recommend that the applicant NOT participate.

Thank you for you time in this matter.

*applies to in person assesment only.