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App-VIIE Medical Clearance Form 10-091 Revised 10/09
MEDICAL CLEARANCE FORM
Your patienthas applied for enrollment in a fitness testing
and/or a structured exercise program at their worksite. As a participant in this program, she/he may be
participating in the activities named below. Under the American College of Sports Medicine guidelines,
medical clearance has been requested for the following reasons:
Fitness Testing: The purpose of fitness testing is to assess cardiorespiratory fitness, muscular strength and
endurance, body composition, and flexibility. The cardiorespiratory test is a submaximal test utilizing a
cycle ergometer, bench stepping, a treadmill walk/run test, or similar test. Muscular strength and
endurance tests require body calisthenics and/or use of exercise equipment such as a bench press. Body
composition analysis is performed via skinfold calipers, bioelectric impedance, and/or tape measurement.
Flexibility testing utilizes active movements as the straight leg raising test and sit and reach test.
Structured Exercise Program: The purpose of an exercise program is to develop and maintain
cardiorespiratory fitness, muscular strength and endurance, body composition, and flexibility. A structured
exercise program is given to each participant based on needs and interests and physician recommendations.
All exercise programs include warm-up, exercise at target heart rate, and cool-down (except for muscular
strength and endurance training, in which target heart rate is not a factor). The programs may involve
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