WaiverMedicalClearance-1 - o unusual shortness of breath at...

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Name of Client:_________________________ Waiver from Medical Clearance to Participate in an Exercise Program There are potential risks involved in participating in an exercise program. Therefore, we  recommend that you get medical clearance from a physician or nurse practitioner or  other health care professional before participating in Total Wellness. However, you may decide to participate without that approval  only if  you: do  not  have symptoms of heart or lung disease or have diabetes, or  have  not  been diagnosed with heart disease, lung disease, diabetes or other  conditions that may increase your risk of having a cardiac event during exercise. I, , have  not  experienced any of the following signs or symptoms suggestive of  cardiovascular and pulmonary disease (as indicated by the American College of Sports  Medicine):  o pain or discomfort in the chest, neck, jaw, arms or other areas;
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Unformatted text preview: o unusual shortness of breath at rest or with mild activity; o dizziness or fainting; o difficulty breathing while lying down or sleeping; o ankle swelling; o palpitations (forceful heart beats); o tachycardia (rapid heart beats); or o periodic numbness/pain in the arms or legs. I have not been diagnosed with heart disease, lung disease, diabetes or other conditions that may increase my risk of having a cardiac event (i.e., heart attack) during exercise. I understand that it is recommended that I obtain approval by a health care professional before participating in Total Wellness, but I have chosen to participate without getting approval. Revised 1/25/2005 ________________ ____________________________________________ Date Signature of Participant ________________ ____________________________________________ Date Signature of Total Wellness Staff...
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This note was uploaded on 11/15/2011 for the course ESS 4317 taught by Professor Staff during the Fall '11 term at Texas State.

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WaiverMedicalClearance-1 - o unusual shortness of breath at...

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