|
Healthy Lifestyles Fitness Center
55 Augustine Herman Highway
Elkton, MD 21921
Tel: 410-620-3101 / FAX: 410-620-3606
Participation in the Life Beyond Cancer Fitness Program requires medical clearance. The testing portion of this program involves a hamstring flexibility test, shoulder range of motion test, arm girth measurements (for individuals who are predisposed to upper extremity lymphedema), postural assessment, core strength and balance tests, muscular strength, and muscular endurance tests.
An exercise program is designed depending on the participant's needs, beginning with basic stretching, flexibility, and core strength exercises and gradually progressing to a resistance training program to increase upper and lower body strength and bone density. Our trainer is a Certified Cancer Exercise Specialist and a Certified Personal Trainer.
If you know of any reason why participation in an exercise program by the applicant would be unwise, please indicate on this form.
|
Life Beyond Cancer Fitness Program
Physician's Consent Form
|
Applicant's Name:
|
Applicant's Address and Phone Number:
|
| To be signed by the physician: |
| In your opinion, is this individual medically cleared to participate in a supervised exercise program? |
| _____ Yes, this individual is medically cleared to participate in a supervised exercise program. |
| _____ No, this individual is not medically cleared to participate in a supervised exercise program. |
_____ This individual should not engage in the following exercises:
|
|
Additional Comments:
|
|
|
|
|
Physician's Signature: |
Signature Date: |
|
