Employee Fitness Medical Clearance Form
Please complete this form to determine your eligibility for participation in workplace fitness activities. All information is confidential and will be used solely for your safety.
Employee Full Name
*
First Name
Last Name
Date of Birth
*
-
Month
-
Day
Year
Date
Employee Email Address
*
example@example.com
Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Job Title / Department
*
Emergency Contact Name and Relationship
*
Emergency Contact Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Please indicate if you have or have ever had any of the following medical conditions:
*
Heart disease or chest pain
High blood pressure
Respiratory issues (e.g., asthma, COPD)
Diabetes
Musculoskeletal injuries (e.g., back, knee, joint problems)
None of the above
Other (please specify)
Are you currently taking any medications? If yes, please list them.
Have you experienced any of the following symptoms recently?
*
Shortness of breath
Dizziness or fainting
Chest pain during activity
Unexplained fatigue
None of the above
Other (please specify)
Healthcare Provider's Assessment: Is the employee medically cleared to participate in fitness activities?
*
Yes, cleared without restrictions
Yes, cleared with restrictions (please specify below)
Not cleared for participation
If restrictions apply, please specify:
Healthcare Provider Name
*
Healthcare Provider Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Healthcare Provider Email Address
example@example.com
Date of Assessment
*
-
Month
-
Day
Year
Date
Healthcare Provider Signature
*
Submit Medical Clearance
Submit Medical Clearance
Should be Empty: