Knee Injury Exercise Clearance Form
Complete this form to determine if you are cleared to resume exercise following a knee injury. All information is kept confidential and is used solely for your health and safety.
Full Name
*
First Name
Last Name
Date of Birth
*
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Email Address
*
example@example.com
Date of Knee Injury
*
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Describe the type and cause of your knee injury
*
Are you currently experiencing any of the following symptoms? (Select all that apply)
*
Pain
Swelling
Instability or giving way
Locking or catching
None of the above
Other
What activities are you currently unable to perform due to your injury?
*
Healthcare Provider's Name
*
Provider's Clearance Decision
*
Cleared for exercise
Not cleared for exercise
Emergency Contact Name and Phone Number
Submit
Should be Empty: