Art Worx Medical Form

Welcome to the Art Worx Personal Fitness Training Medical Form Page

Let Art Worx help you scuplt your body into a WORK OF ART

J Lucky 7 Home Page | Art Worx Personal Fitness Training Home Page | DJ Lucky Home Page

Art Worx Medical Clearance Form

This is a sample page of the Art Worx Personal Fitness Training Program " Medical Clearance Form ". If you wish to mail your " Medical Clearance Form " after your Family Doctor signs it then please mail the completed form to:

Jeffrey L Haggans
314 W Upsal St. 2F
Phila., Pa. 19119

To print a copy for your physician please click here.

Your patient, _______________________________ , has applied to participate in one-on-one Art Worx Personal Training Session with Jeffrey L. Haggans which requires your medical clearance prior to participation. Clearance indicates that this patient has no contraindications for participation in the fitness test described below and one-on-one / group training. The patient will have the following test administered to determine his or her state of fitness.

Health risk appraisal / questionnaire
Resting Measures (i.e., heart rate, blood pressure, % body fat, anthropometrics)
Muscle strength / endurance assessment
Cardio respiratory assessment
Flexibility assessment

Some organizations recommend that an individual over 40 years of age who has not been involved in an exercise program on a regular basis have a diagnostic exercise test prior to beginning such a program. Does your patient's risk factor assessment warrant such a test prior to beginning his or her program?

_____ Yes _____ No

Is your patient physically able to participate in the testing regiment described above and in a vigorous, individually / group instructed exercise program?

_____ Yes _____ No

Signature : ___________________________________ M.D.

Address : ____________________________________

City : _______________________________________ State ______ Zip _________

Please list any restrictions or concerns (including medication). Thank you for your cooperation.

_______________________________________________________________

Jeffrey L Haggans
314 W Upsal St. 2F
Phila., Pa. 19119

To print a copy for your physician please click here.

If you have any questions or comments feel free to e-mail me by clicking the image below.

J Lucky 7 Home Page | Art Worx Personal Fitness Training Home Page | DJ Lucky Home Page