ACT 2 ProgramFITNESS CLASS CLEARANCE FORM

PLEASE READ: While exercise testing and/or exercise participation is relatively safe for most apparently healthy individuals, the reaction of the cardiovascular system to increased levels of physical activity cannot always be totally predicted. Consequently, there is a small but real risk of certain changes occurring during exercise testing and/or participation. Some of these changes may include but are not limited to abnormal blood pressure, irregular heart rhythm, fainting, in rare instances heart attack or cardiac arrest, as well as certain orthopedic conditions including sprains, strains, fractures and/or dislocations.

Exercise may not be advisable under some of the conditions listed below, while others may simply require special consideration. Consider the following questions honestly. If any of the conditions apply, you should consult your medical provider before you participate in an exercise program. If you are unsure if any of the conditions apply, you should consult your medical provider. You should also promptly report to your instructor any exercise-related abnormalities that you may experience during the course of the quarter.

	Yes	No
Has your doctor ever said that you have a heart condition and that you should only perform physical activity recommended by a doctor?
Do you feel pain in your chest when you perform physical activity?
In the past month, have you had chest pain when you were not performing any physical activity?
Do you lose your balance because of dizziness, or do you ever lose consciousness?
Do you have a bone or joint problem that could be made worse by a change in your physical activity?
Is your doctor currently prescribing any medication for your blood pressure or a heart condition?
Are you using any medication that might alter your response to exercise?
Do you know of any other reason why you should not engage in physical activity?