Your patient, _________________________________________, desires to participate in the physical fitness "Targeting Health" Worksite Wellness Program, sponsored by the [sponsoring agency or participant's health promotion group]. Our initial medical screening identified the following potential health risk factors:
__ Age: 40 years or more (male), 50 years or more (female)
__ Elevated blood pressure: ___/___mm/Hg, or on hypertension medication
__ Smoking
__ Diabetes
__ Obesity
__ Family history of cardiovascular disease in parents or siblings prior to age 55
__ Symptoms or signs suggestive of cardiopulmonary disease
__ Known cardiac, pulmonary, or metabolic disease
__ Has not been recently (within 6 months) involved in a regular moderate exercise program
Other: _________________________________________________________________________
_______________________________________________________________________________
Because of these risk factors, our guidelines require your patient to obtain clearance from you prior to participation in the "Targeting Health" Fitness Program. This program is provided and/or recommended by the USACHPPM Worksite Wellness Coordinator under the supervision of the Directorate of Health Promotion and Wellness Staff.
Please complete the attached Physician's Approval Form and return it to [name of Coordinator] at [fax and/or email], or to [contact name], [sponsoring agency or participant's health promotion group], [fax and/or email]. If you have any questions, please call [sponsoring agency or participant's health promotion group] at [phone].
