MWCS FITNESS CENTER

MEDICAL RELEASE FORM

 

I have completed the Physical Activity Readiness Questionnaire (PAR-Q) on the back of this sheet.  I have answered YES to at least one of the questions.  I am required written permission from you to use any of the following equipment at the MWCS Fitness Center.

 

NAME ___________________________

 

Cardiovascular Machines

 

Machine 

Approved 

Disapproved 

Limitations 

Treadmill

 

 

 

Elliptical

  (cross trainer)

 

 

 

Stationary Bike

   (recumbent & upright)

 

 

 

 

Cable Weight Machines

 

Machine

Approved

Disapproved

Limitations

Leg Press

    (quads, hams, glutes)

 

 

 

Leg Extension

    (quadriceps)

 

 

 

Leg Curl

     (hamstrings)

 

 

 

Chest Press

    (pectoralis group)

 

 

 

Rear Deltoid/Pec Fly

    (deltoids & pecs.)

 

 

 

Lat Pulldown/Low Row

    (latissimus dorsi)

 

 

 

 

Free Weights

 

Muscles/Exercise

Approved

Disapproved 

Limitations

Biceps & Triceps

 

 

 

Obliques

 

 

 

Chin Ups & Dips

 

 

 

Squats & Calf Raises

 

 

 

Military & Chest Press

 

 

 

Abdominals

 

 

 

Back Extensions

 

 

 

 

Physician Signature:  _________________________      Date:  _______________