GP/Doctor Clearance Form

The GP should complete this form after reviewing the patient’s medical history and current health status. This clearance is valid for 6 months and should be reviewed unless the patient’s medical condition changes.
Below is a GP clearance form template suitable for seniors or patients with chronic disease or weight issues, seeking to participate in a low-intensity, group-based exercise program. It is designed to ensure safety and clear communication between the referring GP, the exercise provider (Arche Health), and the patient.
Referring Doctor (Name)
Patient Name
Medical History
Patient Physical Status
Selected Value: 0
How would you rate patients current level of fitness? (1) Poor, (2) Fair, (3) Good, (4) Very Good, (5) Excellent.
Selected Value: 0
How would you rate patients current level of strength? (1) Poor, (2) Fair, (3) Good, (4) Very Good, (5) Excellent.
Selected Value: 0
How would you rate your balance? (1) Poor, (2) Fair, (3) Good, (4) Very Good, (5) Excellent.
Medical Authorisation
Please specify reason:
Please specify any restrictions, precautions, or recommendations (e.g., avoid certain movements, monitor blood glucose, supervision required), recent falls including recent hospitalisation/ surgery.