Receipt of Notice of Privacy Practices Written Acknowledgement Form

V02 Testing Participant Activity Readiness Form

You may fill out and submit this form on our Web site!
Or, if you have concerns about providing information
via the Internet, fill it out, and print it prior to an
appointment. Then bring it with you to your first visit to
save time when you arrive.

1. Has a doctor ever stated that you have a heart condition that would limit your activity?

Yes

2. Do you feel pain in your chest when you exercise?

Yes

3. In the past month have you experienced chest pain while inactive?

Yes

4. Do you lose your balance due to dizziness?

Yes

5. Are you currently on prescription pills for blood pressure or heart condition?

Yes

6. Do you have a bone or joint condition that could be made worse by increased activity?

Yes

7. Do you have knowledge of any reason you should not perform physical activity?

Yes

I have read, understood and completed this form truthfully. I agree that the above testing will be undertaken at my own risk and that Physicians Medical Center shall not be liable for any injuries or damages, nor shall be subject to any claim whatsoever.

Name:
Age:
Date of Birth:

Physicians' Medical Center of the Ozarks · 17 Medical Plaza · Mountain Home, AR 72653
Toll-Free 1-866-749-7633 · (870) 425-6212 · Fax (870) 424-3774 · www.physmedcenter.com

http://www.physmedcenter.com
01/22/2008