Physician Medical Release Form

TO BE COMPLETED BY YOUR PRIMARY CARE PROV. OR NEURO

wishes to participate in the Rock Steady Boxing (NON-CONTACT) exercise program for people with Parkinson's disease. Our goal is to help your patient have a better quality of life through fitness and socialization. The activities may involve cardiovascular training (walking, punching heavy bags, etc), flexibility instruction (stretching, getting down and up from the floor), resistance training and core strengthening techniques. Safety and modifications for various levels of fitness and disease progression are considered.

PHYSICIAN'S RECOMMENDATION:

lf your patient is taking medications that will affect their heart rate response to exercise, please indicate the manner of the effect (raises, lowers or has no effect on heart rate response during exercise:

PHYSICIAN COMPLETES

Member lnformation

Welcome to Rock Steady Boxing New Bern!

Emergency Contact lnformation

AHA/ACSM Health/Fitness Facility

Pre-Participation Screening Questionairre

History: (check all that apply)

PDQ‐39 QUESTIONAIRRE

Please complete the following

Please tick one box for each question

Due to having Parkinsoa's disease, how often during the test month have you...