Medical Release Form

Date_____________________

Dear Doctor:________________________________

Your patient, ___________________________________, wishes to start an Online Physical Education Course

through the AMA Educational System Holdings, Inc. (AMAESHI). All activities in the said course require self-
supervision and care by your patient. Activities in the course would include:

 Fitness Tests
 Cardiovascular Activities
 Strength Training – Circuit Training and core exercises

If your patient is currently taking medication/s that will affect his or her exercise capacity or heart-rate response
to exercise, please indicate the manner of the effect (e.g. raises, lowers, or has no effect on exercise capacity or
heart-rate response):
TO BE FILLED OUT BY THE DOCTOR
Types of medication (s)________________________________________________________________
Effects (s)___________________________________________________________________________

Please also identify any recommendations or restrictions that are appropriate for your patient in this online
course:
__________________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________

Thank you.

Sincerely,
AMA Educational Systems Holdings, Inc.
PE 1: Foundations of Physical Fitness

TO BE FILLED OUT BY THE DOCTOR

___________________________________________________has my approval to begin an online Physical

Education Course with the recommendations or restrictions stated above.

Signed________________________________________________ Date_______________________________