MEDICAL PRACTITIONER DETAILS Name: Practice: Address: Suburb: State: Postcode: Phone: Fax: Email: PARTICIPANT DETAILS Gender: Miss / Ms / Mrs / Mr / Other: First Name: Last Name: Date of Birth: Address: Suburb: State: Postcode: Phone: Email: Please indicate any relevant contraindications: Contraindications to Exercise Participation Absolute Contraindications Relative Contraindications Exercise participation should not be granted to the In some instances, individuals with these conditions can participant with absolute contraindications as listed below, participate in physical activity with caution and/or using until those conditions are stabilised or adequately treated. low-level end-points, especially if they are asymptomatic at rest and if the benefits of physical activity outweigh the risk of exercise. □ □ A recent significant change in resting ECG suggesting significant Fasting blood glucose >16.7 mmol/L or >13.9 mmol/L with urinary ischemia, recent myocardial infarction (within 2 days), or acute cardiac ketone bodies event □ Uncontrolled hypertension with resting systolic blood pressure > 160 □ Unstable angina mmHg or diastolic blood pressure >100 mmHg □ □ Uncontrolled cardiac dysrhythmias causing symptoms or Severe autonomic neuropathy with exertional hypotension hemodynamic compromise □ Moderate stenotic valvular heart disease □ Uncontrolled symptomatic heart failure □ Hypertrophic cardiomyopathy and other forms of outflow tract □ Symptomatic severe aortic stenosis obstruction □ □ Suspected or known dissecting aneurysm Tachyarhythmias or bradyarrhythmias
MEDICAL PRACTITIONER DETAILS Name: Practice: Address: Suburb: State: Postcode: Phone: Fax: Email: PARTICIPANT DETAILS Gender: Miss / Ms / Mrs / Mr / Other: First Name: Last Name: Date of Birth: Address: Suburb: State: Postcode: Phone: Email: Please indicate any relevant contraindications: Contraindications to Exercise Participation Absolute Contraindications Exercise participation should not be granted to the participant with absolute contraindications as listed below, until those conditions are stabilised or adequately treated. □ A recent significant change in resting ECG suggesting significant ischemia, recent myocardial infarction (within 2 days), or acute cardiac event □ Unstable angina □ Uncontrolled cardiac dysrhythmias causing symptoms or hemodynamic compromise □ Uncontrolled symptomatic heart failure □ Symptomatic severe aortic stenosis □ Suspected or known dissecting aneurysm Relative Contraindications In some instances, individuals with these conditions can participate in physical activity with caution and/or using low-level end-points, especially if they are asymptomatic at rest and if the benefits of physical activity outweigh the risk of exercise. □ Fasting blood glucose >16.7 mmol/L or >13.9 mmol/L with urinary ketone bodies □ Uncontrolled hypertension with resting systolic blood pressure > 160 mmHg or diastolic blood pressure >100 mmHg □ Severe autonomic neuropathy with exertional hypotension □ Moderate stenotic valvular heart disease □ Hypertrophic cardiomyopathy and other forms of outflow tract obstruction □ Tachyarhythmias or bradyarrhythmias
gp_clearance_form_1.docx