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Medical Clearance Form Template

Streamline Your Health Clearance Process with Ease

Navigating health requirements can be challenging, especially when it comes to securing medical clearances. This Medical Clearance Form template is designed to help healthcare professionals and employers efficiently document an individual's health status. With this template, you can customize clearances for various purposes, ensure compliance with health regulations, simplify the documentation process, and improve communication between patients and providers, all in a user-friendly format. Experience the benefits by exploring the live template now.

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Full legal name
Date of birth
Email address
Phone number
Emergency contact full name
Emergency contact phone
Activity or role requiring clearance
Anticipated start date for activity
Gender
Woman
Man
Non-binary
Prefer to self-describe
Prefer not to say
Past or current medical conditions (select all that apply)
Current medications (include prescriptions, over-the-counter, and supplements)
Do you have any allergies?
Yes
No
Known allergies (drug, food, latex) and reactions
Surgeries or hospitalizations (with dates, if known)
Pregnancy status (if applicable)
Pregnant
Not pregnant
Possibly pregnant
Not applicable
Prefer not to say
Are your routine immunizations up to date?
Yes
No
Unsure
Describe any current symptoms, if applicable
Are you currently experiencing symptoms that could limit safe participation?
Yes
No
Unsure
Height
Weight
Blood pressure
Resting heart rate
Relevant examination findings
Date of examination
If restrictions apply, specify limitations, accommodations, or duration
Clearance valid until (if applicable)
Clearance status
Cleared for full participation without restrictions
Cleared with restrictions
Not cleared for participation
Deferred pending further evaluation
Not applicable
I authorize release of this medical clearance to the organization named below
Yes
No
Recipient organization name
Patient or guardian printed full name (serves as signature)
Date signed (patient or guardian)
I affirm that the information I provided is accurate to the best of my knowledge
Yes
No
Clinician full name
License number
Practice or clinic name
Clinic phone
Clinician printed name (serves as signature)
Date signed (clinician)
Clinician attestation: I reviewed the history and performed an appropriate evaluation related to this clearance
Yes
No
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Paper art illustration featuring a medical clearance form with checkboxes and sections for patient information and signatures

When to use this form

Use this template when an employer, school, or program needs a clinician to confirm someone is fit for a job, sport, surgery, or travel. It covers pre-op reviews, new-hire onboarding, return-to-work after injury, and volunteer screening. You collect history, risks, and any restrictions; a provider signs so you can proceed safely and document compliance. Pair it with the Physician release to return to work form for post-injury cases, and reference prior records with a Medical chart review form. For pre-placement checks, have candidates complete an Employee physical examination questionnaire form. The result is a clear, signed determination that reduces risk and speeds approvals.

Must Ask Medical Clearance Questions

  1. What activity, job, or procedure is this clearance for, and by what date do you need it?

    This defines the risk level and scope so the clinician knows which standards to apply. A due date sets priority and helps you schedule exams or tests without last-minute delays.

  2. Do you have any current symptoms, diagnoses, recent hospitalizations, or chronic conditions we should consider?

    This surfaces red flags that may require deferral or additional evaluation. It also informs whether temporary restrictions or specialist input are needed.

  3. Which medications, supplements, or medical devices do you use, and are there any provider-imposed restrictions?

    Medication lists and devices affect fitness and safety plans. Documented restrictions guide duty modifications and protect you and the organization.

  4. Have you completed a physical exam or labs in the past 12 months? If yes, attach results or reports.

    Recent results can satisfy requirements and prevent duplicate testing. If you need a fresh assessment, align with an Adult physical exam form to capture objective measures.

  5. Who should receive the signed clearance, and what exact wording or form of certificate do they require?

    This ensures the document is addressed correctly and meets employer, school, or agency criteria. Clear delivery details reduce back-and-forth and speed approvals.

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