The StrongWomen Program
A National Fitness Program for Women
Physician Authorization Form
Patient Name: ____________________________________________________________________
Address: _________________________________________________________________________
________________________________________________________________________________
Phone Number: ______________________ Date of Birth: ___________________________
Date of Last Exam: _______________________________
Height: __________ Weight: __________ Pulse: __________ BP: __________
Other: __________________________________________________________________________
Medical Conditions: _______________________________________________________________
Medications: _____________________________________________________________________
________________________________________________________________________________
Special Considerations:_____________________________________________________________
________________________________________________________________________________
________________________________________________________________________________
_____ Yes, my patient can participate.
_____ No, my patient cannot participate at this time due to his/her medical conditions and
health status.
Physician, Physician Assistant, or Nurse Practitioner Signature:
____________________________________________________ Date: _____________________
Print Name: ________________________________________________________
Address: ________________________________________________________________________
________________________________________________________________________________
Phone Number: _________________________ FAX Number: _________________________
(3/2010)
Penn State is committed to affirmative action, equal opportunity, and the diversity of its workforce.