Eat Better and Move More
Physician’s Approval Form
Eat Better and Move More program is a nutrition and walking program designed to get
older adults to eat better and walk more. Participants will be given a step counter to
monitor the number of steps they take each day. Every week they will be given a step
goal based on the number of steps walked the previous week. A new step goal will be
provided by taking 10% of the steps walked the previous week and adding that number
to the previous step goal. The program will also include mini-talks on nutrition and
physical activity. If addition, 15 to 20 minutes of group walking sessions will be offered
twice a week for participants.
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Release to request permission
I give permission to _____________________________________ to ask my physician
if I may be allowed to participate in the Eat Better & Move More program and I give my
physician approval to sign the form.
_________________________ _________________________ ____________
Participant’s Signature
Printed Name
Date
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_________________________ has medical approval to participate in the Eat Better
(Participant’s name)
and Move More program.
__________ I give my approval.
__________ I do not give my approval.
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Physician’s Signature
_________________________
Printed Name
__________________________________________
Physician’s Address
____________
Date
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Physician’s Phone #