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icat
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Dur
g,C.
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Name: Dat
eofBi
rt
h:
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o,H/
o,S/
o,D/
o:

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hePPCmember
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i
ciesandpr
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stand
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hatmymember
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ermi
nat
edatanyt
imeshoul
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pol
i
ciesandpr
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ocedur
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hePPC.

Si
gnat
ure Dat
e

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gnat
ure(
asabov
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Whatar
eyourgoal
sinbegi
nni
nganexer
cisepr
ogr
am ?(
Pleasei
ndi
cat
eal
ltheappl
y.
)

t
olosewei
ght t
oreducest
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t
oimpr
ovecar
diov
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ness t
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f-
est
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t
oimpr
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lexi
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t
oimpr
ovemuscul
arcondi
ti
oni
ng t
oimpr
ovenut
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ti
onhabi
ts

t
oreducel
owbackpai
n t
ofeel
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terov
eral
l

t
ogai
nwei
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/muscl
e t
otone/
fir
m

t
oincr
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gyl
evel t
orehabi
l
itat
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ury
 Ot
her:
Pleasespeci
fy.
.

Forof
fi
ceuseonl
y

PPCMember
shi
pNumber

Phy
sici
an'
srecommendat
ion

Per
sonal
Trai
ner

Aut
hor
izedby

MEDI
CALQUESTI
ONNAI
REFORPOLI
CEPERFORMANCECENTRE

Name W/
o,H/
o,S/
o,D/
o

Age Br
anch

Resi
denceAddr
ess/Of
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ceAddr
ess

Cont
actNos.

1.Doesanymemberofy ourf
amilysuff
erfr
om Di
abet
es,Hy
per
tensi
on,Ar
thr
it
is,
Epi
lepsy
,Hear
tDi
seaseorMental
Troubl
e?
 2.Hav
eyouev
erunder
goneanysur
ger
y?

(
IfYes)
:St
atet
henat
ureofsur
ger
yandy
ear
:

3.Hav
eyouev
erbeenhospi
tal
i
zed&under
goneal
ongt
reat
mentf
oranyi
njur
y?

(
IfYes)
:St
atet
henat
ureofi
njur
yandy
ear
:

4.Haveyouev
ersuf
fer
edf
rom anyoft
hef
oll
owi
ng:(
IfYes)gi
vey
earoft
hel
ast
at
tack:

Di
sease Year

Tuber
cul
osi
s

Di
abet
es

Br
onchi
ti
sAst
hma

Hy
per
tensi
on

Fi
ts

Jaundi
ce

Rheumat
icFev
er/
Gout
s/Ar
thr
it
is/
LBA/
PIVD

Anyki
ndofhear
tdi
sease

Fai
nti
ngat
tacks

Ski
ndi
sease

Vener
eal
disease/
HIV

Ki
dneydi
sease

Ner
vousbr
eakdown,
Depr
essi
on

Fev
erf
orpr
olongeddur
ati
onaccompani
edbycoughorspi
tt
ingofbl
ood&l
oss
ofwei
ght

Di
arr
heaf
orpr
olongeddur
ati
onwi
thl
ossofwei
ght

Gl
aucoma/Ey
edi
sease/
Col
orbl
i
ndness
 5. Pl
easei
ndi
cat
e:

a)Hi
stor
yofEardi
schar
ge/anychr
oni
ceardi
sease.

b)Anyaddi
cti
ont
oTobacco/
Alcohol
/Dr
ug.

c)Hi
stor
yofThy
roi
ddi
sease/Endocr
inal
disor
der
.

d)Hi
stor
yofanypr
olongeddr
ugi
ntakest
eroi
dset
c.f
oranypr
olongedi
l
lness.

e)Hi
stor
yofaut
oimmunedi
seasel
i
kesy
stemi
cLupusEr
ythemat
osuset
c.

f
)Ifot
her
,Pl
easespeci
fy.
.

Not
e:I
ncor
recti
nfor
mat
ionpr
ovi
dedbyt
hei
ndi
vi
dualwi
llbev
iewedser
iousl
y.

Dat
e Si
gnat
ure
 Medi
calCl
ear
anceandPhy
sici
an'
sConsentt
oPar
ti
cipat
einExer
cisePr
ogr
amme

To,

TheSuperi
ntendentofPol
i
ce
CGPolice
Durg,
chhatt
isgar
h

Mr
./Mr
s./
Miss.
..
..
..
..
..
..
..
..
..
..
..
..
..
..
..
..
..
..
..
..
..
..
..
..
..
..
..
..
..
..
..
..
..
..
..
..
,int
endst
opar
ti
ci
pat
e
i
nanexer
cisepr
ogr
am,
whi
chwi
l
lincl
ude,
butnotbel
i
mit
edt
o,r
esi
stancet
rai
ning.The
sessi
onswi
l
llastappr
oxi
mat
ely20t
o60Mi
nut
esandwi
l
lbei
ngatav
erymoder
ate,
sub
maxi
mal
lev
el.

Pl
easebeadv
isedt
hatmyMr
./Mr
s./
Miss.
..
..
..
..
..
..
..
..
..
..
..
..
..
..
..
..
..
..
..
..
..
..
..
..
..
..
,shoul
d
besubj
ectt
othef
oll
owi
ngr
est
ri
cti
oni
nhi
s/herexer
cisepr
ogr
amme:

I hav
e di
scussed t
he f
oregoi
ng r
est
ri
cti
ons wi
th Mr
./Mr
s./
Miss
.
..
..
..
..
..
..
..
..
..
..
..
..
..
..
..
..
..
..
..
..
..
..
..
..
..
..
..
..
..
..
..
.,
andt
hesespeci
fi
crest
ri
cti
ons,
ment
ionedabov
e,
he/
shehasmyper
missi
ont
opur
sueanexer
cisepr
ogr
ammeundert
hegui
danceofa
qual
i
fiedt
rai
ner
.

Dat
e...
..
..
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..
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..
..
..
..
Phy
sici
an
MEDI
CALEXAMI
NATI
ONREPORTFORPOLI
CEPERFORMANCECENTRE

Name W/
o,H/
o,S/
o,D/
o

Age(
Iny
ear
s) Sex

Bl
oodGr
oup Dat
eofMedi
cal
Exami
nat
ion

Gener
alExami
nat
ion
BP(mm ofHg)

Pul
se(
permi
nut
e)

Hei
ght(
cm)

Wei
ght(
Kg)

Chestunexpanded(
cm)

Chestexpanded(
cm)

Ot
her
s

Sy
stemicExami
nat
ion
C.
N.S.
C.
V.S.

G.
I.
T.

R/
S

E.
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Dat
e
Phy
sici
an