Please print this form and have your doctor sign, complete and return it with your completed history form to the Centre for Neurological Rehabilitation.
The History Form and the Medical Clearance Form are for United States patients only.

Date

We will be seeing (print the name of the patient) in the near future to determine eligibility for a home program of mild sensory motor and neuro motor activities.

Would you please assist this family by signing below indicating that the person named above is medically fit to participate in such a program. Your additional comments or concerns will also be appreciated.

Thank you.

This is to state that (name of the patient) is medically capable of mild to moderate exercise.

Doctor's signature

Printed name

Address

City State Zip

Send questions and/or comments to Dr. Unruh at DrUnruh@aol.com

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