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Expectations of physicians in practice

Fitness to participate: Reduce your risk when patients ask for a certificate of fitness

Group of multi-generational people running in a race competition in nature.

5 minutes

Published: April 2022

The information in this article was correct at the time of publishing

Patients may ask physicians to complete forms stating that they are “fit to participate” in certain events. While such forms are standard in the employment context in relation to return to work, they may be requested for other activities, including flights, marathons, and other events carrying significant risk to health or safety.

The CMPA hears from physicians with questions about completing these forms. The forms carry an extra administrative burden at a time when physicians are already overloaded. The forms may also make physicians feel as if they are assuming full responsibility for a patient’s well-being—even if they’ve just met the patient or have only limited information about the sport or event in question.

Despite the challenges associated with fitness to participate forms, some patients will need them signed in order to participate in activities that are important to them. Since the forms have become a part of practice for many physicians, it’s best to approach them in ways that limit medico-legal liability and promote good communication.

The extent of a physician’s obligations

Fitness to participate forms have been the subject of medical regulatory authority (College) complaints and civil actions, but most of these actions have focused on inaccurate or misleading statements made by physicians. While it’s important that all statements made in fitness to participate forms be accurate, the overall medico-legal risk associated with such forms is low.

Physicians have an obligation to provide patients with information about their medical condition. As a result, it may be considered professional misconduct for a physician to refuse to complete a fitness to participate form. However, the obligation to complete the form is limited to answering only those questions on which you are qualified and able to comment. You are not obligated to answer every question on a form if you do not feel capable of commenting on that area, and you are not expected to undertake assessments outside your area of clinical expertise.

Specific fitness to participate forms

a) Air travel

Airlines may request that patients with specific medical issues (such as seizure disorders or cardiac conditions) submit a signed “Fitness for Air Travel” form. Generally, the goal of these forms is to provide some reasonable level of reassurance that a passenger’s condition will not be aggravated by flight or require emergency diversion. To this end, airlines may ask a physician to certify that a passenger will “be able to complete the flight safely.”1

However, without access to a wide range of details—including information about unplanned delays, turbulence, and stopovers—it may not be possible for a physician to confirm that a patient can complete a safe flight. For this reason, you should avoid stating that the patient is “fit to fly.” Instead, you may wish to limit your response to statements about the patient’s overall medical condition and health, as well as specific information about the stability of the patient’s condition and any recent deterioration.2 As with any fitness to participate form, you may choose to submit the form to the airline having answered only the questions you are capable of answering.

b) Sporting and other events

Forms about marathons and other occasional events can be challenging, since the physician may not know the patient particularly well, and it may be the first time the patient has participated in such an event. In these situations, it’s best to approach the form by asking, “Is there any obvious reason the patient should not do this?”3

Conduct a thorough assessment, and consider the patient’s current state and their medical history. If in doubt about contraindications, ask the patient to get more information from the event organizers.

If you are relying on information provided by the patient or the event organizers, be sure to state that in the medical record. The best approach might be to not complete the form, but to instead provide a letter stating that you are relying on information provided by the patient, and to document the findings of your assessment and your general opinion of the patient’s fitness to participate. If attaching a letter instead of completing a form, be sure to tell the patient that the event organizers may contact them for more information.

Communicating with patients about fitness to participate forms

If you are able to complete only parts of a certificate, or plan to attach a letter instead of completing the certificate, it is important to communicate your rationale for doing so with the patient. Similarly, a patient may ask you to complete a form without the patient being examined, as may happen if the patient had recently been examined or an appointment cannot be arranged expeditiously. In such scenarios, you may need to explain that you do not feel comfortable signing the form because there are statements you cannot attest to. In other cases, it may be appropriate to refer the patient to a specialist who may have more expertise about the activity in question in order to complete the form.

The bottom line

  • There have been College complaints and civil actions about fitness to participate forms, but those actions have focused mostly on inaccurate or misleading statements. The overall medico-legal risk associated with these forms is low.
  • While physicians are obligated to consider a patient’s request to complete fitness to participate forms, the obligation extends only to answering questions the physician is qualified and able to comment on.
  • If you feel the form is asking for information you do not have, tell the patient why you cannot complete the entire form. Consider skipping sections you cannot complete, or attaching a letter instead of the form.


  1. For example, see section 4 of Air Canada’s “Fitness for Air Travel” form. Available from: https://www.aircanada.com/content/dam/aircanada/portal/documents/PDF/en/fft.pdf
  2. Medical Protection Society. MPS; 2014 Jun; updated 2020 May. Fit to fly [cited 2022 Apr]. Available from: https://www.medicalprotection.org/uk/articles/fit-to-fly
  3. Medical Protection Society. MPS; 2019 Apr. Should I declare that my patient is fit to run a marathon? [cited 2022 Apr]. Available from: https://www.medicalprotection.org/uk/articles/should-i-declare-that-my-patient-is-fit-to-run-a-marathon

DISCLAIMER: The information contained in this learning material is for general educational purposes only and is not intended to provide specific professional medical or legal advice, nor to constitute a "standard of care" for Canadian healthcare professionals. The use of CMPA learning resources is subject to the foregoing as well as the CMPA's Terms of Use.