ADULT PRE-EXERCISE SCREENING TOOL
|
|
- Jody Allison
- 5 years ago
- Views:
Transcription
1 ADULT PRE-EXERCISE SCREENING TOOL This screening tool does not provide advice on a particular matter, nor does it substitute for advice from an appropriately qualified medical professional- warranty of safety should result from its use. The screening system in no way guarantees against injury or death. responsibility or liability whatsoever can be accepted by Exercise and Sports Science Australia, Fitness Australia or Sports Medicine Australia for any loss, damage or injury that may arise from any person acting on any statement or information contained in this tool. Name: Date of Birth: Male Female Date: STAGE 1 (COMPULSORY) AIM: to identify those individuals with a known disease, or signs or symptoms of disease, who may beat a higher risk of an adverse event during physical activity/exercise. This stage is self administered and self evaluated. Please circle response 1. Has your doctor ever told you that you have a heart condition or have you ever suffered a stroke? 2. Do you ever experience unexplained pains in your chest at rest or during physical activity/exercise? 3. Do you ever feel faint or have spells of dizziness during physical activity/exercise that causes you to lose balance? 4. Have you had an asthma attack requiring immediate medical attention at any time over the fast 12 months? 5. If you have diabetes (type I or type II) have you had trouble controlling your blood glucose in the last 3 months? 6. Do you have any diagnosed muscle, bone or joint problems that you have been told could be made worse by participating in physical activity/exercise? 7. Do you have any other medical condition(s) that may make it dangerous for you to participate in physical activity/exercise? IF YOU ANSWERED'YES'to any of the 7 questions, please seek guidance from your GP or appropriate allied health professional prior to undertaking physical activity/exercise IF YOU ANSWERED'NO'to all of the 7 questions, and you have no other concerns about your health, you may proceed to undertake light-moderate intensity physical activity/exercise believe that to the bestof my knowledge, all of the information I have supplied within this tool is correct Signature ^^^^H. Date J2. ^1 VI (2011) BCHICBE ft WOKIS BOENCE AUSTRALIA Fitness Australia SPORTS MEDICINE AUSTRALIA PAGE!
2 ADULT PRE-EXERCISE SCREENING TOOL STAGE 2 (OPTIONAL) Name: Date of Birth: Date: AIM: To identify those individuals with risk factors or other conditions to assist with appropriate exercise prescription. This stage is to be administered by a qualified exercise professional. RISK FACTORS 1. Age 3? Gender > 45yrs Males or > 55yrs Females +1 risk factor 2. Family history of heart disease (eg: stroke, heart attack) Relative I I Father CD Brother Age Relative 1 I Mother l~~l Sister Age lfmale<55yrs =+1 riskfactor If female < 65yrs =+1 riskfactor Maximum of 1 risk factor for this question 0 _ Son ] Daughter 3. Do you smoke cigarettes on a daily or weekly basis or if yes, {smoke regularly or have you quit smoking in the last 6 months? f J given up within the past 6 months),r =+1 riskfactor If currently smoking, how many per day or week? 4. Describe your current physical activity/exercise levels Frequency sessions per week Duration minutes pet week Sedentary Light Moderate Vigorous D D 5. Please state your height (cm) I^D &>{ Wt weight (kg) g$ 6. Have you been toldjjiat you have high blood pressure? (, 7. Have yoy^been told that you have high cholesterol? /l 8. Have you been told that you have high blood sugar? If physical activity level < 150 min/ week - +1 risk factor If physical activity level > 150 min/ week = -1 risk factor (vigorous physical activity/exercise weighted x 2) Tofdl ^ BMI= BMI > 30 kg/m^ = +1 riskfactor lfyes, = +1 riskfactor lfyes,-+1 riskfactor If yes, = +1 riskfactor q 6 o -o te: Refer over page for risk stratification. STAGE 2 Total Risk Factors = / " V1 (2011) PAGES
3 9. Have you spent time in hospital (including day admission) for If yes, provide details any medical condition/illness/injury during the last 12 months? 10. Are you currently taking a prescribed medication(s) for any medical conditions(s)? /N63) If yes, what is the medical condition(s)? 11. Are you pregnant or have yougiven birth within the last 12 months? If yes, provide details. I am months pregnant or postnatal (circle). 12. Do you have any muscle, bone or joint pain or sorepe&s that is If yes, provide details made worse by particular types of activity? ( ) ^ i*' STAGE 3 (OPTIONAL) AIM:To obtain pre-exercise baseline measurements of other recognised cardiovascular and metabolic risk factors. This stage is to be administered by a qualified exercise professional. (Measures ],2&3- minimum qualification, Certificate III in Fitness; Measures 4 and 5 minimum level. Exercise Physiologist*). RESULTS 1. BMI(kg/m2) BM1 > 30 kg/m? - +1 risk factor 2. Waist girth (cm) Waist > 94 cm for men an< > 80 cm for women^t risk factor 3. Resting BP(mmHg) SBP >14f>mrnHg or DBP >90 mmhg = i^fisk factor 4. Fasting lipid profile" Total cholesterol HDL Triglycerides LDL Total cholesterol > 5.20 mmol/l = +1 risk factor HDL cholesterol >1.55 mmol/l = -1 risk factor HDL cholesterol < 1.00 mmol/l = +1 risk factor Triglycerides > 1.70 mmol/l = +1 risk factor LDL cholesterol > 3.40 mmol/l = +1 risk factor 5 Fastjrfg blood glucose* Fasting glucose> 5.50mmol = +1 risk factor STAGE 3 Total Risk Factors = RISK STRATIFICATION Total stage 2 or Total stage 3 Pius stage 2 (Q1 - Q4) > 2 RISK FACTORS - MODERATE RISKCLIENTS Individuals at moderate risk may participate in aerobic physical activity/exercise at a light or moderate intensity (Refer to the exercis.ejntensity table on page 2) <^2mSK FACTORS - LOW RISKCUENJ^) Individuals at low risk may participate in aerobic physic activity/exercise up to a vigorous or high intensity {Refer to the exercise intensity table on pdyt 2) te: If stages is completed, identified risk factors from stage 2 (Q1-4) and stage 3 should be combined to indicate risk. If there are extreme or multiple risk factors, the exercise professionaf should use professional judgement to decide whether further medical advice is required. VI (2011) PAGE 4
4 AUSTRALIAN INSTITUTE OF FITNESS* FIRST IN FITNESS COURSES & CAREERS Personal Profile "tell us about you" We want to help you! Please take a few minutes to provide us with some personal information. You can answer the questions yourself or work through these with your instructor. Your First Name Your Address Mobile Phone Your Emergency Contact Name Your occupation Your Surname Postcode Work Phone Your DOB Their phone. Todays Date lo - O I Health and Fitness Goals What do you hope to achieve from your exercise program? Please circle the number which best represents the importance of this goal where 1 = extremely important, 3 = somewhat important and 5 = not important. I need to get fitter Other important goalst^ I need to get stronger I need more energy I want more muscle I want muscle definition I want to lose weight I need to get more flexible My number 1 goal right now is I would like to achieve this goal by Why is this goal so important to you? Are there any reasons why you can't achieve this goal? About You Are you currently exercising i or playing sport? If so, please describe how often and how hard this activity is. ( Which statement describes you the best when it comes to exercise (please tick) Self-motivated LI Prefer a training partner^^t In 1-2 words, describe your current health, fitness and body shape? Need regular help U Tend to lose motivation Let's be more specific now - circle the number below to describe how you are feeling at the moment.1 How ENERGETIC are you? I just want to sleep & 10 I am the energizer bunny bo How HEALTHY do you feel? j am always sick 10 at's a Doctor?
5 How FIT do you feel? I get puffed looking at the stairs How STRONG do you feel? I need help to carry my groceries 6~& ' 9 10* I can run the stairs while talking * 9 10 fr I can lift my own bodyweight Lifestyle Review How much time can you dedicate to an exercise program? 7 days/week J^ minutes/day h^r^l^qjc.^ What time of the day can you exercise - Early mornings G Mornings G Afternoons G Evenings 01 /K^>r- What types of exercise/activities interest you (please tick) G ~~w "V» # G Walking G Stationary cycling G Swimming (^-'Weight machines G Stretching / \a Running G Rowing machine G Cross trainer G^ree weights^, Q^Sport G Group exercise classes e.g., Are you following a particular eating plan or currently on a diet? Would you like guidance with your current eating patterns? What changes are you prepared to make to achieve your goals? Health Check Your resting HR is: _ ^^ bpm Your HR rating is: Other? Your resting BP is: ' / "^ mmhg Your BP rating is: 9& Your waist measure is: cm Your hip measure is: Your W/H ratio is:_ 7 ' cm Your W/H rating is: _ cm Do you have any other conditions or concerns not identified in the Pre-exercise Screening questionnaire? Agreement for Participating in Exercise I acknowledge that it is a condition of participating in exercise that I do so at my own risk I accept all risks and hereby indemnify and release the instructor, their agents, affiliates, employees, members, sponsors, promoters and any person or body directly and indirectly associated with the Trainer, against all liability (including liability for their negligence and the negligence of others) claims, demands, and proceeding arising out of or connected with my participation in this exercise I acknowledge that participating in exercise may involve a risk of serious injury or even death from various causes including: over exertion, dehydration, equipment failure and accidents with equipment and surroundings I recognise the difficulties associated with the activity and attest I am physically fit to participate safely in the activity and that a qualified medical practitioner has not advised me otherwise I understand the demanding physical nature of exercise. I am not aware of any medical condition, injury or impairment that will be detrimental to my health if I participate in exercise. In the event that I become aware of any medical condition, injury or impairment that may be detrimental to my health, the instructor will be immediately informed. By continuing to participate in this exercise, I accept the risks despite these conditions and am still, and will always be under the terms of this agreement. I certify that I am 18 years or older and have read this document and fully understand it OR as a parent or guardian of the participant (a) laaree^tti the above for myself and on behalf of the participant and (b) I indemnify and will keep indemnified any (JeTspng^bQciiulifectly or indirectly associated with the conduct of the exercise on the terms referred to. Signature: Full name (please~prtnt): Instructor's Name: (guardian/parent to sjgn if under 18 years of age) Date: 301 Instructor's Signature:
ADULT PRE-EXERCISE SCREENING TOOL
ADULT PRE-EXERCISE SCREENING TOOL This screening tool does not provide advice on a particular matter, nor does it substitute for advice from an appropriately qualified medical professional. warranty of
More informationGENERAL SAFETY INDUCTION INFORMATION SCHOOL OF HEALTH SCIENCES EXERCISE SCIENCE LABORATORIES (G127/C003/EXERCISE CLINIC)
GENERAL SAFETY INDUCTION INFORMATION SCHOOL OF HEALTH SCIENCES EXERCISE SCIENCE LABORATORIES (G127/C003/EXERCISE CLINIC) IMPORTANT Please note that before participating in a practical class you must complete
More informationEXERCISE READINESS QUESTIONNAIRE
EXERCISE READINESS QUESTIONNAIRE A little bit about yourself... First Name Surname Address Postcode Best Contact Phone No. Your Birthday Email Today s Date Occupation Emergency Contact Phone Number About
More informationAdult Pre Participation Screening and Exercise Prescription Practicum
Adult Pre Participation Screening and Exercise Prescription Practicum Objectives of this exercise: To administer pre participation screening and risk stratification for clients To write an appropriate
More informationThanks again, The BodyEvolver team Fitness Technology Partners, LLC bodyevolver.com
Thank you for downloading this comprehensive client intake package. It is our pleasure to provide this tested document which we know will help your business. A complete on-line version of this intake package
More informationHEALTH/MEDICAL QUESTIONNAIRE PHYSICAL ACTIVITY READINESS QUESTIONNAIRE (PAR-Q)
WRC Staff Use Only WRC Staff Initials Physician s Clearance received? Yes No N/A Orientation complete? Yes No Health/Medical History form signed? Yes No Assumption of Risk form signed? Yes No PAR-Q signed?
More informationWaiver, Release and Hold Harmless Agreement Personal Training Services
Waiver, Release and Hold Harmless Agreement Personal Training Services I,, the undersigned, affirm that I am participating voluntarily in Personal Training Services. (Print name) I (together with my parent
More informationFor New Clients TO BE COMPLETED BY FRONT DESK STAFF. Date received: Payment $ Receipt# Staff Initials: TO BE COMPLETED BY SUPERVISOR
For New Clients Client s Name: Phone: R#: Email: Age: Sex: M F Trainer Preferred: M F Name: Check all that apply: Individual Packages: **3-16 sessions must be completed in the same semester purchased 3
More informationI want to improve balance
I want to improve balance Do these exercises several times throughout the day, increasing the time on each exercise as your balance and flexibility increase. If you are unsure about doing any of these
More informationFITNESS ASSESSMENT & WAIVER
Nutrition Counseling & Services/ Eat Well, Be Fit! www.eatwellbefit.com FITNESS ASSESSMENT & WAIVER Client Name: Date: Date of Birth: Age: Sex: Address: City: State: Zip: Phone: (Home): ( ) (Work): ( )
More informationPersonal Training Program Information and Policies
Personal Training Program Information and Policies Welcome to the Student Recreation Center s (SRC) Personal Training Program! We are delighted that you chose us as a part of your commitment to health
More informationRISK REVIEW & PHYSICIAN APPROVAL FORM
RISK REVIEW & PHYSICIAN APPROVAL FORM Burke Restorative Neurology Clinic is offering services meant to target community members with neurological impairments. The program is supervised by medical professionals
More informationJumpstart, Fitness Assessment, & Body Composition
Jumpstart, Fitness Assessment, & Body Composition Waiver, Release and Hold Harmless Agreement In consideration of permission granted by Purdue University allowing me to participate in Personal Training
More informationMacclesfield Physio Pilates Health Questionnaire
General Client Details Title:... Name:... Date Of Birth:... Address:... Postcode:... Phone:... Email:... GP s Name:... GP Address:... How did you hear of us? Pilates Aims Why have you decided to commence
More informationPersonal Training Health Screening Questionnaire
RC Health and Fitness, LLC. 10350 Ironbridge Road Chester, VA 23831 (804)248-0222 Personal Training Health Screening Questionnaire Personal Information Today s date: Title: O DR. O Mr. O Mrs. O Ms. Name:
More informationNon-Member Health Screening
Non-Member Health Screening 1390 Taylor Avenue, Winnipeg, Manitoba, R3M 3V8 Phone: 204-488-8023 / Fax: 204-488-4819 Please select Non-Member type: Adult Guest (with member) Adult Guest (without member)
More informationPAR-Q & LIABILITY WAIVER
PAR-Q & LIABILITY WAIVER Full name: Address: Post code: Mobile: Home phone: Email address: Date of Birth: Occupation: Emergency contact name: Relationship to you: Emergency contact phone number: Tara Blackaby
More informationWe look forward to helping you achieve your fitness goals!
Personal Training Congratulations on your decision to invest in yourself! Our qualified, nationally certified personal trainers will provide you with the right information and right training to help you
More informationBTEC SPORT LEVEL 3 FLYING START
BTEC SPORT LEVEL 3 FLYING START The following tasks will provide the foundation to your first year study topics. You should aim to complete these in time for our first taught lessons. 1) PAR-Q and Informed
More informationCU Recreation Center
CU Recreation Center Personal Training Congratulations on your decision to invest in yourself! Our qualified, nationally certified personal trainers will provide you with the right information and right
More informationPedaling for Parkinson s Colorado What is Pedaling for Parkinson s?
What is Pedaling for Parkinson s? PFP is a non-profit organization focused on improving the quality of life for people with Parkinson s disease. Through a simple innovative exercise program using stationary
More informationGEORGE MASON UNIVERSITY PERSONAL TRAINING REGISTRATION FORM NEW CLIENT
GEORGE MASON UNIVERSITY PERSONAL TRAINING REGISTRATION FORM NEW CLIENT PLEASE PRINT, COMPLETE, AND DELIVER THIS FORM TO THE AQUATIC and FITNESS CENTER, RAC, OR SKYLINE FITNESS FRONT DESK: Ethan Carter
More informationCivilian Wellness and Civilian Fitness Program (AR Health Promotion)
Civilian Wellness and Civilian Fitness Program (AR 600-63 Health Promotion) Enrollment Packet Wellness Program Coordinators: Wendy LaRoche (wendy.laroche@us.army.mil) Celestine Beckett (celestine.beckett.civ@mail.mil)
More informationWelcome to OPEN Gym. To book an induction please
Welcome to OPEN Gym Induction Once you have completed your Gym Membership, Standing Order and Liability Disclaimer form as well as the Physical Activity Readiness Questionnaire (PARQ), the next thing you
More informationGym Memberships. The cost of the membership is per month, plus a one off cost of 5 for the band.
Gym Memberships Membership Form Name: Address: Membership Start Date: Payment Details The cost of the membership is 18.50 per month, plus a one off cost of 5 for the band. This Payment should be made either
More informationThe University of Texas Fitness Institute of Texas Health and Fitness Screening Questionnaire. Name Date Sex Date of Birth Address Phone UTEID
The University of Texas Fitness Institute of Texas Health and Fitness Screening Questionnaire Name Date Sex Date of Birth Address Phone Email UTEID Please answer the following questions to the best of
More informationThe Strong Women Program A National Fitness Program for Women. Join the Strong Women Program Today! Sign up Now! ENROLLMENT IS LIMITED!
Join the Strong Women Program Today! Sign up Now! ENROLLMENT IS LIMITED! Classes for new participants Friday, October 5 to Friday, January 4, 2013: 8-9 a.m. Monday, Wednesday & Friday Noon 1 p.m. Monday,
More informationFitness Training Services Application
Fitness Training Services Application Thank you for your interest in one of our fitness training services with Boston College Campus Recreation. We are committed to helping Boston College students, faculty,
More informationHEALTH HISTORY QUESTIONNAIRE
1 HEALTH HISTORY QUESTIONNAIRE Name: : Address: City: Phone: (Home) (Work) (Cell) E-Mail: of Birth: Emergency Contact: (Name) (Phone) Occupation: Relationship Status: Children: (# & ages) Height: Current
More informationYWCA LOWER CAPE FEAR 2815 S College Rd Wilmington, NC (910)
2815 S College Rd Wilmington, NC 28412 FLOW MOTION REGISTRATION Full Name: APPLICANT INFORMATION Last First M.I. Address: Street Address Apartment/Unit # City State ZIP Code Primary Phone: Email Mobile
More informationPurpose: To inform all employees of the guidelines regarding the correct use of the Employee Gym.
Title: Gym Usage Policy Purpose: To inform all employees of the guidelines regarding the correct use of the Employee Gym. Scope: This policy applies to all employees who have use of the gym facility in
More informationPERSONAL TRAINING CLIENT INFORMATION PACKAGE
WEST VANCOUVER COMMUNITY CENTRE PERSONAL TRAINING PERSONAL TRAINING CLIENT INFORMATION PACKAGE At West Vancouver Community Services, our approach to health and fitness is balanced. Being healthy means
More informationEau Claire Tower Fitness Centre MEMBERSHIP APPLICATION
Eau Claire Tower Fitness Centre MEMBERSHIP APPLICATION SHADED AREAS FOR OFFICE USE ONLY MEMBERSHIP # SECURITY CARD # START DATE DD MM YY NAME: FIRST LAST DATE DD MM YY OF BIRTH HOME ADDRESS HOME/CELL PHONE
More informationPersonal Training New Client Packet Personal Training/Fit for Hire
Personal Training New Client Packet Personal Training/Fit for Hire Date / / Name Address City State Zip Phone Number Email Trainer Preference Male Female No Preference **If you would like to work with
More informationBody Structure Medical Fitness Facility 2600 Gribbin Drive 410 Redding Rd Lexington, KY (859) General Information
Body Structure Medical Fitness Facility 2600 Gribbin Drive 410 Redding Rd Lexington, KY 40517 (859) 268-8190 General Information Full Name Birth date / / Date / / Social Security # - - Driver s License
More informationParticipant Summary Information Sheet
Participant Summary Information Sheet Name: Address: Who was your referral source? (Friend, Doctor, Newspaper, Radio - Please name source) Phone Number: Email Address: Date of Birth: Program Site: Age:
More informationDOCTOR REFERRAL LETTER
DOCTOR REFERRAL LETTER Dear Living Longer Living Stronger Program Co-ordinator, I am recommending my patient/client undertake a monitored Living Longer Living Stronger strength training program that incorporates
More informationPERSONAL TRAINING AT MCGAW YMCA
PERSONAL TRAINING AT MCGAW YMCA Welcome to personal training at the McGaw YMCA! Our personal trainers look forward to working with you and helping you meet your health and fitness goals! There are a few
More informationThe StrongWomen Program
A National Fitness Program for Women Cooperative Extension Service 1675 C Street, #100 Anchorage, AK 99501 Leslie Shallcross, M.S., R.D., L.D. Associate Professor of Extension 907-786-6300 Name Address
More informationThe University of Texas Fitness Institute of Texas Health and Fitness Screening Questionnaire
The University of Texas Fitness Institute of Texas Health and Fitness Screening Questionnaire ID Please answer the following questions to the best of your knowledge by checking either yes or no. Section
More informationPERSONAL TRAINING POLICIES
PERSONAL TRAINING POLICIES SCHEDULING: To schedule your initial session: 1. Complete Interest Form, Health History Questionnaire, and Policies forms and return them to the Fitness Department. 2. Register
More informationFitness Training Services Application
Fitness Training Services Application Thank you for your interest in one of our fitness training services with Boston College Campus Recreation. We are committed to helping Boston College students, faculty,
More informationPersonal Training Initial Packet
Personal Training Initial Packet ****Please complete and return to the reception desk at least 2 days prior to your scheduled Fitness Assessment**** Name: D.O.B: Today s Date: Member or Non-member (circle
More informationSTRENGTH & CONDITIONING INFORMATION AND PRE-ACTIVITY SCREENING
STRENGTH & CONDITIONING INFORMATION AND PRE-ACTIVITY SCREENING Please take the time to read through all the information and ensure all relevant forms are completed. The following questionnaire and waivers
More informationLifestyle/Readiness for Change Assessment
Lifestyle/Readiness for Change Assessment This form asks you a variety of questions about your lifestyle habits. This questionnaire should take about 10 minutes. Fill in the information requested, or place
More informationWeight training is based on individual needs. Beginning weights are provided. Please bring your mat or towel to lay on the floor.
BENEFITS OF THE PROGRAM: IMPROVE MUSCLE MASS & STRENGTH REDUCE RISK OF OSTEOPOROSIS & RELATED FRACTURES REDUCE THE RISK FOR DIABETES, HEART DISEASE, DEPRESSION & OBESITY IMPROVE SELF-CONFIDENCE, SLEEP
More informationCARDIOVASCULAR FITNESS CENTER COMMUNITY PROGRAM
CARDIOVASCULAR FITNESS CENTER COMMUNITY PROGRAM The Community Exercise Program (located on the 1st floor of Mountainside Medical Center) is a medically supervised program for individuals who wish to learn
More informationClient Contact Information. Training Information
Client Contact Information Name Address (Street) (City) (State) (Zip) Home Phone ( ) Cell Phone ( ) Work Phone ( ) Email Date of Birth / / Training Information Type Personal Training - $35 Partner Training
More informationENROLMENT FORM. Title: First Name: Surname: Postal Address: Postcode: Emergency Contact: Relationship: Phone: What is your main fitness goal?
ENROLMENT FORM Personal Information Title: First Name: Surname: Date of Birth: Sex: Female Male Postal Address: Postcode: Phone: Home: Work: Mobile: Email: Preferred method of contact: Letter Phone Email
More informationPersonal Training New Client Form
Personal Training New Client Form Name Date Home Phone # Cell Phone # # of Sessions Purchased Desired Start Date Available days: M T W Th F Sa Su Available times: Early morning mid-morning afternoon evenings
More informationselect class BEST VALUE! $85 $90 $55 $60 $40 $45
Tomahawk Strong Bones Participant Registration Form Mondays and Thursdays January 9 May 25, 2017 Location: United Methodist Church (1104 School Rd, Tomahawk, WI 54487) Our Strong Bones Program follows
More informationName: Date: Address: City: State: Zip: Birthday: / /
PERSONAL TRAINING Name: Date: Address: City: State: Zip: Birthday: / / Sex: Male Female Name of Gym: Occupation: Phone (home): Phone (work): Body Weight: Body Fat: Height: Personal Goals 1. Primary Training
More informationWelcome to the CANYON WELLNESS PROGRAM!
Welcome to the CANYON WELLNESS PROGRAM! This program is designed to allow you to continue/initiate the pursuit of your health/wellness goals. You may have just completed a course of Physical Therapy or
More informationFORMS 1) PAR Q & YOU:
Personal Training New Client Registration Congratulations on taking the first step to healthier and better you! The certified trainers are screened by the Vanderbilt Recreation & Wellness Center (the Rec)
More informationFORMS 1) PAR Q & YOU:
Personal Training New Client Registration Congratulations on taking the first step to healthier and better you! The certified trainers are screened by the Vanderbilt Recreation & Wellness Center (the Rec)
More informationSPARROW FAMILY CHIROPRACTIC
Whom may we thank for referring you to this office? SPARROW FAMILY CHIROPRACTIC Today s Date: PATIENT DEMOGRAPHICS PM#: Name: Birth Date: - - Age: Male Female Address: City: State: Zip: E-mail Address:
More informationClient Assessment Readiness Questionnaire
Client Assessment Readiness Questionnaire The following questions will help determine your level of readiness for change, your motivation towards reaching your goals, and identifying obstacles to your
More informationHeart disease and stroke major health problems
Understanding Heart Disease Introduction We all know that heart health is important and that we should maintain a healthy diet and take regular exercise, but our hectic lifestyles don t always allow for
More informationPersonal Training Program Health History Questionnaire
Personal Training Program Health History Questionnaire PERSONAL Name: Today s Date: Address: Date of Birth: City: State: Zip Code: Home Phone: Cell Phone: Email: EMERGENCY CONTACT INFORMATION Name: Address:
More informationLETTER TO PARTICIPANT. Civilian Employee Wellness Program Participant Marine Corps Community Service Base Henderson Hall
Dear Participant, MARINE CORPS COMMUNITY SERVICES HENDERSON HALL HEADQUARTERS & SERVICE BATTALION, HEADQUARTERS MARINE CORPS, HENDERSON HALL P.O. BOX 4009, ARLINGTON, VIRGINIA 22204 0009 LETTER TO PARTICIPANT
More informationWelcome to the Healthplex!
Welcome to the Healthplex! Program Please check program that applies to you. If unsure, please ask our staff. Aftercare Employee Health Pulmonary Rehab Lung Gym Cardiac Rehab Health Improvement Prenatal/Post-Partum
More informationRPL Form Certificate III in Fitness SIS30315
Please read the information below and complete all sections of this form. RPL Form Certificate III in Fitness SIS30315 Recognition of Prior Learning (RPL) Do you have prior qualifications and/or experience
More informationWAIVER AND RELEASE FROM LIABILITY
COACHING CONTRACT I hereby contract Start-Tri.Com as my personal coach for endurance sports. I agree to pay for coaching services up front at the rate of $255/month for the Tier I package, $165/month for
More informationName: Phone #: Address: Cell Phone #: Address: I d like to participate in:
Strong Women and Strong Women Advance Program 12-Week Participant Registration Form January 8-April 2*, 2018 *Good Friday Week Schedule Changes: Strong Classes class will meet Monday (3/26) instead of
More informationPersonal Training Intake Form
Personal Training Intake Form Name: Date: Cell Phone: Office Phone: E-Mail: USC Affiliation: STUDENT ALUMNI FACULTY/STAFF FACULTY/STAFF SPOUSE Sex: Male Female Age: Trainer preference (if any): How many
More informationTrees Hall. Bellefield Hall. Add a Fitness Center Membership for a small additional price!
Classes Begin: Tuesday, 9/5/2017 Classes End: Friday, 12/8/2017 No Class: Labor Day: 9/4/2017 & Thanksgiving Break: 11/23-24/2017 Trees Hall Kettle + Conditioning Fitness Kickboxing Fitness Kickboxing
More informationPRESENTED BY BECKY BLAAUW OCT 2011
PRESENTED BY BECKY BLAAUW OCT 2011 Introduction In 1990 top 5 causes of death and disease around the world: Lower Respiratory Tract Infections Diarrhea Conditions arising during pregnancy Major Depression
More informationPatient Information Form
Patient Information Form Patient Name: (Last) (First) (MI) Name you prefer to be called: Patient Address: City: State: Zip: Home Phone: Cellular: Birthdate: Age: Sex: M F Email: Employment Information:
More informationPersonal Training Information Form
Personal Training Information Form Personal Training is available to all members and all sessions are 1 hour in length. To register: Please complete the Personal Training Information form. You will be
More informationAPPLICATION FOR CARE AT CORE CHIROPRACTIC
Whom may we thank for referring you to this office? APPLICATION FOR CARE AT CORE CHIROPRACTIC Today s Date: HRN: PATIENT DEMOGRAPHICS Name: Birth Date: - - Age: Male Female Address: City: State: Zip: E-mail
More informationSample Well-being Assessment
Sample Well-being Assessment This assessment addresses the following eight categories, as well as the importance, readiness, and confidence in each category: Energy Stress Management Life Balance Weight
More informationComplete Chiropractic Care
Complete Chiropractic Care CLINICAL NUTRITION HEALTH QUESTIONNAIRE Mr/Mrs/Ms/Miss/Mst: Surname: First Name: Occupation Address Suburb P/C Telephone (H) (W) (M) Date of Birth Marital status e-mail Partners
More informationMEDICAL INFORMATION: Physician s Name: Phone #: When was your last physical examination?:
PERSONAL INFORMATION: HEALTH STATUS QUESTIONNAIRE Name: Phone (hm): (bus): Address: City: State: Zip: Occupation: Male/Female: Age: Height: Weight: Lbs.: Emergency Contact: Phone: Relationship: MEDICAL
More informationSTEPS Instrument for NCD Risk Factors (Core and Expanded Version 1.4)
WHO/NMH/CCS/03.03 Version.4 DISTRIBUTION: LIMITED STEPS Instrument for NCD Risk Factors (Core and Expanded Version.4) The WHO STEPwise approach to Surveillance of noncommunicable diseases (STEPS) ncommunicable
More informationFort Belvoir Commander s Civilian Health and Fitness Employee / Supervisor Agreement
Fort Belvoir Commander s Civilian Health and Fitness Employee / Supervisor Agreement Name of Employee: Directorate: Phone Number: Name of Supervisor: E-mail Supervisor s Phone Number: Bldg. Number: I (supervisor),,
More informationINFORMATION SHEET. Assessment of health, fitness & performance
INFORMATION SHEET Assessment of health, fitness & performance You are invited to take part in physiological/assessment tests as part of educational/ consultancy activities conducted by the Sport and Exercise
More informationJoin the StrongWomen Program today!
Join the StrongWomen Program today! Dr. Miriam Nelson, a professor at Tufts University in Boston, Massachusetts, has developed a strength-training program specifically for midlife and older women. The
More informationAPPLICATION FOR CARE AT LAUNCH CHIROPRACTIC
Whom may we thank for referring you to this office? APPLICATION FOR CARE AT LAUNCH CHIROPRACTIC Today s Date: PATIENT DEMOGRAPHICS HRN: Name: Birth Date: - - Age: o Male o Female Address: City: State:
More informationDate of Birth. Black/African American. What is your occupation? Retired? Yes No
Health Risk Assessment Today s Date: Name Date of Birth GENERAL INFORMATION What is your race? American Indian or Alaskan Native Native Hawaiian or Other Pacific Islander Asian, Chinese, Japanese, Korean
More informationPhysical Activity Readiness Questionnaire
page 1 Health/Medical History Questionnaire This information is used solely as an aid and will not be released without your knowledge and consent. Name Date Birth date Address Street City State Zip Phone
More informationAPPLICATION FOR CARE
3023 Eastland Blvd. Suite 101 Clearwater, FL 33761 Ph: 727-797-9900 Fax: 727-797-7695 APPLICATION FOR CARE Date: Name: Address: City, State, Zip: Home Phone: Work Phone: Cell Phone: Email Address: Birth
More informationMEMBERSHIP APPLICATION
MEMBERSHIP APPLICATION Join Date: Full Pay Draft 20/20 Membership Type: Household One Parent Household Two Adult Household Senior Household Adult Young Adult Youth Senior First Name MI Last Birth Date
More informationGymnasium Sign In/Sign Out Sheet. Please sign in before commencing your workout
Gymnasium Sign In/Sign Out Sheet Please sign in before commencing your workout Name Date Time In Time Out Signature Pre Activity Questionnaire Name: 1) Have you undertaken an exercise program before? Yes
More informationEXS 145 Guidelines for Exercise Testing & Prescription
EXS 145 Guidelines for Exercise Testing & Prescription 11-3-11 Andrew Weiler M.Ed MCCD Adjunct Faculty CGCC Employee Wellness Coordinator SRPMIC Employee Wellness Coordinator Pot & Window LLC Today How
More informationRPL Form Certificate III in Fitness SIS30315
Please read the information below and complete all sections of this form. RPL Form Certificate III in Fitness SIS30315 Recognition of Prior Learning (RPL) ACFB provides a simple process in gaining Recognition
More informationWorkbook GET YOUR BODY BUZZING. Module Five Exercise for Peak Performance
GET YOUR BODY BUZZING Module Five Exercise for Peak Performance Workbook Julie Meek. Performance Specialist. julie@juliemeek.com.au. www.juliemeek.com.au Exercise for Peak Performance Outcomes At the end
More informationNew Client Reformer Session Packet
New Client Reformer Session Packet Welcome and thank you for your interest in the Pilates Reformer program with University Recreation. You are taking the first steps towards improved health and wellness.
More informationRPL Form Certificate IV in Fitness SIS40215
Please read the information below and complete all sections of this form. RPL Form Certificate IV in Fitness SIS40215 Recognition of Prior Learning (RPL) ACFB provides a simple process in gaining Recognition
More informationStrongWomen Program Presented by:
StrongWomen Program Presented by: Dr. Miriam Nelson, a professor at Tufts University in Boston, Massachusetts, has developed a strength-training program specifically for midlife and older women. The StrongWomen
More informationObesity Prevention and Control: Provider Education with Patient Intervention
Obesity Prevention and : Provider Education with Patient Summary Evidence Table and Population Cohen et al. (1991) 1987-1988 : RCT Location: Pittsburgh, PA Physician training session by a behavioral psychologist
More information3. How Long Has This Been An Issue?
NEW PATIENT INTAKE FORM Aspire Chiropractic 124 W Harwood Rd. Ste. B Hurst, TX 76054 Name: Occupation: DOB: Age: Sex: Male Female Employer: Marital Status: Single Married Other Name/Age of Kids: Phone:
More informations PERSONAL FITNESS PLAN
s PERSONAL FITNESS PLAN Name Period Teacher Year Due Date: http://www.cnusd.k12.ca.us/page/22178 7 th Grade Standards: 3.3, 3.4, 3.6, 4.1, 4.2, 4.3 8 th Grade Standards: 3.2, 3.3, 3.5, 4.1, 4.2, 4.3 1
More informationto:
Welcome Pack The Holistic Boot Camp would like to congratulate you for choosing to make positive changes in your life by attending our retreat to transform your mind, body and soul. To make sure that you
More informationRe-accreditation for Lift for Life Trainers
Re-accreditation for Lift for Life Trainers Exercise professionals delivering the Lift for Life program are registered for 2 years after attending a 2 day training workshop and completing the required
More informationDepartment of Campus Recreation: SouthFit Personal Training
Steps to sign up Step 1: Choose the personal training package that you would like on page 2. Personal training is only available to members of the USA Student Recreation Center. Step 2: Fill out all pages
More informationPersonal Training Initial Packet
Personal Training Initial Packet ****Please complete and return to the reception desk at least 2 days prior to your scheduled Fitness Assessment**** Name: D.O.B: Today s Date: Member or Non-member (circle
More informationColorado Mesa University Campus Rec Services Massage Therapy Health History Questionnaire
Colorado Mesa University Campus Rec Services Massage Therapy Health History Questionnaire Client Name: Today s : Contact Number: E-Mail: Occupation: Age: How did you hear about us? Have you ever had a
More informationATHLETE START UP QUESTIONNAIRE The first step in the coaching process is filling out the athlete questionnaire. Once completed, back to me.
ATHLETE START UP QUESTIONNAIRE The first step in the coaching process is filling out the athlete questionnaire. Once completed, email back to me. General/Medical 1. Name 2. Address 3. E-mail 4. Phone Best
More informationThe University of Texas at Dallas Department of Recreational Sports Nutritional Guidance Registration Form
The University of Texas at Dallas Department of Recreational Sports Nutritional Guidance Registration Form Directions: Please, fill out as much information as possible. If you are unsure, leave that question
More informationCancerCheck Questionnaire
July 2018 CancerCheck Questionnaire Please complete pages 2 to 6 before your appointment. You will be asked to complete page 1 in Vhi Medical Centre during your appointment. Page 1 Affix identification
More information