Tidelands HealthPoint Stronger Through Movement Program Participant Information

Transcription

1 Tidelands HealthPoint Stronger Through Movement Program Participant Information Please Print: Name: DOB: First Middle Last Address: Phone: Street City Zip Address: Emergency Contact: Phone: First Middle Initial Last Relationship: Referring Provider: Phone: Primary Care Provider: Phone: Occupation: Employer/Firm_ Medical Information: Past Medical History (cardiovascular, orthopedic, neurological, etc ) Current Medications (include dosage, if able) Allergies: List any major illnesses/injuries/surgical procedures in the past (give dates): (please turn over)

2 List any hospitalizations in the past (give dates): Current Smoker? Yes No Packs per day: Smoke in the past? (give quit date) Packs per day: Diabetes? Yes No How Long? Family History? Yes No Who?_ High Blood Pressure? Yes No How Long? Family History? Yes No Who?_ Heart Disease? Yes No How Long? Family history? Yes No Who?_ Chest pain? Yes No Chest pain on exertion? Yes No Heart Murmurs? Yes No Shortness of breath at rest? Yes No -after 2 flights of stairs? Yes No Do you currently exercise? Yes No If so, how many minutes per week? Have you exercised in the past? Yes No If so and not currently exercising, why did you stop? Have you ever been told by your physician that you shouldn t exercise? Yes No What concerns do you have regarding beginning an exercise program? Signed:

3 TIDELANDS HEALTHPOINT STRONGER THROUGH MOVEMENT PROGRAM RELEASE/RECEIVE MEDICAL INFORMATION Physician/facility sending/receiving information (Name & Address) I,, hereby authorize the above mentioned physician(s) and/or facilities to release specified information concerning me to Tidelands HealthPoint Center for Health and Fitness Stronger Through Movement Program, Ocean Highway, Pawleys Island, SC. I also authorize the above mentioned physician(s) and/or facilities to receive specified information concerning me from Tidelands HealthPoint Stronger Through Movement Program. The specified information may include: Patient information, exercise prescription, exercise adherence, fitness goals, vocational information, nutritional information, psychological assessment, physical exam results and cholesterol screening information. I understand that I may revoke this consent at any time except to the extent that action based on this consent has been taken. This consent will expire automatically upon my request, unless it is a blanket release to an insurance company for hospitalization benefits or for research purposes. This authorization and request is fully understood and is made voluntarily by me. Signed: Witness:

4 Tidelands HealthPoint Stronger Through Movement Program Informed Consent for Patients in Exercise Treatment 1. In order to improve my physical fitness and function, I hereby consent to voluntarily engage in the Stronger Through Movement Program at Tidelands HealthPoint Center for Health and Fitness. 2. Before I undergo the exercise program, I will be clinically evaluated. My medical history and physical examination consisting of heart rate, blood pressure, weight, BMI, waist and hip circumference, and physical fitness will be reviewed to determine if any condition exists that would contraindicate the exercise treatment. 3. During the program, my referring physician Dr. will continue to retain primary responsibility for my care. 4. The exercise treatment which I will undergo will be designed to place a gradually increased workload on my body. The amount of exercise will be regulated on the basis of my tolerance. There exists the possibility of adverse changes occurring during the exercise treatment. They could include abnormal blood pressure, disorders of the heart rhythm and in very rare instances heart attack. Every effort will be made to minimize them by observations during the exercise. Basic emergency equipment and trained personnel are available to deal with the unusual situations which may arise. 5. Before I start the exercise treatment, I will be instructed as to the signs and symptoms which I should report promptly to the supervisor of the exercise treatments and which will alert to the changes which would suggest that I modify my exercise. Signed: Witness:

5 Personal Training Contract/Agreement Welcome to Tidelands HealthPoint and congratulations on your decision to begin a personal training program! We are delighted you have chosen us as part of your commitment to health and fitness. With the help of your exercise physiologist ( trainer ), you can greatly improve your ability to accomplish your training goals faster, safer and with maximum benefit. What you learn in your training sessions can be used for a lifetime. To maximize your progress, it is important to follow program guidelines during supervised and, if applicable, unsupervised training days. Remember, exercise and a healthy diet are EQUALLY important! During your exercise program, every effort will be made to assure your safety. However, as with any exercise program, there are risks, including increased heart stress and the chance of musculoskeletal injuries. In volunteering for this program, you agree to assume responsibility for these risks and waive any possibility for personal damage. You also agree that, to your knowledge, you have no limiting physical conditions or disability that would preclude an exercise program. By signing below, you accept full responsibility for your own health and well-being AND acknowledge an understanding that no responsibility is assumed by the leaders of the program. We ask that you please arrive 15 minutes prior to your scheduled session to give adequate time to warm up to get the most out of your training session. Personal Training Terms and Conditions 1. Personal training sessions that are not rescheduled or canceled 24 hours in advance will result in a forfeiture of the session and a loss of the financial investment at a rate of one session. 2. Clients arriving late will receive the remaining scheduled session time, unless other arrangements have been previously made with the trainer. 3. No personal training refunds will be issued for any reason, including but not limited to relocation, illness and unused sessions. 4. You may refuse or stop any exercise for any reason. It is your responsibility to notify your trainer of any discomfort or pain arising from or during exercise, as well as any and all other known limitations you have or experience, so that your trainer may accommodate you and substitute other exercises. 5. While no personal training refunds will be issued for any reason, personal training sessions will not expire. We wish you the best of luck in your new personal training program! Participant name (please print clearly) Participant signature Parent/guardian signature (if participant under 18) Witness signature : : : Adapted from: NSCA, 2012, NSCA s essentials of personal training, 2 nd ed., J. Coburn & M. Malek (eds.), (Champaign, IL: Human Kinetics).