Independent Exercise: exercise independently, following your own exercise regime, in the pool

Transcription

1 Dear Community Participant: Thank you for expressing interest in the Aquatics Program at Helen Hayes Hospital. This program offers an array of different services, designed to meet individual needs, including an Independent Pool Exercise, an Adapted Fitness Aquatic Program (AFAP) and Ai Chi program. The Helen Hayes Hospital Therapeutic Pool is a 25 x 60 foot warm water (90-94 ) pool, offering accessibility to those of all abilities. Platforms are provided in the 5 section bringing the floor bottom to 4 1/2 feet. The pool features an accessible lift. Stairways fitted with handrails are also available. The pool is open Monday-Friday from 9:00 am-1:00 pm. And NEW HOURS for Tuesday and Thursday are 3:45-5:45 pm. The Adapted Fitness Aquatic Program (AFAP)) is offered: Tues and Thurs: 9:15 am-10:00 am, 11:15 am-12:00 pm, and 4:05 pm-4:50 pm. AFAP is a group exercise program that is usually conducted by a group leader. The Ai Chi Program is offered: Wednesdays (1:15-2:00). Independent Exercise: exercise independently, following your own exercise regime, in the pool You must supply your own bathing suit, towel, and aquatic non-slip shoes. You must provide your own aide if you require assistance in the locker room and/or pool. ENROLLMENT PROCESS 1. Please read, fill out and sign all therapeutic pool enrollment forms, including your address and two emergency contacts and either mail or bring them to the pool office. Upon acceptance into the program, you will receive notification of your start date. 2. You may attend any program for the monthly fee of: (Please inquire for annual payment discount). 1 session/week= $ session/week =$ session/week =$ session/week =$ session/week =$150.00

2 You are welcome to attend your weekly session(s) any day/time we are open. We are unable to offer a refund for any reason, including temporary illness, traveling out of town or re-location. This a pay in advance program. Please submit payment by the 15 th of the current month for the following month(s) you would like to attend. 3. All payments and completed payment forms may be put in an envelope and placed in the locked mailbox in the Pool Office or mailed to Helen Hayes Hospital, Rt. 9W, West Haverstraw, N.Y , Attn. Pool. 4. Please see cashier for cash payments Credit card payments can be made using the back of the Payment Receipt form. Credit card payments may not be accepted verbally or over the phone. Your card verification and signature is required. Please put your address on the front of the payment form. 5. You will not receive a bill or a reminder phone call. 6. There is $25.00 fee for a check returned for insufficient funds. 7. If attending a group session please come 15 minutes before the scheduled time. We look forward to having you participate in our Aquatic Program. If you have any questions, please call me at (845) Sincerely yours, Alyssa Chagares, CTRS Aquatics Director

3 NAME:_ DATE: (Print) HELEN HAYES HOSPITAL West Haverstraw, New York AQUATICS QUESTIONNAIRE Regular physical activity is fun and healthy! More people are becoming more active every day. Check with your doctor before starting any exercise program. You may be able to do any activity you want - as long as you start slowly and build up gradually. Or, you may need to restrict your activities to those which are safe for you. Talk with your doctor about the kinds of activities you wish to participate in and follow his/her advice. Condition/Reason for Attendance: Birth Date: Common sense is your best guide when you answer these questions. Please read the questions carefully and answer them honestly. Yes No Do you have uncontrolled seizures?. Are you in End State Cardiac Failure?. Are you incontinent of feces (consistently unsuccessful bowel regime)?. Do you have a Trach? Do you have acute infections?.. Do you have open draining wounds? Do you have a G Tube? Do you have a Heplock, Intravenous or Hichman Line?. Do you wear a transdermal pain patch?... If your answer to any of the above questions is yes, you will not be able to attend this program. If your condition changes, please resubmit. Do you have a history/presence of any of the following: Yes No Seizure (controlled) Cardiac Disease. Multiple Sclerosis. Joint Replacement.. A. Total Hip Replacement B. Total Knee Replacement.. C. Other: Rotator Cuff Repair. Ligament Damage.. Arthritis. Back Problems Persistent pain in a specific location. Recent Fracture. Hypertension. Incontinent of Urine.. Allergies (e.g. Chlorine) Respiratory Disorders... Active Skin Condition(s)... Ileostomy or Colostomy Bags.. Pacemaker/Neurostimulator/Defibrilator(please circle)... Over

4 If the answer to any of the previous questions is yes please explain current status (state whether condition is controlled or not). Consult your doctor if you have answered yes. If your health changes so that you then answer yes to any of the above questions, tell the Aquatics Director and your doctor. Ask your doctor whether you should change your physical activity plan. Helen Hayes Hospital assumes no liability for persons who undertake physical activity. If you are in doubt after completing this questionnaire, consult your doctor prior to physical activity. If assistance is needed, please state what kind and how much. If this questionnaire is being given to a person before he or she participates in a physical activity program, this section may be used for legal and administrative purposes. I have read, understood and completed this questionnaire. Any questions I had were answered to my full satisfaction. Participant s Signature/Date: Print name: Participant s Telephone Number: Address: If participant is under 18 years of age - Guardian/Parent Signature/Date: Print Name: In case of emergency contact: (This section must be completed in order to attend!) Print Name: Print Address: Print Name: Print Address:_ Telephone Number: Telephone Number: Relationship: Relationship: How did you learn about this program? U:\Pool\AquaticsQuestionnaire AC 3/16

5 Date: Dear Doctor: Your patient, is interested in joining the Therapeutic Recreation Pool exercise program at Helen Hayes Hospital, which is a self-guided, gentle exercise program for lower and upper extremity strengthening, range of motion and endurance. This is a therapeutic pool with temperatures ranging from Patients provide us with a detailed health questionnaire and medication list. However, we also request that you provide us with information that might impact on their exercise program. Please check all that apply in the list below: Cardiovascular Disease q Myocardial infarction q Percutaneous intervention q CABG q Chronic stable angina q ICD q Pacemaker q LVEF<40% q Atrial fibrillation q Peripheral arterial disease q Other Allergies Lung Disease q COPD q Interstitial Fibrosis q Asthma q Other Musculoskeletal Disease q Osteoarthritis q Osteoporosis q Chronic pain syndrome q Spinal stenosis Advanced Directives: q Full Code q DNR q Do not intubate Neurological Disease q Stroke q Spinal Cord Injury q Brain injury q Multiple Sclerosis q Dementia q Seizures q Peripheral neuropathy Other Chronic Conditions q Diabetes q Hypertension q Chronic kidney disease q Peptic ulcer disease q Anemia q Pain q Transdermal Patch q My patient may participate in the Helen Hayes Hospital Therapeutic Pool Program q My patient may participate in the Helen Hayes Hospital Therapeutic Pool with the following limitations: q Aquatic Exercise is contraindicated for my patient Physician s Signature: Date: RETURN FORM TO YOUR PATIENT OR HELEN HAYES HOSPITAL AQUATIC DIRECTOR Helen Hayes Hospital, Route 9W, West Haverstraw, NY Attention: Alyssa Chagares, CTRS Fax: If you have any questions in regards to the program please contact Alyssa Chagares, CTRS, Aquatics Director at Thank you. (MD Consent Letter - 2/2016)

6 Route 9W, West Haverstraw, NY (845) Personal Profile Name Date Medication Dosage Frequency Please draw a line through discontinued medications. Personal Profile 10/12

7 RETURN TO POOL STAFF PARTICIPANT AGREEMENT HELEN HAYES HOSPITAL WEST HAVERSTRAW, NEW YORK AQUATIC EXERCISE PROGRAM This agreement is made with (Participant)_ Date:. It includes the terms and conditions for participation in the Helen Hayes Hospital Aquatic Exercise Program as follows: I. Attendance: I understand that: A. I must notify the aquatics director as soon as able if I will be under medical care resulting in missing multiple sessions; B. The open format is based on a schedule with the week ending each Friday and the month ending the last day of the month; C. The fee is NOT pro-rated for missed classes; D. There are NO refunds of any payment. II. III. Bathing Attire, Valuables and Shower Room Practices A. I will bring my own bathing suit, towel and non-slip pool shoes to each session. B. I understand that if I am incontinent of urine I must supply and wear a diaper and rubber pants under my bathing suit. (If incontinent of feces-cannot participate unless on bowel regimen that is working). C. I understand that I must bring someone to assist me if I am not independent in dressing/undressing. (There will be no one available to assist me in the shower room). D. I will not disrobe or remove my bathing suit in the shower area or general locker room areas. Curtained areas have been provided for changing. F. I am responsible for my valuables. There are lockers available for my use on which I can put my own lock. I must remove the lock before I leave. (Helen Hayes Hospital staff will remove any locks left on after a session has ended). G. I will wear non-slip pool shoes at all times on the deck, in the pool and in the locker rooms. Pool Rules A. I understand that I must abide by the Helen Hayes Hospital therapeutic pool rules (see attached) at all times. If I fail to abide by the rules, my right to participate in this program will be jeopardized. B. I understand that I may only use pool equipment assigned by a therapist. C. I understand that visitors will wear shoe cover-ups, before entering the pool area and remain seated during the session.

8 IV. Medical Status A. I understand that I must complete an Aquatics Questionnaire (attached) before attending the aquatics program. B. I understand that, if I have any open draining wounds or emergent skin conditions, I will not be able to go into the pool. C. I understand that I am responsible for ensuring that Helen Hayes Hospital is informed of any medical problems which may impact on this program. I am also responsible for informing Helen Hayes Hospital of any medical problems which arise after my referral has been signed and reviewed. Failure to inform Helen Hayes Hospital will lead to my privileges being revoked. V. Payment Agreement A. All payments are due by the 15 th of the month for the following month. You will not receive a bill. B. Pool participants must call the Aquatics Director at (845) to make arrangements to re-start this program. If returning after an absence of one month or more a new medical clearance form must be submitted. Pool participants should not assume that they will be able to return to the same class if their participation has been interrupted. I agree to participate in the Helen Hayes Hospital Aquatic Exercise Program to the best of my ability and agree to my responsibilities as outlined above. Participant Signature: Participant Name: Date: (Please Print) Aquatic Director:Date: ****************************************************************************** EA 34/1/16

9 HELEN HAYES HOSPITAL WEST HAVERSTRAW, NEW YORK AQUATIC EXERCISE PROGRAM PARTICIPANT AGREEMENT KEEP FOR YOUR RECORDS This agreement is made with (Participant)_ Date:. It includes the terms and conditions for participation in the Helen Hayes Hospital Aquatic Exercise Program as follows: I. Attendance: I understand that: A. I must notify the aquatics director as soon as able if I will be under medical care resulting in missing multiple sessions; B. The open format is based on a schedule with the week ending each Friday and the month ending the last day of the month; C. The fee is NOT pro-rated for missed classes; D. There are NO refunds of any payment. II. III. Bathing Attire, Valuables and Shower Room Practices A. I will bring my own bathing suit, towel and non-slip pool shoes to each session. B. I understand that if I am incontinent of urine I must supply and wear a diaper and rubber pants under my bathing suit. (If incontinent of feces-cannot participate unless on bowel regimen that is working). C. I understand that I must bring someone to assist me if I am not independent in dressing/undressing. (There will be no one available to assist me in the shower room). D. I will not disrobe or remove my bathing suit in the shower area or general locker room areas. Curtained areas have been provided for changing. F. I am responsible for my valuables. There are lockers available for my use on which I can put my own lock. I must remove the lock before I leave. (Helen Hayes Hospital staff will remove any locks left on after a session has ended). G. I will wear non-slip pool shoes at all times on the deck, in the pool and in the locker rooms. Pool Rules A. I understand that I must abide by the Helen Hayes Hospital therapeutic pool rules (see attached) at all times. If I fail to abide by the rules, my right to participate in this program will be jeopardized. B. I understand that I may only use pool equipment assigned by a therapist. C. I understand that visitors will wear shoe cover-ups, before entering the pool area and remain seated during the session.

10 IV. Medical Status A. I understand that I must complete an Aquatics Questionnaire (attached) before attending the aquatics program. B. I understand that, if I have any open draining wounds or emergent skin conditions, I will not be able to go into the pool. C. I understand that I am responsible for ensuring that Helen Hayes Hospital is informed of any medical problems which may impact on this program. I am also responsible for informing Helen Hayes Hospital of any medical problems which arise after my referral has been signed and reviewed. Failure to inform Helen Hayes Hospital will lead to my privileges being revoked. V. Payment Agreement A. All payments are due by the 15 th of the month for the following month. You will not receive a bill. B. Pool participants must call the Aquatics Director at (845) to make arrangements to re-start this program. If returning after an absence of one month or more a new medical clearance form must be submitted. Pool participants should not assume that they will be able to return to the same class if their participation has been interrupted. I agree to participate in the Helen Hayes Hospital Aquatic Exercise Program to the best of my ability and agree to my responsibilities as outlined above. Participant Signature: Participant Name: Date: (Please Print) Aquatic Director:Date: ****************************************************************************** EA 34/1/16

11 HELEN HAYES HOSPITAL WEST HAVERSTRAW, NEW YORK AQUATIC EXERCISE PROGRAM PARTICIPANT/ASSISTANT AGREEMENT This agreement is made with(aide)_ Date:, who is the authorized assistant in the Aquatic Exercise Program. I understand that: A. As the "assistant" for I understand that by being in (name of participant) the pool to assist with the independent exercise program by either guarding him/her for safety reasons or by providing verbal cues, this does not qualify me to be certified or to be an "expert" in the Aquatic Exercise Program. B. This program is taking place in the Helen Hayes Hospital Therapeutic pool, which is a specific environment with a specific pool temperature and physical structure that does not necessarily carry over to other public or private swimming pools. C. I will not perform any exercises while in the pool. My purpose for being in the pool is to assist the person named above for safety. D. I must abide by the following terms and conditions for participation in the Helen Hayes Hospital Aquatic Exercise Program: 1. Attendance: I understand that: a. I must be consistent in my attendance and notify the appropriate people if I will not be able to attend; b. Can only attend the session stipulated on the participant's monthly receipt. 2. Bathing Attire/Valuables and Shower Room Practices: a. I will bring my own bathing suit, towel and non-slip pool shoes to each session. b. I understand that if I am incontinent of urine I must supply and wear a diaper and rubber pants under my bathing suit. (If incontinent of feces-cannot participate unless on bowel regimen that is working). c. I will not disrobe in the shower area. Curtained areas have been provided for changing. d. I am responsible for my valuables. There are lockers available for my use on which I can put my own lock. I must remove the lock before I leave. (Any locks left on after a session has ended will be removed by Helen Hayes Hospital staff). e. I will wear non-slip pool shoes at all times on the deck, in the pool and in the locker room.

12 AQUATIC EXERCISE PROGRAM ASSISTANT AGREEMENT 3. Pool Rules a. I understand that I must abide by the Helen Hayes Hospital therapeutic pool rules (see attached) at all times. If I fail to abide by the rules, my right to participate in this program will be taken away. b. I understand that I can only use pool equipment assigned by the therapist. c. I understand that anyone I bring with me will wear shoe cover-ups before entering the pool area and remain seated during the session. NO unsupervised children will be allowed. 4. Medical Status a. I understand that, if I have any open draining wounds, I will not be able to go into the pool. b. I understand that I am responsible for ensuring that Helen Hayes Hospital is informed of any medical problems which may impact on this program. Failure to inform Helen Hayes Hospital will lead to my privileges being revoked. 5. Renewal of Agreement a. I understand that my continued monthly participation in this program is not automatic. It will depend on participant's level of need, availability in the appropriate session, and participant's adherence to the conditions of this agreement. I agree to participate as an assistant for in the Helen Hayes Hospital Aquatic Exercise Program to the best of my ability and agree to my responsibilities as outlined above. Assistant Signature: Assistant Name: (Please Print) Date:_ Participant Authorization Signature: (Parent or Legal Guardian when indicated) Participant/Parent/Legal Guardian Name: Date:_ (Please Print) U:\POOL\PARTICIPANT-ASST. 2/16 ac

13 HELEN HAYES HOSPITAL West Haverstraw, New York HELEN HAYES HOSPITAL AQUATIC EXERCISE PROGRAM ASSISTANT HEALTH CHECKLIST Authorized Assistant Name: Date of Birth: Please complete the following checklist with consideration to your current health status. Do you have a history/presence of any of the following: YES NO 1. Seizure ( controlled) 2. Cardiac Disease 3. Multiple Sclerosis 4. Joint Replacement 5. Recent Fracture 6. Hypertension 7. Incontinent of urine 8. Allergies (e.g., Chlorine) 9. Respiratory Disorders 10. Active Skin Conditions 11. Illeostomy or Colostomy bag 12. Frequent Diseases 13. Transdermal Patch *If the answer to any of the questions stated in the right column is YES, please explain current status (state whether condition is controlled or not). To the best of my knowledge, I am generally in good health and I know of no medical condition that I currently have which would prevent me from serving as an assistant to the Participant of the Aquatic Exercise Program. Assistant s Signature/Date: Assistant s Telephone Number: Assistant s Address AC2/16

14 1. Lifeguard must be present whenever the pool is in use. 2. No diving. 3. No jumping. Therapeutic Swimming Pool 4. Health Department rules for sanitation and safety must be observed by every patron. Persons with physical disorders such as skin lesions, inflamed eyes, nose, mouth or ear discharges, or bandages may not swim. Spitting and other discharges into the pool is prohibited. 5. Maximum number of bathers permitted: No running on the deck. 7. No food or drink in the pool area or locker rooms. 8. No glass in the pool area. 9. Only persons in proper bathing attire permitted in the pool. No cut-offs or rolled-up pants. No street clothes in the pool area. 10. No bare feet outside the pool deck and dressing area. 11. No personal hairdryers. 12. No gum chewing in the pool area or locker rooms. 13. Non-slip pool shoes must be worn in and out of pool and into locker rooms. 14. No cell phones. ~ RULES ~ Pool Rules 3/07