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Transcription:

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 Pool Cardiac Cancer Rehab Senior Health (initial) Maintenance PERSONAL INFORMATION TODAY S DATE / / Name: Birthdate: / / Age: Address: City: State: Zip: Phone: (home) (work) Email Address: Gender: Male Female Race: White/Caucasian Hispanic Asian (optional) Native American Black/African American Other Employed Retired Disabled Former or current occupation: Marital Status: Single Married Widowed; Spouse s Name: Emergency Contact Name: Relationship: PHYSICIAN CONTACTS Primary Care Physician: Referring Physician: Other Physicians (include specialty): HEALTH INSURANCE COMPANY:

HEALTH HISTORY QUESTIONNAIRE 1. Have you had any of the following heart or blood vessel conditions? Aneurysm Cardiomyopathy Heart Transplant Surgery Angina (Chest Pain) Congenital Heart Disease Heart Valve Problem Angioplasty (PTCA) Congestive Heart Failure Implantable Defibrillator Angioplasty with Stent Coronary Artery Disease Pacemaker Atrial Fibrillation Heart Attack Pericarditis Blood Clots Heart Murmur Stroke Bypass Surgery (CABG) Heart Rhythm Problems Other: If you answered yes to any of the above, please explain (include dates when applicable) 2. Do you have or have you ever had any of the following medical conditions? Anemia Epilepsy Osteoarthritis Back Pain Fibromyalgia Osteoporosis Bone or joint issues Gastroesophageal Reflux Parkinson s Disease Cancer Kidney Disease Rheumatoid Arthritis Cerebral Palsy Multiple Sclerosis Urinary Problems Chronic Fatigue Muscular Dystrophy Other: If you answered yes to any of the above, please explain (include dates when applicable) 4. Has a doctor told you that you have diabetes? If yes, do you take insulin for your diabetes? Do you check your blood sugar levels? Last A1c: Date: 5. Do you have any form of the following pulmonary (lung) illnesses? Asthma Emphysema Pulmonary Hypertension Bronchiectasis Lung Cancer Pulmonary Fibrosis Bronchitis Pleurisy Sinusitis COPD Pneumonia Sleep Apnea Cor Pulmonale Pulmonary Embolism Tuberculosis Oxygen use: liters/minute hours/day Circle uses: Daytime Night With Activity Type of home system Type of Portable Continuous Flow or Pulsed 6. Do you have problems sleeping at night? If yes describe: Do you feel rested??

7. Do you currently smoke cigarettes, cigars, pipes or use chewing tobacco? If yes, do you want assistance to quit? If you smoked in the past, what age did you start? Age when quit: What was/is the average number of packs per day you smoke(d)? If you tried to quit smoking, what method(s) have you tried? Does anyone smoke in your household? 8. Please check if the following apply to you: You are a man older than 45 years You are a woman older than 55 years, have had a hysterectomy, or are postmenopausal You smoke, or quit smoking within the previous 6 months Your blood pressure is greater than 140/90 mm Hg You do not know your blood pressure You take blood pressure medication Your cholesterol level is greater than 200 mg/dl You do not know your cholesterol level You have a close blood relative who had a heart attack or heart surgery before age 55 (father or brother) or age 65 (mother or sister) You are physically inactive (less than 30 minutes of physical activity on at least 3 days a week) You are greater than 20 pounds overweight 9. Please circle any of the following conditions experienced by your immediate blood relatives: Diabetes High Blood Pressure High Cholesterol Stroke 10. How would you rate your stress / anxiety level? Low Average High Would you like to speak to a staff nurse about anxiety concerns? 11. Do you feel safe at home? Would you like to speak to a nurse about safety concerns? 12. Have you fallen within the last 30 days or do you fall often? Members are expected to provide their own attendant to assist with mobility needs while visiting or working out at the Healthplex. Please discuss with our exercise staff if this is an issue for you. 13. Pain: Are you having pain at this time? Location & Description: Have you experienced pain or discomfort during exercise in the past? If yes, please explain:

14. Please name all of your medications, their dosages, and how often you take them: (for example: Zocor, 5 mg, 1 time a day) _ 15. Allergies (include medication allergies): 16. Physical injuries / limitations: Circle mobility aides you use: Cane Wheelchair Walker Crutches Braces Other: 17. Past surgeries (include dates): 18. Do you have any of the following problems that might affect your learning? Visual Hearing Reading Speech Learning 19. Would you like information about your conditions / illnesses / injuries? If yes, please specify: Classes Handouts Videos One-on-One Learning 20. Please list other issues we should know about that might affect treatment and / or progress? (i.e., language barriers, cultural or religious beliefs, scheduling, or transportation needs) 21. Please identify your personal fitness goals at the Healthplex: Cardiovascular Fitness Goals Improve endurance of the heart and lungs Rehabilitation from heart surgery / procedure Improve activities of daily living (Please list specific activities you would like to improve) Strength Fitness Goals Physical independence Improve posture Reshape or tone body (improve muscular endurance) Injury prevention or rehabilitation or joint replacement issues Increase size of muscles or increase amount of weight lifted (improve strength) Improve sports / activity performance Sport(s) / Activity: Increase bone density (osteoporosis issues) Additional Goals Improve flexibility Improve diet / eating habits Decrease body fat / weight loss Prepare for childbirth (i.e., strengthen back, etc.) Other Pain Goal Using a 0 to 10 scale, 0 being NO pain and 10 being the Worst Pain Possible, please specify the level of pain that is acceptable to you:

Presbyterian Healthplex EXERCISE PROGRAM Participant Agreement Name of Participant: I have enrolled to participate in the Presbyterian Exercise Program. The Program, including its anticipated benefits and risks, has been fully explained to me. I have been informed about the advisability of discussing the risks and benefits of participation with my physician and agree to request additional clarification and/or follow-up with my physician as may be necessary. I agree to comply with all the rules and regulations of the Exercise Program and to accept full responsibility for my actions and any injuries that may result from my participation in the Program at the Presbyterian Healthplex. I realize that there are certain associated risks with exercise that may occur during my physical activity regiment. I also realize that I will be able to ask questions and seek advice from staff at the Healthplex regarding my exercise prescription and behavior change strategy towards enhancing my health at the Presbyterian Healthplex. I hereby release Presbyterian Healthcare Services, its officers, directors, employees and agents from any and all claims, demands, damages or liabilities in any way arising from or related to my participation in the Program. I have read the foregoing and I understand it. Any questions that I raised have been answered to my satisfaction. Date Signature Date Witness G:\Hplxdata\Copy of Gym Chart\PARTICIPANT AGREEMENT.DOC

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