Employee Name: Male Female Employee Personnel Number: T# Date of Birth / / Age Employee Referred by Name:

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Transcription:

HOW DID YOU HEAR ABOUT US? (PLEASE CHECK ONE) Building Tour Café Display CO-Worker/Friend Email Flyers Wired I m a Previous Member Intern Coordinator New Hire Orientation Other: Employee Name: Email: Male Female Employee Personnel Number: T# Date of Birth / / Age Employee Referred by Name: Email: HOME ADDRESS: CITY: STATE: ZIP: PHONE ( ) - P&G WORK LOCATION: EMPLOYEE/RETIREE PHYSICIAN NAME EMPLOYEE/RETIREE EMERGENCY CONTACT PHONE ( ) - PHONE ( ) - PHONE ( ) - Do you currently have any of the following? Y N Hypercholesterolemia (total cholesterol greater than 200 mg/dl or HDL less than 35 mg/dl) Y N Hypertension, blood pressure greater than or equal to 140/90 mmhg, or on hypertensive medication Y N Smoking habit (current) Y N Diabetes Y N WOMEN: Are you 55 yrs of age or older? Y N WOMEN: Had a baby weighing > 9 lbs.? Y N MEN: Are you 45 years of age or older? How many days per week do you get moderate to intense physical activity such as a brisk walk? How many minutes per day do you perform activities such as this? Do you have a history of any of the following diseases? Y N Heart disease, heart attack, angina Y N Thyroid or metabolic disorder Y N Coronary angioplasty/cardiac surgery Y N Diabetes Y N Rapid heartbeats (greater than 100bpm)/palpitations Y N Kidney disease Y N Heart murmurs or unusual cardiac findings Y N Cancer Y N Peripheral vascular disease Y N Other diagnosed disease/disorder (specify) Y N Stroke Select the statement that best describes your level of stress over the last 6 months: No stress Occasional mild stress Frequent mild/moderate Constant high stress I verify all information noted above is accurate and I understand it is my responsibility to update the fitness staff of any changes in health status, which would alter my ability to safely participate in a fitness program. Signature: Date: / / Y N Other heart/vascular problems (specify) Do you have a history of the following signs or symptoms? Y N Fainting or dizziness Y N Asthma Y N Chest discomfort at rest or during exertion Y N Chronic bronchitis Y N Unusual fatigue or shortness of breath Y N Emphysema or COPD Y N Pregnancy (current or within 2 months postpartum) Y N Other respiratory problems (specify) Y N Major surgery/hospitalization/rehabilitation/illness within the past 6 months Do you have a history of any of the following? Please Specify: List all medications you are taking. Y N Orthopedic problems (joint/bone) within the past 6 months MEDICATION REASON Specify 1) Y N Chronic back problems Specify 2) Y N Arthritis Specify 3) Do you have any other medical situations or physical limitations, which should be considered prior to your participation in an exercise program? No Yes if yes, please explain For staff use: BP / HR Height Weight BMI BF% Staff PCF required: yes no Risk Assessment: DLR DMR DMHR DHR LR MR MHR HR

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HOW DID YOU HEAR ABOUT US? (PLEASE CHECK ONE) Spouse Domestic Partner Building Tour Café Display CO-Worker/Friend Email Flyers Wired I m a Previous Member Intern Coordinator New Hire Orientation Other: Name: Email: Male Female Spouse Domestic Partner Drivers License/Personnel Number: T# Date of Birth / / Age HOME ADDRESS: CITY: STATE: ZIP: PHONE ( ) - Spouse Domestic Partner Referred by Name: Email: PHYSICIAN NAME EMERGENCY CONTACT PHONE ( ) - PHONE ( ) - Do you currently have any of the following? Y N Hypercholesterolemia (total cholesterol greater than 200 mg/dl or HDL less than 35 mg/dl) Y N Hypertension, blood pressure greater than or equal to 140/90 mmhg, or on hypertensive medication Y N Smoking habit (current) Y N Diabetes Y N WOMEN: Are you 55 yrs of age or older? Y N WOMEN: Had a baby weighing > 9 lbs.? Y N MEN: Are you 45 years of age or older? How many days per week do you get moderate to intense physical activity such as a brisk walk? How many minutes per day do you perform activities such as this? Do you have a history of any of the following diseases? Y N Heart disease, heart attack, angina Y N Thyroid or metabolic disorder Y N Coronary angioplasty/cardiac surgery Y N Diabetes Y N Rapid heartbeats (greater than 100bpm)/palpitations Y N Kidney disease Y N Heart murmurs or unusual cardiac findings Y N Cancer Y N Peripheral vascular disease Y N Other diagnosed disease/disorder (specify) Y N Stroke Select the statement that best describes your level of stress over the last 6 months: No stress Occasional mild stress Frequent mild/moderate Constant high stress I verify all information noted above is accurate and I understand it is my responsibility to update the fitness staff of any changes in health status, which would alter my ability to safely participate in a fitness program. Signature: Date: / / Y N Other heart/vascular problems (specify) Do you have a history of the following signs or symptoms? Y N Fainting or dizziness Y N Asthma Y N Chest discomfort at rest or during exertion Y N Chronic bronchitis Y N Unusual fatigue or shortness of breath Y N Emphysema or COPD Y N Pregnancy (current or within 2 months postpartum) Y N Other respiratory problems (specify) Y N Major surgery/hospitalization/rehabilitation/illness within the past 6 months Do you have a history of any of the following? Please Specify: List all medications you are taking. Y N Orthopedic problems (joint/bone) within the past 6 months MEDICATION REASON Specify 1) Y N Chronic back problems Specify 2) Y N Arthritis Specify 3) Do you have any other medical situations or physical limitations, which should be considered prior to your participation in an exercise program? No Yes if yes, please explain For staff use: BP / HR Height Weight BMI BF% Staff PCF required: yes no Risk Assessment: DLR DMR DMHR DHR LR MR MHR HR

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