Non-Member Health Screening

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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) Youth Guest (with member) Youth Guest (without member) DATE: Member Name: Member Name: Out-Of-Town Guest Program Participant Buddy for Member Program Name: Program Start Date: PERSONAL INFORMATION NAME: DOB: Month Day Year ADDRESS: PHONE: EMAIL: MB HEALTH # PHIN # EMERGENCY CONTACT Name: Relationship: Phone: REQUIRED IF PARTICIPATING IN CHRONIC DISEASE MANAGEMENT PROGRAM Physician Name: Clinic Address: Specialist Name: Clinic Address:

HEALTH SCREENING Section 1 Do you have a history of any of the following? (please check all that apply to you) Cardiovascular Disease: cardiac catheterization cardiac disease cerebrovascular disease (stroke/tia) congenital heart disease coronary angioplasty heart attack heart failure heart surgery heart transplantation heart valve disease pacemaker/implantable cardiac defibrillator peripheral vascular disease (PVD) Metabolic Disease: diabetes (Types 1 or 2) renal disease Section 2 Pulmonary Disease: asthma chronic obstructive pulmonary disease cystic fibrosis interstitial lung disease Major Signs and Symptoms of Cardiovascular, Pulmonary or Metabolic Disease: chest discomfort with exertion dizziness, fainting, or blackouts unpleasant awareness of a forceful rapid heart rate take heart medications ankle swelling unreasonable breathlessness (at rest, with mild exercise, or when lying down) burning or cramping sensation in your lower legs when walking short distances pain or discomfort in the chest, neck, jaw, arms or elsewhere that may be due to ischemia (relative lack of blood supply) Are you presently? male and older than 45 years female and older than 55 years, had a hysterectomy (with ovaries removed), or are postmenopausal smoker (or quit within the past 6 months) hypertensive (blood pressure is >140/90 mm Hg) or on blood pressure medication more than 20 pounds overweight (BMI> 30) physically inactive (not exercising >=30 minutes, 3x/week for past 3 months) pre-diabetic (impaired fasting glucose 6.1 to 6.9 mmol/l or oral glucose tolerance test 7.8 to 11.0 mmol/l) Do 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) high total cholesterol >5.2 mmol/l high HDL (good) cholesterol (>=1.6 mmol/l) Page 2 of 6

HEALTH QUESTIONS Are you pregnant? Do you have any musculoskeletal problems/recent injuries (muscle, bone, or joint) that may affect your ability to exercise at Reh-Fit? If yes, please explain: Do you have concerns about your ability to exercise safely at Reh-Fit (weakness, lack of coordination, poor balance, poor memory, pain, swelling or decreased range of motion etc.)? If yes, please explain: Have you undergone any surgeries that may limit/affect your ability to exercise safely at the Reh-Fit? If yes, please explain: Do you have a history of falls? Do you use a walking aid? (please circle in addition to selecting Y/N) Have you ever been diagnosed with or prescribed medication for any of the following conditions? Neuropathies (problems with sensations) Multiple sclerosis Other neurological conditions Arthritis Parkinson s disease Polio/post-polio syndrome Osteoporosis Cancer Epilepsy or other seizure disorder Anxiety/Depression High cholesterol Cardiovascular disease High blood pressure Stroke Diabetes Thyroid disease Other (please specify): Do any of your medications cause side effects that might affect your ability to exercise (weakness, drowsiness, dizziness, confusion, lack of coordination, muscle or joint pain etc.)? If yes, please explain: Do you have any allergies to medication? If yes, please specify: BODY COMPOSITION Current Height cm/inches Current Weight kg/pounds Page 3 of 6

Guest Waiver of Liability I wish to be a Guest of the Manitoba Cardiac Institute (Reh-Fit) Inc. (hereinafter referred to as the Reh-Fit Centre ) and to utilize the property, facilities, and services of the Reh-Fit Centre, and I knowingly and willingly assume the risks associated with doing so. In consideration of having access to the Reh-Fit Centre and of being able to utilize the property, facilities, and services of the Reh-Fit Centre, I hereby agree to complete the Health and Lifestyle questionnaire and to follow the exercise intensity recommendations based on the risk classification level to which I am assigned, and to undertake and complete whatever assessment is recommended or required by the Reh-Fit Centre based on the Health and Lifestyle Questionnaire. I further agree that, regardless of whether or not I follow the exercise intensity recommendations, or undertake and complete the assessment program required or recommended by the Reh-Fit Centre, the Reh-Fit Centre shall not be liable for any injuries, accidents, or death occurring to me, arising either directly or indirectly out of my participation in or use of the Reh-Fit Centre s facilities, programs, and services. I do hereby expressly release and undertake not to sue the Reh-Fit Centre, its officers, directors, agents, or employees for any and all claims, demands, injuries, damages, or causes of action, arising directly or indirectly out of my participation in or use of the Reh-Fit Centre s facilities, programs, and services. I also acknowledge that the Reh-Fit Centre is not responsible or liable for the loss, theft or damage of my personal property while on the Reh-Fit Centre land and premises, including, without limiting the generality of the foregoing, the loss, theft, or damage of any of my personal property in a motor vehicle in the Reh-Fit Centre parking lot, or in a locker on the Reh-Fit Centre premises. I hereby waive and forego any claim or potential claim against the Reh-Fit Centre relating to the loss or damage of my personal property while on the Reh-Fit Centre land and premises. Dated the day of, Signed: Consent to Email Communication I give my consent to receive electronic communications from the Reh-Fit Centre such as newsletters, program announcements or changes, healthy living tips, and membership information. Date Participant/Guardian Signature Page 4 of 6

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OFFICE USE ONLY Date of Assessment: Risk Stratification: 1. Low 2. Moderate 3. High Recommended: Fitness Assessment A Fitness Assessment B Fitness Assessment D Physiotherapist Consultation Nutrition Consultation Cardiac Rehabilitation Program Reason for Risk Stratification & Assessment: How Hard Can I Exercise Form Handout provided & Low Intensity Recommended Handout provided & Moderate Intensity Recommended Staff Name Operational forms/membership/non-member Screening Form June 28, 2017 Page 6 of 6

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