Category 1 Category 2 Category 3
(continued)
Form 26
Coronary Risk Factor Identification Form
Member name Member # Date
Place a check next to any lines below that apply to the member.
1. Age: (Circle) Men >45 Women >55
2. Family history: MI or sudden death before 55 years of age for father or other first degree male relative
MI or sudden death before 65 years of age for mother or other first degree female relative
3. Cigarette smoker: (Current)
4. Hypercholesterolemia: Blood cholesterol > 200 mg/dl
5. Hypertension: Blood pressure > 140/90 mm Hg or on hypertensive meds.
6. Diabetes mellitus: Classified with disease as follows:
NIDDM > 35 years or older.
IDDM > older than 30 or having IDDM for 15 years minimum.
7. Sedentary lifestyle: Physical inactivity.
Apparently healthy:
Asymptomatic and apparently healthy with no more than one major coronary risk factor.
Risk factors:
Increased risk:
An individual who has signs or symptoms suggestive of possible cardiopulmonary or metabolic disease and/or two or more major coronary risk factors.
Risk factors:
**Physician’s note required** Date contacted:
Known disease:
An individual with known cardiac, pulmonary, or metabolic disease.
Risk factors:
**Physician’s note required** Date contacted:
Form 27
Fitness Testing Form
Name Member # Gender Age
INITIAl 30 DAy 60 DAy
DATE RESTING HR
Resting BP
Systolic Diastolic Circumferences
Biceps Chest Waist Hip Thigh Skinfolds
Pectoral (M) Abdominal (M)
Thigh (F/M) Tricep (F) Suprailliac
Sum
% body fat 3-minute step test
HR Fitness level Push-ups
Flexibility
Sit and reach Height
Weight
Form 30
Fit Quest Medical Clearance Form
Form 28
Medical Clearance Form
Information requested for Physician’s name
Telephone number
Please sign the statement that reflects your wishes:
1. I concur with my patient’s participation if he/she restricts activities to those that are moderate.
2. I do not concur with my patient’s participation in this program. (If checked, the individual will not be accepted.)
3. Other:
Return form to:
Form 231
Fit Quest Exercise Contract
Form 29
Exercise Contract
Member name
Member contact no. (W) (H) (C)
Fitness motivator
Motivator contact no. (W) (H) (C)
Goals and Objectives My main exercise goal is to
To achieve my main goal, I need to do the following:
a. 30-day goal
b. 60-day goal
c. 90-day goal
d. 6-month goal
I commit to do the following:
1. Cardiovascular
2. Strength training
3. Nutrition
4. Flexibility
What barriers do you expect might arise to prevent you from achieving your goals and how can we assist in overcoming them?
Exercise Contract Overview
1. When establishing this contract with a Member, be certain to set SMART goals (Specific, Measurable, Achievable, Realistic, and Timed).
2. To help achieve the desired results, use the following options as incentives to keep the Member motivated:
a. If not yet committed to an exercise program. Additional training sessions; setting them up with an exercise “buddy” in the same exercise situation; discounts for club services such as massage, lessons, classes, etc.; educational materials on benefits of exercise; group training sessions; and incentives or rewards.
b. If already participating in a program but just recently started. The focus is on preventing lapses (short breaks from exercise) and relapses (long periods of inactivity). Use buddy programs and group training options for social support. Additional complimentary training and incentives rewards work well also.
3. The support you provide as the motivator is critical to the success.
Form 30
Health, Fitness, and Racquet Sports Club Incident Report
Month Day year Time of Accident
A.M. P.M.
Club member yes No
Club name Club location
NI Uj RE D PE RS ON
First name (M.I.) last name Age
Hospital or first aid squad notified yes No Name:
Number and street
Time of initial call:
Times of follow-up calls:
1. 3.
2. 4.
City State Zip
Time of arrival:
Time of departure:
Business phone
Home phone
Taken to hospital?
Name of first aid attendant:
DESCRIPTION OF ACCIDENT:
CHECK ITEMS THAT APPLY TO INjURED PERSON:
Bleeding injury: yes No Other visible injury: yes No No visible injury, but complaint of pain: yes No
If eye injury, wearing eyeguards? yes No
DESCRIBE EXACT INjURY SUSTAINED: DESCRIBE FIRST AID ADMINISTERED BY CLUB:
(Complete for all incidents and report immediately—please print)
FIRST WITNESS SECOND WITNESS
First name (M.I.) last name First name (M.I.) last name
Number and street Number and street
City State Zip City State Zip
Business phone Home phone Business phone Home phone DESCRIPTION OF ACCIDENT BY WITNESS
Signature:
DESCRIPTION OF ACCIDENT BY WITNESS
Signature:
DA TE
Courtesy of Creative Agency Group.
HEAlTH, FITNESS & RACQUET SPORTS ClUB INCIDENT REPORT [continued]
Name of club personnel Position Date of who inspected the scene: inspection
Conditions found:
Action taken, if practical, to avoid recurrence:
DESCRIPTION OF PlACE OF ACCIDENT
Interior Exterior Walking area Playing surface locker room Physical fitness room Other:
Conditions: Dry Wet Smooth Even surface Slippery Foreign substance? yes No If “yES”, description:
If injury took place outside club building, check appropriate items:
Weather condition: Dry Rain Snow Ice Day Night lighting conditions:
IMPORTANT: If injury took place on a court, provide name, address, and telephone number of those individuals who used or rented the court during the prior hour.
ADDITIONAl COMMENTS
Did police investigate? Name and rank of officer: Department: Phone number yes No
Submitted by (signature): Telephone: Date / Time
This information is for reporting purposes only. The information provided is the responsibility of the insured and/or club.
Form 31
Housekeeping Checklist—Fitness Equipment Room
Note: Follow manufacturer’s recommendation for maintaining belts, rods, bearings, chains, gears, and upholstered surfaces of exercise equipment.
DAIly
Remove trash for disposal and replace liners Dust all horizontal surfaces
Spot-clean mirrors and glass
Spot-clean doors, door handles, light switches, trash containers, etc.
Spot-clean walls
Clean and disinfect all benches and equipment Polish vinyl pad surfaces with furniture polish Vacuum carpets
Remove spots and stains from carpet Spray odor counteractant
BIMONTHly
Completely clean mirrors, rubber floor, equipment, benches, etc.
Clean HVAC vents Clean light fixtures
Move all equipment and clean underneath QUARTERly
Bonnet-clean carpets yEARly
Extraction-clean carpets Wash all walls
MAINTENANCE PEST CONTROl
Report any repairs required Report any evidence of insects or rodents