I understand that this program may or may not benefit my physical fitness or general health. I recognize that involvement in the exercise sessions will allow me to learn proper ways to perform conditioning exercises, use fitness equipment, and regulate physical effort. These experiences should benefit me by indicating how my physical limitations may affect my ability to perform various physical activities. I further understand that if I closely follow the program instructions, I will likely improve my exercise capacity after a period of 3 to 6 months.
4. cOnfidentiality and USe Of infOrmatiOn
I have been informed that the information obtained in this exercise program will be treated as privileged and confidential and will consequently not be released or revealed to any person without my express writ- ten consent. I do, however, agree to the use of any information that is not personally identifiable with me for research and statistical purposes so long as same does not identify me or provide facts that could lead to my identification. Any other information obtained, however, will be used only by the program staff in the course of prescribing exercise for me and evaluating my progress in the program.
5. inqUirieS and freedOm Of cOnSent
I have been given an opportunity to ask certain questions as to the procedures of this program. Generally these requests have been noted by the interviewing staff member, and his/her responses are as follows.
I further understand that there are also other remote risks that may be associated with this program. Despite the fact that a complete accounting of all these remote risks has not been provided to me, I still desire to participate.
I acknowledge that I have read this document in its entirety or that it has been read to me if I have been unable to read same.
I consent to the rendition of all services and procedures as explained herein by all program personnel.
Date
Participant’s signature
Witness’ signature
Test supervisor’s signature
Note: The law varies from state to state. No form should be adopted or used by any program without individualized legal advice.
Reprinted, by permission, from D. Herbert, 1994, Legal aspects of sports medicine, 2nd ed. (Canton, OH: Professional Reports Corporation).
(continued)
Form 11
Express Assumption of Risk Form
I, the undersigned, hereby expressly and affirmatively state that I wish to participate in __________________.
I realize that my participation in this activity involves risks of injury, including but not limited to ____________
(list) ____________ and even the possibility of death. I also recognize that there are many other risks of injury, including serious disabling injuries, that may arise due to my participation in this activity and that it is not possible to specifically list each and every individual injury risk. However, knowing the material risks and appreciating, knowing, and reasonably anticipating that other injuries and even death are a possibility, I hereby expressly assume all of the delineated risks of injury, all other possible risk of injury, and even risk of death, which could occur by reason of my participation.
I have had an opportunity to ask questions. Any questions I have asked have been answered to my complete satisfaction. I subjectively understand the risks of my participation in this activity, and knowing and appreciating these risks, I voluntarily choose to participate, assuming all risks of injury or even death due to my participation.
Witness Participant
Dated
Notes of questions and answers
This is, as stated, a true and accurate record of what was asked and answered.
Participant
To be checked by program staff Checked Initials I. Risks were orally discussed.
II. Questions were asked, and the participant indicated complete understanding of the risks.
III. Questions were not asked, but an opportunity to ask questions was provided and the participant indicated complete understanding of the risks.
Staff member Dated
Note: The law varies from state to state. No form should be adopted or used by any program without individualized legal advice.
Reprinted, by permission, from D. Herbert, 1994, “Avoiding allegations of misrepresentation/fraud in program documents,” The Exercise Standards and Malpractice Reporter 3(2): 30-31.
Form 12
Physician’s Release for Activity Form
has recently enrolled for membership at East Side/West Side Athletic Clubs. The club membership includes two complimentary orientation sessions with our qualified fitness professionals (degreed and/or certified in the field), as well as the opportunity to participate in numerous group fitness classes and individual programs.
On completion of the PAR-Q (Physical Activity Readiness Questionnaire), it has been determined that this new member is best served by additional or supplemental recommendations by his/her care provider.
Please take the time to review your client’s medical history and the PAR-Q accompanied with this request. If he/she can be released for physical activity, please complete the information below and let us know if there are any modifications or special needs.
Member’s signature for release of information Date
Club staff faxing this information (print name)
As a physician, it is my understanding that the person listed above wishes to participate in physical activ- ity at the Club and has been referred to myself (his/her physician) before beginning a regular program.
Here are my specific recommendations and/or comments regarding this new member and his/her involvement in an exercise program:
Physician’s printed name Date
Physician’s signature
Reprinted, by permission, from East Side Athletic Club (Milwaukie, OR: East Side Athletic Club).
Form 13
Guest Agreement and Waiver With Brief Medical History
Date Name
Company name Mailing address
City State Zip
Phone: (W) (H)
Guest of:
Please answer the following seven questions YES NO
1. Has your doctor ever said you have heart trouble?
2. Do you frequently have pains in your heart and chest?
3. Do you often feel faint or have spells of severe dizziness?
4. Has a doctor ever said your blood pressure was too high?
5. Has your doctor ever told you that you have a bone or joint problem such as arthritis that has been aggravated by exercise or might be made worse by exercise?
6. Is there any good physical reason not mentioned here why you should not follow an activ- ity program even if you wanted to?
7. Are you over age 65 and not accustomed to vigorous exercise?
Guest Agreement/Waiver
The undersigned guest agrees to abide by the rules of the Club, including the completion of the above medical questionnaire.
The undersigned guest agrees that all use of the Club’s facilities, services and programs shall be under- taken at his/her sole risk and the Club shall not be liable for any injuries, accidents or deaths occurring to guest, arising either directly or indirectly out of utilizing the Club’s facilities, services and programs. The guest, for him/herself and on behalf of his/her executors, administrators, heirs, and assigns, does hereby expressly release, discharge, waive, relinquish, and covenant not to sue the Club, its officers, and agents for all such claims, demands, injuries, damages, or causes of action, with respect to use of the Club’s facilities, programs, and services.
The undersigned guest declares that he/she has completed the enclosed medical questionnaire as required by the Club and that he/she declares he/she is physically able to participate in physical activity.
Furthermore, guest declares that the Club has advised guest to obtain a medical clearance in the event he/
she answer yes to any of the medical history questions, or if he/she is unsure of his/her physical health and that guest maintains that he/she is physically capable of pursuing physical activity in the Club without such steps being taken or has done so.
Guest signature Date
Form 14
Emergency Medical Authorization Form
I/we, the undersigned, am/are the father and mother of minor(s).
cOnSent
I/we hereby give consent, in the event I/we cannot be contacted within a reasonable time, for (1) the admin- istration of any treatment deemed necessary for my/our children by Dr. , or any of his/her associates, the preferred physician, or Dr. , or any of his/her associates, the preferred dentist, or in the event the appropriate preferred practitioner is not avail- able, by another licensed, qualified physician or dentist; and (2) the transfer of any of my/our children to
Hospital, the preferred hospital, or any hospital reasonably accessible.
majOr SUrgery
This authorization does not cover nonemergency major surgery unless the medical opinions of two other licensed physicians or dentists concurring in the necessity for such surgery are obtained prior to the perfor- mance of such surgery and unless all reasonable attempts to contact me/us have been unsuccessful, defining such period for nonemergency surgery as 24 hours.
medical data
The following is needed by any hospital or practitioner not having access to my/our children’s medical history:
Allergies:
Medication being taken:
Physical impairments:
Other pertinent facts to which physician should be alerted:
Medical insurance coverage:
I/we, the undersigned parent(s), also do by these premises appoint and constitute
and and/or as temporary custodians of my/our children
above mentioned, for the period of , 20 , through and including , 20 , and do hereby authorize them to obtain any X-ray examination, anesthesia, medical or surgical diagnosis or treatment, and hospital care to be rendered to my/our children in our absence, under the gen- eral or special supervision, and on the advice of, a licensed physician, surgeon, anesthesiologist, dentist, or other qualified personnel acting under their supervision.
Witnesses
State of SS:
County
Note: The law varies from state to state. No form should be adopted or used by any program without individualized legal advice.
Reprinted, by permission, from D. Herbert, 1994, Legal aspects of sports medicine, 2nd ed. (Canton, OH: Professional Reports Corporation).
Member name Membership number
Member address City State (Zip) Member phone number
Physician’s name
Physician’s address City State (Zip) Physician’s phone number
Form 15
Fitness Evaluation Form
Note: RHR = resting heart rate; RBP = resting blood pressure; MET = unit of metabolic measurement; HVHR = hyperventilating heart rate; FEV = forced expiratory volume; HR = heart rate; BP = blood pressure; DP = double product; ST = S-T segment; KgR = kilogram right hand; KgL = kilogram left hand.
The law varies from state to state. No form should be adopted or used by any program without individualized legal advice.
Stage Time Speed KPM Grade HR BP DP ST Comments
1
1 2
3
1
2 2
3
1
3 2
3
1
4 2
3
1
5 2
3
R 1
e 3
s 6
t 9
Date _____ / _____ / _____
VII. General physiological information Birth date _____ / _____ / _____
1. Age ___________ 2. Sex M F 3. Risk category _______________ 4. Height _______ ft _______ in.
5. Weight _____________ 6. RHR ____________ 7. RBP _____________ 8. Predicted Max HR ____________
Medications__________________________________________ _________________________________________
Exercise history ____________________________________________________________________________________
VII. Cardiovascular assessment 1. RHR supine__________________
2. RBP supine _________________
3. RBP standing ________________
4. Predicted heart rate
Max __________
90% __________
80% __________
70% __________
5. HVHR _____________________
Protocol ______________________
Equipment ____________________
Max HR _____ Max BP ____/____
Max met ______________________
III. Lung capacity
1. Vital capacity ___/___% Pred.
2. FEV ___/___% Pred.
IV. Flexibility
1. Sit’n’reach ___ ___ ___in.
V. Muscular strength and endurance
1. Grip ____/____/____ KgR ____/____/____KgL 2. Trunk curl/sit-up __________#__________ Time 3. _____________________ _____________________
VI. Body composition
A. Skin folds 1 2 Avg.
1. Chest ________ ________ ________
2. Subscapula ________ ________ ________
3. Suprailliac ________ ________ ________
4. Umbilical ________ ________ ________
5. Tricep ________ ________ ________
6. Ant. thigh ________ ________ ________
Total skin folds ________
C. Girths
1. Neck _____
2. Shoulder _____
3. Chest _____
4. Waist _____
5. Hips _____
B. Body fat
1. Percent fat ________ % 2. Fat wt. ___________ lb 3. Lean wt. __________ lb 4. Ideal percent fat ____ % 5. Ideal wt. __________ lb
VII. Blood chemistry 1. Cholesterol ______
2. Chol./HDL ______
3. LDL/HDL _______
4. Triglycerides _____
5. Glucose _________
6. Hematocrit ______
6. Thigh ___ R ___ L 7. Calf ___ R ___ L 8. Bicep ___ R ___ L 9. Forearm ___ R ___ L
Form 16
Fitness Integration Tracking Form
Member’s name Age Acct.# Acct. type
Consultation appt. Date/time Fit specialist Coach
SUcceSS Plan
1. My MAIN objective is: ____________________________________________________________________
2. Why? ___________________________________________________________________________________
3. How will this accomplishment make you feel? _______________________________________________
4. When would you like to accomplish this? ____________________________________________________
5. Why by then? ____________________________________________________________________________
6. Baby Steps: ______________________________________________________________________________
7. Will you need support in accomplishing these steps or changes? yes/no
From whom? (family, training coach, social group, work peers, etc.) _____________________________
8. What days of the week do you see yourself using the Club (circle) S M T W Th F S 9. Time of day? # of Club visits per week? _______________________________________
10. Are #8 and #9 above realistic for you? yes/no _______________________________________________
11. If you consistently follow through on Baby Steps, how will you feel? ____________________________
12. Do you foresee any potential obstacle or distractions? _________________________________________
13. How can I assist you in accomplishing your goals? ____________________________________________
14. What type of coaching/support would benefit you most?
________________________________________________________________________________________
15. Notes: __________________________________________________________________________________
________________________________________________________________________________________
Adapted, by permission, from East Side Athletic Club (Milwaukie, OR: East Side Athletic Club).
reaSOnS
(check) (rank)
Lose body fat Stress release Meet similar folk Family recreation Strengthen/Tone Self-esteem increase Energy level increase
intereStS
Lose body fat Karate Personal training Weight training Massage Child care Swimming Water exercise classes Physical therapy Exercise group classes Fitness evaluation Nutrition Youth activities Swim lessons Social events Racquetball Sports leagues Volleyball Basketball Fitness leagues
Sauna/steam Jacuzzi
Form 17
Cardiovascular Assessment Data Sheet
Note: BP = blood pressure; MET = unit of metabolic measurement; RPM = rotations per minute; RPE = rate of perceived exertion.
The law varies from state to state. No form should be adopted or used by any program without individualized legal advice.
Reprinted, by permission, from Fitcorp, 1990, Fitcorp program manual (Boston, MA: Fitcorp).
Name Date Age
Weight (kg) Resting heart rate
Age-predicted max heart rate
60% 65% 70% 90%
Mode of cardiovascular evaluation: bike RPMs , treadmill (please circle one) I. Warm-up workload:
1 min RPE
2 min BP
3 min 4 min
II. Target workload #1:
1 min RPE
2 min BP
3 min 4 min
III. Target workload #2 (if indicated):
1 min RPE
2 min BP
3 min 4 min
IV. Cool-down workload:
1 min RPE
2 min BP
V. VãO2 max calculation conversion to METs:
Predicted VãO2 max (L/min) ì age factor = maximum VãO2 (L/min) VãO2 max (ml/min) – wt (kg) = VãO2max (ml/kg/min)
VãO2 max (ml/kg/min) – 3.5 = predicted maximal capacity in METs VI. Summary
• Predicted maximal capacity (METs)
• Recommended training range (METs)
• Recommended training range (heart rate)
Form 18
Release of Information Form
To whom it may concern:
Please be advised that ( ) and any member, associ-
ate, or designee of that firm is hereby authorized to inspect and copy or be furnished copies of any and all hospital, dental, or medical records of any sort as well as charts, notes, medical bills, dental bills, X-rays, lab reports, and prescriptions and is to be furnished any and all other information without limitations pertaining to any confinement, examination, treatment, or condition of myself, including medical, dental, psychologi- cal, or other treatment; examinations; or counseling for any medical, dental, or psychological condition.
This authorization shall be considered as continuing and you may rely on it in all respects unless you have previously been advised by me in writing to the contrary. It is expressly understood by the undersigned and you are hereby authorized to accept a copy or photocopy of this medical authorization with the same validity as though an original had been presented to you.
Dated this day of , 20 .
X
Note: The law varies from state to state. No form should be adopted or used by any program without individualized legal advice.
Reprinted, by permission, from B.E. Koeberle, 1990, Legal aspects of personal fitness training (Canton, OH: Professional Reports Corporation), 149.
Form 19
Progress Notes
Date Physician Member’s name
Weight Date of last program review
Medical history changes
Exercise prescription
Comments
Note: The law varies from state to state. No form should be adopted or used by any program without individualized legal advice.
Reprinted, by permission, from Fitcorp, 1990, Fitcorp program manual (Boston, MA: Fitcorp).
Form 20
Incident Report Form
Date of accident Time of accident
Member’s name Member number
Address
Home phone Business phone
Location of accident Staff attending
Witnesses (nonstaff)
Details of accident
Action taken by staff
Staff reporting Date
Department head’s signature Date
Note: The law varies from state to state. No form should be adopted or used by any program without individualized legal advice.
Form 21
Theft Report Form
Date of incident Time of incident
Item reported missing
Member’s name Member number
Address
Home phone Business phone
Location of incident Description of incident
Witnesses
Reporting by Date and time
Action taken
Supervisor’s signature Date
Form 22
Sample Exercise Card
Example: wt sets + reps Activity Prescription H.R. Resting B.P. Warm-up exercises 1. 2. 3. 4. 5. 6. 7. 8. 9. 10. 11. 12. 13. 14. 15. 16. 17. 18. 19. Personal fitness motivator’s initials Please see your motivator when finished with your card.
Member number _____________ Member name ________________________________________
Seat heights Sex M F Age ______________ Resting heart rate ___________________ Resting blood pressure ____________________ Training pulse________________________ History _____________________________________________________________________________________________________________
Form 23
Physical Activity Readiness Medical Exam Form (PARmed-X)
(continued)
Following is a checklist of medical conditions for which a degree of precaution and/or special advice should be considered for those who answered "YES" to one or more questions on the PAR-Q, and people over the age of 69. Conditions are grouped by system. Three categories of precautions are provided. Comments under Advice are general, since details and alternatives require clinical judgment in each individual instance.
References:
Arraix, G.A., Wigle, D.T., Mao, Y. (1992). Risk Assessment of Physical Activity and Physical Fitness in the Canada Health Survey Follow-Up Study. J. Clin. Epidemiol.
45:4 419-428.
Mottola, M., Wolfe, L.A. (1994). Active Living and Pregnancy, In: A. Quinney, L. Gauvin, T. Wall (eds), Toward Active Living: Proceedings of the International Conference on Physical Activity, Fitness, and Health.
Champaign, IL: Human Kinetics.
PAR-Q Validation Report, British Columbia Ministry of Health, 1978.
Thomas, S., Reading, J., Shephard, R.J. (1992). Revision of the Physical Activity Readiness Questionnaire (PAR-Q). Can. J. Spt. Sci. 17:4 338-345.
Cardiovascular
Infections
Metaboli
Pregnancy
Absolute Contraindications
Permanent restriction or temporary restriction until condition is treated, stable, and/
or past acute phase.
Relative Contraindications
Highly variable. Value of exercise testing and/or program may exceed risk. Activity may be restricted.
Desirable to maximize control of condition.
Direct or indirect medical supervision or exercise program may be desirable.
Special Prescriptive Conditions
Individualized prescriptive advice generally appropriate:
• limitations imposed; and/or
• special exercises prescribed.
May require medical monitoring and/or initial supervision in exercise program.
aortic aneurysm (dissecting) aortic stenosis (severe) congestive heart failure crescendo angina
myocardial infarction (acute) myocarditis (active or recent) pulmonary or systemic embolism—acute thrombophlebitis ventricular tachycardia and other dangerous dysrhythmias (e.g., multi-focal ventricular activity)
acute infectious disease (regardless of etiology)
aortic stenosis (moderate) subaortic stenosis (severe) marked cardiac enlargement supraventricular dysrhythmias (uncontrolled or high rate) ventricular ectopic activity (repetitive or frequent) ventricular aneurysm hypertension—untreated or uncontrolled severe (systemic or pulmonary)
hypertrophic cardiomyopathy compensated congestive heart failure
subacute/chronic/recurrent infectious diseases (e.g., malaria, others) uncontrolled metabolic disorders (diabetes mellitus, thyrotoxicosis, myxedema)
complicated pregnancy (e.g., toxemia, hemorrhage, incompetent cervix, etc.)
aortic (or pulmonary) stenosis—mild angina pectoris and other manifestations of coronary insufficiency (e.g., post-acute infarct) cyanotic heart disease shunts (intermittent or fixed) conduction disturbances • complete AV block • left BBB
• Wolff-Parkinson-White syndrome
dysrhythmias—controlled fixed rate pacemakers intermittent claudication hypertension: systolic 160-180; diastolic 105+
chronic infections HIV
renal, hepatic, & other metabolic insufficiency obesity
single kidney
advanced pregnancy (late 3rd trimester)
Advice
• clinical exercise test may be warranted in selected cases, for specific determination of functional capacity and limitations and precautions (if any).
• slow progression of exercise to levels based on test performance and individual tolerance.
• consider individual need for initial conditioning program under medical supervision (indirect or direct).
progressive exercise to tolerance progressive exercise; care with medications (serum electrolytes;
post-exercise syncope; etc.) variable as to condition
variable as to status
dietary moderation, and initial light exercises with slow progression (walking, swimming, cycling) refer to the “PARmed-X for PREGNANCY”
(continued)