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So that we can better plan your exercise program, please check the following risk factors if they apply to you. Because these risk factors indicate increased risk of cardiovascular disease (except for pregnancy), if you have more than one of these risk factors, you must have physician approval before being cleared for fitness testing or exercise. Following review of these risk factors and your medical health history, we will send a consent letter to your physician for clearance into our program.

I understand that if I have more than one of the above risk factors or I am pregnant, I must have physician clearance before participating in fitness testing or exercise. I have completed the form to the best of my ability.

yes no

How much do you weigh?
lbs.

In the past year, have you:
gained weight lost weight or maintained your weight?

If a change, how many pounds?

Do you feel you are overweight?
no yes

Have you had surgery within the last six months?
no yes

If yes, what type of surgery and date:

I have taken medications (including over-the-counter), supplements, or vitamins within the last 12 months no yes

Please list any medications (including over-the-counter), supplements, or vitamins you are currently taking or have taken within the last 12 months:

Medication/supplement/vitamin Dose Health Condition(s)

When was your last physical examination?

Where the any problems noted at your last physical examination?
no yes

If any problems were noted please explain

Have you ever had a graded exercise stress test (with EKG monitoring) performed at the request of a physician?
no yes

If yes, was it normal?
no yes

Has a physician ever made any recommendations on limiting your physical exertion?
no yes
If Yes, what were the limits?

Are you presently participating in an exercise program?
yes no
If Yes, what and how often?

How would you rate your physical activity on a daily basis?
very little moderateactive

Overall, how stressful is your life? (check one)
very stressful moderately stressfulmildly stressfulnot stressful

In which areas do you experience significant stress? (check all that apply)
employment-related stress

family-related stress

health-related stress

social/interpersonal concerns

financial worries

other

How effective are you with managing your stress? Check the one that best fits you now:
very effective (I've got stress under control)

somewhat effective (I've got a handle on stress, but could benefit from more ideas or support in coping with it)

Ineffective (I need to learn some new ways to cope with stress)

very ineffective (my stress is overwhelming and I need help coping with it)

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What are your health and wellness goals?
Be specific as possible. "I want to lose 10 lbs. by Christmas" is a better goal than "I want to lose weight." Listed below are some general examples to get you started.

List three primary goals that you want to focus on achieving.
A well written goal will include a specific action, by when and how.

Example: I will lose 5 pounds by January 1st, 2003 by exercising 3 times a week for 30 minutes each session.

Rank these goals, putting the most important one first.
1.

2.

3.

Why is that first goal the most important to you?

What steps are you going to take to reach your most important goal? Be specific.

How will you know when you have reached your goal? Is there a way to measure your progress?

How long do you think it will take to reach this goal? Why? Is your goal realistic and attainable?

How can we help you to achieve your goals?

MOTIVATION

While you are working toward your goal, how do you plan to stay motivated?

Are there smaller goals you can set that will lead you to achieving your big goal?

What are some barriers that you feel may prevent you from reaching your goal? How do you plan to overcome these?

We find that, especially early in a program, many start out enthused and then gradually return to old habits. From our standpoint, if we haven't seen you, we worry; we don't know if you are injured, frustrated or discouraged, have questions, or are simply too busy right now. Periodically, we check our records to determine who hasn't been here in awhile. If we notice you haven't been here lately, may we give you a call and make sure everything is going okay with your program?
Yes No

The exercise program at GRMC is a safe activity as long as certain safety guidelines and precautions are followed. The exercise activity should elevate your heart rate to a range of 60-85% of your predicted target heart rate zone, which will increase your cardiovascular endurance and improve other fitness components. Blood pressure also raises during exercise, which is normal and desirable.

Major muscle groups in the legs, back, arms, shoulders, abdomen, and chest are used in all aspects of our program. If you have any past or current medical problems with your heart, lungs, muscles, joints, blood pressure or other medical problems, you must list these on your medical health history. Physician consent is required with certain medical conditions.

There are certain risks to participating in an exercise program. These include, but are not limited to: blisters, bruises, muscle and joint soreness, muscle strains and ligament sprains in any part of the body. There is an unlikely event of broken or cracked bones, paralysis, heart attack, cardiac arrest, stroke, or death.

We request that you, the participant be responsible for your safety while exercising with us. You should specifically follow your exercise prescription, read and follow any and all safety guidelines in the Member Manual or posted in the facility. Follow any specific instructions given by Wellness staff.

It is required that you participate in an orientation session before beginning the program. The orientation will familiarize you with equipment safety and use, stretching exercises, warm up and cool down, and target heart rate.

Always inform the Wellness staff of any physical abnormalities that you may experience before, during, or after exercise.

CONSENT
After reading the above information, I agree to participate in the GRMC Wellness Program and presently understand the inherent risks of participation. I agree to follow all safety guidelines and further state that I have no other health/medical condition that would prevent me from participating in the exercise program. If I do have any health/medical conditions, I have received a written physician approval to participate. I acknowledge that I am voluntarily participating in this program and for my heirs, and myself I do not hold Grinnell Regional Medical Center, its affiliates, employees or staff responsible or liable for any injuries and/or damages which may occur while participating in this program. I also consent to allow my exercise results to be used for anonymous research purposes. My questions have been answered satisfactorily by Wellness staff.

Yes No