Heart Wellness Physical Activity Screening Questionnaire Consent

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					     Heart Wellness Physical Activity Screening Questionnaire & Consent Form
                                  (Program takes place at Garratt Wellness Centre)

Name: _______________________________________________                       Date: _________________________

Birthdate: D________ M________ Y________                       Male: ________        Female: ________

Home Address: ________________________________________________                   Postal Code: ______________

E-mail Address: ____________________________________________________________________________

Home Phone: _____________________             Work: ____________________        Other: _____________________

Person to contact in case of Emergency: _______________________________              Phone: ________________

Physician’s Name:___________________________________                Office Phone: _________________________

Cardiologist’s Name:_________________________________              Office Phone: _________________________

Health History (please complete the following)
1)    Heart Attack     No            Yes           If yes, when: _________________________________________
2)    Hypertension     No            Yes
3)    Arrhythmias      No            Yes           If yes, type: ______________________________________
4)    Congestive Heart Failure       No            Yes          Date: ________________________________
5)    Intermittent Claudication     No            Yes
6)    Cerebral Vascular Episode No                 Yes         If yes, when: ______________________________
7)    Angina Pectoralis     No              Yes          If yes, please describe:____________________________
8)    Angiogram        No             Yes           If yes, findings: __________________________________
9)    Angioplasty      No             Yes           Date:_________________________
10)   Cardiac Related Surgery      No             Yes         If yes, please describe: _______________________

Additional comments: _______________________________________________________________________

Medications you are taking and the dosage:
_______________________________________                        _______________________________________

_______________________________________                        _______________________________________
_______________________________________                        _______________________________________

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11) Do you have Diabetes?        No         If yes, Type I         Type II       Boarder-line
                         (Please bring blood glucose monitor to class each time)
12) Do you take Insulin?          No         Yes

13)   Type of insulin?   Humalog       Regular        NPH      Ultralente          Lente         Premix

      Humalog Mix 25        30/70        50/50        20/80      40/60

14)   What is the range of your blood sugar test results (lowest to highest)? _____________________________

15)   How often do you have a reaction? __________ per week               __________ per month

16)   Which symptoms make you aware of your hypoglycaemia?
       Weakness ____            Anxious/nervous ____                        Numbness of lips or tongue ____
       Hunger ____              Light-headed ____                           Blurred vision ____
       Sweaty ____              Headache ____         Shaky ____            Other (specify) ____________

17) Have you ever passed out from low blood sugar?      No         Yes             When?    _____________
18)   What do you eat or drink for low blood sugar? _____________________________

19) Do you carry this with you always?      No         Yes

20) How often do you forget, skip, or take your pills more than one hour later than planned? ______________

Diabetes Medications        Do you take pills to control your diabetes?     No           Yes
Name of first pill taken: _______________        Dose: ______________            Time(s) of Day: _____________
Name of second pill taken: _____________         Dose: ______________            Time(s) of Day:_____________
Name of third pill taken: _______________        Dose: ______________            Time(s) of Day: _____________

Health History (please complete the following)
a)     Aneurysm                                                  No                Yes
b)     Broncho-Pulmonary Disease (Asthma, COPD)                  No                Yes
c)     Problems with weight management                           No                Yes
d)     Hyperlipidemia                                            No                Yes
e)     Long-term inactivity                                      No                Yes
f)     Arthritis                                                 No                Yes
g)     Diagnosed Osteoporosis                                    No                Yes
h)     Joint injury                                              No                Yes
i)     Lower back problems                                       No                Yes
If yes, to any of the above listed, please comment: _________________________________________________

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Physician Referral Form and Physical Activity Readiness Conveyance (Please complete the following)

Please identify any recommendations or restrictions for your patient’s fitness program below. Based upon a
current review of the health status of ________________________________ , I recommend avoidance of:
_________________________________________________. Unrestricted physical activity start slowly and
build up gradually: ______________________________________________________.

Risk Stratification for exercise (check one):          Low               Moderate                 High

Please attach a copy of the most recent stress test results.

A1C: ____________              Date: ____________

Lipid Profile:         Total: ____________       HDL:____________         LDL: ____________

Triglycerides: ____________       VLDL: ____________           Cholesterol: ____________

I consider my patient ____________________________, to be a reasonable candidate for the Richmond Heart
Wellness Physical Activity program at a recommended training heart rate of _________________.

Further, I understand this is a Phase IV Community Cardiac exercise program without medical supervision and
suitable for my patient.

Physician or Cardiologist’s signature: _____________________________                Date: __________________

Participant Informed Consent Form

I understand that the Richmond Heart Wellness physical activity program will provide me with a personalized
exercise program based upon the information provided in my referral form, which was completed by my
physician. My program will be regulated by the staff of the program. The activities included in my exercise
program are designed to place a gradually increasing workload on the cardiovascular system. I understand that
the reaction of the system to such activities cannot always be predicted with complete accuracy and therefore
there is a risk associated with exercising. I also understand and accept that these risks may occur during or
following an exercise session. I understand and accept the risks of participating in any physical activity,
including the risks resulting from my participating in the Richmond Heart Wellness physical activity program,
and that I may suffer personal injury while participating in the program.
By signing this release, I assume all the risks of injury, loss, or expense of any kind resulting from my
participation in the program. I will not hold the Richmond Fitness and Wellness Association, City of Richmond
or the staff associated with the program, liable for any injury, loss, or expense suffered as a result of my
participation. This release will apply to each and every session that I participate in the program.
I have read, understood, and fully agree to the foregoing. Any questions I had have been answered to my

Signed on the __________ day of (month)______________________________, 20__________

By ________________________________________                     ________________________________________
              Participant’s signature                                          Print name

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