Fill - Free fillable Texas Woman’s University - ADA Lead-Up Welcome Packet and Forms PDF form

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LEAD-UP

A Lifestyle Education Access for Diabetics: a University Program

Texas Woman’s University

HEALTH AND PHYSICAL ACTIVITY AGREEMENT

Before starting a wellness program with Texas Woman’s University Kinesiology

Department I, _____________________, certify to TWU that I have fully and accurately

completed the Health and Physical Activity History form presented to me by a TWU

LEAD-UP staff member; and that I have provided accurate responses to the questions

as indicated on the form or asked by the LEAD-UP staff. I understand that it is

important that I provide complete and accurate responses to the interviewer; I

acknowledge that Texas Woman’s University has relied on my responses in its decisions

regarding my personal training program, and I recognize that my failure to give complete

and accurate responses could lead to possible injury to myself during the program. I

understand that a medical clearance form may be needed by my physician depending

upon the responses I give, in accordance to ACSM guidelines.

I have been given the opportunity to ask questions regarding the TWU LEAD-UP

Health and Physical Activity History form and my supervised fitness program, and I have

received satisfactory answers to those questions.

I have read this Health and Physical Activity Agreement and understand all of its terms.

I have provided complete and accurate information to the best of my ability regarding my

current and prior physical status, including any pre-existing injuries or special medical

conditions.

Participant Signature Witness Signature

Print Name Print Name

Date Date

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signature

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RELEASE FOR PARTICIPATION

Purpose and Explanation of Procedures

I, ________________________, hereby consent to voluntarily engage in the TWU

LEAD-UP Wellness Program. Initially, I will be involved in a wellness program only

where I am free to participate in the available exercise activities within the given program

hours. The levels of exercise I perform will be based upon my cardiorespiratory fitness

(heart and lungs) and my muscular fitness. I acknowledge it is required by the TWU

LEAD-UP Wellness Program that I am examined by a physician of my choice and

obtain his/her approval for my participation in the program. I have been given a medical

clearance form to be signed by my physician to authorize me to begin a supervised

walking program, in accordance to ACSM guidelines. Furthermore, within a twelve (12)

month period preceding the date of this release, I have not been advised by a physician or

other health care professional of any medical condition which would prevent me from

participating safely in a physical fitness or conditioning program. I will be given

instructions regarding the amount and type of exercise I should perform. I understand that

I am expected to follow my physician’s instructions with regard to any exercise and

fitness related programs. If I am taking prescribed medications, I have already so

informed the TWU LEAD-UP Wellness Program and further agree to inform the staff

of any changes which my physician or I have made with regard to use of any medications

or change in my medical status.

I have been informed that during my participation in the TWU LEAD-UP Wellness

Program, I will be allowed to engage in the available physical activities unless symptoms

such as fatigue, shortness of breath, chest discomfort or similar occurrences appear. At

that point, I have been advised that it is my complete right to decrease or stop exercise

and that it is my obligation to inform the staff of my symptoms. I hereby state that I have

been so advised and agree to inform the staff of my symptoms, should any develop.

I understand that during the performance of the wellness program or any other

assessments I consent to, physical touching and positioning of my body by the staff may

be necessary to assess my muscular and bodily reactions to specific exercises as well as

to ensure that I am using proper technique and body alignment. I expressly consent to the

physical contact for the stated reasons above.

Risks

It is my understanding and I have been informed that there exists the possibility during

exercise of adverse changes including, but not limited to, abnormal blood pressure,

fainting, physical dizziness, disorders of heart rhythm, and, less likely, heart attack,

stroke or even death. I further understand and have been informed that there exists the

risk of bodily injury including, but no limited to, injuries to the muscles, ligaments,

tendons and joints of the body. I have been advised that appropriate efforts will be made

to minimize these occurrences by proper assessments of my condition before each

session, staff supervision during exercise and by my own control of exercise efforts.

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I fully understand the risks associated with exercise, including the risk of bodily injury,

heart attack, stroke or even death, and knowing these risks, it is my desire to participate

as herein indicated.

Inquiries and Freedom of Consent

I have been given the opportunity to ask questions regarding the procedures of the

TWU LEAD-UP Wellness Program and I have received satisfactory answers to those

questions. I agree that TWU shall not be liable or responsible for any injuries to me

resulting from my participation in the TWU LEAD-UP Wellness Program (whether at

home, a health club or other fitness facility, outdoors, or other public places), and I

release and discharge TWU as a whole, its employees, agents and/or administrators or

assigns from any claims and suits as a result of any injury or other damage which may

occur in connection with my participation in the TWU LEAD-UP Wellness Program,

excepting only an injury caused by the gross negligence or intentional act of such person

or persons. This release shall be binding upon my heirs, executors, administrators and/or

other assigns. I have read this form and understand all of its terms. I consent to the

rendition of all services and procedures as explained herein by the TWU LEAD-UP

Wellness Program staff.

Participant Signature TWU LEAD-UP Staff Signature

Print Name Print Name

Date Date

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________________________________________________________________________

Date:___________________

PERSONAL INFORMATION

Name:______________________________ Birth Date:_________________

Gender: Male Female Age:_____

LocalAddress:____________________________________________________________

City/State:__________________________ Zip:__________

NOTE: As a LEAD-UP participant, you will receive a monthly newsletter and calendar.

You can receive it via mail or email. Please indicate below which you prefer by staring

(*) next to the information. Please still provide both pieces of information for our files.

Home Phone:____________________ Work Phone:___________________

Cell Phone:____________________ Email: ________________________

Emergency Contact:

Name: _____________________________ Relationship: __________________

Phone: _____________________________

Physician Information (required):

Name: ______________________________ Phone: _______________________

Address:

PAR-Q QUESTIONNAIRE

Yes No

___ ___ 1. Has your doctor ever said that you have a heart condition and that you

should only do physical activity recommended by a doctor?

___ ___ 2. Do you feel pain in your chest when you do physical activity?

___ ___ 3. In the past month, have you had chest pain when you were not doing

physical activity?

___ ___ 4. Do you lose your balance because of dizziness or do you ever lose

consciousness?

___ ___ 5. Do you have a bone or joint problem that could be made worse by a

change in your physical activity?

___ ___ 6. Is your doctor currently prescribing medication for your blood pressure

or heart condition?

___ ___ 7. Do you know of any other reason why you should not do physical

activity?

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HEALTH HISTORY INFORMATION

1. Have you ever been told that you have high blood pressure? ______

If yes, do you know what your blood pressure usually is: ______/______

2. Have you ever been told that you have high cholesterol? ______

Do you know your cholesterol level: ______

3. Do you currently use tobacco? ______

If yes, how many packs per day? ______ How many dips? ______

4. Do you have a family history of cardiovascular disease (heart disease)? ______

5. Have you ever been diagnosed with any type of cardiovascular disease? ______

If yes, what was the diagnosis? _________________________

6. Have you been diagnosed with diabetes______or borderline diabetes______?

If yes,

1. How long? __________________

2. What is your fasting glucose level? ____________ HgbA1c? ______

3. When was the last time you had either checked? ______

4. Do you monitor your glucose daily? ______

5. What medication(s) are you currently on for diabetes or borderline diabetes?

7. What medications are you currently taking? (please list all): _____________________

8. Do you currently take any vitamin/mineral or herbal supplements? (please list all):

9. What is your current weight? _________ Height: _________

How much did you weigh a year ago? _________ 5 years ago? _________

LIFESTYLE INFORMATION

1. Reasons for joining the TWU LEAD-UP Wellness Program?

___Weight Control/Loss ___Staying in Shape

___Cardiovascular Conditioning ___Increasing Strength

___Stress Reduction ___Physician request

___ To prevent diabetes diagnosis ___ To lower intake of diabetic medication

___ Improve health & overall well-being

___Other - ________________________________________________________

2. Have you ever participated in diabetes diet education consultation or program?

Yes______ No______ If yes, when? _____________________________

3. Have you met with a dietitian before? Yes ______ No _______

If yes, were you prescribed a specific diet? Yes ______ No _______

What type? ________________________

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4. Have you ever been on any special diet (fad or other)? Yes ______ No ______

If yes, what kind of diet(s)? __________________________________________

When? __________________________________________________________

Was there any component of the diet(s) that worked well?

5. Have you changed your eating habits in the last 6 months?

Yes ____ No ____

If yes, please explain:

6. How many times do you eat meals away from home each week?

Breakfast __________ Lunch __________ Dinner __________

7. When you eat away from home, where do you usually eat?

Cafeteria ______ Fast food _______ Dine-In restaurants ______ Car _____

Vending machines ______ Desk _________ Friends/Family homes _________

Other ____________________________________________________________

8. How is most of your food cooked?

Boiled _____ Fried ______ Baked _____ Broiled ______ Grilled _______

Other ___________________________________________________________

9. Do you drink beer, wine, or any other alcohol? Yes _____ No _____

If yes, what do you drink? ____________________________________________

How often? ________________________________________________________

10. Do you currently exercise on a regular basis (3-5 times per week)? ________

If yes, how many days? __________

What form(s) of exercise? ____________________________________________

11. How would you rank your current knowledge level about diabetes?

 Excellent  Good  Moderate  Poor  Extremely poor

12. What lifestyle habit(s) would you most like to change?

13. If you had to choose 2 main goals for yourself initially, what would they be?

1. ________________________________________________________________

2. ________________________________________________________________

How often do you plan on using the TWU LEAD-UP Program facilities for exercise?

(check appropriate boxes)

Monday Tuesday Wednesday Thursday Friday

6:30-8am

not available

11-1pm

5:30-7:30pm

not available

Thank you for the completion of this questionnaire. All information is kept confidential.

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Fillable Texas Woman’s University - ADA Lead-Up Welcome Packet and Forms

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