Download Risk factor form and physicians release - Providence

Risk Factor Identification Form
Name:
Date:
/
/
.
Check all that apply to you:
Age: Man over 45 or Woman over 55. (please circle which one)
Family History: Heart attack or sudden death before age 55 for father or any other male immediate family
member (brother) or heart attack or sudden death before age 65 for mother or any other female immediate
family member (sister).
Cigarette smoker: currently
High Cholesterol: >200mg/dl
Hypertension: Blood pressure above 140/90 mm Hg or taking hypertensive medication
Diabetes: Classified with disease as follows:
Non-insulin dependent >35 years of age
Insulin dependent >35 years of age
Sedentary Lifestyle: No physical activity
Personal Health history; check all that apply to you:
Loss of balance because of dizziness or loss of consciousness
Stroke
Pregnant
Asthma or other respiratory condition that causes difficulty when breathing.
If yes, please describe:
Orthopedic condition(s) that restricts physical activity
If yes, please describe:
Currently taking medications that may impact the ability to safely perform physical activity.
If yes, or unsure, please list medications:
I hereby attest that the above information is accurate and true to the best of my knowledge.
Signed:
Date:
/
/
.
FITNESS SPECIALIST USE ONLY:
Apparently Healthy: Asymptomatic with no more than one major coronary risk factors
*Increased risk: Has signs or symptoms suggestive of possible cardiopulmonary or metabolic disease
and/or 2 or more coronary risk factors.
*Known disease: Known cardiac, pulmonary or metabolic disease.
Physician’s Statement and Clearance Form
(Only necessary if you have 2 or more risk factors from above)
Providence Health & Service Fitness Centers, your safety is our primary concern. For that reason, we comply with the
health and fitness standards of the American College of Sports Medicine and the International Health, Racquet and
Sports club Association. On the Health History Questionnaire you completed, you identified that you have two or more
coronary and/ or medical risk factors that may impair your ability to exercise safely. For this reason, you need to have a
physician complete and return this medical clearance form before you begin exercising at a Providence Fitness Center.
We recognize that you are eager to start your fitness program, and we sincerely regret any inconvenience that this may
cause you. However, please keep in mind that we want your exercise experience to be as safe as possible.
In order to expedite this process, we will gladly fax this form directly to the physician of your choice. If the doctor is
aware of your medical history, he/she may be able to complete this form and fax it back right away. In many cases the
delay can be several days. I hereby give my physician permission to release any pertinent medical information to the
staff at Providence Health & Services Fitness Center. All information will be kept confidential.
Patient’s signature ___________________________
Date ___
_____
Physician’s name: ______________________________ Phone: _____________________ Fax: ______________________
Address: _____________________________________________________________________________________________
City: __________________________________________________________ State: _______
Zip:___________________
FOR FITNESS SPECIALIST USE ONLY:
Requesting release for your patient to exercise in a
X
STAFFED or
NON-STAFFED facility.
Information requested for (Name) ________________________________
Patients risk factor(s) __________________________________________________________________________________
____________________________________________________________________________________________________
FOR PHYSICIANS USE ONLY: Please check one of the following:
__ I concur with my patient’s participation in an exercise program with NO restrictions as stated above
__ I concur with my patient’s participation in an exercise program but with the following restrictions:
__ I do NOT concur with my patient’s participation in an exercise program at this time. (If checked, individual will not
be allowed to join any Providence Fitness Centers at this time)
Physician’s name (Type or print) _________________________________________________________________________
Physician’s signature _________________________________________________________ Date _____________________
PLEASE RETURN FAX TO:
X Mercantile Health & Fitness Center
Providence Portland Medical Center (Body Works)
Providence St. Vincent Medical Center (Wellness Works)
Fax: 503 216-6613
Fax: 503 215-6248
Fax: 503 216-2634
Phone: 503 216-6606
Phone: 503 215-6911
Phone: 503 216-2662