Download Client Health History Form for Active

Recreation Oak Bay ACTIVE REHABILITATION
CLIENT PACKAGE
Included in this package you will find:
o Par – Q, ParMed-X (to be completed by a physician)
o Health History Form
o Pricing Information
Instructions:
1. Please read and complete each form accurately and completely;
2. The ParMed-X form must be completed by your physician and returned
with all other forms;
3. When ALL forms are completed drop package off at either the Oak Bay
or Henderson Recreation Centres;
4. Purchase your Active Rehabilitation sessions when you drop off your
forms, please note you must purchase a minimum of TWO sessions;
5. Once payment is received you will be contacted within 72 hours by a
Rehab Specialist to set up your first appointment;
6. Rehab Trainers bio’s can be found at www.recreation.oakbay.ca
Please note:
o Packages expire after 1 year from the date of purchase
o 24 hours notice required for appointment cancellations
Cancellation Policy:
• 24 hours notice is required for appointment cancellations
• To cancel an appointment, first attempt to contact the trainer directly. If you are
unable to reach the trainer or if you leave a message, please also call our
reception at 250-595-7946 and provide them with your appointment date,
trainers name and reason for cancellation.
• If you cancel within 24 hours you may be charged for the appointment.
If you have any questions please call 250-370-7117
Thank-you.
Fitness Programmer
Recreation Oak Bay
PRICING INFORMATION
Based on your needs, abilities and comfort level choose either Active Rehabilitation in the Fitness Studio or Water
Rehabilitation in the Pool. Both methods of Rehab offer one-on one sessions that foster an environment conducive to
your needs. The Rehab Specialist will create an individualized program based on your abilities that will help you
achieve your goals.
If you are unsure how many sessions you will require, start by purchasing the minimum 2 sessions, and the Rehab
Specialist can advise you how many sessions you will need based on the first two appointments.
From your first two sessions you can expect:
•
Sessions 1: An assessment appropriate to your injury or condition to determine what type of program you will
require and what your limitations may be.
•
Session 2: The Rehab Specialist will deliver the program they created based on Session 1’s Assessment. The
trainer will make necessary recommendations for future appointments.
ACTIVE REHABILITATION (One-on One)
A medical exercise specialist will work with you in the fitness studio to develop a safe and effective program in a oneon one environment. Designed for those recovering from an injury due to sport, work or motor vehicle accident and
those who may have physical limitations due to musculoskeletal, neurological or respiratory illnesses. Active
Rehabilitation will help you improve your quality of life by allowing you to improve your function in everyday tasks.
Insurance coverage accepted.
1 hour/$63 – minimum of two sessions $126 + Tax
WATER REHABILITATION (One-on One)
The Water Rehabilitation program allows people the freedom of movement needed to be able to train when they would
otherwise not be able. Benefits of training in a water environment include anatomically balanced 3-dimensional
resistance, reduced impact and cooler temperatures. The individually tailored program builds full body strength,
endurance, and health propelling anyone towards an active and independent life. Insurance coverage accepted.
1 hour/$63 – minimum of two sessions $126 + Tax
SPECIALIZED PROGRAMS
• Joint Motion – Total Hip and Knee
Joint Motion - Total Hip and Knee is a personal training program designed for those returning from physiotherapy
following a major lower body joint replacement (hip, knee) to gain function and mobility. In this program, the trainer will
put you through a series of strengthening exercises using gym machines, bands, free weights, steps and agility balls to
challenge you in a gently progressive manner. Cardiovascular conditioning on stationary bikes, treadmills and ellipticals
will also be incorporated into each session. A personal 1 hour fitness assessment with the trainer prior to the first
session is required to assess your current strength and function. To participate, Medical Clearance is required.
Participants must have completed physiotherapy prior to the course and be at least 12 weeks post-surgery.
5 sessions
$284
Private Active Land or Water Rehabilitation (one on one)

2 Private Sessions
$126

5 Private Sessions
$284

10 Private Sessions
$504

15 Private Sessions
$709

Joint Motion – Total Hip and Knee
$284
*(Can be purchased as single sessions after a minimum of 2 sessions are purchased)
REHAB SPECIALISTS
Rehabilitation Specialists - Dry Land Rehabilitation

Amaiah Paradine – Dry Land Rehabilitation ONLY
- AAHFRP American Academy of Health, Fitness and Rehabilitation Professionals
-BCRPA Certified Personal Trainer
- Medical Exercise Specialist and Post-Rehabilitation Conditioning Specialist

Kamma Wiggins – Dry Land Rehabilitation ONLY
- Bachelor of Athletic & Exercise Therapy, Camosun College & (CATA) Canadian Athletic Therapists Association
- CSEP-CEP Certified Exercise Physiologist
-BCRPA Certified Personal Trainer
- Medical Exercise Specialist and Post-Rehabilitation Conditioning Specialist

Justin Wolfe – Dry Land Rehabilitation ONLY
- Bachelor of Sport & Fitness Leadership, Camosun College
- CSEP-CEP Certified Exercise Physiologist
- Certified Strength & Conditioning Specialist – National Strength and Conditioning Association, NSCA

Ryan Anderson – Dry Land Rehabilitation ONLY
- Bachelor of Kinesiology, Sport & Recreation Administration, University of Regina
-Certified Strength and Conditioning Specialist, National Strength and Conditioning Association, NSCA
Rehabilitation Specialists – Water Rehabilitation

Daniela Sigurgeirson - Water Rehab & Dry Land Rehabilitation
-CALA Certified Water Instructor, CALA Aqua Arthritis and Joint Specialist
-Canfit Pro Certified Personal Trainer
Client Details
Name
Phone: (h)
(c)
Address
Age
Postal Code
Email
Occupation
Referral Source (If any):
Emergency Contact
Phone
Doctor
Phone
Physiotherapist
Phone
Health History Form
1. Have you had any bone, joint or muscle injuries in the past? Check and Explain.
Shoulder
Knee
Hip
Ankle
Foot
Wrist
Neck
Head
Arm
Legs
Chest
Stomach
Lower Back
Upper Back
Other
_________________________________________________________________________________________________________
_________________________________________________________________________________________________________
_________________________________________________________________________________________________________
2. Do you have any chronic illnesses? Check and Explain.
Diabetes
Osteoporosis
Arthritis
Stroke
Asthma
Heart
Fibromyalgia
Thyroid
Kidney
Liver
Lung
Epilepsy
High Blood Pressure
High Cholesterol
Cancer
Other
_________________________________________________________________________________________________________
_________________________________________________________________________________________________________
_________________________________________________________________________________________________________
3. Do you take any medication?
Prescription Medication? Explain.
For Example Insulin, Coumadin, Etc.
_________________________________________________________________________________________________________
_________________________________________________________________________________________________________
Over-The-Counter Medication or Preparations? Explain.
For Example Herbal, Dietary, Etc.
_________________________________________________________________________________________________________
_________________________________________________________________________________________________________
4. Have you been under the care of a Physiotherapist/Chiropractor/other specialist  YES
 NO
If yes, who and how often?_________________________________________________________________________________
5. Have you had any surgery?
 YES  NO
If yes, please list:_________________________________________________________________________________________
6. What activities do you participate in currently? Explain.
_________________________________________________________________________________________________________
_________________________________________________________________________________________________________
7. What is your main concern/reason for pursuing Active Rehabilitation? Explain.
_________________________________________________________________________________________________________
_________________________________________________________________________________________________________
_________________________________________________________________________________________________________
8. What goals would you like to achieve through the Active Rehabilitation program?
_________________________________________________________________________________________________________
_________________________________________________________________________________________________________
_________________________________________________________________________________________________________
9. How many times per week would you like to meet with your trainer? ______________
10. How many times per week are you prepared to train on your own? _______________
11. Which location would you like to train at?
 Oak Bay Recreation Centre
 Henderson Recreation Centre
12. Which type of Active Rehabilitation are you purchasing today?

Water Rehab

Daniela Sigurgeirson

Dry Land Rehab

Amaiah Paradine

Kamma Wiggins

Justin Wolfe

Ryan Anderson
Availability
14. What days and times work best for you? Check all that apply.
Monday
Tuesday
Wednesday
Thursday
Friday
Sat/Sun
6-9am






9am-12pm






12-5pm






5-9pm






Questions? Please call 250-370-7117
Participation in Fitness Activity/Exercise/Personal Training Program
Recreation Oak Bay
Informed Consent Agreement
Thank you for participating in an Exercise/Personal Training program through Recreation Oak Bay. For your
health and safety, we request you read and understand the following information regarding an Exercise/Personal
Training program and sign the informed consent agreement.
I, ______________________________________________(Name),
declare that I intend to voluntarily participate in a Fitness/Exercise/Personal Training program at Recreation Oak
Bay including using the facilities, programs and services provided. I understand that the information provided
is educational and recreational in nature. I am responsible for my choices to use or apply, at my own risk, any
portion of the information or instruction I receive.
I am aware that there are risks associated with participating in a Fitness/Exercise/Personal Training program.
These risks may include, but are not limited to: physical injury or even death, discomfort or aggravation of an
existing or past injury. I am aware of the risks of physical injury including, but not limited to: muscle, ligament,
tendon and joint injuries of the body. I have been told that every effort will be made to minimize these risks by
staff supervision and direction during the Fitness/Exercise/Personal Training Activity.
I assume full responsibility during and after my participation in such Fitness/Exercise/Personal Training programs
and understand my participation is voluntary and I freely accept and assume full responsibility for all risks and
possibilities of personal injury, death or loss as a result of my participation in these activities.
I understand that I may stop, reduce or modify my involvement in any of the activities at any time and it is my
responsibility to do so in the event that I feel any physical discomfort including: chest discomfort, difficulty
breathing, lightheadedness, dizziness, fainting, nausea, joint or muscle injury etc.
I understand that part of the risk involved in undertaking any of the Fitness/Exercise/Personal Training program
activities is relative to my own level of fitness or health (physical, mental or emotional) and the awareness, care
and skill with which I conduct myself in any of the activities.
I have read the above list of possible risks associated with starting a Fitness/Exercise/Personal Training program
and I consent to taking the above risks by voluntarily participating in such activities through Recreation Oak Bay.
I declare that I have read, understood and agree to the contents of this Informed Consent Agreement.
Client/Guardian Name (Print): ______________________________________________
Client/Guardian Signature: ________________________________
Witness Name (Print): ____________________________________
Witness Signature: _________________________________
Date: __________________________
Privacy Information:
The personal information contained in this form is collected in accordance with the Freedom of Information and
Protection of Privacy Act and will only be used for the purpose for which it was collected.
PAR-Q & YOU
Physical Activity Readiness
Questionnaire - PAR-Q
(revised 2002)
(A Questionnaire for People Aged 15 to 69)
Regular physical activity is fun and healthy, and increasingly more people are starting to become more active every day. Being more active is very safe for most
people. However, some people should check with their doctor before they start becoming much more physically active.
If you are planning to become much more physically active than you are now, start by answering the seven questions in the box below. If you are between the
ages of 15 and 69, the PAR-Q will tell you if you should check with your doctor before you start. If you are over 69 years of age, and you are not used to being
very active, check with your doctor.
Common sense is your best guide when you answer these questions. Please read the questions carefully and answer each one honestly: check YES or NO.
YES
NO
If
you
answered
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 (for example, back, knee or hip) that could be made worse by a
change in your physical activity?
6.
Is your doctor currently prescribing drugs (for example, water pills) for your blood pressure or heart condition?
7.
Do you know of any other reason why you should not do physical activity?
YES to one or more questions
Talk with your doctor by phone or in person BEFORE you start becoming much more physically active or BEFORE you have a fitness appraisal. Tell
your doctor about the PAR-Q and which questions you answered YES.
• You may be able to do any activity you want — as long as you start slowly and build up gradually. Or, you may need to restrict your activities to
those which are safe for you. Talk with your doctor about the kinds of activities you wish to participate in and follow his/her advice.
• Find out which community programs are safe and helpful for you.
➔
NO to all questions
If you answered NO honestly to all PAR-Q questions, you can be reasonably sure that you can:
• start becoming much more physically active – begin slowly and build up gradually. This is the
safest and easiest way to go.
• take part in a fitness appraisal – this is an excellent way to determine your basic fitness so
that you can plan the best way for you to live actively. It is also highly recommended that you
have your blood pressure evaluated. If your reading is over 144/94, talk with your doctor
before you start becoming much more physically active.
DELAY BECOMING MUCH MORE ACTIVE:
• if you are not feeling well because of a temporary illness such as
a cold or a fever – wait until you feel better; or
• if you are or may be pregnant – talk to your doctor before you
start becoming more active.
PLEASE NOTE: If your health changes so that you then answer YES to
any of the above questions, tell your fitness or health professional.
Ask whether you should change your physical activity plan.
Informed Use of the PAR-Q: The Canadian Society for Exercise Physiology, Health Canada, and their agents assume no liability for persons who undertake physical activity, and if in doubt after completing
this questionnaire, consult your doctor prior to physical activity.
No changes permitted. You are encouraged to photocopy the PAR-Q but only if you use the entire form.
NOTE: If the PAR-Q is being given to a person before he or she participates in a physical activity program or a fitness appraisal, this section may be used for legal or administrative purposes.
"I have read, understood and completed this questionnaire. Any questions I had were answered to my full satisfaction."
NAME ________________________________________________________________________
SIGNATURE _______________________________________________________________________________
DATE______________________________________________________
SIGNATURE OF PARENT _______________________________________________________________________
or GUARDIAN (for participants under the age of majority)
WITNESS ___________________________________________________
Note: This physical activity clearance is valid for a maximum of 12 months from the date it is completed and
becomes invalid if your condition changes so that you would answer YES to any of the seven questions.
© Canadian Society for Exercise Physiology
Supported by:
Health
Canada
Santé
Canada
continued on other side...
PAR-Q & YOU
Choose a variety of
activities from these
three groups:
A D A’ S
AN
Physical Act ivit y Guide
Endurance
to Healthy Active Living
4 -7 days a week
Continuous activities
for your heart, lungs
and circulatory system.
Physical activity improves health.
Flexibility
Every little bit counts, but more is even
Get active your way –
4 -7 days a week
Gentle reaching, bending
and stretching activities to
keep your muscles relaxed
and joints mobile.
build physical activity
Strength
better – everyone can do it!
2-4 days a week
Activities against resistance
to strengthen muscles and
bones and improve posture.
into your daily life...
• at home
• at school
• at work
• at play
Starting slowly is very
safe for most people.
Not sure? Consult your
health professional.
• on the way
...that’s
active living!
For a copy of the
Guide Handbook and
more information:
1-888-334-9769, or
www.paguide.com
Eating well is also
important. Follow
Canada’s Food Guide
to Healthy Eating to
make wise food choices.
Increase
Endurance
Activities
Health
Canada
Increase
Flexibility
Activities
Increase
Strength
Activities
Reduce
Sitting for
long periods
Canadian Society for
Exercise Physiology
Santé
Canada
Physical Activity Readiness
Questionnaire - PAR-Q
(revised 2002)
Get Active Your Way, Every Day–For Life!
Scientists say accumulate 60 minutes of physical activity
every day to stay healthy or improve your health. As
you progress to moderate activities you can cut down to
30 minutes, 4 days a week. Add-up your activities in periods
of at least 10 minutes each. Start slowly… and build up.
Time needed depends on effort
Very Light Light Effort
60 minutes
Effort
• Strolling
• Dusting
•
•
•
•
Light walking
Volleyball
Easy gardening
Stretching
Moderate Effort Vigorous Effort Maximum
30 -60 minutes 20 -30 minutes Effort
•
•
•
•
•
•
Brisk walking
Biking
Raking leaves
Swimming
Dancing
Water aerobics
•
•
•
•
•
•
Aerobics
Jogging
Hockey
Basketball
Fast swimming
Fast dancing
• Sprinting
• Racing
Range needed to stay healthy
You Can Do It – Getting started is easier than you think
Physical activity doesn t have to be very hard. Build physical
activities into your daily routine.
• Walk whenever you can – get
off the bus early, use the stairs
instead of the elevator.
• Reduce inactivity for long
periods, like watching TV.
• Get up from the couch and
stretch and bend for a few
minutes every hour.
• Play actively with your kids.
• Choose to walk, wheel or
cycle for short trips.
• Start with a 10 minute walk –
gradually increase the time.
• Find out about walking and
cycling paths nearby and
use them.
• Observe a physical activity
class to see if you want to try it.
• Try one class to start – you don t
have to make a long-term
commitment.
• Do the activities you are doing
now, more often.
Benefits of regular activity:
Health risks of inactivity:
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
better health
improved fitness
better posture and balance
better self-esteem
weight control
stronger muscles and bones
feeling more energetic
relaxation and reduced stress
continued independent living in
later life
premature death
heart disease
obesity
high blood pressure
adult-onset diabetes
osteoporosis
stroke
depression
colon cancer
No changes permitted. Permission to photocopy
this document in its entirety not required.
Cat. No. H39-429/1998-1E ISBN 0-662-86627-7
C
C
...continued from other side
AN
A D A’ S
Physical Act ivit y Guide
to Healthy Active Living
Source: Canada's Physical Activity Guide to Healthy Active Living, Health Canada, 1998 http://www.hc-sc.gc.ca/hppb/paguide/pdf/guideEng.pdf
© Reproduced with permission from the Minister of Public Works and Government Services Canada, 2002.
FITNESS AND HEALTH PROFESSIONALS MAY BE INTERESTED IN THE INFORMATION BELOW:
The following companion forms are available for doctors' use by contacting the Canadian Society for Exercise Physiology (address below):
The Physical Activity Readiness Medical Examination (PARmed-X) – to be used by doctors with people who answer YES to one or more
questions on the PAR-Q.
The Physical Activity Readiness Medical Examination for Pregnancy (PARmed-X for Pregnancy) – to be used by doctors with pregnant
patients who wish to become more active.
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.
For more information, please contact the:
Canadian Society for Exercise Physiology
202-185 Somerset Street West
Ottawa, ON K2P 0J2
Tel. 1-877-651-3755 • FAX (613) 234-3565
Online: www.csep.ca
© Canadian Society for Exercise Physiology
Supported by:
The original PAR-Q was developed by the British Columbia Ministry of Health. It has
been revised by an Expert Advisory Committee of the Canadian Society for Exercise
Physiology chaired by Dr. N. Gledhill (2002).
Disponible en français sous le titre «Questionnaire sur l'aptitude à l'activité physique
- Q-AAP (revisé 2002)».
Health
Canada
Santé
Canada
PARmed-X
Physical Activity Readiness
Medical Examination
(revised 2002)
PHYSICAL ACTIVITY READINESS
MEDICAL EXAMINATION
The PARmed-X is a physical activity-specific checklist to be used by a physician with patients
who have had positive responses to the Physical Activity Readiness Questionnaire (PAR-Q). In addition, the
Conveyance/Referral Form in the PARmed-X can be used to convey clearance for physical activity participation,
or to make a referral to a medically-supervised exercise program.
Regular physical activity is fun and healthy, and increasingly more people are starting to become more active every day. Being more active
is very safe for most people. The PAR-Q by itself provides adequate screening for the majority of people. However, some individuals may
require a medical evaluation and specific advice (exercise prescription) due to one or more positive responses to the PAR-Q.
Following the participant's evaluation by a physician, a physical activity plan should be devised in consultation with a physical activity
professional (CSEP-Professional Fitness & Lifestyle Consultant or CSEP-Exercise Therapist™). To assist in this, the following instructions
are provided:
PAGE 1:
• Sections A, B, C, and D should be completed by the participant BEFORE the examination by the physician. The bottom
section is to be completed by the examining physician.
PAGES 2 & 3:
PAGE 4:
• A checklist of medical conditions requiring special consideration and management.
• Physical Activity & Lifestyle Advice for people who do not require specific instructions or prescribed exercise.
• Physical Activity Readiness Conveyance/Referral Form - an optional tear-off tab for the physician to convey clearance for
physical activity participation, or to make a referral to a medically-supervised exercise program.
A
This section to be completed by the participant
PERSONAL INFORMATION:
NAME ______________________________________________________
B
ADDRESS ___________________________________________________
____________________________________________________________
TELEPHONE_________________________________________________
BIRTHDATE _______________________________ GENDER _________
PAR-Q:
Please indicate the PAR-Q questions to
which you answered YES

Q1
Heart condition

Q2
Chest pain during activity

Q3
Chest pain at rest

Q4
Loss of balance, dizziness

Q5
Bone or joint problem

Q6
Blood pressure or heart drugs

Q7
Other reason:
MEDICAL No. ________________________________________________
C
____________________________________
RISK FACTORS FOR CARDIOVASCULAR DISEASE:
Check all that apply
 Less than 30 minutes of moderate physical
activity most days of the week.
 Excessive accumulation of fat around
waist.
 Currently smoker (tobacco smoking 1 or
more times per week).
 Family history of heart disease.
D
 High cholesterol level reported by physician.
What physical activity do you intend to do?
________________________________________
Please note: Many of these risk factors
are modifiable. Please refer to page 4
and discuss with your physician.
 High blood pressure reported
by physician after repeated measurements.
PHYSICAL ACTIVITY
INTENTIONS:
________________________________________
________________________________________
This section to be completed by the examining physician
Physical Activity Readiness Conveyance/Referral:
Physical Exam:
Ht
Wt
BP
i)
/
BP
ii)
/
 Respiratory
 Abdominal
 Other
Information:
Attached
To be forwarded
Available on request
 Progressive physical activity:
 with avoidance of: _________________________________
 with inclusion of: __________________________________
Tests required:
 ECG
 Blood
 No physical activity
Further



 Only a medically-supervised exercise program until further
medical clearance
Conditions limiting physical activity:
 Cardiovascular
 Musculoskeletal
Based upon a current review of health
status, I recommend:
 Exercise Test
 Urinalysis
© Canadian Society for Exercise Physiology
 X-Ray
 Other
 under the supervision of a CSEP-Professional Fitness &
Lifestyle Consultant or CSEP-Exercise Therapist™
 Unrestricted physical activity–start slowly and build up gradually
Supported by:
Health
Canada
Santé
Canada
1
Physical Activity Readiness
Medical Examination
(revised 2002)
PARmed-X
PHYSICAL ACTIVITY READINESS
MEDICAL EXAMINATION
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 judgement in
each individual instance.
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 of exercise program
may be desirable.
Cardiovascular
 aortic aneurysm (dissecting)
 aortic stenosis (moderate)
 aortic stenosis (severe)
 subaortic stenosis (severe)
 congestive heart failure
 marked cardiac enlargement
 crescendo angina
 supraventricular dysrhythmias
(uncontrolled or high rate)
 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)
Infections
Metabolic
 acute infectious disease
(regardless of etiology)
 ventricular ectopic activity
(repetitive or frequent)
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.
ADVICE
 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
 ventricular aneurysm
 hypertension—untreated or
uncontrolled severe (systemic
or pulmonary)
• complete AV block
• left BBB
• Wolff-Parkinson-White
syndrome
 hypertrophic cardiomyopathy
 dysrhythmias—controlled
 compensated congestive heart
failure
 fixed rate pacemakers
• 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).
 intermittent claudication
progressive exercise to tolerance
 hypertension: systolic
160-180; diastolic 105+
progressive exercise; care with
medications (serum electrolytes;
post-exercise syncope; etc.)
 subacute/chronic/recurrent
infectious diseases (e.g.,
malaria, others)
 chronic infections
variable as to condition
 uncontrolled metabolic
disorders (diabetes mellitus,
thyrotoxicosis, myxedema)
 renal, hepatic & other
metabolic insufficiency
variable as to status
 obesity
dietary moderation, and initial light
exercises with slow progression
(walking, swimming, cycling)
 HIV
 single kidney
Pregnancy
• clinical exercise test may be
warranted in selected cases,
for specific determination
of functional capacity and
limitations and precautions
(if any).
 complicated pregnancy
(e.g., toxemia, hemorrhage,
incompetent cervix, etc.)
References:
Arraix, G.A., Wigle, D.T., Mao, Y. (1992). Risk Assessment of Physical
Activity and Physical Fitness in the Canada Health Survey FollowUp 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.
 advanced pregnancy (late 3rd
trimester)
refer to the "PARmed-X for
PREGNANCY"
The PAR-Q and PARmed-X were developed by the British Columbia
Ministry of Health. They have been revised by an Expert Advisory
Committee of the Canadian Society for Exercise Physiology chaired
by Dr. N. Gledhill (2002).
No changes permitted. You are encouraged to
photocopy the PARmed-X, but only if you
use the entire form.
Disponible en français sous le titre
«Évaluation médicale de l'aptitude à l'activité physique (X-AAP)»
Continued on page 3...
2
Physical Activity Readiness
Medical Examination
(revised 2002)
Special Prescriptive
Conditions
Lung
 chronic pulmonary disorders
 obstructive lung disease
ADVICE
special relaxation and breathing exercises
breath control during endurance exercises to tolerance; avoid polluted air
 asthma
Musculoskeletal
CNS
Blood
Medications
 exercise-induced bronchospasm
avoid hyperventilation during exercise; avoid extremely cold conditions; warm up adequately;
utilize appropriate medication.
 low back conditions (pathological, functional)
avoid or minimize exercise that precipitates or exasperates e.g., forced extreme flexion,
extension, and violent twisting; correct posture, proper back exercises
 arthritis—acute (infective, rheumatoid; gout)
treatment, plus judicious blend of rest, splinting and gentle movement
 arthritis—subacute
progressive increase of active exercise therapy
 arthritis—chronic (osteoarthritis and above
conditions)
maintenance of mobility and strength; non-weightbearing exercises to minimize joint trauma
(e.g., cycling, aquatic activity, etc.)
 orthopaedic
highly variable and individualized
 hernia
minimize straining and isometrics; stregthen abdominal muscles
 osteoporosis or low bone density
avoid exercise with high risk for fracture such as push-ups, curl-ups, vertical jump and trunk
forward flexion; engage in low-impact weight-bearing activities and resistance training
 convulsive disorder not completely controlled by
medication
minimize or avoid exercise in hazardous environments and/or exercising alone (e.g.,
swimming, mountainclimbing, etc.)
 recent concussion
thorough examination if history of two concussions; review for discontinuation of contact
sport if three concussions, depending on duration of unconsciousness, retrograde amnesia,
persistent headaches, and other objective evidence of cerebral damage
 anemia—severe (< 10 Gm/dl)
control preferred; exercise as tolerated
 electrolyte disturbances
 antianginal
 antiarrhythmic
 antihypertensive
 anticonvulsant
 beta-blockers
 digitalis preparations
 diuretics
 ganglionic blockers
NOTE: consider underlying condition. Potential for: exertional syncope, electrolyte
imbalance, bradycardia, dysrhythmias, impaired coordination and reaction time, heat
intolerance. May alter resting and exercise ECG's and exercise test performance.
 others
Other
 post-exercise syncope
moderate program
 heat intolerance
prolong cool-down with light activities; avoid exercise in extreme heat
 temporary minor illness
postpone until recovered
 cancer
if potential metastases, test by cycle ergometry, consider non-weight bearing exercises;
exercise at lower end of prescriptive range (40-65% of heart rate reserve), depending
on condition and recent treatment (radiation, chemotherapy); monitor hemoglobin and
lymphocyte counts; add dynamic lifting exercise to strengthen muscles, using machines
rather than weights.
*Refer to special publications for elaboration as required
The following companion forms are available online: http://www.csep.ca/forms.asp
The Physical Activity Readiness Questionnaire (PAR-Q) - a questionnaire for people aged 15-69 to complete before becoming much more physically
active.
The Physical Activity Readiness Medical Examination for Pregnancy (PARmed-X for PREGNANCY) - to be used by physicians with pregnant
patients who wish to become more physically active.
For more information, please contact the:
Canadian Society for Exercise Physiology
202 - 185 Somerset St. West
Ottawa, ON K2P 0J2
Tel. 1-877-651-3755 • FAX (613) 234-3565 • Online: www.csep.ca
Note to physical activity professionals...
It is a prudent practice to retain the completed Physical Activity
Readiness Conveyance/Referral Form in the participant's file.
© Canadian Society for Exercise Physiology
Supported by:
Health
Canada
Santé
Canada
Continued on page 4...
3
C
PARmed-X
PHYSICAL ACTIVITY READINESS
MEDICAL EXAMINATION
Get Active Your Way, Every Day–For Life!
Choose a variety of
activities from these
three groups:
A D A’ S
AN
Scientists say accumulate 60 minutes of physical activity
every day to stay healthy or improve your health. As
you progress to moderate activities you can cut down to
30 minutes, 4 days a week. Add-up your activities in periods
of at least 10 minutes each. Start slowly… and build up.
Physical Act ivit y Guide
Endurance
to Healthy Active Living
4 -7 days a week
Continuous activities
for your heart, lungs
and circulatory system.
Physical activity improves health.
Time needed depends on effort
Flexibility
Every little bit counts, but more is even
Get active your way –
4 -7 days a week
Gentle reaching, bending
and stretching activities to
keep your muscles relaxed
and joints mobile.
build physical activity
Strength
better – everyone can do it!
2-4 days a week
Activities against resistance
to strengthen muscles and
bones and improve posture.
into your daily life...
• at home
• at school
• at work
• at play
• on the way
active living!
For a copy of the
Guide Handbook and
more information:
1-888-334-9769, or
www.paguide.com
Eating well is also
important. Follow
Canada’s Food Guide
to Healthy Eating to
make wise food choices.
Increase
Endurance
Activities
Health
Canada
Increase
Flexibility
Activities
Increase
Strength
Activities
Reduce
Sitting for
long periods
Canadian Society for
Exercise Physiology
Santé
Canada
• Strolling
• Dusting
•
•
•
•
Light walking
Volleyball
Easy gardening
Stretching
•
•
•
•
•
•
Brisk walking
Biking
Raking leaves
Swimming
Dancing
Water aerobics
•
•
•
•
•
•
Aerobics
Jogging
Hockey
Basketball
Fast swimming
Fast dancing
• Sprinting
• Racing
Range needed to stay healthy
You Can Do It – Getting started is easier than you think
Physical activity doesn t have to be very hard. Build physical
activities into your daily routine.
• Walk whenever you can – get
off the bus early, use the stairs
instead of the elevator.
• Reduce inactivity for long
periods, like watching TV.
• Get up from the couch and
stretch and bend for a few
minutes every hour.
• Play actively with your kids.
• Choose to walk, wheel or
cycle for short trips.
Starting slowly is very
safe for most people.
Not sure? Consult your
health professional.
...that’s
Moderate Effort Vigorous Effort Maximum
30 -60 minutes 20 -30 minutes Effort
Very Light Light Effort
60 minutes
Effort
• Start with a 10 minute walk –
gradually increase the time.
• Find out about walking and
cycling paths nearby and
use them.
• Observe a physical activity
class to see if you want to try it.
• Try one class to start – you don t
have to make a long-term
commitment.
• Do the activities you are doing
now, more often.
Benefits of regular activity:
Health risks of inactivity:
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
better health
improved fitness
better posture and balance
better self-esteem
weight control
stronger muscles and bones
feeling more energetic
relaxation and reduced stress
continued independent living in
later life
premature death
heart disease
obesity
high blood pressure
adult-onset diabetes
osteoporosis
stroke
depression
colon cancer
No changes permitted. Permission to photocopy
this document in its entirety not required.
Cat. No. H39-429/1998-1E ISBN 0-662-86627-7
C
Physical Activity Readiness
Medical Examination
(revised 2002)
AN
A D A’ S
Physical Act ivit y Guide
to Healthy Active Living
Source: Canada's Physical Activity Guide to Healthy Active Living, Health Canada, 1998 http://www.hc-sc.gc.ca/hppb/paguide/pdf/guideEng.pdf
© Reproduced with permission from the Minister of Public Works and Government Services Canada, 2002.

PARmed-X Physical Activity Readiness Conveyance/Referral Form
Based upon a current review of the health status of _______________________________________________ , I recommend:

No physical activity

Only a medically-supervised exercise program until further medical clearance

Progressive physical activity

with avoidance of: _______________________________________________

with inclusion of: ________________________________________________

under the supervision of a CSEP-Professional Fitness &
Further



Information:
Attached
To be forwarded
Available on request
Physician/clinic stamp:
Lifestyle Consultant or CSEP-Exercise Therapist™

Unrestricted physical activity — start slowly and build up gradually
_______________________________________________ M.D.
4
_________________________________________ 20_______
(date)
NOTE: This physical activity clearance is valid
for a maximum of six months from the date
it is completed and becomes invalid if your
medical condition becomes worse.
FITNESS - REHABILITATION
24
with Justin Wolfe
Take Heart Cardiac Rehabilitation
Henderson Recreation Centre Fitness Studio
TAKE HEART ASSESSMENT
1 session for $60
TAKE HEART - 12 WEEK COURSE
$339
For people who have had a cardiac event or those who have heart
disease risks. The course includes an individual assessment and
exercise prescription followed by 3 months of twice weekly sessions.
Senior Fitness Testing
The Senior Fitness Test is a series of effective assessment
exercises used to evaluate the functional fitness of older adults
including aerobic capacity, strength and flexibility.
Test results are used to highlight areas of limitation to aid in
program recommendation and suggested exercise prescription.
Take Heart is a partnership between VIHA, the Victoria Inter-Municipal
Recreation Centres & YMCA-YWCA.
For Take Heart information or appointments
please call Jenny Rhodes at 250-370-7120.
TAKE HEART MAINTENANCE
For participants who have completed the 12-week course.
Participants referred from other programs need to have an assessment.
137768
Mon,Wed 10-11:30am
Sep 7-28
7/$60
137772
Mon,Wed 11:30am-1pm
Sep 7-28
7/$60
137769
Mon,Wed 10-11:30am
Oct 3-31
8/$69
137773
Mon,Wed 11:30am-1pm
Oct 3-31
8/$69
137770
Mon,Wed 10-11:30am
Nov 2-30
9/$78
137774
Mon,Wed 11:30am-1pm
Nov 2-30
9/$78
137771
Mon,Wed 10-11:30am
Dec 5-21
6/$51
137775
Mon,Wed 11:30am-1pm
Dec 5-21
6/$51
Designed for those recovering from injury due to sport, work, or motor
vehicle accident and those who may have physical limitations due
to musculo-skeletal, neurological or respiratory illnesses.
137777
Tue,Fri
1:30-3pm
Sep 2-30
9/$78
137875
Tue,Fri
3-4:30pm
Sep 2-30
9/$78
137872
Tue,Fri
1:30-3pm
Oct 4-28
8/$69
This program will help you improve your quality of life by allowing you
to improve your function in everyday tasks and increase mobility.
Insurance coverage accepted.
137876
Tue,Fri
3-4:30pm
Oct 4-28
8/$69
137873
Tue,Fri
1:30-3pm
Nov 1-29
8/$69
137877
Tue,Fri
3-4:30pm
Nov 1-29
8/$69
• Minimum 2 sessions $126 ($63 per session hour)
Tax not included.
137874
Tue,Fri
1:30-3pm
Dec 2-23
7/$60
137879
Tue,Fri
3-4:30pm
Dec 2-23
7/$60
1 Hour 1/$63
Active Rehabilitation
Active Rehabilitation
The Active Rehabilitation program will assist you in developing a
safe and effective program in a one-on-one environment within the
fitness studios.
Water Rehabilitation
The Water Rehabilitation program allows people the freedom
of movement needed to be able to train when they would otherwise
not be able. Benefits of training in a water environment include
anatomically balanced 3-dimensional resistance, reduced impact
and cooler temperature.
The individually tailored program builds full body strength, endurance,
and health propelling anyone towards an active and independent life.
Insurance coverage accepted.
• Minimum 2 sessions $126 ($63 per session hour)
Tax not included.
From your first two Active Rehab sessions you can expect:
Session 1:
An assessment appropriate to your injury or condition
to determine what type of program you will require.
Session 2:
The Rehab Specialist will deliver the program they
create based on Session #1’s assessment. The trainer will
make necessary recommendations for future appointments.
Call 250-370-7117 for more details
Tax exempt
Joint Motion Personal Training
JOINT MOTION – TOTAL HIP AND KNEE
Are you returning from physiotherapy following a major lower body
joint replacement (hip, knee) and would like to increase your fitness
and function?
Joint Motion - Total Hip and Knee is a personal training program
designed to meet your fitness needs to gain function and mobility. In
this program, the trainer will put you through a series of strengthening
exercises using gym machines, bands, free weights, steps and agility
balls to challenge you in a gently progressive manner.
Cardiovascular conditioning on stationary bikes, treadmills and
ellipticals will also be incorporated into each session.
A personal 1 hour fitness assessment with the trainer prior to the first
session is required to assess your current strength and function.
To participate, medical clearance is required. Participants must have
completed physiotherapy prior to the course and be at least 12 weeks
post-surgery.
5 sessions
$284