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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