ࡱ> dfc[ "bjbjmm 4Lbbnzzzzz8$AnnnnnIII@@@@@@@$CE@zII@zznn@Fznzn@@{*h+nY. 4*{@@0A*F F +Fz+I|sdIII@@IIIAFIIIIIIIIIB @: ˾ Employee Wellness Program Physical Fitness Readiness Questionnaire Name: ______________________ Age: ______ Date of Birth: _________ Email: __________________________________ Phone Number: ________________________ Emergency Contact and Phone Number: _______________________________________ Membership Type: Student Faculty Staff ˾ Alumni Domestic Partner Other: _________________ What Type of exercise interest you? (Check all that apply) Cardio Machines Jogging, running, walking Strength Training Flexibility training How much time per week are you willing to devote to an exercise program? Minutes/Day: _____________ Days/Week: _________________________ How often would you like to work with a trainer? _______________________________ Why do you want to sign up for personal training? _______________________________ Do you have a specific training you are requesting? ______________________________ Please list any activities you are currently doing. Training Availability (list time in availably block of each day so we can match with a trainer) Monday____________________ Tuesday ____________________ Wednesday: _________________ Thursday: ___________________ Friday: ______________________ Saturday: ____________________ Sunday: ______________________ Please initial to indicate that you have read and understood our policies. ___ I understand that personal training sessions expire one year from the date of purchase. ___ I understand that personal training sessions are non-refundable and non-transferable, unless a doctors not is provided. ___ I understand that if my health changes, I will notify my trainer and complete a new health history form. OVER This survey will help you determine if you are ready to participate in a vigorous physical activity program. For most people physical activity should not pose any problem or hazard. This questionnaire will help identify those small number of adults for whom vigorous physical activity might be inappropriate or for those people who should have medical advice about the kinds of activities or intensity levels most suitable for them. Common sense is the best guide in answering these questions. Please read each question carefully and check either yes or no for each one. YES____NO____1. Has your doctor ever said you have heart trouble? YES____NO____2. Have you ever had chest pain or heavy pressure in your chest as a result of exercise, walking, or other physical activity such as climbing a flight of stairs? YES____NO____3. Do you ever feel faint or experience severe dizziness? YES____NO____4. Has a doctor ever told you that you have high blood pressure or diabetes? YES____NO____5. Have you ever had a real or expected heart attack or stroke? YES____NO____6. Do you have any physical condition, impairment or disability, including any joint or muscle problems, that should be considered before you begin an exercise program? YES____NO____7. Have you ever taken medication to reduce your blood pressure or your cholesterol levels? YES____NO____8. Are you excessively overweight?YES____NO____9. Is there any good physical reason not mentioned here why you should not follow an activity program even if you wanted to? YES____NO____10. Are you over age 35 and not accustomed to vigorous exercise? YES____NO____11. Are you pregnant? If you answered YES to one or more questions, and if you have not recently done so, consult with your doctor by phone or in person BEFORE starting an exercise program. Ask your doctor if you may participate in: Unrestricted physical activity on a gradually increasing basis OR 2) Restricted activity to meet your specific needs. If you answered NO to ALL questions, you have reasonable assurance that you may begin a graduated exercise program or have an exercise test. ˾ Employee Wellness Program Participation in State Agency Fitness Program Waiver The undersigned desires to voluntarily participate in the programs and/or use the facilities and equipment provided by ˾, through the Department of Recreational Sports/Wellness Programs for the purpose of personal fitness. In consideration of the right and privilege of being permitted to participate in these programs and/or have access to and use the said facilities and equipment, the: ____undersigned does hereby agree to the conditions set forth herein and acknowledges that the voluntary participation in the aforementioned programs and/or access to and use of the facilities and equipment is not a condition of employment, is not related to his or her employment and therefore; the undersigneds participation in the aforesaid programs and/or use of facilities and equipment, should any injury occur, will not be covered by workers compensation. ____undersigned acknowledges that he or she is fully aware that there are risks for certain individuals participating in activities involving physical exertion. ____undersigned affirmatively acknowledges that he or she has obtained independent medical approval, or satisfactorily completed the Physical Fitness Readiness Questionnaire provided by ˾, prior to participating in these programs and/or using these facilities or equipment, for any activities involving physical exertion and has no knowledge of any physical condition or disease which would preclude his or her participation in these programs and/or use of these facilities or equipment. ____undersigned specifically agrees to withdraw from the programs and/or discontinue use of these facilities and equipment should he or she become aware by any means whatsoever that participation is medically contraindicated. ____undersigned agrees to notify the wellness director if he or she detects any hazards or defects in any of the facilities or equipment to which he or she is allowed access for these activities. ____undersigned agrees to accept full responsibility for any injuries sustained while participating in a fitness program or using facilities and equipment made available for that purpose if he or she fails to meet these conditions described herein under which access to and use of the programs, facilities and/or equipment is being allowed. 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")Segoe UI?= *Cx Courier New;WingdingsA$BCambria Math"h1X@X@X } /} /!824aa3QHP ?L2!xxZvd 5Midwestern State University Employee Wellness ProgramA Valued MWSU Customer Reay, Angie      Oh+'0 $4 HT t   8˾ Employee Wellness ProgramA Valued MWSU CustomerNormal Reay, Angie7Microsoft Office Word@H'@@n@}՜.+,04 hp  ˾/ a 6˾ Employee Wellness Program Title  !"#$%&()*+,-.0123456789:;<=>?@ABCDEFGHIJKLMNOPQRTUVWXYZ\]^_`abeRoot Entry F@37 gData '1Table/FWordDocument4LSummaryInformation(SDocumentSummaryInformation8[CompObjr  F Microsoft Word 97-2003 Document MSWordDocWord.Document.89q