Membership Signup Process. Initial Assessment. Orientation. Blood Work

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1 Welcome to Huntsville Hospital Wellness Center! Below are some guidelines to help you begin your membership with us. Membership Signup Process Please complete paperwork and return it to the front desk. At this time, payment is required for your Assessment/ Orientation and first month s dues. Please be sure to choose a payment method for your future dues. If you decided on bank draft, please provide a voided check. If you would not like payment by automatic billing, we request that dues be paid a minimum of three months at a time. Your Assessment and Orientation appointments are made at this time and you should receive a form to have your blood drawn at our laboratory. You may begin using the facility as soon as you join! Anytime you come to the facility, you should be in comfortable clothes, ready to work out!! The two appointments will consist of the following: Initial Assessment - Test will take minutes, testing includes measurements of strength, flexibility, cardiovascular fitness, muscle endurance, body composition and measurements, blood pressure and heart rate. - Wear comfortable clothing for exercising (ex. shorts, sweats, T-shirt, athletic shoes, no footed tights or pantyhose). - Do not exercise before your appointment. - DO NOT eat a heavy meal for four hours prior to appointment. - Be well hydrated-drink plenty of water before your appointment. No caffeinated or alcoholic beverages. Orientation - Appointment will take approximately 1 hour. - Results from your Health/Lifestyle Questionnaire, blood work and fitness assessment are discussed at this time. - Your personal exercise program is designed at this time. You will physically go through your program so dress appropriately. Blood Work - No appointment necessary to have blood drawn, however you must have a blood work form (available at our front desk). - Lipid profile, total cholesterol, HDL cholesterol, cholesterol/ HDL ratio, triglycerides and glucose are measured. - Blood work is separate from the Assessment and Orientation and should be done at least 3 days prior to your Orientation; it can be done before or after your Assessment. - Please see blood work form for Lab location and operating hours nearest you. - A 12 hour fast is recommended for accurate results. You may either have water, black coffee or coffee with sweetener and any medications you are currently taking. Diabetics, please follow regular eating schedule.

2 Rules and Regulations 1. All members must check into the center each visit by either manually entering their member ID or by scanning key tag. 2. Memberships are non-transferable. One-Time Payment Options are not refundable. 3. Any member may be expelled by the management. Cause for expulsion may consist of any violation of the Rules and Regulations of the Center, or any conduct which in the opinion of the management is detrimental to the welfare or character of the center. 4. Membership definitions: a. Individual: 22 years or older for independent use of facility. b. Youth: Applicants years must have parent or legal guardian co-sign application. Members must have parent, guardian or responsible adult supervision while in the center. c. Spouse: Member who is legally married to an Individual Member. d. Family: Membership for immediate family (mother, father, sons and/or daughters) residing together (with accommodations made for children residing elsewhere i.e. college, etc.) e. Corporate: Membership for current employees of companies with at least 3 members of center. 5. Leave of Absence (LOA) may be granted for medical, military, job or school issues. Member must fill out the LOA form (prior to the 20 th of the month before the LOA is to start), pay a $10 processing fee and have a current, paid in full membership. LOA s are granted for up to a 3 month basis. LOA s are not intended for non-use of facility. 6. Members who are terminating membership must present written notification prior to the 20 th day of the previous month before termination. Huntsville Hospital employees who payroll deduct their dues should give 30 day notice of termination to allow for payroll deduction to be stopped. There is a $50 reinstatement fee if the member wishes to rejoin within 6 months of termination. This fee does not include an assessment. After 6 months, the membership fee will be at current initial pricing. 7. All members and guests must be clothed appropriately at all times. Cut off blue jeans are not permitted. Swim suits or the like are required in the sauna, steam room, whirlpool and pool. Pool shoes are encouraged in those areas. Swim suits are not permitted in the gym or aerobic area. Closed-toed shoes must be worn to workout in the gym area. 8. Lockers are provided for member use. Members are responsible for their own personal possessions and keeping lockers locked while using the facility. Lockers are not permitted for overnight use. The center or its employees will not be responsible for items placed in lockers. 9. Showers are required prior to using the sauna, whirlpool, steam room and pool. Showers are also required after the sauna/steam room IF the member is going to the pool/whirlpool. 10. Sauna/Steam room/whirlpool should be limited to 15 minutes of total use per member. For some members, these areas may cause undue cardiovascular stress. Elderly persons and those suffering from heart disease, diabetes, high or low blood pressure, have open wounds, infections virus or diseases, or who are pregnant should not use these areas. 11. In the event of thunder/lightning in the area, the pool/whirlpool area will be closed down until 30 minutes after the last episode of thunder/lightning. 12. Diving in the pool is prohibited. There is no lifeguard on duty and members swim at their own risk. Do not enter the pool if you have an open wound, infectious virus or disease. 13. Smoking, smokeless tobacco, alcohol or the use of non prescription drugs are strictly prohibited within the center. Food and open containers of beverages are prohibited in the gym area. 14. It is prohibited for anyone, other than an authorized law enforcement officers to bring or have in possession a weapon, explosive or other items classified by law as a weapon at the center. 15. Play care is available for the centers members and guests. Specific guidelines will be provided upon enrollment in that program. 16. The fitness equipment in this facility presents hazards which, if not avoided, could cause serious injury or death. Read warning labels and instructions. Seek assistance if you have questions. Immediately report improperly working equipment to staff. Do not attempt to repair any malfunctioning equipment.

3 Membership Application First: MI: Last: Sex: ( ) Male ( ) Female Address: DOB: City, State, Zip: SS: Phone: ( ) Home ( ) Cell ( ) Work Phone: ( ) Home ( ) Cell ( ) Work Employer: Referred by: Emergency contact: Phone: Relation: PAYMENT INFORMATION ( ) Automatic billing by Checking / Savings Account (must have voided check) Bank name: Account number: ( ) Automatic billing by credit card Master Card / Visa account number: Expiration date: ( ) Payroll deduction (Huntsville Hospital employees only) Employee ID: I hereby authorize Huntsville Hospital Wellness Center to initiate debit entries as shown in this application. I may cancel this authorization in writing with a 30 day notice. Applicant s signature Date ( ) No automatic billing (must pay 3 months in advance) Applicant s signature / date FOR OFFICE USE ONLY: Employee initials: MEMBER ID: Today s date: Member type: Assessment/Orientation Amount: $ Date joined: Monthly dues: $ Payment type: Prorated Amount: $ Key tag: $ Keytag barcode #: Total paid: $ Date to begin auto billing / expiration date:

4 Name: Height: Weight: Age/Gender: Yes No Has a doctor ever diagnosed you with a heart condition? If yes, please list Cardiologist's name: Yes No Has a doctor ever recommended medication for a heart condition? If yes, please list any current medications: Yes No Do you have breathing problems (COPD, chronic bronchitis, symptomatic asthma)? If yes, please list doctor's name: Yes No Do you have a kidney, liver, or thyroid disorder? If yes, please list doctor's name: Yes No Has a doctor ever diagnosed you with Cancer? If yes, please list Oncologist's name: Yes No Do you have Diabetes? If yes, circle one: Type 1 or Type 2 How long? If yes, please list doctor's name: Yes No Have you ever had a stroke or TIA (Transcient Ischemic Attack)? If yes, please list doctor's name: SECTION B Yes No Do you have pain in your legs when walking moderate distances? Yes No Do you have chest pain brought on by physical activity? Yes No Have you had any problems with dizziness, fainting or seizures? If yes, circle one. Yes No Do your ankles swell (edema)? Yes No Do you have bone or joint problems that could be aggravated by physical activity? Yes No Do you get short of breath with mild exertion? Yes No Has a doctor ever recommended medication for your blood pressure? Please list meds. below. Yes No Has your total cholesterol been measured at greater than 200mg/dl? Please list meds. below. Yes No Has your doctor ever said that your blood sugar is too high (Fasting 100mg/dl)? List meds. below. Yes No Do you have family history of heart disease in a relative younger than 55? Relation: Yes No Do you use tobacco products? Which and how long? Yes No Are you physically inactive on most days? Yes No Are you pregnant or recently pregnant? If currently pregnant, please list OBGYN below. Yes No Are you aware of any other physical reason that would prohibit you from exercising without medical supervision? If yes to any of the above in section B, please give specifics: Please list any current medications (prescriptions or over the counter): Please list primary care physician's and other specialist's information (please print): Name: Phone: Location: Name: Phone: Location: OFFICE Risk Stratification: LOW or MODERATE or HIGH Staff Signature: USE ONLY Medical Clearance Required? YES or NO Date Sent:

5 Program and Medical Clearance Waiver / Disclaimer for Individual Participation has enrolled in membership at the Huntsville Hospital Wellness Center. I have enrolled in this program of my own free will and hereby release and discharge Huntsville Hospital, the Wellness Center and its employees/instructors from any claims of action, suits, manner of actions and causes of actions whatsoever, for or by any reasons of any cause or matter arising out of my participation in this program, including any activities in which I may participate in that occur on the property or off the Wellness Center s property. If member is between the ages of 12-14, I understand that he/she must be supervised by a parent/guardian while on the premises, unless he/she is participating in a Wellness Center sponsored program which provides supervision. As a member of the Huntsville Hospital Wellness Center, I agree to abide to all Rules & Regulations of the Center. These rules were provided to me by the Center, and I understand it is my responsibility to read and abide by these rules. I understand that if my health history indicates a need for medical clearance according to the American College of Sports Medicine, I currently wish to waive the need for medical clearance at my own risk. I shall hold the Wellness Center owners and their directors, officers and employees harmless from any and all loss, cost, claim, injury, damage and liability sustained and/or resulting from an act that I may incur from participating in any activity, service or program of the Huntsville Hospital Wellness Center. I also authorize the Huntsville Hospital Wellness Center to use or disclose my health information to: Physician: Address: Phone number: for the purpose of developing and administering my wellness programs. I do not have a primary care physician. Signature of Member or Parent / Guardian Date

6 Health and Fitness Profile Please take a moment to fill out the information below. This information will enable us to more effectively establish a wellness plan specific to your needs. If you have any questions, please ask one of our employees for clarification. Please turn the completed form in at the front desk with the rest of your registration information. Thank you. Name Date What is your exercise history? *Nothing *Workout at home *Sports/recreation *Have used cardio and weight machines *Other: What activities or types of exercise do you enjoy? *Individual activities *Competitive *Specific: *Group activities *Outdoors What has limited your success in an exercise/wellness program in the past? *Not enough time *Injury/Health *Other: *Boredom *Motivation What are your specific goals regarding your health and fitness? What do you need/want to improve? *Lose weight [Goal weight: ] *Improve eating habits *Build muscle *Tone *Increase flexibility *Reduce stress *Strengthen *Reduce Joint pain *Other: *Reduce/get off meds *Increase energy Please circle if you would like to receive more information about: Personal Training Massage Therapy Smoking Cessation Nutrition Stress management Other: What is your motivation level? High Medium Low What is your confidence level regarding exercise? High Medium Low

7 Healthy Living Lifestyle Assessment Questionnaire This form asks you a variety of questions about your lifestyle habits, and takes about 3 minutes to complete. Please fill in the information requested, or place a check in the appropriate space. We thank you for your time and effort in completing this questionnaire. Personal Information Today s date: Age: Your Name: Height: (without shoes) Weight: Sex: Male Female What is the most you have ever weighed? pounds Are you NOW trying to: Lose weight Stay about the same Medical History Yes No Gain weight Not trying to do anything Has your father or brother had a heart attack or died suddenly of heart disease before the age of 55; has your mother or sister experienced these heart problems before the age of 65 years? Has a doctor told you that you have high blood pressure (more than 140/90mm Hg), or are you on medication to control your blood pressure? OR If you know your blood pressure, please check the appropriate category: Less than 120/80 140/90 to 159/99 120/80 to 129/84 160/100 to 180/ /85 139/89 More than 180/110 Do not know Is your total blood cholesterol greater than 240 mg/dl, or has a doctor told you that your cholesterol is at a high risk level? OR If you know your blood cholesterol, please check the appropriate category: Less than 160 mg/dl More than Do not know Do you have diabetes? During the past year, would you say that you experienced enough stress, strain, and pressure to have a significant effect on your health? Health and Nutrition In general, compared to other persons your age, rate how healthy you are: Not at all Somewhat Extremely Healthy healthy healthy

8 Outside of your normal work or daily responsibilities, how often do you engage in exercise that at least moderately increases your breathing and heart rate, and makes you sweat, for at least 20 minutes (such as brisk walking, cycling, swimming, jogging, aerobic dance, stair climbing, rowing, basketball, racquetball, vigorous yard work, etc.). 5 or more times per week 3 to 4 times per week 1 to2 times per week Less than 1 time per week Seldom or never Do you eat foods nearly every day that are high in fat and cholesterol such as fatty meats, cheese, fried foods, butter, whole milk, ice cream, or eggs? Yes No On average, how many servings of fruit and vegetables do you eat per day? (One serving = 1 medium fruit, ½ cup of chopped, cooked, or canned fruit/vegetable, ¾ cup of fruit or vegetable juice). None or more On average, how many servings of bread, cereal, rice, or pasta do you eat per day? (One serving = 1 slice of bread, 1 ounce of ready-to-eat cereal, ½ cup of cooked cereal, rice, or pasta). None or more Lifestyle Habits How have you been feeling in general during the past month? In excellent spirits In good spirits mostly In low spirits mostly In very good spirits I ve been up and down in spirits a lot In very low spirits On average, how many hours of sleep do you get in a 24-hour period? Less than 5 5 to to 9 More than 9 How would you describe your cigarette smoking habits? Never smoked Used to smoke How many years has it been since you smoked? Less than 1 year More than 15 Still smoke How many cigarettes a day do you smoke on average? More than 40 How many alcoholic drinks do you consume? (A drink is a glass of wine, a wine cooler, a bottle/can of beer, a shot glass of liquor, or a mixed drink). Never use alcohol Less than 1 per week 1 to 6 per week 1 per day 2 to 3 per day More than 3 per day When driving or riding in a car, do you wear a seat belt: All or most of the time Some of the time Once in awhile Rarely or never