Please use the contact information below for questions or concerns. Abraham Lincoln High School Name: Eric Nicholson Email: Eric_Nicholson@dpsk12.org Phone: 7204235043 Bruce Randolph School Name: Greg Ahrnsbrak Email: Gregory_Ahrnsbrak@dpsk12.org Phone: 7204241168 Denver Center for International Studies Name: Mary Lou Miller Email: MaryLou_Miller@dpsk12.org Phone: 7204234207 George Washington High School Name: Syrae Weikle Email: Syrae_Weikle@dpsk12.org Phone: 7204238640 Step 1: Complete the attached Health Appraisal and Medical History Questionnaire, Goal Inventory, and Liability Waiver. Step 2: Return completed forms to the Fitness Center; forms will be faxed to your physician for approval. Step 3: Schedule a Fitness Center orientation when paperwork is completed with physician s signature. Step 4: Meet Physical Education Teacher to set goals, plan program based on physician s recommendations. Step 5: Start your program and enjoy the results!
The First Day of the New You! Registration Form Date: Name Date of Birth / / Gender M F Address City State: Zip Phone Email Address Emergency? Friend/Relative Phone Physician Phone Please circle your workout location and time choices: Fitness Center Monday Tuesday Wednesday Thursday Friday Abraham Lincoln HS *6:00am8:00 am # 3:30pm5:00pm *6:00am8:00 am # 3:30pm5:00pm *6:00am8:00 am Bruce Randolph * 3:30pm5:15pm * 3:30pm5:15pm * 3:30pm5:15pm *3:30pm 4:15pm Denver Center for International Studies George Washington HS *4:30pm6:30pm *6:00 am8:00am *4:30pm6:30pm *6:00 am8:00am #6:00am7:30am #3:00pm4:30pm #6:00am7:30am #3:00pm5:00pm * Community and Denver Public Schools Employees # Students and Denver Public Schools Employees For school closures call school site. Page 1 12/19/2009
Health Appraisal and Medical History Questionnaire Please complete this form carefully. All information will be treated as strictly confidential. When were you last seen by a physician? Reason? May we call him/her? Yes No Phone: Height Weight Blood Pressure Resting Heart Rate (count heart rate wrist location, for one minute while sitting) Please provide the following information about your current health, fitness, or disability: Check all Health Risks that apply: 1. 2. 3. 4. 5. 6. 7. 8. 9. 10. 11. 12. 13. 14. 15. 16. 17. 18. 19. 20. 21. Cat. I Yes No Cat. II Yes No Cat. III Yes No Risk Stratification Results For use by physical education teacher: D NT WRITE IN THIS BX High Risk (13) Moderate Risk (413) Low Risk (1421) Note: 1. Has your doctor ever told you that you have heart disease? 2. Do you currently have diabetes? 3. Do you have asthma or other lung disease? 4. Pain or discomfort in chest, neck, jaw, arms, or other areas caused by partial or total blockage of an arteryischemia. 5. Shortness of breath at rest or with mild exertion. 6. Dizziness or syncope (loss of consciousness). 7. Abnormal awareness of breathing at rest in recumbent position relieved by sitting up or standing. 8. Abnormal awareness of breathing after the onset of sleep. 9. Ankle edema. 10. Rapid beating of heart. 11. Pain in a muscle stressed by exercise with inadequate blood supply. 12. Known heart murmur. 13. Unusual fatigue or shortness of breath with usual activities. 14. Are you a 45 or older male/or a 55 or older female? 15. Family history heart disease father/brother death, before 55 or, or mother/sister death before 65 16. Do you currently smoke cigarettes or quit within last 6 months, or are exposure to environmental smoke. 17. Sedentary Lifestyle; not participating in minimum of 30 minutes of moderate activity three days of the week for at least three months. 18. besity; body mass index based on weight and height, or waist girth greater than 40 for males and greater than 35 for females. 19. High blood pressure, hypertension 20. Do you know your cholesterol; HDL and LDL level/ or use medication. 21. Prediabetes Page 2 12/19/2009
Medical History Have you ever had, or do you currently have, any of the following: Cardiac Disorder Cancer Dizziness Diabetes Abnormal EKG Stomach Problems Irregular heart beats Numbness or tingling in arms, hands, legs High triglycerides Thyroid Condition Asthma Chest pains Shortness of breath Hernia Anemia Hypoglycemia Arthritis Embolism Respiratory Infections High cholesterol Allergies to food, medicines, insects Nerve damage Surgery Emphysema Gout High blood pressure Epilepsy Kidney problems Pulmonary disorder Bone fracture Back Pain ther medicals Please explain and give dates and age of onset for any items checked above: Please list any other medical conditions or chronic illnesses you have or have had: Injury to: Hip or Pelvis Shoulder Knee/Thigh Ankle/Foot Clavicle Back Arm/Elbow Face/Head Wrist/Hand Page 3 12/19/2009
Name Date Please list any medications you are currently taking the reasons for taking them: Medication Reason Affects Notes: Do you have any conditions that limit range of motion at nay joint or part of your body that may be aggravated by exercise? Yes No If yes, please describe in detail and give dates of onset. I have answered the preceding questions to the best of my ability. I further understand that thorough and honest responses to these questions are essential to my safety and prudent recommendations and guidance from the physical education instructors and personal trainers at this Denver Public Schools Fitness Center. Instructors are not engaged in rendering medical, health or any other kind of personal professional services. I can consult medical, health, or other competent professionals. The instructors, school personnel, school district specifically disclaim all responsibility for any liability, loss, or risk, personal or otherwise, which is incurred as a consequence, directly or indirectly, of the use and application of any of the exercise equipment. Signature Date Medical Clearance ID Consult Date rientation Date Page 4 12/19/2009
Name Date Goal Inventory/Health Habits Do you regard yourself as verweight Underweight ptimal Weight Do you think of yourself as Sedentary Somewhat Active Very Active Do you think of yourself as Unfit Somewhat Fit Very Fit Do you think of yourself as Very Stressed Somewhat Stressed Without Stress Do you think of yourself as Unhealthy Somewhat Healthy Very Healthy Do you think of yourself as Always Fatigued ccasionally fatigued Energetic How many times per week do you currently engage in physical activity of at least a 10 minute duration? Type of Activity Frequency (Days/Week) Intensity (mild/moderate/intense) Please describe the type of exercises/physical activities that you enjoy the most: Are there any exercises/ physical activities you would be interested in trying with this program? Notes: Page 5 12/19/2009
Name Date To be completed during consult time. 1. What I want to accomplish in the Sound Body Sound Mind Fitness Program: Short Term (semester) Goals: Long Term Goals: 2. Why I want to accomplish these goals: These goals are very important to me because: How will we measure your success? How will you feel when you accomplish your goals? 3. I will do almost anything, except What do you consider to the greatest barrier to your participation in an exercise program? 4. What are your concerns regarding participation in an exercise program? How can we keep you motivated? Do you feel like you are able to accomplish your goals? Why or why not? What will your personal rewards be for achieving your goals? Page 6 12/19/2009