A Working Out at Work Program encouraging employees to take time for physical activity during the work day.
Send below form back to Wellness.
WCA Wellness Program
Physical Activity Readiness Questionnaire
To find out if you should consult a doctor before you start, use the following checklist taken from the American Heart Association Guidelines.
Mark those items that apply to you:
_____Your doctor said you have heart trouble, a heart murmur, or you had a
heart attack or stroke
_____You frequently have pains or pressure in the left or midchest area,
neck, shoulder or arm during or right after you exercise.
_____You often feel faint or have spells of severe dizziness.
_____Your doctor said your blood pressure was too high and is not under
control or you don’t know whether or not your blood pressure is
_____Your doctor said you have bone or joint problems such as arthritis.
_____You are over 50 and not accustomed to regular vigorous exercise.
_____You have a family history of premature coronary artery disease or
_____You have a medical condition not mentioned here, which might need
special attention i.e. stroke, diabetes etc.
If you have checked one or more items, talk to your doctor before you start. You will need a slip sent to Wellness from your M.D. that it is ok for you to exercise.
If you have checked no items, you can start on a gradual, sensible exercise program tailored to your needs.
WCA Wellness Program
Medical Information for Exercise Room Use
Name: ___________________________ Physician:_______________________
Birthdate: __________________________ Age: ______________
Home Address: _________________________________________________________
Occupation: ____________________ Department: ________________ Ext. ________
Person to contact in case of emergency: __________________________________
Current Risk Factors -
_____ High Blood Pressure ____Stress/tension on daily basis
____Diabetes _____Smoking _____ Sedentary __ High Cholesterol
Height _______ Weight _____ Any recent weight changes? _________
Type of regular physical activity: _____________________________________
Duration in minutes: _______________________________________________
Frequency : ( times / week ) __________________________________________
Are there any other issues with your medical history that are not covered above that we should be aware of?
What do you hope to achieve from using the exercise equipment?
Informed Consent for WCA Hospital Based Exercise Room and Equipment Use.
I desire to engage voluntarily in the use of the WCA Hospital employee exercise equipment in order to improve my cardiovascular function and my fitness level.
Before I use the exercise equipment I will have answered a Wellness Physical Activity Readiness and Medical History questionnaire. The purpose of this is to detect any condition that would indicate that I should not engage in an exercise program without a follow up with a physician.
Before I use the exercise equipment, I will be instructed on all of the machines and the signs and symptoms that will alert me to modify my activities.
The exercise equipment is designed to place a graduated increase workload on the circulation and thereby improve its function. Individual reaction to such workload cannot be predicted with complete accuracy. There is a risk of certain changes occurring during and following the exercise. These changes include abnormalities of blood pressure, disorders of the heartbeat, and in rare instances a heart attack and/or sudden death.
I have read the above and I fully understand my responsibilities in using the exercise equipment along with its potential benefits and risks. I do not hold WCA Hospital responsible for any undue incidents that may occur while in the exercise room or while using the exercise equipment.
Employees Signature and Date