Embed Size (px)
Citation preview
Congratulations of your decision to commence an exercise program at Healthy Connections Exercise Clinic. This facility represents an extension of the health and fitness activities which have been offered at Burnie Brae for over 30 years. We are delighted to provide a facility where seniors can exercise and increase muscle strength in a secure, supported and friendly environment under the supervision of Accredited Exercise Physiologists. Whilst we believe that exercise is important for people of all ages, we need to make sure that an exercise program is suitable for you as an individual. To ensure your safety, there are a couple of steps that we would like you to take before you commence your exercise regime. To begin the process of becoming a member of Healthy Connections, please take the following steps:
1. Complete the Medical and Health History Questionnaire and Participation Consent Form. 2. You will need to have your GP complete and sign the GP Consent Form if you answered yes to any
of the seven questions listed on the preparation form. 3. Phone Healthy Connections and arrange an assessment appointment. Bring along all completed
forms. The appointment will take approximately 45 minutes. 4. Following the appointment you will be required to attend an orientation session introducing you to
your individually tailored program. At the end of the session you can arrange your membership and discuss with staff the days and times you will attend the Clinic.
We hope you enjoy being part of Healthy Connections Exercise Clinic and look forward to working with you to increase your health, fitness and wellbeing. Yours sincerely Karen Stewart-Smith Master Clinical Ex Phys (MCEP); Bachelor HMS (BHMS); AEP ESSAM Accredited Exercise Physiologist Chermside Venue Manager
PREPARATION FOR INITIAL ASSESSMENT Please talk with your doctor regarding any questions you’ve answered YES to, PRIOR to attending your initial assessment and have them sign the ‘GP Consent Form’.
PRE-PARTICIPATION SCREENING QUESTIONNAIRE Please tick
1. Has your doctor ever told you that you have a heart condition or have you ever suffered a stroke?
Yes No
2. Do you ever experience unexplained pains in your chest at rest or during physical activity/exercise?
Yes No
3. Do you ever feel faint or have spells of dizziness during physical activity/exercise that causes you to lose balance?
Yes No
4. Have you had an asthma attack requiring immediate medical attention or hospitalisation at any time over the last 12 months?
Yes No
5. If you have diabetes (type I or type II) have you had trouble controlling your blood glucose in the last 3 months?
Yes No
6. Do you have any diagnosed muscle, bone or joint problems that you have been told could be made worse by participating in physical activity/exercise?
Yes No
7. Do you have any other medical condition(s) that may make it dangerous for you to participate in physical activity/exercise?
Yes No
8. Do you have any other medical condition(s) that may make it dangerous for you to participate in physical activity/exercise.
Yes No
Exercise/Training • No intense training the day before, or the morning of testing
Stimulants • No smoking, alcohol or caffeine within 3 hours of testing
Fluids & Food
• Please drink plenty of water in the 24 hours leading up to the assessment • Water and other non-milk fluids may be consumed as normal • No food within one hour of testing • No large meal within 3 hours of testing
Medications
• Please continue with your regular schedule of any medications taken • Persons with Diabetes, pulmonary or cardiac complications please bring
any necessary medications with you to the assessment. e.g. insulin, inhalers or any nitro-based medications
What to Bring With You
• Comfortable clothes to exercise in (shorts/slacks, T-shirt) • Enclosed footwear • Water bottle • Towel • Completed forms (medical history questionnaire, signed consent, GP
consent if required, any scan reports or additional information)
Showers and change facilities are available for your use.
GP CONSENT FORM To be completed by a Medical Practitioner
WHAT IS HEALTHY CONNECTIONS EXERCISE CLINIC?
Healthy Connections Exercise Clinic is a specialised facility, providing clinical exercise programs for people suffering chronic diseases, musculoskeletal pathologies, cardiac rehabilitation, disabilities or just general healthy populations. This facility is run by Accredited Exercise Physiologists, who are specialised allied health with a primary focus on prevention, rehabilitation and management of a wide range of conditions.
Every participant is prescribed an individual clinical exercise program, based upon the results of a comprehensive health and fitness assessment and previous medical history. All exercise sessions are supervised at all times by an Accredited Exercise Physiologist. Your client has started their journey to better their health and is either interested in joining our general exercise physiology group sessions, cardiac rehabilitation sessions or other specialised clinical exercise sessions.
WHAT WE REQUIRE FROM YOU
By completing this form, your patient has started the process with us and would like to participate in regular, supervised exercise sessions. Whilst most individuals will be suitable to exercise, the ‘Consent to participate form’ allows contraindications to exercise to be assessed by the exercise physiologist, ensuring that the clinical exercise prescription is the most accurate and safe as it can be. If your client gives consent it would be appreciated if you would attach a patient health summary. Please complete parts 1, 2 and 3.
1. MEDICAL PRACTITIONER DETAILS
Name: Practice:
Address: Suburb: Postcode:
Phone: Fax:
2. PARTICIPANT DETAILS
Miss /Ms /Mrs /Mr /Other
First Name: Last Name:
Date of Birth:
Please Turn Over to complete both sides
As the supervising doctor, I found this individual was medically stable at the time of this
examination and therefore approve their participation in an exercise program. I have
indicated relevant contraindications to my knowledge and understand that should the
participant experience a medical incident during participating, I will be informed
immediately.
I have attached a copy of the patient’s medical summary to this form.
Medical Practitioner’s signature: _____________Date:____________
3. Contraindications to Exercise Participation
Absolute Contraindications (please tick if applicable)
Unstable angina
Uncontrolled hypertension – that is resting systolic blood pressure (SBP) >180mmHg and /or
resting diastolic BP (DBP) >110mmHg.
Orthostatic BP drop of >20mmHg with symptoms
Significant aortic stenosis (aortic valve area <1.0cm2)
Uncontrolled atrial or ventricular arrhythmias
Uncontrolled sinus tachycardia (>120 beats/min)
Uncompensated heart failure
Third-degree atrioventricular block (AV) without pacemaker
Active pericarditis or myocarditis
Recent embolism
Acute thrombophlebitis
Acute systematic illness or fever
Uncontrolled diabetes mellitus
Severe orthopaedic conditions that would prohibit exercise
Other metabolic conditions, such as acute thyroiditis, hyokalemia, hyperkalemia, or
hypovolemia (until adequately treated)
Relative Contraindications (please tick if applicable)
Fasting blood glucose >16.7mmol/L
Uncontrolled hypertension with resting systolic blood pressure >160mmHg or diastolic blood
pressure >100mmHg
Severe autonomic neuropathy with exertional hypotension
Moderate stenotic valvular heart disease
Tachyarrhythmias or bradyarrhythmias
Neuromuscular, musculoskeletal or rheumatoid disorders that are exacerbated by exercise
Microvascular complications (retinopathy, neuropathy, nephropathy)
Macrovascular complications (cerebrovascular, CVD, PVD)
Please list any other diagnosed medical conditions or recommendations:
_________________________
PARTICIPANT DETAILS
Personal Details
Title: Ms/Miss/Mrs/Mr/Dr/other: ...................
Name: ...............................................................
Address: ...........................................................
Suburb: .............................................................
Post code: ........................................................
Date of Birth: ...................................................
Gender (circle): Male/Female
Ph: ....................................................................
Mob: .................................................................
Email address: ..................................................
General Practitioners Details
GP’s Name: .......................................................
Practice Name: .................................................
.........................................................................
Address: ...........................................................
.........................................................................
Ph: ....................................................................
Fax: ..................................................................
Health Fund/Services
Private Health Fund: ........................................
Private Health Fund Number: ……………………….
Medicare Number: ..........................................
Medicare client reference number: ................
Medicare card expiry: ......................................
DVA file number: .............................................
DVA card type (circle): GOLD/WHITE
For white card holders, condition: ..................
.........................................................................
Emergency contact 1
Name: ..............................................................
Relationship: ....................................................
Ph: ....................................................................
Mob: ................................................................
Emergency contact 2
Name: ..............................................................
Relationship: ....................................................
Ph: ....................................................................
Mob: ................................................................
Date: ...................................................
Family Name: ...................................................
Given Name: ...................................................
Date of Birth: ...................................................
Sex: M F
MEDICAL HISTORY QUESTIONNAIRE
Do you have any family history of heart disease, lung disease or cancer?
Relative Age Condition
Are you or were you
ever a smoker? No Yes Details
Age you started
smoking - -
Age you quit smoking - -
Average number of
cigarettes smoked per
day
- -
Has a doctor told you that you have ever had any of the following conditions or symptoms?
No Yes Diagnosis Date/Comments
Cardiovascular
Angina (chest pain)
Heart disease
Heart attack (MI)
Heart failure
High blood pressure/
Hypertension
Low blood pressure/
Hypotension
High cholesterol
Stroke
Arrhythmia
Pacemaker or ICD
Valvular disease
Vascular disease
(blood vessels)
Heart surgery
Other:
Respiratory
Asthma
COPD
Bronchitis
Emphysema
Pneumonia
Other:
No Yes Diagnosis Date/Comments
Metabolic & Endocrine
Type 2 diabetes
Gestational diabetes
Kidney disease
Thyroid disorder
Cancer Type:
Colon problems
(IBD, diverticulitis)
Other:
Neurological & Psychological
Depression
Anxiety
Epilepsy
Multiple Sclerosis
Parkinson’s disease
Cerebral Palsy
Intellectual impairment
Do you experience
sudden tingling,
numbness or loss of
feeling in your arms,
hands, legs or face?
Other:
Musculoskeletal
Osteoarthritis
Rheumatoid arthritis
Rheumatic disease
(Fibromyalgia, lupus)
Osteoporosis/osteopenia Date of most recent DXA scan:
What age did menopause
start? (females only) - -
Broken bones
Other:
Please indicate on the image below any areas you currently experience pain:
Have you had any other surgeries, significant injuries or hospitalisations?
Please list your current medications:
Medication Dose Time taken
(AM/PM)
Other
Are you currently seeing any other allied health
professionals? (i.e. physiotherapist, occupational therapist,
dietician, diabetes educator, podiatrist,
psychologist/psychiatrist)
No Yes AHP
Participant Signature: ...........................................................................................................................................
Date: .....................................................................................................................................................................
Practitioner Use Only
Risk Stratification LOW MOD HIGH
Cardiovascular risk Stratification LOW MOD HIGH
GP consent requested Y N Date:
PARTICIPANT CONSENT FORM
Upon receiving your consent and to provide you with the best possible service, our exercise
physiologists, will collect relevant information to assist you. We treat all our valued clients’
personal information in the highest of confidence.
At Healthy Connections we respect and uphold your right to privacy and will ensure your personal
information is maintained as per the requirements stipulated under the Australian Privacy
Principles and Privacy Amendment Enhancing Privacy Protection) Act 2012.
Should you at any time wish to raise a complaint relating to our service or processes please
contact: [email protected] or complete a ‘Feedback’ form located at any of
our reception locations. If you are not satisfied with your complaint outcome, please contact the
Health Quality and Complaints Line located on the back of the Feedback Form.
This document has been developed to:
1. Explain how we use your personal information
2. Explain situations where we might need to use your information without your permission
3. Give you the opportunity to choose who we can share information with on your behalf.
It is our policy to comply with the Australian Privacy Principles and Privacy Amendment
(Enhancing Privacy Protection) Act 2012 in all its practices. This means that we observe the
following:
We only collect information that is relevant to the service/s provided
We inform you of the need to collect information
You have the right to access your Healthy Connections records and to request
amendments to any incorrect information held
We seek informed consent from you to collect and share your information with certain
people and/or organisations in order to provide the best possible service
We secure and safeguard your records.
While you are accessing our services, you and your exercise physiologist may agree it would be
helpful to refer you to other professional services or organisations. In this case your exercise
physiologist may use some of your personal information to do this. Each time this occurs we will
discuss it with you first and explain what information we will be sharing.
At times, your information will be audited internally or by our accredited body, to ensure we are
meeting your aims and our contractual obligations under the program. We also keep records to
generate statistical data to analyse the progress of outcomes. In this case no personal details
such as your name, address or personal information will be disclosed.
The only time any of your workers can disclose information about you to another party without
your consent is at times where we have a duty of care (example police, ambulance, GP) or if we
are legally instructed to by a subpoena from the courts.
An example of this could be if we need to contact your doctor during times of health relapse and
we felt that you might be at risk.
Private and Confidential information cannot be passed on to any other person without
your agreement.
1. I ______________________________ understand my requirement in reporting and
obtaining approval from my GP before commencing the Healthy Connections program.
The Healthy Connections program has been explained to me by a Healthy Connections
staff member and I fully understand my obligations as a participant.
2. I understand Healthy Connections may report back to my referring doctor.
3. I do/do not authorise participation in any Burnie Brae Ltd. marketing material or
campaigns.
4. I authorise Healthy Connections to obtain and exchange information to the following
parties:
My GP
Community Organisations___________________________________
Other Health Professionals___________________________________
Associated Government Funding Bodies
Other parties______________________________________________
5. I have been informed and understand how this information will be used, and that this
information will not be passed on to other parties except as outlined above. I
understand that I can change my mind about the people I want my Exercise
Physiologist to talk to. If I change my mind, I will let my Exercise Physiologist know.
6. I understand that my participation in sessions at Healthy Connections imposes the risk
of possible physical injury/ physical harm.
7. I understand that I have the freedom to withdraw from any program, at any time and for
any reason, without prejudice.
8. I understand and agree to follow the prescribed exercise program that is delivered to me.
If I fail to follow the program I am exercising at my own risk and take full responsibility
for my actions.
9. I agree to indemnify Burnie Brae Ltd. and Healthy Connections Exercise Clinic as principal
from all actions, costs, claims, charges, expenses, penalties etc. arising from my
participation in activities at the Burnie Brae Centre, but only to the extent the damage is
caused by or attributable to me as a participant or to an associated person(s).
Clients Signature Date
HEALTHY CONNECTIONS PASSES
Starters Pack $125.00 Includes Full Assessment & Set up Fee Plus 3 Sessions Pass (Valid 13 weeks from time of purchase)
Burnie Brae MemberPLUS Bonus Starters Pack $100 Only available when client purchases or upgrades to BB MemberPLUS Includes assessment, program and orientation PLUS 2 free member sessions or 1 free specialised program session
(Valid 13 weeks from time of purchase)
Assessment $90 Includes Full Assessment and Set up fee
The Assessment gives us a comprehensive view of your functional capacity and provides us with the necessary
information to effectively and accurately prescribe an exercise program that is correct for you. It will also assist us in
tracking your improvement.
10 Session Pass $110 Valid for 13 Weeks from time of purchase Pension Discount of 10%
3 Months Unlimited Pass $260 Valid for 13 weeks from time of purchase (Can be deferred for holidays and sickness*) Pension Discount of 10%
*Our deferment policy only applies for our 3 Month passes. The policy states that members are able to defer twice in their membership. For a 1-2 weeks period, this is to accommodate clients going on holidays and extended periods of sickness.
GYM HOURS Monday 6-12pm, 3-6pm Tuesday 6-12pm, 3-6pm Wednesday 6-12pm, 3-6pm Thursday 6-12pm, 3-5pm Friday 6-12pm, 3-6pm Saturday 6-10am
Chermside Clinic P 3624 2185 F 3624 2160
Taringa Clinic P 3624 2188 F 3871 3987
MEMBERSHIP AGREEMENT Please indicate your preference from the options below, then read and sign the Terms and Conditions on the back of this form. .
Normal Starter Pack $125.00 Includes assessment, program and orientation PLUS 2 free member sessions or 1 free specialised program session Valid for 13 weeks from time of purchase
3 Months Unlimited Usage $260.00 Valid for 13 weeks from time of purchase
Pension discount 10% $234.00
MemberPLUS Bonus Starter Pack $100.00 Includes assessment, program and orientation PLUS 2 free member sessions or 1 free specialised program session Valid for 13 weeks from time of purchase
10 Session Pass $110.00 Valid for 13 weeks from time of purchase
Pension discount 10% $99.00
P L E AS E I N D I C AT E Y O U R C H O I C E O F PAY M EN T
I would like to make a lump sum payment
CASH
CREDIT CARD Mastercard / Visa
EFTPOS
DIRECT DEPOSIT
National Australia Bank Chermside Senior Citizens BSB 084 150 A/c 620626880 Reference your surname
Installment Calculation First Month Installment $ _ _ _ Subsequent Installment _ _ months x $ _ _ $ _ _ _ Total $ _ _ _
I would like to pay my membership off
Direct Debit - Refer to Separate Form for this option
Mastercard Visa
Card Name ……………………………………… Card Number _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ Expiry Date _ _ / _ _ CCV _ _ _
Signed ……………………………………………..
TERMS AND CONDITIONS Please read the following Terms and Conditions carefully. It is your responsibility to familiarise yourself with the undermentioned conditions and once signed, we will assume that you have read and understood these.
1. Each participant must complete all required documentation and agree to follow the direction of Healthy Connections staff in their recommendation of an appropriate program for your individual need.
2. Full Assessments are compulsory prior to commencement of General Membership at Healthy Connections.
3. A Doctors Consent must be obtained unless otherwise stated by Healthy Connections staff.
4. A referral from a medical practitioner or health professional is required prior to commencement of any
Specialised Program at Healthy Connections.
5. Exercise clinic members agree to inform Healthy Connections staff of any change in their health status (not already stated on the Medical and Health History Questionnaire) which may increase their risk of injuring themselves through participation in a Healthy Connections exercise program.
6. Exercise Clinic members agree to stop exercising and inform Healthy Connections staff if they experience any condition, such as dizziness, muscular pain or soreness.
7. Pre-booking of all exercise sessions is essential and participants must notify the Receptionist if you are unable to attend a weekly session. In the case of 10 Session Membership, failure to advise of non-attendance may result in the loss of that session. Failure of a member to attend their booked time slot for three consecutive sessions, with no fore-advised reason, will see their allocation to that timeslot cancelled and allocated to another member on the waiting list.
8. Alterations to allocated session times (i.e. changing days) can be accommodated provided the new session
time is not already at full capacity. All changes must be arranged with exercise clinic staff prior to attendance.
9. All types of membership may be transferred to another party. Original use and expiry dates will still apply.
The original member must notify Healthy Connections in writing informing them to whom the membership is being transferred and their contact details. This person will be required to undergo a full Assessment before. The full Assessment cost will apply.
10. Members holding a 3 Monthly Membership will be able to defer or suspend their membership. The following limitations apply: 3 monthly memberships may be suspended for a period of 1 to up to 2 weeks twice during the period of their membership. Suspensions of less than 1 week will not be accepted. Once the suspensions have been used, the pass or membership period will continue to expiry. These situations may occur as a result of e.g. health issues, holidays etc. Requests for a pass or membership suspension should be given in advance and in writing to clinic administration.
11. A Cooling off Period of 48 hours applies from the date of signing this agreement. This does not include Assessment costs incurred.
12. Members are entitled to terminate the Agreement at any time. In this instance, membership fees will be reimbursed less $15.00 per session already attended plus a $75.00 administration fee.
13. Healthy Connections reserves the right to terminate Membership Agreements for failure to follow directions, misconduct, inappropriate behavior and bullying of other members or staff.
I Agree to the Terms and Conditions stated above DATE……………………………
MEMBER NAME.............................................................SIGNATURE………………………………………………. APPROVED BY
NAME………………………………………………SIGNATURE ……………………………………………………….. (REPRESENTATIVE OF HEALTHY CONNECTIONS)
How did you hear about Healthy Connections?
Family
Friends
Doctors
Burnie Brae Centre
Brochures
Referral from another community organisation
Radio
Newspaper
