Lanark Site - Fit for Life Exercise-Gentle Balance (Falls Prevention): CHC Lanark; 9:00-10:00 AM

If you need any assistance with registering, please contact Pam at 613-259-2182, ext. 2306 or Kara at 613-259-2182 ext. 2302

Name(Required)

First Last

Preferred Name (if different from above)

Date of Birth(Required)

Address(Required)

Street Address Address Line 2 City Province Postal Code

Telephone Number (Please provide only numbers where you permit us to call)

Preferred(Required)

Message Allowed(Required)

Alternate

Message Allowed

Email(Required)

Please provide an email address that you permit us to use to contact you.

Emergency Contact

Name(Required)

First Last

Relationship(Required)

Phone Number(Required)

Privacy

As a participant of this group, I will respect the privacy and confidentiality of other individuals in the group.(Required)

Yes

Get Active Questionnaire

Physical activity improves your physical and mental health. Even small amounts of physical activity are good, and more is better.

For almost everyone, the benefits of physical activity far outweigh any risks. For some individuals, specific advice from a health care provider is advisable. This questionnaire is intended for all ages - to help move you along the path to becoming more physically active.

PREPARING TO BECOME MORE ACTIVE

The following questions will help to ensure that you have a safe physical activity experience. Please answer YES or NO to each question before you become more physically active. If you are unsure about any question, answer YES.

1. Have you experienced ANY of the following (A to F) within the past six months?

(A) A diagnoses of, or treatment for, heart disease or stroke, or pain, discomfort/pressure in your chest during activities of daily living or during physical activity(Required)

YES

Physical activity is likely to be beneficial. If you have been treated for heart disease but have not completed a cardiac rehabilitation program within the past six (6) months, consult your primary care provider - a supervised cardiac rehabilitation program is strongly recommended. If you are resuming physical activity after more than six (6) months of inactivity, begin slowly with light-to moderate-intensity physical activity. If you have pain, discomfort, or pressure in your chest and it is new for you talk to your primary care provider. Describe the symptom and what brings it on.

If you have pain, discomfort, or pressure in your chest and it is new to you within the past six (6) months, talk to your primary care provider. Please describe the symptoms and what brings it on.

(B) A diagnosis of, or treatment for, high blood pressure (BP), or a resting BP of 160/90 mmHg or higher?(Required)

YES

Physical activity is likely to be beneficial if you have been diagnosed and treated for high blood pressure (BP). If you are unsure of your resting BP, consult your primary care provider to have it measured. If you are taking BP medication and your BP is under good control, regular physical activity is recommend as it may help to lower your BP. Your primary care provider should be aware of your physical activity level so your medication needs can be monitored. If your BP is 160/90 or higher, you should receive medical clearance and discuss what is safe appropriate physical activity.

If you have pain and/or discomfort, and it is new for you within the past six (6) months, talk to your primary care provider. Please describe the symptoms and what brings it on.

YES

There are several possible reasons for feeling this way and many are not worrisome. Before becoming more physically active, consult your health care provider to identify reasons and minimize risk. Until then, refrain from increasing the intensity of our physical activity.

If you have had dizziness or light-headedness during physical activity and it is new for you within the past six (6) months, talk to your primary care provider. Please describe the symptoms and what brings it on.

(D) Shortness of Breath(Required)

YES

If you have asthma and this is relieved with medication, light to moderate physical activity is safe. If your shortness of breath is not relieved with medication, consult your primary care provider.

If you have shortness of breath at rest and it is new for you within the past six (6) months, talk to your primary care provider. Please describe the symptoms and what brings it on.

(E) Loss of consciousness or fainting for any reason?(Required)

YES

Before becoming more physically active, consult your primary care provider to identify reasons and minimize risk and discuss types of physical activity suitable for your condition.

If you have loss of consciousness or fainting for any reason during physical activity and it is new for you within the past six (6) months, talk to your primary care provider. Please describe the symptoms and what brings it on.

(F) Concussion(Required)

YES

A concussion is an injury to the brain that requires time to recover. Increasing physical activity while still experiencing symptoms may worsen your symptoms, lengthen your recovery, and increase your risk for another concussion. Your health care provider will let you know when you can start becoming more physically active.

If you have had a concussion and it is new for you within the past six(6) months, talk to your primary care provider. Pleas describe any restrictions you may have because of a concussion

2. Do you currently have pain or swelling in any part of your body (such as from an injury, acute flare up or arthritis, or back pain) that affects your ability to be physically active.(Required)

YES

If this swelling or pain is new, consult your primary care provider. Otherwise keep joints healthy and reduce pain by moving your joints slowly and gently through the entire pain-free range of motion. If you have hip, knee or ankle pain, choose low-impact activities such as swimming or cycling. As the pain subsides, gradually resume your normal physical activities starting at a level lower than before the flare-up.

If you have swelling in any part of your body and it is new for you within the past six (6) months, and it affects your ability to be physically active, talk to your primary care provider. Please indicate any restrictions you may have because of swelling or pain in any part of your body

3. Has a health care provider told you that you should avoid or modify certain types of physical activity?(Required)

Yes

Listen to the advise of your primary care provider and ask them about any considerations and to provide specific advice for physical activity that is safe and that takes your lifestyle and health into account.

Please list what types of physical activity your health care provider has told you should be modified.

4. Do you have any other medical or physical conditions (such as diabetes, cancer, osteoporosis, asthma, spinal cord injury) that may affect your ability to be physically active?(Required)

Yes

Some people may worry if they have a medical or physical condition that physical activity might be unsafe. In fact, regular physical activity can help to manage and improve many conditions. Physical activity can also reduce the risk of complications. If you are unsure consult with your primary care provider.

Please list her any conditions that you feel your fitness instructor should be aware of.

ASSESS YOUR CURRENT PHYSICAL ACTIVITY LEVEL

Answer the following questions to assess how active you are now.

1. During a typical week, how many days do you do moderate-to-vigorous-intensity aerobic physical activity (such as a brisk walk, cycling or jogging)?(Required)

2. On days that you do at least moderate-intensity aerobic physical activity (such as brisk walking) how many minutes do you do this activity?(Required)

3. Multiply your average number of days/week by the average number of minutes/day(Required)

Canadian Physical Activity Guidelines recommend that adults accumulate at least 150 minutes of moderate-to-vigorous-intensity physical activity per week. Strengthening muscles and bones at least two times per week for adults, is also recommended. Increase your physical activity gradually so that you have a positive experience. Build physical activities that you enjoy into your day (e.g., take a walk with a friend, ride your bike, park your car father away from store entrances) and reduce your sedentary behaviour (e.g., prolonged sitting)

DECLARATION

To the best of my knowledge, all of the information I have supplied on this questionnaire is correct. If my health changes, I will complete this questionnaire again.(Required)

I answered NO to all the questions

I answered YES to at least one of the questions, and

IF answered yes in previous question(Required)

I have consulted a health care provider who has recommended that I become more active

I am comfortable with becoming more physical active on my own without consulting a health care provider

Lanark Site – Fit for Life Exercise-Gentle Balance (Falls Prevention): CHC Lanark; 9:00-10:00 AM

Telephone Number (Please provide only numbers where you permit us to call)

Emergency Contact

Privacy

Get Active Questionnaire

ASSESS YOUR CURRENT PHYSICAL ACTIVITY LEVEL

DECLARATION

ABOUT US

EVENTS

OUR SERVICES

ConnectWell

MORE INFORMATION