ABC LOGO myAmeren Wellness Center 1901 Chouteau Ave. | St. Louis, MO. 63103 | 314.554.6292 [email protected] 24/7 Access Monday – Friday: 5:30am – 7:00pm Membership Packet | Fax: 314.612.2662 | myAmeren Wellness Center Registration Form Dear Valued Member: It is our pleasure to welcome you to the myAmeren Wellness Center! Your decision to join this program is a positive step toward a healthier lifestyle! Whether you are an avid exerciser or just getting started, our team will create an enjoyable, caring and safe atmosphere to meet your needs, goals, and interests. We look forward to assisting you with your fitness and wellness goals! In good health, The myAmeren Wellness Center Team MediFit maintains the confidentiality of your personal health information. Last Name: Date of Birth: Work Phone: First Name: Sex: Male Female Employee ID #: Work Email: Secondary Email: Department/Location: Emergency Contact: Relationship: Emergency Contact Phone (H/W/C) #: Emergency Contact: Relationship: Emergency Contact Phone (H/W/C) #: I heard about the wellness center from: new hire orientation wellness program other referred by friend intranet flyer myAmeren Wellness Center Health Information Questionnaire (HIQ) Regular exercise is healthy and fun! For most people, physical activity should not pose any problems; however, some individuals should see their doctor prior to joining a wellness center. Answer all questions honestly. All information in the HIQ is kept confidential and will be used to design a safe History (You have had) A heart attack Heart surgery Cardiac catheterization Coronary angioplasty (PTCA) Pacemaker/implantable cardiac defibrillator/ rhythm disturbance Heart valve disease Heart failure Heart transplantation Congenital heart disease Other Health Issues Symptoms You experience chest discomfort with exertion. You experience unreasonable breathlessness. You experience dizziness, fainting, blackouts. You take heart medications. You are pregnant. You have concerns about the safety of exercise. You have had major surgery or hospitalization that could limit your physical activity. You have diabetes. You have asthma or other lung disease. You have burning or cramping sensation in your lower legs when walking short distances. You have musculoskeletal problems that limit your physical activity. You take prescription medications that could limit your physical activity. You have another medical condition or physical limitation that could limit your physical activity. If you marked one for or more exercise program you. of the above you must obtain your physician’s consent prior to joining the Wellness Center. (Staff will provide you with a physician’s consent form for you and your doctor to complete.) Cardiovascular Risk Factors You are a man older than 45 years. You are a woman older than 55 years or you have had a hysterectomy or you are post menopausal. You smoke, or quit smoking within the past 6 months. Your blood pressure is greater than 140/90 mm/Hg. You don’t know your blood pressure. Your blood cholesterol is greater than 200 mg/dl. You do not know your cholesterol level. You are physically inactive (i.e. you get less than 30 minutes of exercise on at least 3 days per week.) If you marked two or more of the above you should consult your physician before engaging in exercise. I verify that I have answered all questions truthfully and to the best of my knowledge. I understand that my responses are not a substitute for a regular physician’s examination. If I experience a change in my health status during the course of my membership, I will notify the Wellness Center staff immediately and provide updated information. If a change in health status indicates the need for a physician’s consent, I will obtain this prior to my next exercise session at the Wellness Center. Print Name: Date: Signature: Staff Initial: Member Initial: Adapted from: AHA/ACSM Health/Fitness Facility Preparticipation Screening Questionnaire (Modified) in: ACSM’s Guidelines for Exercise Testing and Prescription 8th Edition. 2009. Lippincott, Williams & Wilkins. Philadelphia PA. ABC LOGO myAmeren Wellness Center 1901 Chouteau Ave. | St. Louis, MO. 63103 | 314.554.6292 [email protected] 24/7 Access Monday – Friday: 5:30am – 7:00pm | Fax: 314.612.2662 |