“GET FIT”
Therapy Center Fitness Program
653 Willow Grove Street
Hackettstown, NJ 07840
(908)850-6922
Hours:
Monday –Friday
Saturday – Sunday
6:00 am – 7:00pm
7:30 am – 2:30 pm
Fees:
Enrollment Fee
$42.00
HRMC Emp/Volunteer enrollment fee $16.00
Transfer (Cardiac Rehab, PT/OT)
$0
Monthly
Individual (age under 50)
Health Link (age 50 or better)
HRMC Emp/Volunteer
Drop-in Fee
$45
$36
$28
$8
Quarterly Annual
$121
$99
*Plus 7% NJ state sales tax as required by law
$458
$360
GET FIT!
Medical Approval Form
 NEW MEMBER
 RESTART
 CR TRANSFER
 PT TRANSFER
Name of participant:
Participant’s home phone:
Name of doctor:
Doctor’s phone number:
REASON FOR MEDICAL APPROVAL:
FAX:
Participation in the fitness program at the Therapy Center of
Hackettstown Regional Medical Center.
To The Physician:
Hackettstown Regional Medical Center provides a fitness facility equipped with various types of
ergometers and resistance machines. The participant will be engaging in relatively vigorous physical fitness
activities which place a demand on his/her physiology. The purpose of our program is to guide the participant in
exercise to promote the improvement of health-related physical fitness.
We require your patient to obtain your signature of approval prior to starting our program.
The following individual has been medically evaluated by me and is cleared to participate in the
health-fitness program at Hackettstown Regional Medical Center’s Therapy Center Fitness Program.
Physician’s comments (if any):
_______________________________
Participant’s Signature
________________________
Date
_______________________________
Physician’s Signature
________________________
Date
** KINDLY FAX THIS FORM WITH YOUR SIGNATURE TO: (908) 979-8700
If you have any questions please call our Therapy Center at: (908) 850-6922
Client Data Questionnaire
This information will help us to track your progress with our facility. Please answer each
of these questions as accurately as you can. Should you have any questions, feel free to
ask. Your responses will be treated in a confidential manner.
Name: ______________________________________ Date: _____/_____/_____
Sex: Male / Female (circle one)
Date of Birth: _____/_____/_____
Address: __________________________________________________________
City: ________________________________ State: ________ Zip: ___________
Phone: ______-______-______ Email: __________________________________
Emergency Contact: ______________________ Phone: ______-______-______
Doctor: _________________________________ Phone: ______-______-______
□ Check to receive the Therapy Center E-Newsletter
Medical History
__________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
Name: __________________________________
Your average blood pressure: _____/_____
Please check all that apply:
□ Abnormal EKG?
□ Limited range of motion?
□ Stroke?
□ Abnormal chest X-
□ Arthritis?
□ Epilepsy or seizures?
□ Bursitis?
□ Chronic headaches
□ Rheumatic Fever?
□ Swollen or painful joints?
□ Persistent fatigue?
□ Low blood pressure?
□ Foot problems?
□ Stomach problems?
□ Asthma?
□ Knee problems?
□ Hernia?
□ Bronchitis?
□ Back problems?
□ Anemia?
□ Emphysema?
□ Shoulder problems?
□ Pregnant?
□ Other lung problems?
□ Recently broken bones?
Ray?
□
Has a doctor imposed any restrictions? If so, please describe:
_____________________________________________________________________________________
_____________________________________________________________________________________
________________________________________________________________
Family History
__________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
Have your mother, father or siblings suffered from any of the following:
□ Heart attack prior to age 55
□ High cholesterol
□ Stoke prior to age 55
□ Diabetes
□ Congenital heart disease or left
□ Obesity
ventricular hypertrophy
□ Hypertension
□ Asthma
□ Leukemia or cancer prior to age 55
□ Osteoporosis
>>>>>OVER>>>>>
Medications
__________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
Please check all that apply:
□ Diuretics
□ Other Cardiovascular
□ Beta Blockers
□ NSAIDS/Anti-inflammatories (Advil, Motrin)
□ Vasodilators
□ Cholesterol
□ Alpha Blockers
□ Diabetes/Insulin
□ Calcium Channel Blockers
□ Other Drugs (record below)
Please list the specific medications that you currently take:
_____________________________________________________________________________________
_____________________________________________________________________________________
________________________________________________________________
Other
__________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
Please indicate any other medical conditions or activity restrictions that you may have. It is important that
this information be as accurate and complete as possible.
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
__________________________________________________
ACSM Health Status Questionnaire
______________________________________________________________________________________________________________________________________________________________________________________________________________________________________
Please answer every question as accurately as possible so that a correct assessment can be made. Please
check off any question that is “Yes”, leave blank if answer is “No”. Your responses will be treated in a
confidential manner.
Today’s date: ____/____/____
Name: ________________________________________
□ Any personal history of coronary or atherosclerotic disease?
□ Any personal history of metabolic disease (thyroid, renal, liver)?
□ Have you had diabetes for less than 15 years?
□ Have you had diabetes for more than 15 years?
□ Have you experienced chest pain/discomfort apparently due to blood flow deficiency?
□ Any accustomed shortness of breath (perhaps during light exercise)?
□ Have you had any problems with dizziness or fainting?
□ Do you have difficulty breathing while standing or sudden breathing problems at night?
□ Do you suffer from ankle edema (swelling)?
□ Have you experienced a rapid throbbing or fluttering of the heart?
□ Have you experienced severe pain in the leg muscles during walking?
□ Do you have a known heart murmur?
□ Do you have a family history of cardiac or pulmonary disease prior to age 55?
□ Have you been assessed as hypertensive on at least 2 occasions?
□ Has your serum cholesterol been measured at greater than 240 mg/dl?
□ Are you a cigarette smoker?
□ Are you pregnant?
□ Do you have bone or joint problems that could be made worse by a change in your activity?
□ Do you know of any other reason you should not do physical activity?
Additional health conditions that we should be aware of, that may limit or require modifications in your
exercise program. The more information you provide, the better we can tailor your program to meet your
individual needs.
_______________________________________________________________________________
_______________________________________________________________________________
_______________________________________________________________________________
Get Fit! Program
Policy/Membership Agreement
All Members must scan their membership card or report to the fitness
desk to check-in with the staff on duty prior to beginning every session.
Members are responsible for timely payment of membership. Failure to
comply may result in revoked membership. Please place a check in the locked
box at the Fitness desk made out to: HRMC (Hackettstown Regional Medical
Center). Members may also make payments by cash or credit card (see staff for
assistance).
Freezing Membership: required for any leave of 4 consecutive weeks or
longer. If a member is to freeze a membership for a medical reason, medical
clearance must be given to staff prior to continuing the Get Fit program. If
freezing membership for longer than 3 months, for any reason, member will
be required to have medical clearance to return. Freezing a membership for 12
months will result in re-enrollment into the program. Member accounts will be
credited appropriately for membership freeze. Memberships will be credited
on a monthly basis only. If there is more than one visit during a month you
will not receive any credit.
Keep the Therapy Center clean: place empty cups in a garbage can and the
towels in a hamper located in the locker rooms. Cleaning wipes are should be
used to clean the equipment after use.
Therapy Center will only provide small hand towels (for perspiration). Please
be advised, there is not a towel service provided. If a larger towel is need,
member will be responsible.
When dumbbells, balls, chairs, etc. are used, kindly return the items to their
original location.
The lockers are for daily-use only. Please do not leave personal belongings
overnight.
>>>OVER>>>
Be advised, Therapy Center is NOT responsible for any valuables lost. Please
keep valuables locked in car or bring a lock for the lockers.
When other members are waiting for equipment, kindly limit exercise time to
15 min on that particular piece.
Be advised that any use of offensive language and/or behavior towards other
members or staff may result in your membership being revoked.
Please do not walk or run on the treadmill while holding hand weights. Staff
will provide safe alternatives for increasing a member’s workout intensity.
Please practice safety when performing an exercise routine. Do not hesitate if
assistance is needed, the staff would be happy to help.
I fully understand the above guidelines and agree to comply with all of the Therapy
Center’s regulations. I further understand that non-compliance may result in my
membership being revoked.
Member’s Signature_________________________
Date________________
Staff Signature______________________________
Date________________
Get Fit!
Informed Consent for Participation
Name _______________________________________________
I hereby consent to voluntarily engage in fitness training program. The levels of exercise I
perform will be based upon my cardio respiratory (heart and lungs) and muscular fitness. I
understand I may be required to undergo a graded exercise test as well as other fitness tests
prior to the start of my fitness program in order to evaluate and assess my present level of
fitness. Professionally trained exercise specialists will direct my activities, monitor my
performance, and otherwise evaluate my effort. Depending upon my health status, I may
or may not be required to have my blood pressure and heart rate evaluated during these
sessions to regulate my exercise within desired limits. I understand that the fitness
professional may reduce or stop my exercise program when any of these findings so
indicate that this should be done for my safety and benefit. (Please initial ______)
If I am taking prescribed medications, I have already informed the program staff. If there
is any change to my medication, whether physician ordered or by self, I will notify staff. I
will be given the opportunity for periodic assessment and evaluation at regular intervals
after the start of the program. (Please initial ______)
I understand that this program may or may not benefit my physical fitness and general
health. I recognize that the fitness staff has the freedom to supervise and train me to
perform my conditioning exercises, use fitness equipment, and regulate physical effort in a
safe and accurate manner. (Please initial ______)
I understand that my safety and enjoyment, as well as the safety and enjoyment of the other
members are affected by my behavior. This includes, but is not limited to:
(1) Following the program recommendations of staff members, (2) adhering to the
instructions for the use of each piece of equipment, and (3) respecting others, both
members and staff, by refraining from offensive language or behavior. Further, I
understand that by not complying with the above terms, my membership could be
cancelled. (Please initial ______)
>>>OVER>>>
I understand and have been informed that there exists the remote possibility of adverse
changes occurring during exercise including, but not limited to, abnormal blood pressure,
fainting, dizziness, disorders of heart rhythm, and very rare instances of heart attack,
stroke, or even death. I further understand and I have been informed that there exists the
risk of bodily injury including, but not limited to, injuries to the muscles, ligaments,
tendons, and joints of the body. I have been told that every effort will be made to
minimize these occurrences by proper staff assessments of my condition before, during and
after each session. I will inform staff of any change in my condition before, during or after
each session. I will properly use all equipment in the gym according to staff instruction. If
I am unsure how to operate equipment I will ask staff.
(Please initial ______)
I acknowledge that I have had a physical examination and have been given my physician’s
permission to participate in an exercise program. (Please initial ______)
I have been given the opportunity to ask certain questions as to the procedures of this
program. I acknowledge that I have read this document in its entirety or that it has been
read to me if I have been unable to read same. (Please Initial ______)
I hereby give my consent and agreement to the performance of the fitness training program
activities, assume all risks and consequences involved and further agree to indemnify and
save blameless the aforementioned doctor, his assistants, the Hospital and its employees
and agents in the event any action is brought against them or any of them because of a
breach of the representations and warranties made by me herein. I further release said
doctor, his assistants, the Hospital and its employees and agents from liability for any and
all claims and demands whatsoever I or my heirs, executors, administrators or assigns may
have against any of them by reason of any matter relative or incident to such fitness
training program activities. (Please Initial ______)
Signature ________________________
Witness _____________________________
Date _______________________
Fitness Testing
INFORMED CONSENT
1.
Explanation of Exercise Tests
The assessments you are about to undergo are designed to give a reasonable
measure of your current level of fitness, and will include the following:
Aerobic Capacity - see below
Flexibility - sit and reach test
Muscular Strength - grip strength, chest press
Muscular Endurance - partial curls up
The aerobic capacity test consists of a submaximal exercise test (aerobic capacity)
on a stationary bicycle or motor-driven treadmill. The exercise intensity will begin
at a level you can easily accomplish and will be advanced in stages depending on
your fitness level. We may stop the test at any time because of signs of fatigue, or
because of personal feelings of fatigue or discomfort.
2.
Risks and Discomforts
There exists the possibility of certain changes occurring during the test. They include, but
are not limited to, abnormal blood pressure, fainting, irregular heart beat and in rare
instances, heart attack, stroke, or death. Every effort will be made to minimize these risks by
evaluation of preliminary information relating to your health and fitness and by observations
during testing. Emergency equipment and trained personnel are available to deal with
unusual situations should they arise.
3.
Responsibility of the Participant
Information you possess about your health or previous experiences of unusual
feelings with physical effort may affect the safety and value of your exercise test.
Your prompt reporting of feelings with effort during the exercise test itself is also of
great importance. You are responsible to fully disclose such information when
requested by the testing staff.
>>>OVER>>>
4.
Benefits to be Expected
Your assessment results will help to determine your present level of fitness, and
highlight any areas of specific need. This will be particularly useful when designing an
exercise program that will be personalized, safe, and effective.
5.
Inquiries
Any questions about the procedures used in the exercise test or health assessment are
encouraged. If you have any doubts or questions, please ask us for further information.
6.
Freedom of Consent
Your permission to perform this assessment is voluntary. You are free to deny consent
if you so desire.
I have read and I understand the test procedures that I will perform. I consent to participate
in the test(s). I have been informed that the fitness evaluation is not covered by my medical
insurance and I am solely responsible for any fees accrued. Fee schedule has been explained
to me prior to participation.
Signature of Client_______________________________
Date_________________
Signature of Witness______________________________
Date__________________