The
WELLNESS CENTER
CAROLINAS HOSPITAL SYSTEM-MARION
We have the KEY to your wellness.
PO DRAWER 1150 TELEPHONE# (843) 431-2620
MARION, SC 29571 FAX# (843) 431-2623
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FITNESS CENTER
REGISTRATION PACKET
Congratulations on your decision to include fitness as part of your lifestyle. As a wellness member you are entitled to:
· A free exercise orientation.
· Use of cardiovascular machines and a variety of strength training equipment.
· Free fitness and wellness information.
· Access to towels.
· Use of the member’s lounge
Please read and fill out the following forms, making sure to sign where needed, and return the completed forms to the Wellness Center. Call or come by to make an appointment for your first day of exercise. If you have any questions, please call the Wellness Center at (843) 431-2620.
FITNESS CENTER RULES & REGULATIONS
1. The Wellness Center is for authorized participants only.
2. Participants must be trained on equipment before use.
3. Participants must sign in when using the Wellness Center. This enables us to track participation.
4. Proper attire must be worn. No dress shoes or thong-style leotards.
5. To prevent injury, DO NOT exceed exercise guidelines.
6. Follow recommended warm-up and cool-down exercises before and after working out.
7. MUSIC: Please bring headsets and players in order to accommodate your music preferences.
8. Due to the chance of injury, NO children are allowed in the department while the member is exercising.
9. MEMBERSHIP FEE DUE THE FIRST WEEK OF THE MONTH.
MONTHLY MEMBERSHIP PRICES:
Individual $30.00 Additional Spouse $15.00 Family $60.00 (limit of four, then an additional $10.00)
Senior $25.00 Student $20.00 (Age 12-25 - Must have School ID) Active Military $ 25.00
Family membership includes a family of four. Families larger than four pay a reduced rate of $10.00 for each additional member. Children must be 12 or older. Also all family members must live in the same household.
CORPORATE OR GROUP MEMBERSHIPS
Please see staff for participating businesses or to find out how to qualify for a group discount.
6 MONTH OR 12 MONTH MEMBERSHIP AGREEMENT
6-month 12-month
Individual $160.00 $300.00
Couple $250.00 $460.00
Family $330.00 $600.00
For senior and student rates please see staff
Note: Only one discount can apply on any membership also rates are subject to change upon renewal.
Hospital employees – Physicians – Volunteers – Please see staff for fees.
FACILITY HOURS FOR WELLNESS MEMBERS
MONDAY – FRIDAY
5:00 am to 7:00 pm
SATURDAY
CLOSED
SUNDAY
CLOSED
NOTE: HOURS ARE SUBJECT TO CHANGE. Also the facility may be closed or have varying hours during holidays or due to inclement weather (Hurricane, Snow, Ice Storm, etc.). PLEASE CALL AHEAD.
NOTE: FOR MONDAY, WEDNESDAY, & FRIDAY
Any member may be asked to allow a Cardiac Rehab patient to use their equipment in the event that all of the equipment is full. This is due to the time restraints for Cardiac Rehab patients. This will only be done when it is absolutely necessary.
The
WELLNESS CENTER
CAROLINAS HOSPITAL SYSTEM-MARION
We have the KEY to your wellness.
CAROLINAS HOSPITAL SYSTEM-MARION
GENERAL INFORMATION
NAME: ______DOB:______
ADDRESS: ______
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EMPLOYER: ______
HOME PHONE: ______WORK PHONE: ______
Email: ______
PHYSICIAN: ______
ARE YOU A:
Carolinas Hospital System –Marion Employee?______If yes, where do you work?______
How did you hear about us? (Friend, Physician, Newspaper, flyer, etc.) ______
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The
WELLNESS CENTER
CAROLINAS HOSPITAL SYSTEM-MARION
We have the KEY to your wellness.
CAROLINAS HOSPITAL SYSTEM-MARION
HEALTH HISTORY FORM
Name: ______Sex: M______F______
Physician: ______Physician’s phone: ______
Person to contact in case of emergency: ______
Relationship: ______Phone:______
Please describe your exercise program now: ______
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DO YOU HAVE NOW OR IN THE PAST: YES NO
1) History of heart problems, chest pain, or stroke? Y N
2) Increased blood pressure? Y N
3) Any chronic illness or condition? Y N
4) Difficulty with physical exercise? Y N
5) Advice from a physician not to exercise? Y N
6) Recent surgery (last 12 months)? Y N
7) Pregnancy (now or within last 3 months)? Y N
8) History of breathing or lung problems? Y N
9) Muscle, joint, back disorder, or any previous injury still affecting you? Y N
10) Diabetes or thyroid condition? Y N
11) Cigarette smoking habit? Y N
12) Obesity (more than 20% over ideal body weight)? Y N
13) Increased blood cholesterol? Y N
14) Hernia, or any condition that may be aggravated by lifting weights? Y N
15) Family history of heart problems (parents, brother, sister, etc.)? Y N
PLEASE LIST MEDICATION ALLERGIES______
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PLEASE EXPLAIN ANY YES ANSWERS:______
CHS-MARION WELLNESS PROGRAM
CONSENT FOR PARTICIPATION IN THE WELLNESS PROGRAM
I desire and am voluntarily entering the CHS-Marion wellness exercise program. As an enrollee, I accept the following statements:
1. The program is an opportunity provided by CHS-Marion to upgrade my physical fitness level while enrolled in a program of exercise.
2. The program is designed to improve cardiovascular health, flexibility, muscular strength and endurance.
3. I do not know of any physical condition that would effect my participation in this program (Examples: heart problems, high blood pressure, diabetes, knee, back and or foot problems, pregnancy, or epilepsy). I will promptly report any changes in my health or any signs or symptoms indicating any abnormality or distress which could affect my continuing in the program to the staff of the Wellness Center.
4. The American College of Sports Medicine recommends that “apparently healthy individuals under age 45 can usually begin exercise programs without the need for exercise testing………. at or above age 45 it is desirable to have a maximal exercise test before beginning an exercise program. Also, an exercise test prior to beginning a vigorous exercise program is desirable for high-risk individuals of any age. Persons with symptoms suggestive of coronary, pulmonary, or metabolic disease should have a physician supervised maximum exercise test prior to beginning a vigorous exercise program at any age.”
MAJOR CORONARY RISK FACTORS INCLUDE:
1. History of high blood pressure
2. Elevated cholesterol/lipid levels
3. Cigarette smoking
4. Abnormal resting EKG - including evidence of ischemia, conduction defects or dysrhythmias.
5. Family history of coronary or other atherosclerotic disease prior to age 50.
6. Diabetes mellitus.
Having read the above, I understand that:
A. If I am 45 years old or older with major coronary risk factors, I agree to bring a signed medical consent form from my physician stating that I can participate in this program. The American College of Sports Medicine recommends that a treadmill test be done for anyone over 45 starting an exercise program. The need for a treadmill will be determined by my physician.
B. At any age, if I have at least one major coronary risk factor I agree to bring a signed medical consent form from my physician stating that I can participate in this program. My physician will determine the need for exercise testing.
I understand that there are risks involved in participating in an exercise program. I have assumed whatever risk may occur which could harm my body by placing excessive stress on any part of my body. My participation in this program is purely voluntary on my part and on my own evaluation that the potential benefits of the fitness program outweigh the risks.
Applicant’s Signature______
AGE______Date______
CHS-MARION
PAR-Q Status
Name:______Phone: ______Age: ______
Many health benefits are associated with regular exercise and the completion of this PAR – Q is a sensible first step to take if you are planning to increase the amount of physical activity in your life. For most individuals, physical activity should not pose any problems or hazards. This PAR - Q has been designed to identify the smaller number of individuals for whom physical activity might be inappropriate, or those who should have medical advice concerning the type of activity most suitable for them. Common sense is your best guide in answering the following questions, please read them carefully and check the correct answer opposite the question.
YES NO
______Has your doctor ever said that you have a heart condition or heart trouble?
______Do you frequently have pains in your heart and chest?
______Do you often feel faint or have spells of severe dizziness?
______Do you have a bone or joint problem that could be made worse by a change in your physical activity?
______Are you currently on any medications? Please list all medication that you are on: ______
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______Has your doctor ever said you should not participate in a physical activity program?
______Are you over the age of 65?
______Is there any reason not mentioned above why you should not follow an activity program even if you wanted to?
Please state reason: ______
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In consideration of participation in the wellness program, I agree to assume all risks of injury and will hold harmless from any and all liability, actions, causes of actions, claims, and demands of every kind and nature whatsoever which I now have or which may arise of or in connection with any participation activities arranged by CHS-Marion programs, its employees, and staff. These terms will serve as a release and assumption of risk for my heirs, executors and administrators for all members of my family including minors.
I understand and acknowledge that my physician may be contacted concerning participation in the wellness program and that he may divulge health information that may be taken into consideration for membership. I do hereby voluntarily consent to the release of such information. I further understand that my membership application may be denied based upon the information provided to CHS-Marion by my physician. In the event there is such a denial, I will hold CHS-Marion, The Wellness Center’s Wellness Program, its agents, officers, employees free from any claim of liability or negligence that I have as a result of the denial.
I have read this agreement and understand the exercise in which I will be engaged. I have agreed to the conditions stated above.
Signature: ______Date: ______
Signature of Parent: ______
Or Guardian (for participants under the age of 18)