Y BE FIT PHYSICIAN’S RELEASE FOR EXERCISE

Dear Doctor,

Your patient has answered “yes” to at least one question on the PHYSICAL ACTIVITY READINESS QUESTIONNAIRE (refer to other side of this paper). Therefore, we need your authorization to proceed with the physical fitness testing portion of the Y Be Fit Comprehensive Wellness Program at Brigham Young University.

The physical fitness testing portion includes:

1)A submaximal treadmill test to measure cardiorespiratory fitness. This treadmill test involves walking or joggingon a treadmill for a period of 6-10 minutes at a workload difficult enough to elicit a rating of perceived exertion of 6-9 on a scale of 1-10.

2)Muscular strength and flexibility testing (push-ups, plank, leg press exercise at or near maximal exertion, shoulder flexibility test, and a sit and reach test).

At the end of this testing, the client may be taught about physical activity guidelines.

Please check one:

[ ] I, hereby authorize ______to participate in the Y Be-Fit Comprehensive Wellness Program at Brigham Young University.

[ ] ______needs toreceive a Graded Exercise Test (GXT) under the supervision of a physician before participating in the Y Be Fit Comprehensive Wellness Program at Brigham Young University.

Signed:______

Physician’s Name:______

Address:______Phone:______

______

______

PHYSICAL ACTIVITY READINESS QUESTIONAIRE – PARQ

Client Name:

Major Coronary Risk Factors
Yes No
Age: Are you a male older than 45, or a female older than 55?
Family History: Do you have a family history of coronary (heart) disease or other atherosclerotic disease in parents or siblings prior to age 55?
Current cigarette smoking: Do you smoke?
Hypertension: Do you have elevated blood pressure (>than or = to 140/90 mmhg)?
Hypercholesterolemia: Do you have high blood cholesterol (> than or = to 240 mg/dL)?
Sedentary Lifestyle/physical inactivity: Are you a physically inactive individual?
Major Signs or Symptoms
Yes No
Do you experience pressure of pain in your chest, neck, shoulders, or arm during or right after physical activity?
Do you often have difficulty breathing?
Do you become very short of breath with just mild exertion?
Do you often feel faint or have spells of severe dizziness?
Do you have difficulty in breathing when you are lying down or sleeping?
Do you experience swollen or painful ankles?
Have you had bouts of rapid or irregular heart beats?
Do you suffer from pain or cramps in your legs after walking short distances?
Do you have a heart murmur?
Is there a good physical reason not mentioned here why you should not participate in an exercise program? If so, what?
Known Disease
Yes No
Has your doctor ever said you have heart trouble (i.e. diagnosed heart disease, abnormal ECG, atriatachycardia, etc.)?
Has you doctor ever said you have diabetes?
Has your doctor ever said you have a lung ailment (i.e. asthma, bronchitis, emphysema)?
Do you have any other chronic illness?
Please list medications you are presently taking (if any) and for what reason:

Physicians Release Criteria:

2 or more from the risk factors and/or signs and symptoms sections

and/or

1 or more from the known disease section

Physicians Release Needed: Yes No

PARQ checked by: ______Date: ______