Foothills - LIVESTRONG at the YMCA - Clearance, HIPAA, Informed Consent, Intake, Assessments, Results

Medical Clearance Form

Client's Name

First NameLast Name
Date of Birth

MonthDayYear
Date
Please select the branch preference:
Client's Phone
Physician's Name

First NameLast Name
Physician's Email
example@example.com
Physician's Phone Number
Please enter a valid phone number.
Dear Doctor,

This is a medical clearance form for the patient, First Name Last Name to participate in LIVESTRONG at the YMCA: A Cancer Survivor Exercise Program at the [Insert YMCA Name]. At the start of this program your client will participate in a fitness assessment, including the 6-minute walk test, one repetition max test for upper and lower body, and balance and flexibility test. Following the fitness assessment, your patient will partake in cardiorespiratory fitness, muscular strength and endurance, and flexibility and balance activities. A specific, individualized exercise program will be created for the participant based on the needs, interests and any recommendations you might have. The LIVESTRONG program is designed to start easy and become progressively more difficult over a 12-week period. All fitness assessments and exercise activities will be administered by qualified personnel trained in conducting exercise test and exercise program.

This program requires a physician's clearance prior to participation in the LIVESTRONG at the YMCA program. By completing the form below, you are not assuming any responsibility for our administration of the fitness assessment or exercise program. If you know of any medical or other reasons why participation in the LIVESTRONG at the YMCA program would be unwise for your patient, please indicate so on this form.
Physician's Report
My Patient, listed above is:

NOT CLEARED to exercise at this timeCLEARED to exercise with NO RESTRICTIONSCLEARED to exercise with RESTRICTIONS LISTED BELOW
LIST RESTRICTIONS HERE:
If you have any questions regarding your patient participating in the LIVESTRONG at the YMCA Program, please provide those below and a YMCA staff will be in touch with you soon:
Physician's Signature

Clear
Proof of Medical Clearance - if not sent from Physician through JotForm

Cancelof
Date

MonthDayYear
Date

AUTHORIZATION FOR RELEASE OF INFORMATION TO HEALTH CARE PROVIDER

I voluntarily authorize Foothills Area YMCA to release or disclose my protected health information related to my participation in the LIVESTRONG at the YMCA Program to my primary care physician and/or other individuals referenced below. I understand I have a right toreceive a copy of this authorization, and the information disclosed pursuant to this authorization may be redisclosed by the person(s) listed below. I understand I am not required to sign this form to participate in the program and that I may revoke this authorization at any time by submitting my revocation in writing to the YMCA.
Primary Care Physician Practice
Physician Name
Physician Phone Number
Physician Email
example@example.com
Address
City
State
Zip Code
Fax Number
Other Individual(s)

ex: Family, friend, lymphedema specialist, etc.
Name
Address
City
State
Zip Code
Fax Number
Phone Number
Email
example@example.com
If this authorization has not been revoked, it will terminate five (5) years after your completion of your last program, unless a shorter period is specified under state law.
Signature of participant

Clear
Date

MonthDayYear
Date

YMCA STAFF ONLY

Patient Contact Log & Enrollment Status

FOR YMCA STAFF ONLY
Patient Contact Log/Enrollment Status
Patient is:

ContactedEnrolledWaitlistedWaiting on Medical ClearanceWithdrewCompletedDeclined
Cohort Enrolled Into
YMCA Association
Branch
If a nonmember, did the participant join the YMCA after the program?

YesNo

Promis-29 Progress Report

DO NOT MANIPULATE FIELDS BELOW

Physical % change
Anxiety % change
Depression % change
Fatigue % change
Sleep % change
Social Role Satisfaction % change
Pain Interference % change
Pain Intensity % change

Functional Assessment Progress Report

DO NOT MANIPULATE FIELDS BELOW

Total Distance - % of Change
Laps Walked - % of Change
Ending RPE- % of Change
Upper Body Strength % of Change
Lower Body Strength % of Change
Right Back Scratch % of Change
Left Back Scratch % of Change
Arm Reach % of Change
Balance Right % of Change
Balance Left % of Change

Attendance Report
Total # of Classes Attended
Should be Empty:

	Date	Attended Class
Session 1
Session 2
Session 3
Session 4
Session 5
Session 6
Session 7
Session 8
Session 9
Session 10
Session 11
Session 12
Session 13
Session 14
Session 15
Session 16
Session 17
Session 18
Session 19
Session 20
Session 21
Session 22
Session 23
Session 24

	Without any difficulty	With a little difficulty	With some difficulty	With much difficulty	Unable to do
Do chores such as vacuuming or yard work?
Go up and down stairs at a normal pace?
Go for a walk of at least 15 minutes?
Run errands and shop?

	Never	Rarely	Sometimes	Often	Always
I felt fearful
I found it hard to focus on anything other than my 6 anxiety
My worries overwhelmed me
I felt uneasy

	Never	Rarely	Sometimes	Often	Always
I felt worthless
I felt helpless
I felt depressed
I felt hopeless

	Not at all	A little bit	Somewhat	Quite a bit	Very much
I feel fatigued
I have trouble starting things because I am tired
How run-down do you feel on average?
How fatigued did you feel on average?

LIVESTRONG at the YMCA

HEALTH INFORMATION

Medical Clearance Form

Physician's Report

Other Individual(s)

YMCA STAFF ONLY

Patient Contact Log & Enrollment Status

Program Attendance & Goal Tracker

PROMIS-29

ANXIETY

DEPRESSION

FATIGUE

SLEEP DISTURBANCE

SATISFACTION WITH SOCIAL ROLE

PAIN INTERFERENCE

PAIN INTENSITY

Functional Assessment

AEROBIC FUNCTION

6 Minute Walk Test

STRENGTH TESTING

FLEXIBILITY AND BALANCE

PROMIS-29

ANXIETY

DEPRESSION

FATIGUE

SLEEP DISTURBANCE

SATISFACTION WITH SOCIAL ROLE

PAIN INTERFERENCE

PAIN INTENSITY

Functional Assessment

AEROBIC FUNCTION

6 Minute Walk Test

STRENGTH TESTING

FLEXIBILITY AND BALANCE

Promis-29 Progress Report

Functional Assessment Progress Report

Attendance Report

	Not at all	A little bit	Somewhat	Quite a bit	Very much
I had a problem with my sleep
I had difficulty falling asleep

	Not at all	A little bit	Somewhat	Quite a bit	Very much
I am satisfied with how much work I can do (including work from home)
I am satisfied with my ability to do regular personal and household responsibilities
I am satisfied with my ability to perform my daily routines
I am satisfied with my ability to participate in social activites

	Not at all	A little bit	Somewhat	Quite a bit	Very much
How much did pain interfere with your day to activities?
How much did pain interfere with work around the home?
How much did pain interfere with your ability to
How much did pain interfere with your