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

LIVESTRONG at the YMCA

Intake Form

Registration Date*

MonthDayYear
Date
YMCA Branch Preference*
Name*

First NameLast Name
Date of Birth*

MonthDayYear
Date
Sex:*

MaleFemalePrefer not to answerOther
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Email*
example@example.com
Phone Number*
Please enter a valid phone number.
Preferred Contact Method*

EmailHome PhoneMobile- CellMobile- TextOther
How did you hear about the program?*

Current/former Program ParticipantDoctor/Other Health Care ProfessionalEmployerFamily/Friend/Word of MouthHealth Insurance CompanyMedia/MarketingScreening Event/Health FairY Staff Member/VolunteerOther
What is your highest level of education?*

Less than high schoolHigh school diploma or GEDAssociate degreeBachelor's degreeMaster's degreeDoctorateProfessional degreeOther
What is your race? (Check all that apply.)*

American Indian/Alaska NativeAsianBlack or African AmericanNative Hawaiian or Other Pacific IslanderWhite or CaucasianOther
Are you of Hispanic, Latino(a), or Spanish Origin?*

YesNoPrefer not to answer.
Are you a member of the Y?*

YesNo
Employer Name:*
HEALTH INFORMATION

All information provided will be held confidential under HIPAA Laws. Please fill out the form to your best of ability so that your Instructor for the LIVESTRONG class can prescribe a safe and effective workout according to your Medical History and current symptoms.
Where were you treated? *
Physician name:*

First NameLast Name
Have you ever had any of the following health conditions (Select all that apply) ?*

Pulmonary (lung) problemHeart problems or surgeryDiabetesAltered heart rateDizziness or fainting (unrelated to cancer treatment)Chest, neck or arm painPain or cramping in legs while walkingShort-term weakness on one side of the bodyElevated blood pressureLow blood pressureHigh cholesterolSmoker or previous smokerArthritisNoneOther
If you checked the box for a condition above, please describe briefly the condition and it's effect on your life at this present time:
Type of Cancer:*

BladderBoneBrainBreastCervicalColon and RectalEndometrialEsophagealHead and NeckKidney (renal cell)LeukemiaLiverLungLymphomaMyelomaOralOvarianPancreaticProstateRectalMelanomaSkin (Non Melanoma)Stomach (gastric)TesticularThyroidUterineOther
Cancer Diagnosis Date (MM/YYYY)*
Surgery?*

NoIf Yes, date of most recent surgery:
Chemotherapy?*

NoIf yes, date of last treatment:
Radiation?*

NoIf Yes, date of last treatment:
Do you have an implemented port or Central Venous Access Catheter?*

NoIf yes, please specify location:
Are you experiencing peripheral neuropathy (i.e. tingling/loss of sensation in your fingers and/or toes)?*

NoIf yes, specify location:
Has the cancer spread to any bones?*

NoIf yes, please describe where:
Have you had any lymph nodes removed?*

YesNo
Where have you had lymph node involvement?

Head and NeckLeft Upper ExtremityLeft Lower ExtremityRight Upper ExtremityRight Lower Extremity
Check all that are true:

I have been DIAGNOSED with Lymphedema.I am currently experiencing STIFFNESS or LOSS OF RANGE OF MOTION in the area that the lymph nodes have been removed.I am currently experiencing PAIN or DISCOMFORT in the area that the lymph nodes have been removed.
Are there any other medical illnesses, injury, or issues (physical or psychological) we should be aware of?*

NoIf yes, please explain:
List current medications, including vitamins and over the counter (If not applicable, record 0)
Describe your health at the present time:*

PoorFairGoodVery goodExcellent
Do you participate in exercise regularly?*

NoYes
Please describe the FREQUENCY of your exercise:*

Daily2-6 times weeklyOnce a weekLess than once a weekMonthly
Please describe the INTENSITY of your exercise:*

LightModerateHeavy
Please list the TYPES of exercise you participate in regularly*
Do you have any physical limitations that restrict your daily living activities or ability to exercise?*

NoIf yes, please explain:
Are there any limitations since your cancer diagnosis?*

NoIf yes, please explain:
If you're working, what is your level of activity at work:*

SedentaryLightModerateVigorousNot relavent
If you're not working, when did you stop?

MonthDayYear
Date
Describe your past experience with resistance training and aerobic training*
What expectations do you have from this program?*
Do you have any concerns about starting this exercise program?*

SELECT ALL the times that you could attend the 90-minute class. Example of class times are: Mon/Wed from 2-330 or Tues/Thurs from 6-730

	Monday	Tuesday	Wednesday	Thursday	Friday
10-1130
2-330
3-430
6-730

Medical Clearance Form

If completed via hard copy, UPLOAD a copy AND enter Physician Data Below

Cancelof
Client's Name

First NameLast Name
Date of Birth

MonthDayYear
Date
Client's Phone
Physician's Name

First NameLast Name
Phsyician's Email
example@example.com
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
Date

MonthDayYear
Date

AUTHORIZATION FOR RELEASE OF INFORMATION TO HEALTH CARE PROVIDER

I voluntarily authorize YMCA of Greenville 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

Participant Contact Log

Patient Contact Log & Enrollment Status

FOR YMCA STAFF ONLY
Patient Contact Log/Enrollment Status
Patient is: Contacted, Waiting on Medical Clearance, Cleared to Participate, Waitlisted, Enrolled, Declined, Completed

ContactedWaiting on Medical ClearanceCleared to ParticipateWaitlistEnrolledDeclinedWithdrewCompleted
Cohort Enrolled Into
YMCA Association
Branch

Promis-29 Progress Report

DO NOT MANIPULATE FIELDS BELOW

Physical Function % 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

6 Minute Walk Total Distance - % of Change
Chest Press % of Change
Leg Press % 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:

	Check Box if they Attended	Goals	Progress Notes	Check Box if a Goal Achieved
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