Columbia YMCA -  LIVESTRONG at the YMCA - Clearance, HIPAA, Informed Consent, Intake, Assessments, Results Logo
  • LIVESTRONG at the YMCA

    Intake Form
    • Click this dropdown box to complete LIVESTRONG Enrollment Form. Estimated time to complete 5-10 minutes. 
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    • 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.
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  • YMCA STAFF ONLY

    Participant Contact Log
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    • Patient Contact Log & Enrollment Status

      FOR YMCA STAFF ONLY
  • Program Attendance & Goal Tracker

    STAFF ONLY
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  • PROMIS-29

    PROMIS-29

    BASELINE ASSESSMENT
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    • Please respond to each question or statement by marking one box per row.

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    • ANXIETY

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    • DEPRESSION

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    • FATIGUE

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    • SLEEP DISTURBANCE

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    • SATISFACTION WITH SOCIAL ROLE

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    • PAIN INTERFERENCE

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    • PAIN INTENSITY

  • Functional Assessment

    Functional Assessment

    BASELINE Report
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    • AEROBIC FUNCTION

    • 6 Minute Walk Test

    • STRENGTH TESTING

    • FLEXIBILITY AND BALANCE

  • PROMIS-29

    PROMIS-29

    Post Program Assessment
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    • Please respond to each question or statement by marking one box per row.

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    • ANXIETY

    •  
    • DEPRESSION

    •  
    • FATIGUE

    •  
    • SLEEP DISTURBANCE

    •  
    •  
    •  
    • SATISFACTION WITH SOCIAL ROLE

    •  
    • PAIN INTERFERENCE

    •  
    • PAIN INTENSITY

  • Functional Assessment

    Functional Assessment

    Post Program Report
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    • AEROBIC FUNCTION

    • 6 Minute Walk Test

    • STRENGTH TESTING

    • FLEXIBILITY AND BALANCE

  • Promis-29 Progress Report

    DO NOT MANIPULATE FIELDS BELOW
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  • Functional Assessment Progress Report

    DO NOT MANIPULATE FIELDS BELOW
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  • Attendance Report

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