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  **Name:**                                     **     **    

  **Mail Stop:**                                **     **    
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**GET FIT FOR LIFE!**

**JOIN THE PREVENTIVE HEALTH FITNESS CLUB**

Welcome to the Preventive Health Fitness Club! The Preventive Health
Fitness Club is designed to serve individual needs and aspirations.
Whether you are a seasoned athlete in need of some training tips or just
want to get started on an effective exercise program, Preventive Health
can help.

**To join the Preventive Health** **Fitness Club, you must complete
the:**

> **\* Physical Activity Readiness Questionnaire (PAR-Q) Form**
>
> **\* Release form and return both forms to Preventive Health at** **MS
> 1032, fax 505-844-4091 or email to hbe@sandia.gov**

All Preventive Health Fitness Club members must be medically cleared to
participate in an exercise program. This medical screening process may
take anywhere from one day to approximately two weeks, depending upon
your health status. You will receive notification of your medical
clearance as soon as possible.

Upon joining, Sandia employees have unlimited access to Preventive
Health fitness classes and/or individualized exercise assessments and
consultations. Sandia contractors have access to Preventive Health
fitness classes as space permits. Preventive Health requires
participants to complete a PAR-Q every two years.

Contact 505-844-HBES (4237) or <hbe@sandia.gov> with questions.

**Physical Activity Readiness Questionnaire (Par-Q)**

+-------+-------------------------------------+----+------------------+
| **N   | **     **                           | #  | **     **        |
| ame** |                                     |  S |                  |
|       |                                     | S# |                  |
+-------+-------------------------------------+----+------------------+

+-----------+----------------------------+---------+------------------+
| **Work    | **     **                  | #       | **     **        |
| Phone**   |                            | Org/MS  |                  |
+-----------+----------------------------+---------+------------------+

+-------+------+-------------------------------+-----------------------+
| *     | *    | # Which Preve                 | **     **             |
| *Date | *    | ntive Health service/activity |                       |
| of    |   ** |                               |                       |
| Bi    |      | # d                           |                       |
| rth** |      | o you plan to participate in? |                       |
+-------+------+-------------------------------+-----------------------+

For most people physical activity should not pose any problem or hazard.
The Par-Q has been designed to identify the small number of adults 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 these questions. Please
read them carefully and check **YES** or **NO** if it applies to you. If
a question is answered with **YES**, ***please use the available space
to explain your answer and give additional details.***

+---+------------------------------------------------------+-----+-----+
| 1 | Has a doctor ever said that you have a heart         | *   | **N |
| \ | condition and that                                   | *YE | O** |
| . |                                                      | S** |     |
|   | you should only do physical activity recommended by  |     |     |
|   | a doctor?                                            |     |     |
+---+------------------------------------------------------+-----+-----+

  ----- ------------------------------------------------------ --------- --------
  2\.   Do you feel pain in your chest when you do physical    **YES**   **NO**
        activity?                                                        

  ----- ------------------------------------------------------ --------- --------

+---+------------------------------------------------------+-----+-----+
| 3 | In the past month, have you had chest pain when you  | *   | **N |
| \ | were not doing                                       | *YE | O** |
| . |                                                      | S** |     |
|   | physical activity?                                   |     |     |
+---+------------------------------------------------------+-----+-----+

+---+------------------------------------------------------+-----+-----+
| 4 | Do you lose your balance because of dizziness or do  | *   | **N |
| \ | you ever lose                                        | *YE | O** |
| . |                                                      | S** |     |
|   | consciousness?                                       |     |     |
+---+------------------------------------------------------+-----+-----+

+---+------------------------------------------------------+-----+-----+
| 5 | Do you have a bone or joint problem that could be    | *   | **N |
| \ | made worse by a                                      | *YE | O** |
| . |                                                      | S** |     |
|   | change in your physical activity?                    |     |     |
+---+------------------------------------------------------+-----+-----+

+---+------------------------------------------------------+-----+-----+
| 6 | Is your doctor currently prescribing drugs (for      | *   | **N |
| \ | example, water pills) for                            | *YE | O** |
| . |                                                      | S** |     |
|   | your blood pressure or heart condition?              |     |     |
+---+------------------------------------------------------+-----+-----+

  ----- ------------------------------------------------------ --------- --------
  7\.   Do you know of any other reason why you should not do  **YES**   **NO**
        physical activity?                                               

  ----- ------------------------------------------------------ --------- --------

+---+-------------------------------------+---------------+-----+-----+
| 8 | Do you currently participate in any |               | *   | **N |
| \ | regular activity program designed   |               | *YE | O** |
| . |                                     |               | S** |     |
|   | to improve or maintain your         |               |     |     |
|   | physical fitness.                   |               |     |     |
+---+-------------------------------------+---------------+-----+-----+
|   | If yes, what activity program do    | **     **     |     |     |
|   | you participate in?                 |               |     |     |
+---+-------------------------------------+---------------+-----+-----+
|   | **     **                           |               |     |     |
+---+-------------------------------------+---------------+-----+-----+

**Medical History**

  ---------------------------------------- ------------------------------
  *[Cardiovascular Disease Risk            *[Medication Use]{.underline}*
  Factor]{.underline}*                     

  **Has a doctor or health professional    **Are you currently taking any
  ever told you that you have any of the   of the following
  following conditions?**                  medications:**

  Heart Disease                            Blood Pressure Medication

  Family history of heart disease          Cholesterol Medication

  High Blood Pressure                      Blood Sugar Medication

  High Cholesterol                         Heart Medication

  Obesity                                  Other Medication(s).

  Lack of physical activity                **Please list:     **

  Diabetes                                 

  Impaired fasting glucose                 

  High HDL (negative risk factor)          
  ---------------------------------------- ------------------------------

+----------------------------------------+-----------------------------+
| ### Do you have any of the following?  | **Which best describes your |
|                                        | current smoking status?**   |
| Back Pain                              |                             |
+----------------------------------------+-----------------------------+
| Joint, tendon, or muscular pain        | I have NEVER smoked or quit |
|                                        | more than 6 months ago?     |
| Lung disease (asthma, emphysema, etc.) |                             |
+----------------------------------------+-----------------------------+
| **Please explain:     **               | I CURRENTLY smoke or quit   |
|                                        | within the last 6 months.   |
+----------------------------------------+-----------------------------+
|                                        |                             |
+----------------------------------------+-----------------------------+
|                                        |                             |
+----------------------------------------+-----------------------------+
|                                        |                             |
+----------------------------------------+-----------------------------+

*[Overall State of Health]{.underline}*

How would you rate your overall state of health?

  ------------- ---------------------------------------------------------
  Poor          Good

  Fair          Excellent
  ------------- ---------------------------------------------------------

**[For Medical Use Only]{.underline}**

  ---------------- --- ---------- ------------- -------------------- ----------
  Cleared to           with       without                            
  participate                     restriction                        

  based on review      Par-Q      Chart         Discussion with      Exam
  of                                            patient              
  ---------------- --- ---------- ------------- -------------------- ----------

  -------------- -------------------------------------------------------------
  Restriction:   **     **

                 
  -------------- -------------------------------------------------------------

  ----------------------------- -- ---------------- ---------------------
                                                    

  Physician's Signature            Date             
  ----------------------------- -- ---------------- ---------------------

  ----------------------------- -- ---------------- ---------------------
                                                    

  Reviewed by Preventive Health    Date             
  Staff                                             
  ----------------------------- -- ---------------- ---------------------

**Please return these forms to Preventive Health**

**mailstop 1032, fax 505-844-4091, or email: hbe@sandia.gov**

**RELEASE FORM FOR PARTICIPATION**

**IN A SANDIA PREVENTIVE HEALTH** **FITNESS PROGRAM**

I hereby request the opportunity to participate in an exercise program
consisting of physical exercise designed to improve cardiovascular
efficiency, improve flexibility and develop muscular strength and
endurance. I hereby acknowledge that my participation in such program is
entirely voluntary on my part. My participation does not arise out or in
the course of employment with Sandia Corporation and is not a
requirement of any such employment. Such participation is solely for my
own pleasure and benefit.

I will be taught how to properly operate all equipment necessary for my
participation. I realize that the physical fitness equipment provided
can be potentially dangerous and that if I am unsure of the proper
operation of any equipment, I should ask for assistance from the fitness
staff. In addition, I understand that I should immediately cease using
any malfunctioning equipment and report to the fitness staff equipment
in need of repair.

It is possible that certain unhealthy changes may occur during exercise
(e.g., dizziness/fainting, abnormal heart rhythms, and in rare
instances, heart attacks). I hereby accept all risks of such changes.
The information which is obtained through this program will be
confidential and become a part of my Sandia medical records. The data
obtained, however, may be used for statistical purposes.

In consideration of acceptance of my participation in such program, I
hereby release Sandia, the United States Government, and all officers,
directors, employees and agents (as a group and as individuals) of any
of the foregoing for liability for any injury or damage sustained by me
while participating in such a program.

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  (Sign Name)                                       (Date)
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  **     **                                         **     **

  (Print Name)                                      (last 4 digits of
                                                    social security
                                                    number)
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  **     **                               

  (Org./MS))                              
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**Please return these forms to HBE Preventive Health**

**mailstop 1032, fax 505-844-4091, or email: hbe@sandia.gov**