Client Information Form - St. Mary Medical Center

St. Mary Way to Wellness ProgramPhone: 215.710.2815Fax: 215.710.6931, Attention: Merle EskowitzParticipant ApplicationPlease indicate session/group and time preference. If your preference is closed, indicate a second choice, if possible.2012Winter/SpringSessions Group 22 - Tuesdays, January 10 – March 13 Group 23 - Saturdays, January 14 – March 17 3:45 – 6:00 pm 5:45 – 8:00 pm9:45 am – noonLast Name First Name MIDate of Birth Age Gender M FAddressCity, State and Zip CodeTelephone (Home/Cell) (Work)OccupationE-mail AddressEmergency Contact Name and NumberAre you a member of the St. Mary Gym? Yes No If Yes, please be sure to have your membership placed on hold.For St. Mary Colleagues Only Shift: Day Evening Night Health Insurance Carrier********************************************************************************************************In general, how would you describe your physical health? Excellent Good Fair PoorIn general, how would you describe your emotional state? Excellent Good Fair PoorAre you experiencing or have you been treated for any of the following:AllergiesAnxiety/DepressionArthritisAsthmaBlood clotsCancerCardiac ailmentChronic fatigue/fatigueDiabetesDigestive disorderDizzinessEating disorderFibromyalgiaHigh cholesterolHypertensionInfectionInsomniaMental health issuesOrthopedic issuesPanic attacksPulmonary ailmentsSkin conditionStressStrokeThyroid diseaseVascular ailmentOther, explain __________________________________________________________________________________What has led you to seek this program now? Please check all that apply. To feel healthier To lose weight To modify my behavior To increase my energy level To help with my illness To decrease my stress To enhance my quality of life To sleep better My doctor recommended it Other, explain _____________________________________________________________________________Confidential Page 1 10/11

Please check the appropriate boxes:1. Are you currently under a medical doctor’s care? Reason, if not indicated earlier. 1. Yes No_____________________________________________________________________2. Do you take blood pressure or heart medication? 2. Yes No3. Do you take other prescription medications? If yes, please list.3. Yes No__________________________________________________________________________________________________________________________________________4. Have you suffered an acute injury or trauma recently? 4. Yes No5. Have you ever had surgery? Please describe if not indicated earlier.5. Yes No_____________________________________________________________________6. Are you pregnant? 6. Yes No7. Do you exercise regularly/participate in sports? If yes, how often?7. Yes No_____________________________________________________________________8. Do you have orthopedic problems that could worsen with physical activity? 8. Yes No9. Do you wear contact lenses or dentures? 9. Yes No10. Are you taking vitamin or mineral supplements? If yes, please list.10. Yes No_____________________________________________________________________11. Do you have any food allergies or intolerance? If yes, describe.11. Yes No_____________________________________________________________________12. Do you follow any diet restrictions? If yes, describe. _________________________ 12. Yes No_____________________________________________________________________13. Do you do the cooking and/or food shopping at home? If no, who does?13. Yes No_____________________________________________________________________14. Have you tried weight loss programs in the past? If yes, please list.14. Yes No_____________________________________________________________________15. Do you have concerns or challenges with regard to starting this program? If yes, 15. Yes Nodescribe _____________________________________________________________16. Would you like to focus on coping with stress? 16. Yes No17. Do you have any other health challenges or concerns to discuss prior to beginning theprogram?17. Yes NoUnderstanding Your CommitmentWay to Wellness requires a time commitment as well as a dedication to make program participation apriority. You may want to ask yourself…18. Can I realistically commit to two hours per week for classes plus three to five hoursper week for exercising in the St. Mary gym?18. Yes No19. Am I ready to make behavior change a high priority in my life? 19. Yes No20. Will I be comfortable with the slow weight loss that is recommended? 20. Yes No21. Will I keep a daily journal of everything I eat and look up calories as required? 21. Yes No22. Do I want to participate in a 10-week program that is NOT a quick fix? 22. Yes NoConfidential Page 2 10/11

St. Mary Way to Wellness ProgramPhone: 215.710.2815Fax: 215.710.6931, Attention: Merle EskowitzPlease read and sign the following:I understand that:I am participating in this program to complement my current health care regimen.This program is not a substitute for professional medical advice/examination/diagnosis/treatment and I amto contact my physician for clarification on any information I might receive.I have stated all my known medical conditions and have completed the Participant Application to the bestof my ability.I will update my program team on changes to my physical health as needed.I am responsible for payment in full in the agreed upon manner, at the time of my evaluation with theW2W Coordinator. No refunds are permitted, without exception.In order to receive health insurance reimbursement and/or to participate in the St. Mary Colleague benefit,I must meet the requirements of the 10-week program, as described. I will not receive reimbursement or acertificate of program completion if I have not met the criteria. I am to speak with the W2W Coordinatorfor clarification, if needed.Note: The information relevant to your program participation is kept in a file, which is shared by the programteam you work with during your 10-week program. In order to best meet your needs, your program must be acooperative effort between you and your team. Information in your file is confidential and is not shared withanyone outside the team.SignatureDateName (please print)In compliance with hospital privacy regulations, please indicate by signing below that the St. Mary Way toWellness program team may contact you via telephone, e-mail and/or mail regarding classes, appointments,services, newsletters and/or upcoming events. Telephone E-Mail (used most) Mail SignatureFor W2W Use Only: COL COL-G AFFL AFFL-G PG _______ FAM COMConfidential Page 3 10/11