Community Health Team Physical Activity Screening Form

    Screening form must be submitted 5 business days before your program start date.

    Red asterisk (*) indicates that the information is required.

    Personal Information

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    Please enter full phone number, including area code (902) 111-2222.

    Program are you looking to register for

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    Please select conditions that you have
    Kidney Disease

    Osteoporosis (thinning of bones)

    Pain in calves when walking

    Swelling in both feet that’s worse at night

    Dizziness, fainting, or blackouts?    		 Aneurysm (either yourself or a close relative)

    Connective tissue disease

    Stroke

    Arthritis: If yes, which joints?

    Please answer all the questions below
    Do you have:

    Shortness of breath

    COPD

    Do you use puffers

    Diabetes  If yes, do you regularly have blood sugars below 4 or above 11?

    Angina (chest pain/tightness)  If yes, Do you carry nitroglycerin with you?  

    High blood pressure  If yes, Is it controlled with medication?  
    Have you had:

    Cancer  If yes, have you received treatment within the last three months?

    Have you ever seen a health care provider because of your heart?

    If Yes, please select any that apply:

    Heart murmur

    Heart Attack

    Heart Surgery

    Heart Palpitations

    Other

    Please answer the questions below regarding walking and balance
    Do you use a mobility aid, such as a cane or walker?

    Type:

    Can you get out of a chair without using your hands?

    Can you stand alone without holding onto anything?

    How long can you walk without needing to stop and take a rest?

    Do you have poor balance or a Fear of Falling?

    Have you fallen in the past year?

    If yes, how many times

    One of our health care providers will review this form to determine if you are appropriate for one of our programs. An individual assessment, with the physiotherapist, may be booked if you meet the criteria for the Low Intensity Exercise Program or Building Better Balance.

    I give the Community Health Team permission to contact me for more information by phone,email, and/or leave a message.

    I give the Community Health Team permission to obtain information from my family practice provider if needed.

     

    Captcha

    Please only hit the submit button once, might take some time to process.