August 20, 2021 Exercise Is Medicine EIM Registration Thank you for connecting with us. Completing this form is the first step in creating your customized health and well-being program designed by our certified EIM coaches. Step 1 of 3 33% Name* First Last Email* URI 100 number* Current Year at URI*First-Year StudentSophmoreJuniorSeniorFifth YearGraduate StudentHeight Weight Where did you find out about EIM Coaching Sessions?* Health Services Counseling Center Psychological Consultation Center Social Media (ie. Campus Rec Instagram) What are you looking to achieve from working with an EIM Coach?* Weight loss/maintenance Improved physical health (ie. blood pressure, disease prevention, etc.) Improved mental health Increase physical activity Make social connections Have you worked with another provider on these goals before(physician, physical therapist, psychologist etc)?*Would you prefer to work with a male/female/no preference?* Male Female No Prefernce What times are you available to meet with your EIM Coach?*please enter the days/times you are available and we will do our best to accommodate. Example: Friday 12-5pm, Monday 9-11am HiddenPhysical Activity Readiness Questionnaire (PAR-Q) and You*(A Questionnaire for People Aged 15-69) Regular physical activity is fun and healthy, and increasingly more people are starting to become more active every day. Being more active is very safe for most people. However, some people should check with their doctor before they start becoming much more physically active. If you are planning to become much more physically active than you are now, start by answering the seven questions below. If you are between the ages of 15 and 69, the PAR-Q will tell you if you should check with your doctor before you start. If you are over 69 years of age, and you are not used to being very active, check with your doctor. Common sense is your best guide when you answer these questions. Please read the questions carefully and answer each one honestly. Has a doctor ever said that you have a heart condition and that you should conduct physical activity with a doctor’s approval?* Yes No Do you feel pain in your chest when you do physical activity?* Yes No In the past month, have you had chest pain when you were not doing physical activity?* Yes No Do you lose your balance because of dizziness or do you ever lose consciouness?* Yes No Do you have a bone or joint problem that could be worsened by a change in your physical activity?* Yes No Is your doctor currently prescribing drugs (for example, water pills) for your blood pressure or heart condition?* Yes No Do you know of any other reason why you should not do physical activity?* Yes No If you answered YES to one or more questions . . . YOUR DOCTOR MUST PROVIDE MEDICAL CLEARANCE BEFORE YOU BEGIN AN EXERCISE PROGRAM! Talk with your doctor by phone or in person BEFORE you start becoming much more physically active or BEFORE you have a fitness appraisal. Tell your doctor about the PAR-Q and which questions you answered YES. You may be able to do any activity you want – as long as you start slowly and build up gradually. Or, you may need to restrict your activities to those which are safe for you. Talk with your doctor about the kinds of activities you wish to participate in and follow his/her advice. Find out which community programs are safe and helpful for you. If you answered NO to all of the questions . . . If you answered NO honestly to all PAR-Q questions, you can be reasonably sure that you can: Start becoming much more physically active – begin slowly and build up gradually. This is the safest and easiest way to go. Take part in a fitness assessment – this is an excellent way to determine your basic fitness level so that you can better plan a healthy lifestyle. It is also highly recommended that you have your blood pressure evaluated. If your reading is over 144/94, talk with your doctor before you start becoming much more physically active.PLEASE NOTE If your health changes so that you then answer YES to any of the above questions, tell your fitness or health professional. Ask whether you should change your physical activity plan. DELAY BECOMING MUCH MORE ACTIVE: If you are not feeling well because of a temporary illness such as a cold or a fever – wait until you feel better; or If you are or may be pregnant – talk to your doctor before you start becoming more active. I have read, understood and completed this questionnaire. Any questions I had were answered to my full satisfaction. I agree* I have read, understood and completed the questionnaire. All questions I have answered to to my best of ability.Signature* Please type name Date MM slash DD slash YYYY Δ
