Readiness Questionnaire

Readiness Questionnaire

This questionnaire will help us guide you to programs that may be most appropriate for you. Before becoming more physically active or if your health changes, we encourage you to speak to your doctor about any recommendations, contraindications, physical limitations or restrictions you may have.
Note: Please complete a Readiness Questionnaire for each individual person applying for membership at Lakeshore.
Name

First NameLast Name
Date of Birth

MonthDayYear
Is anyone else in your household joining?
Name of other household member who should be on the same account as you.

First NameLast Name
Proof of Residence

Provide one document to verify principal residence by providing one of the following documents: Valid Driver License or Identification Card, Voter Registration Card, Current Lease or Rental agreement for housing, current Utility bill (Water, Gas, or Electric), School Enrollment documentation (report card), Any State or Federal government issued documents indicating resident's address.
Cancelof
Do you currently have or have had any bone or joint problems, or orthopedic surgeries that might limit you from engaging in physical activity?
Please specify.
Please provide details about bone or joint problems, or orthopedic surgeries.
Do you have arthritis, osteoporosis, or back problems?
Please specify which condition.
Do you currently have cancer of any kind?
Briefly describe your current cancer diagnosis and treatment if applicable.
Do you have a heart or cardiovascular condition? (i.e. Coronary Artery Disease, Heart Failure, or a diagnosed heart rhythm abnormality)
Please select the condition(s) that apply to you.

Other
Do you currently have high blood pressure?
Do you have difficulty managing your blood pressure with medication or other physician-prescribed treatments?
Do you have any metabolic conditions? (i.e. Diabetes or pre-diabetes, chronic kidney disease or liver problems)
Which of the following best describes your metabolic condition?
Do you have difficulty managing your metabolic condition with medication or other physician-prescribed treatments?
Do you have a respiratory disease? (i.e. Chronic Obstructive Pulmonary Disease, Asthma, Pulmonary High Blood Pressure, Emphysema)
Which of the following best describes your respiratory disease?

Other
Do you have a spinal cord injury?
What best describes your spinal cord injury?
Date of injury

MonthDayYear
2 digit month, 2 digit day, 4 digit yearPlease input date of spinal cord injury
Have you had a stroke?
How has your stroke affected you?
Date of stroke

MonthDayYear
2 digit month, 2 digit day, 4 digit yearPlease input date of stroke
Do you use a mobility device(s) to get around inside the home or in the community?

Other
Do you have any other medical condition not listed above?
Please check the box(es) below that apply to your health.
Type of Amputation
Do you have a prosthesis?
Do you require assistance with community mobility?
Have you had a seizure in the last 6 months?
Date of head injury

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Do any of the following apply to you?
Do you have difficulty seeing, even if wearing glasses?
Do you have difficulty remembering or concentrating?
Do you have difficulty hearing, even if using a hearing aid(s)?
Do you have difficulty with self-care, such as washing all over or dressing?
Do you have difficulty walking or climbing steps?
Using your usual language, do you have difficulty communicating, for example understanding or being understood?
In case of emergency, is there any information you would want shared with emergency personnel? (i.e. allergies, hospital preference)
I have read, understood, and completed this questionnaire. I agree that I have been encouraged by the Lakeshore Foundation staff to seek advice from my doctor before becoming more physically active, or if my health changes.
Signature
Lakeshore offers new members a complimentary session in the Fitness Center and Aquatics Center to help you use the areas independently and safely. These sessions are by appointment only. Please stop by the Fitness Island desk or the Aquatics office to set up your appointment with one of our specialists.
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