Town of Poughkeepsie



TOWN OF POUGHKEEPSIE SENIOR CENTER

SENIOR EXERCISE PROGRAM

The Town of Poughkeepsie Senior Center is running a Senior Exercise Program on Tuesday and Thursday mornings starting on May 5th.

This exercise program is a progressive weight training and balance

improvement program designed specifically for seniors. Evidenced based research has shown participation will lead to improvement in balance, mobility, muscle strength, and independence.

The 60-minute classes meet on Tuesdays and Thursdays at 9:30 AM. To receive the full benefit of the program, regular attendance twice a week is important. An Application/Medical History form and a Doctors Consent Form (with signature) or a doctor’s script must be completed prior to starting class.

This program has been developed by the Dutchess County Office for the Aging. There are over similar 50 classes located throughout Dutchess County with almost 1000 seniors participating in this program.

For more information contact the Senior Center at 845-462-0265.

TOWN OF POUGHKEEPSIE SENIOR CENTER

SENIOR EXERCISE PROGRAM

Doctor Consent Form

Participant Name__________________________Phone _____________

Please print

Dear Dr. _______________________________(print physician’s name),

Your patient, (name) _______________________________________has requested enrollment in an exercise program designed to reduce injury, improve balance, mobility and muscle strength for older adults participating in this program. It is based on an Osteoporosis Prevention Program developed at Tufts University by Miriam Nelson, Ph.D.

The class meets twice a week for one hour and the exercises consist of:

? balance exercises

? weight exercises with leg cuffs and hand weights, starting with 1 LB pellets and increasing as participant feels able

? strength exercises using body weight for resistance

Ankle cuffs with removable pellets and one pound hand weights allow for

individualizing the exercises for each participant and tailoring their progression with their comfort level.

Your approval is required before participation can begin. In the event of withdrawal from the program for medical reasons or any extended period of time, your consent will again be required before resuming exercises.

Please return this form to the patient, or to the Senior Center, 14 Abes Way, Poughkeepsie, NY 12601. If you have any questions, please call the Center at 845-462-0265.

I give consent for (patient’ name)_________________________________

to participate in a supervised progressive weight training program.

Comments/restrictions:___________________________________________________

______________________________ ___________________

Physician’s Name (please print) Physician’s Phone Number

________________________________Physician’s Signature ________________Date

TOWN OF POUGHKEEPSIE SENIOR CENTER

SENIOR EXERCISE PROGRAM

APPLICATION - SENIOR EXERCISE PROGRAM

Name______________________________ Address_____________________________City______________________Zip______

Phone______________ Date of Birth__________email__________________________

Emergency contact & phone_______________________________________________

Primary Physician________________________________ Phone__________________

Previously in exercise class? Yes No (circle answer) If yes, When?____________

Please answer all

Medical History (Circle answer)

Polio Survivor yes no

Cardiovascular disease yes no

Diabetes yes no

Hypertension yes no under control

Arthritis (Rheumatoid or osteoarthritis) yes no

Osteoporosis or osteopenia yes no

Stroke in the past six months yes no

Surgery in the past six months yes no

Cataract surgery in the past six months yes no

Fractured bone in the past six months yes no

Knee Operation - (date_______________) yes no

Hip Operation - (date _______________) yes no

Memory loss/dementia diagnosis yes no

Lyme Disease yes no

Use cane or walker yes no

Significant Health Events (past 3 months)

Chest Pain, shortness or breath, palpitations during exertion yes no

Dizziness, falling, tripping (circle all that apply) yes no

Painful joints, muscle pain or back pain (circle what applies) yes no

Evaluation or treatment of newly diagnosed condition yes no

Under the care of a medical doctor, chiropractor, physical

therapist or other doctor in the past 6 months. yes no

Explain _____________________________________________________________

Legal Release: I will choose the level of activity which will not harm me. In consideration of my participation in this wellness/exercise program, I hereby release

The Town of Poughkeepsie, Dutchess County Office for the Aging, leaders, and Program Coordinator of this exercise facility from any liability or claims, for personal injury or otherwise, arising out of or in any way connected to my participation in this

wellness/exercise program.

_________________________________________ ______________________

Participant’s Signature Date

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