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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