Registration

If you're interested in joining one of Mackie Shilstone's Programs, please complete the registration form. Space is limited. All applications are accepted. Your application will be evaluated and you will be contacted. All information will be kept confidential.

Click here for a printable application. Return completed application by fax to (504) 457-3111.

Note: Fields marked with an asterisk (*) are required.

Personal Information
Program Interest: *
First Name: *
Last Name: *
Address:
City, State, Zip:
Home Phone:
Daytime Phone:
Email Address:
Age:
Sex:
Marital Status:
Health:
Dominant Side:
Height:
Weight:
% Body Fat (if known):
   
Health History
Primary Care Physician:
Physician's Address:
Physician's City, State, Zip:
Physician's Phone Number:
Injury (if any):
Date Injury Occurred:
If injured, where and how did the injury occur?
Physician's Diagnosis of Injury:
Status of Injury (i.e., surgery/rehab):
If surgery, name of surgeon:
Surgeon's Phone Number:
If rehab, name of therapist:
Therapist Phone Number:
Where was rehab performed?
Any other injuries or non-sports related health problems?
   
Tell Us A Little About Yourself
Background (school, hobbies, career objectives)
Your expectations of The Fitness Principle
How did you hear about The Fitness Principle?
EJGH.org    
Mackie Shilstone website Current Client
Advertising Other
   
Medical History (To be completed by applicant)
Applicant's Name:
Address:
City, State, Zip:
Date of Birth:
Home Phone:
Sports:
SSN:
Employer:
Work Phone:
Insurance Company:
Policy #:
Family Physician:

Please answer the following questions by selecting the appropriate response. Use the space below to explain any "Yes" answers to the following questions. Have or do you:

01. Have a medical problem or injury since your evaluation? Yes No
02. Ever not been allowed to participate in sports for a medical reason? Yes No
03. Ever been hospitalized? Yes No
04. Ever had surgery? Yes No
05. Have any missing organs (i.e., kidney, eye, testicle)? Yes No
06. Presently take any medication? Yes No
07. Have any allergies to medicine or insect bites? Yes No
08. Passed out during or after exercise? Yes No
09. Been dizzy during or after exercise? Yes No
10. Have chest pain during or after exercise? Yes No
11. Tire more quickly than your friends during exercise? Yes No
12. Have high blood pressure? Yes No
13. Been told you have a heart murmur? Yes No
14. Have racing of the heart or skipped heartbeats? Yes No
15. Have a family member that died of heart problems or sudden death before age 50? Yes No
16. Have any skin problems? Yes No
17. Ever had a head or neck injury? Yes No
18. Ever been knocked out or unconscious? Yes No
19. Ever had a seizure? Yes No
20. Ever had a stinger, burner, or pinched nerve? Yes No
21. Ever had heat cramps? Yes No
22. Ever been dizzy or passed out in the heat? Yes No
23. Have trouble with breathing or coughing during or after activity? Yes No
24. Use any special equipment (pads, braces, neck rolls, eye guards, kidney belt, etc.)? Yes No
25. Have any problems with vision? Yes No
26. Wear glasses or contacts? Yes No
27. Ever sprained/strained, dislocated, fractured, or had repeated swelling for any bones or joints? Yes No
28. Have any medical problems listed below?
If Yes, please check all that apply:		 Yes No
 
High Blood Pressure Hepatitis Asthma
Rheumatic Fever Abnormal Bleeding Mononucleosis
Diabetes Tuberculosis Other (List)
Please explain all YES answers from the questions above:
 
Health Behavior
01. Do you sometimes feel that if you could only lose weight, you would then be able to achieve most or all of your other goals? Yes No
02. Are you frequently depressed or anxious because you feel fat or overweight? Yes No
03. Do you feel "good" or "bad" according to how much you eat, how much you weigh, or how much exercise you get in? Yes No
04. Are you frightened at the thought of eating situations where you will have to eat a "normal" meal? Yes No
05. Do you frequently eat beyond the point of fullness, to the point of physical discomfort? Yes No
06. When you feel full, do you also feel self-hatred, desperation, panic or depressed? Yes No
07. Do you have a list of "good" foods and "bad" foods? Yes No
08. Do you avoid eating for long periods of time as a way to control your weight? Yes No
09. Do you feel compelled to eat when you are home alone? Yes No
10. Do your eating and weight loss activities interfere with work, school and/or relationships? Yes No
11. Do you feel frightened of food or eating? Yes No
12. Do you get angry at people if they question what or how much you eat? Yes No
13. Do you find you cannot stop thinking about food and/or weight? Yes No
14. Do you blame others for the way you look and feel? Yes No
15. Do you have trouble making decisions? Yes No
16. Do you think that your weight makes you lonely? Yes No
17. Do you eat when you are stressed, angry or sad? Yes No
18. Do you feel like you deserve to look and feel good? Yes No
19. Do you think that if you lose weight people will like you better? Yes No
20. Are you afraid that if you lose weight people will notice you more? Yes No
   
You must answer all questions below in order to be considered:
01. The above information is current and correct to the best of my knowledge. Yes No
02. If in the judgment of a representative of the Program, I need care or treatment as a result of an injury or sickness, I do hereby request, consent to and authorize such care as may be deemed necessary. Yes No
03. I recognize the evaluation to be done is a standard pre-participation screening examination, and that no in-depth testing, x-rays, lab work, or cardiac test work will be performed. Yes No
 
Waiver
Review the Waiver of Liability
The Waiver of Liability should be reviewed by the applicant, or by the applicant's legal guardian if applicant is under 18 years of age, as well as by the applicant's physician were indicated below.

(“Participant”) acknowledges that he/she will be taking part in a program of exercise and athletic training including but not limited to activities of the Fitness Principle and/or The EJGH Wellness Center. The undersigned acknowledges that the participant has undergone a complete medical examination exclusively in anticipation of this program by an independent physician who has determined that the participant is in appropriate medical condition to participate in a program of vigorous exercise and athletic training activities which may include, but are not limited to jumping, running, weight lifting and conditioning and other exercises. It is acknowledged that medical clearance has been obtained specifically for such activities.

The undersigned desires to voluntarily utilize the services and, if applicable, facilities and equipment provided by The Fitness Principle and/or The Wellness Center for the purpose of personal fitness, recreation, or fitness evaluation. As a consideration for the right and privilege of being permitted access to, and the use of, services or programs offered by The Fitness Principle and/or The Wellness Center, and if applicable, facilities and equipment, the undersigned does hereby release The Fitness Principle, EJGH Wellness Center, East Jefferson General Hospital, its officers, agents and employees from any and all liabilities of any kind whatsoever arising out of any physical or mental injury incurred or sustained by the undersigned while at or participating in any of the fitness programs, recreational or evaluation services and facilities and use of equipment provided by The Fitness Principle and/or The Wellness Center; and furthermore, agrees to save and hold harmless The Fitness Principle, EJGH’s Wellness Center, East Jefferson General Hospital, its officers, employees, assigns, rising out of the undersigned’s use of the facilities and/or services.

Furthermore, the undersigned acknowledges that he or she may participate in activities involving physical exertion or exposure to heat or steam. The undersigned acknowledges that he or she has obtained independent medical approval to use the services or programs, and if applicable, facilities and equipment provided by The Fitness Principle and/or The Wellness Center for the undersigned’s participation in activities involving physical exertion and that he has made the Fitness Principle Director aware of any limitations suggested by his/her physicians.

The undersigned acknowledges and affirms that he or she has carefully read this release and has asked and obtained a satisfactory explanation of any part that he or she does not understand.

 
Yes, I Agree *
 
 
Medical Clearance
01. Do you have a primary care physician? Yes No
  If yes, is your primary care physician at East Jefferson General Hospital? Yes No
  Name of Provider:
02. Have you had a physical from a health care provider within the past 12 months? Yes No
03. Have you had blood work from a heath care provider within the past 12 months? Yes No
04.

Would you like East Jefferson General Hospital to provide your medical clearance to enter into The Fitness Principle with Mackie Shilstone at East Jefferson General Hospital?

 Yes No
  If no, please supply the name of the name of the provider that will provide medical clearance:
  Name of Provider:
 

I understand that there may be diagnostic tests performed that may not be covered by insurance and that I will be responsible for those tests. I understand that if I have had a physical by my health care provider for medical clearance at this time, I will be personally responsible for any services not covered by my insurance.
Yes, I Agree *
   
Medical Release Form
Click here to download and print the Physician Checklist.