The StrongWomen Program · This is the safest and easiest way to go. • Take part in a fitness...

The StrongWomen Program A National Fitness Program for Women

Join the StrongWomen Program today!

Dr. Miriam Nelson, a professor at Tufts University in Boston, Massachusetts, has developed a strength-training program

specifically for midlife and older women.

The StrongWomen Program will help you increase your strength, bone density, balance, and energy, and you will look and feel better!

For further information the StrongWomen Program in your community, please contact:

___________________________________________

___________________________________________ [Name, phone number, & email address]


The StrongWomen Program

Your StrongWomen Classes Will Meet: Days (circle): Mon Tues Wed Thu Fri Sat Sun Time: _______am/pm to ______am/pm

Location: ___________________________________________________________________

All StrongWomen Program Participants Should Wear:

- Comfortable, loose, breathable clothing

- Closed-toe shoes with rubber soles, preferably athletic shoes or sneakers

- Minimal jewelry – especially on hands and wrists For Each Class, StrongWomen Program Participants Should Bring (program leader to check boxes next to items that participant needs to supply):

- At least one full water bottle

- 1-2 sets of appropriate weight dumbbells

- At least one adjustable ankle weight

- Exercise mat or towel


Participant Summary Information Sheet

Name:

Address: _______________________________________________________________

Phone Number:

Email Address:

Date of Birth: Age:

Program Site:

Start Date: End Date:

In case of emergency, please call:

Name:

Relationship:

Phone Number: Email address:______________________

Yes—Please provide my contact sheet to the StrongWomen Program. (Mark box on left if YES)

Would you like to be contacted by the StrongWomen Program director (Miriam Nelson, PhD), manager (Rebecca Seguin, MS, CSCS), or one of their direct colleagues regarding your participation in this program?

If so, please check the YES box below, and this contact sheet will be provided to the StrongWomen Program so that you may be contacted in the future. If not, please check the NO box below; your contact sheet will not be provided to the program.

No—Please do NOT provide my contact sheet to the StrongWomen Program. (Mark box on left if NO)


Medical History and Current Health Survey

Name Please read the following list carefully and circle Yes or No as it applies to your medical history

and current health. Please include any additional information and conditions for which you are

receiving medical care.

Medical History

Aneurysm Yes No

Arthritis (Rheumatoid or Osteoarthritis) Yes No

Asthma Yes No

Back Pain Yes No

High Blood Pressure (Last reading / ) Yes No

Low Blood Pressure (Last reading / ) Yes No

Bone Fractures Yes No

Cancer (Please provide type and treatment) Yes No

High Cholesterol (Last reading / ) Yes No

Diabetes (Type I or Type II) Yes No

Emphysema Yes No

Epilepsy Yes No

Heart Disease Yes No

Family History of Heart Disease (Mother, Father, Siblings) Yes No

Hernia Yes No

Joint or Ligament Injuries (Please specify) Yes No

Muscle Injuries (Please specify) Yes No

Neck Pain or Injury Yes No

Osteoporosis Yes No

Stroke Yes No

Surgery Yes No


Terminal Illness Yes No

Medical History (continued)

Vertigo or Lightheadedness Yes No

Other:

Yes No

Current Health – Past month

Back Pain Yes No

Chest Pain or Tightness Yes No

Discomfort from the Waist Up Yes No

Heart Palpitations Yes No

Indigestion Yes No

Jaw Pain Yes No

Joint Pain Yes No

Lightheadedness Yes No

Muscle Pain Yes No

Nausea Yes No

Neck Pain Yes No

New Medication or Dosage Changes Yes No

Shortness of Breath Yes No

Other:

Yes No

Signature Date


Participant Consent

I have voluntarily enrolled in a program of progressive exercise. The

program is designed to place a gradually increased workload on the heart, lungs, muscles and bones to help improve their function. I understand that participation in such a program may be associated with some risks. These risks may include but are not limited to: muscle soreness, fainting, disorders of heart beat, abnormal blood pressure, and in very rare instances, heart attack. To the best of my knowledge I do not have any limiting physical conditions or disability that would preclude an exercise program. Effort will be made to minimize any risks to me by a pre-exercise assessment and a medical screening. I release everyone who has designed, promoted, or conducted the StrongWomen Program from all claims or liabilities whatsoever resulting from my participation in this program. I assume all risks and responsibility for any injury, damage, or any other adverse event that may result from my participation in this program.

Before I begin this program I understand that a pre-exercise assessment and physician screening consent form may be required. I understand that each person may react differently to these fitness activities and these reactions cannot be predicted with complete accuracy. I will inform the Program Leader and/or my health care provider if I experience any unusual symptoms.

Signature

Printed Name

Date _____________________


Physical Activity Readiness Questionnaire (PAR-Q)

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 in the box 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.

Question Yes No

Has your doctor ever said that you have a heart condition and that you should only do physical activity recommended by a doctor?

Do you feel pain in your chest when you do physical activity?

In the past month have you had chest pain when you were not doing physical activity?

Do you lose your balance because of dizziness or do you ever lose consciousness?

Do you have a bone or joint problem that could be made worse by a change in your physical activity?

Is your doctor currently prescribing drugs for your blood pressure or heart condition? (for example: water pills blood thinners)

Do you have any other reason why you should not do physical activity?

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. -Informed use of the PAR-Q: The Canadian Society for Exercise Physiology Health Canada and their agents assume no liability for persons who undertake physical activity and if in doubt about completing this questionnaire consult your doctor prior to physical activity.


If you answered "YES" to one or more questions:

Talk to 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 appraisal. This is an excellent way to determine your basic fitness so that you can plan the best way for you to live actively.

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 you 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.

• Name: _______________________________________________

• Signature: ____________________________________________

• Date: ________________________________________________

• Witness: _____________________________________________


Physician Authorization Form Patient Name: ______________________________________________

Address: ___________________________________________________

___________________________________________________________

Phone Number: _____________Date of Birth: ___________________

Date of Last Exam: ________________

Height: _______Weight: ______ Pulse: ______ BP: ______

Other: _____________________________________________________

Medical Conditions: __________________________________________

Medications: _________________________________________________

____________________________________________________________

Special Considerations: ________________________________________

____________________________________________________________

_____________________________________________________________

________Yes, my patient can participate.

________ No, my patient cannot participate at this time due to his/her medical

conditions and health status.

Physician’s Signature: ________________________________________

Print Name:

__________________________________________________________

Address:

___________________________________________________________

Phone Number: _______________FAX Number: __________________


Participant Evaluation

Participant name: ________________________ Date of birth: ______ ____

Program leader: ______________________ Site name: ____________________

Dates of participation: _____________________ _______ How did you hear about the class? _______________ _____________________

What prompted you to enroll in the class? _________________ _____________

For the following questions, please answer by circling the most appropriate response on the right.

The number 1 corresponds to “not at all,” number 3 to “somewhat,” and number 5 to “very

much.” Numbers 2 and 4 are in between.

Not at all Somewhat Very much

Overall, were you satisfied with the class? 1 2 3 4 5

Was your instructor(s) helpful? 1 2 3 4 5

Was the facility safe, clean, and comfortable? 1 2 3 4 5

Do you feel that your health is better

because of the program? 1 2 3 4 5

Do you feel physically stronger? 1 2 3 4 5

Do you have more energy? 1 2 3 4 5

Do you sleep better? 1 2 3 4 5 Are your joints any less painful? 1 2 3 4 5

Have you become more active? 1 2 3 4 5

Please comment on the exercise program. Which exercises did you like the best and which ones

did you like least?

__________________________________________________ __________________

________________________________________________________ ___________

__________________________________________________ _________________

________________________________________________________ ___________


Participant Evaluation (page 2) Name: ____________________

Did you like the equipment that was used for the program?

____________________________________________________________________

____________________________________________________________________

What was the best aspect of your entire experience during your participation in the program?

____________________________________________________________________

____________________________________________________________________

____________________________________________________________________

What was the worst aspect of your entire experience during your participation in the program?

____________________________________________________________________

____________________________________________________________________

____________________________________________________________________

If you could change any aspect of the program, what would you change?

____________________________________________________________________

____________________________________________________________________

____________________________________________________________________

Additional comments are welcome:

____________________________________________________________________

____________________________________________________________________

____________________________________________________________________

____________________________________________________________________

____________________________________________________________________


Sample scorecard

Scorecard: Senior Fitness Test Date______________ Name________________________ Age ______ Ht ______ Wt ______ Test item Trial 1 Trial 2 Comments: 1. Chair Stand Test ______ (# in 30 secs) 2. Arm Curl Test ______ (# in 30 secs) 3. 2-Minute Step Test* ______ (# of steps) 4. Chair Sit-and-Reach Test ______ ______ (L or R leg) (nearest 1/2 in. +/-) 5. Back Scratch Test ______ ______ (L or R hand up) (nearest 1/2 in. +/-) 6. 8-Foot Up-and-Go Test ______ ______

(nearest 1/2 in. +/-) 6-Minute Walk Test ______ (# of yards)

* omit 2-minute step test if 6-minute test is used.

Reprinted, by permission, from R.E. Rikli & C.J. Jones, 2001, Senior Fitness Test Manual, (Champaign, IL: Human Kinetics), pages 61-74 and 125-131.


Normal Values for Participant Assessment

Chair Stand Test (Women)

Percentile rank 60-64 65-69 70-74 75-79 80-84 85-89 90-94 95 90

21 20

19 18

19 18

19 17

18 17

17 15

16 15

85 80 75

19 18 17

17 16 16

17 16 15

16 16 15

16 15 14

14 14 13

13 12 11

70 65 60

17 16 16

15 15 14

15 14 14

14 14 13

13 13 12

12 12 11

11 10 9

55 50 45

15 15 14

14 14 13

13 13 12

13 12 12

12 11 11

11 10 10

9 8 7

40 35 30

14 13 12

13 12 12

12 11 11

12 11 11

10 10 9

9 9 8

7 6 5

25 20 15

12 11 10

11 11 10

10 10 9

10 9 9

9 8 7

8 7 6

4 4 3

10 5

9 8

9 8

8 7

8 6

6 4

5 4

1 0

Adapted from Rikli & Jones 1999. Reprinted, by permission, from R.E. Rikli & C.J. Jones, 2001, Senior Fitness Test Manual, (Champaign, IL: Human Kinetics), pages 61-74 and 125-131.


Arm Curl Test (Women)

Percentile rank 60-64 65-69 70-74 75-79 80-84 85-89 90-94 95 90

24 22

22 21

22 20

21 20

20 18

18 17

17 16

85 80 75

21 20 19

20 19 18

19 18 17

19 18 17

17 16 16

16 15 15

15 14 13

70 65 60

18 18 17

17 17 16

17 16 16

16 16 15

15 15 14

14 14 13

13 12 12

55 50 45

17 16 16

16 15 15

15 14 14

15 14 13

14 13 12

13 12 12

11 11 10

40 35 30

15 14 14

14 14 13

13 13 12

13 12 12

12 11 11

11 11 10

10 9 9

25 20 15

13 12 11

12 12 11

12 11 10

11 10 9

10 10 9

10 9 8

8 8 7

10 5

10 9

10 8

9 8

8 7

8 6

7 6

6 5


2-Minute Step Test (Women)

Percentile rank 60-64 65-69 70-74 75-79 80-84 85-89 90-94 95 90

130 122

133 123

125 116

123 115

113 104

106 98

92 85

85 80 75

116 111 107

117 112 107

110 105 101

109 104 100

99 94 90

93 88 85

80 76 72

70 65 60

103 100 97

104 100 96

97 94 90

96 93 90

87 84 81

81 79 76

69 66 63

55 50 45

94 91 88

93 90 87

87 84 81

87 84 81

78 75 72

73 70 67

61 58 55

40 35 30

85 82 79

84 80 76

78 74 71

78 75 72

69 66 63

64 61 59

53 50 47

25 20 15

75 71 66

73 68 63

68 63 58

68 64 59

60 56 51

55 52 47

44 40 36

10 5

60 52

57 47

52 43

53 45

46 37

42 39

31 24



Chair-Sit-and-Reach Test (Women)

Percentile rank 60-64 65-69 70-74 75-79 80-84 85-89 90-94 95 90

8.7 7.2

7.9 6.6

7.5 6.1

7.4 6.1

6.6 5.2

6.0 4.6

4.9 3.4

85 80 75

6.3 5.5 4.8

5.7 5.0 4.4

5.2 4.5 3.9

5.2 4.4 3.7

4.3 3.6 3.0

3.7 3.0 2.4

2.5 1.7 1.0

70 65 60

4.2 3.7 3.1

3.9 3.4 2.9

3.3 2.8 2.3

3.2 2.7 2.1

2.4 1.9 1.4

1.8 1.3 0.8

0.4 -0.1 -0.7

55 50 45

2.6 2.1 1.6

2.5 2.0 1.5

1.9 1.4 0.9

1.7 1.2 0.7

1.0 0.5 0.0

0.4 -0.1 -0.6

-1.2 -1.7 -2.2

40 35 30

1.1 0.5 0.0

1.1 0.6 0.1

0.5 0.0 -0.5

0.2 -0.3 -0.8

-0.4 -0.9 -1.4

-1.0 -1.5 -2.0

-2.7 -3.3 -3.8

25 20 15

-0.6 -1.3 -2.1

-0.4 -1.0 -1.7

-1.1 -1.7 -2.4

-1.3 -2.0 -2.8

-2.0 -2.6 -3.3

-2.6 -3.2 -3.9

-4.4 -5.1 -5.9

10 5

-3.0 -4.0

-2.6 -3.9

-3.3 -4.7

-3.7 -5.0

-4.2 -5.0

-4.8 -6.3

-6.8 -7.9


Back Scratch Test (Women)

Percentile rank 60-64 65-69 70-74 75-79 80-84 85-89 90-94 95 90

5.0 3.8

4.9 3.5

4.5 3.2

4.5 3.1

4.3 2.8

3.5 1.9

3.9 2.2

85 80 75

2.9 2.2 1.6

2.6 1.9 1.3

2.3 1.5 0.8

2.2 1.3 0.6

1.8 0.9 0.2

0.8 -0.1 -0.9

0.9 -0.1 -1.0

70 65 60

1.1 0.7 0.2

0.7 0.2 -0.3

0.3 -0.2 -0.8

0.0 -0.5 -1.1

-0.4 -1.0 -1.6

-1.6 -2.1 -2.8

-1.8 -2.5 -3.2

55 50 45

-0.2 -0.7 -1.2

-0.7 -1.2 -1.7

-1.2 -1.7 -2.2

-1.6 -2.1 -2.6

-2.1 -2.6 -3.1

-3.3 -3.9 -4.5

-3.8 -4.5 -5.2

40 35 30

-1.6 -2.1 -2.5

-2.1 -2.6 -3.1

-2.6 -3.2 -3.7

-3.1 -3.7 -4.2

-3.7 -4.2 -4.8

-5.0 -5.7 -6.2

-5.8 -6.5 -7.2

25 20 15

-3.0 -3.6 -4.3

-3.7 -4.3 -5.0

-4.2 -4.9 -5.7

-4.8 -5.5 -6.4

-5.4 -6.1 -7.0

-6.9 -7.7 -8.6

-8.0 -8.9 -9.9

10 5

-5.2 -6.4

-5.9 -7.3

-6.6 -7.9

-7.3 -8.8

-8.0 -9.5

-9.7 -11.3

-11.2 -13.0



8-Foot Up-and-Go Test (Women)

Percentile rank 60-64 65-69 70-74 75-79 80-84 85-89 90-94 95 90

3.2 3.7

3.6 4.1

3.8 4.0

4.0 4.3

4.0 4.4

4.5 4.7

5.0 5.3

85 80 75

4.0 4.2 4.4

4.4 4.6 4.8

4.3 4.7 4.9

4.6 5.0 5.2

4.9 5.4 5.7

5.3 5.8 6.2

6.1 6.7 7.3

70 65 60

4.6 4.7 4.9

5.0 5.1 5.3

5.2 5.4 5.6

5.5 5.7 5.9

6.1 6.3 6.7

6.6 6.9 7.3

7.7 8.2 8.6

55 50 45

5.0 5.2 5.4

5.4 5.6 5.8

5.8 6.0 6.2

6.1 6.3 6.5

6.9 7.2 7.5

7.6 7.9 8.2

9.0 9.4 9.8

40 35 30

5.5 5.7 5.8

5.9 6.1 6.2

6.4 6.6 6.8

6.7 6.7 7.1

7.8 8.1 8.3

8.5 8.9 9.2

10.2 10.6 11.1

25 20 15

6.0 6.2 6.4

6.4 6.6 6.8

7.1 7.3 7.7

7.4 7.6 8.0

8.7 9.0 9.5

9.6 10.0 10.5

11.5 12.1 12.7

10 5

6.7 7.2

7.1 7.6

8.0 8.6

8.3 8.9

10.0 10.8

11.1 12.0

13.5 14.6


6-Minute Walk Test (Women) Percentile rank 60-64 65-69 70-74 75-79 80-84 85-89 90-94

95 90

741 711

734 697

709 673

696 655

654 612

638 591

564 518

85 80 75

690 674 659

673 653 636

650 630 614

628 605 585

584 560 540

560 534 512

488 463 441

70 65 60

647 636 624

621 607 593

599 586 572

568 553 538

523 508 491

493 476 458

423 406 388

55 50 45

614 603 592

581 568 555

561 548 535

524 509 494

477 462 447

443 426 409

373 357 341

40 35 30

582 570 559

543 529 515

524 510 497

480 465 450

433 416 401

394 376 359

326 308 291

25 20 15

547 532 516

500 483 463

482 466 446

433 413 390

384 364 340

340 318 292

273 251 226

10 5

495 465

439 402

423 387

363 322

312 270

261 214

196 150



Food Guide Pyramid Adapted from StrongWomen and Men Beat Arthritis

Vegetables >3 servings

SweetsUse s

ggs

<

paringlySweets

Use sparingly

2 servings

egumes

>1 servings

At least half fromwhole grains

Grains 4-9 servings

Fish, soy, nuts & l

Meat, poultry & e

Fruits >2 servings

Fats and oils, especially omega-3sUse other fats sparingly

ings Milk, yogurt & cheese2-3 serv

Supplements Multivitamin, Calcium, and Vitamin D


MyPyramid from the 2005 Dietary Guidelines


Strong Women Stay Young Two-Day Exercise Log

Name _____________________________Site_____________________________________

Week Week

Date:

WARM-UP

2 sets / 10 reps 2 sets / 10 reps 2 sets / 10 reps 2 sets / 10 reps

STRENGTH TRAINING Wt EIS Wt EIS Wt EIS Wt EIS

Wide Leg Squat

Standing Leg Curl LB/KG LB/KG LB/KG LB/KG

Knee Extension LB/KG LB/KG LB/KG LB/KG

Side Hip Raise LB/KG LB/KG LB/KG LB/KG

Biceps Curl LB/KG LB/KG LB/KG LB/KG

Overhead Press LB/KG LB/KG LB/KG LB/KG

Bent Forward Fly LB/KG LB/KG LB/KG LB/KG

Toe Stand

COOL-DOWN & FLEXIBILITY

Hold

20-30 seconds

Hold

20-30 seconds

Hold

20-30 seconds

Hold

20-30 seconds

Hamstrings & Calves

Quadriceps

Chest & Arms

Upper Back

Notes


Strong Women, Strong Bones Two-Day Exercise Log Name _____________________________Site_____________________________________

Week Week

Date:

WARM-UP

2 sets / 10 reps 2 sets / 10 reps 2 sets / 10 reps 2 sets / 10 reps

STRENGTH TRAINING Wt EIS Wt EIS Wt EIS Wt EIS

Wide Leg Squat

Overhead Press LB/KG LB/KG LB/KG LB/KG

Bent Forward Fly LB/KG LB/KG LB/KG LB/KG

Biceps Curl LB/KG LB/KG LB/KG LB/KG

Wrist Curl LB/KG LB/KG LB/KG LB/KG

Standing Calf & Toe Raise

Back Extension

Tummy Tuck

Side Leg Raise LB/KG LB/KG LB/KG LB/KG

Chest Press LB/KG LB/KG LB/KG LB/KG

BALANCE

One-legged Stork

Tandem Walk


Hold

20-30 seconds

Hold

20-30 seconds

Hold

20-30 seconds

Hold

20-30 seconds

Hamstrings & Calves

Quadriceps

Chest & Arms

Upper Back

Notes


Strong Women Stay Young Three-Day Exercise Log

Name _____________________________Site_____________________________________

Week

Date:

WARM-UP

2 sets / 10 reps 2 sets / 10 reps 2 sets / 10 reps

STRENGTH TRAINING Wt EIS Wt EIS Wt EIS

Wide Leg Squat

Standing Leg Curl LB/KG LB/KG LB/KG

Knee Extension LB/KG LB/KG LB/KG

Side Hip Raise LB/KG LB/KG LB/KG

Biceps Curl LB/KG LB/KG LB/KG

Overhead Press LB/KG LB/KG LB/KG

Bent Forward Fly LB/KG LB/KG LB/KG

Toe Stand


Hold

20-30 seconds

Hold

20-30 seconds

Hold

20-30 seconds

Hamstrings & Calves

Quadriceps

Chest & Arms

Upper Back

Notes


Strong Women, Strong Bones Three-Day Exercise Log Name _____________________________Site_____________________________________

Week

Date:

WARM-UP

2 sets / 10 reps 2 sets / 10 reps 2 sets / 10 reps

STRENGTH TRAINING Wt EIS Wt EIS Wt EIS

Wide Leg Squat

Overhead Press LB/KG LB/KG LB/KG

Bent Forward Fly LB/KG LB/KG LB/KG

Biceps Curl LB/KG LB/KG LB/KG

Wrist Curl LB/KG LB/KG LB/KG

Standing Calf & Toe Raise

Back Extension

Tummy Tuck

Side Leg Raise LB/KG LB/KG LB/KG

Chest Press LB/KG LB/KG LB/KG

BALANCE

One-legged Stork

Tandem Walk


Hold

20-30 seconds

Hold

20-30 seconds

Hold

20-30 seconds

Hamstrings & Calves

Quadriceps

Chest & Arms

Upper Back

Notes


Keeping Track of Participant Screening Forms

Last Name First Name, MI Paid (If Applic.)

Summary Sheet

Medical History

PAR-Q & You

Participant Consent

Doctor Approval

R

Y

G


Participant Contact Sheet Program Leader Name_ ________________ ______ _____

Site_____________________________________ Starting date ________ __ _____ Last Name First Name, MI Address Phone Email Emergency Contact


Participant Attendance Sheet Program Leader Name_ ________________ ______ _____

Site_____________________________________ Starting date ________ __ _____ DATE

Last Name First Name, MI

The StrongWomen Program · This is the safest and easiest way to go. • Take part in a fitness...

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