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Home My WebLink AboutR-1991-D5919 Physical Fitness / YMCA• • RESOLUTION NO. 015919 A RESOLUTION authorizing the execution of a contract with the Young Men's Christian Association of Yakima. Inc., a Washington Corporation for Fire Depart- ment physical fitness testing. WHEREAS, the City of Yakima desires to test members of its Fire Department for physical fitness; and WHEREAS, such testing is necessary to determine the level of fitness on the part of members of the Fire Department staff to perform their duties; and WHEREAS, the YMCA possesses the necessary staff and expertise to perform physical fitness testing on members of the City's Fire Department staff, now, therefore, BE IT RESOLVED BY THE CITY COUNCIL OF TBE CITY OF YAKIMA: The City Manager and City Clerk are hereby authorized and directed to execute "Contract For Physical Fitness Testing Services Between The City Of Yakima And The Young Men's Chris- tian Association of Yakima, Inc., a Washington Corporation," a true copy of which is attached hereto, together with attach- ments, and incorporated herein. ADOPTED BY THE CITY COUNCIL this 00 day of /VI al 1991. ATTEST: City Clerk (res/ftnststg.jv) Mayor CONTRACT FOR PHYSICAL FITNESS TESTING SERVICES BETWEEN THE CITY OF YAKIMA AND YOUNG MEN'S CHRISTIAN ASSOCIATION OF YAKIMA, INC., A WASHINGTON CORPORATION WHEREAS, the City of Yakima Fire Department desires to test the physical fitness of the members of its staff; and WHEREAS, the Young Men's Christian Association of Yakima, a Washington Corporation Inc. has the equipment and expertise to test such fitness, now, therefore, The City of Yakima, hereinafter called "City" and the Young Men's Christian Association of Yakima, Inc., a Washington Corpora- tion, hereinafter called "YMCA," mutually agree as follows: 1. Services. YMCA shall conduct a seven -part physical fitness test on all members of the City Fire Department staff who are referred to the YMCA by the Chief of the Fire Department (Chief) or his designee. The test shall be the YMCA Physical Fitness Test Battery and shall be scored for each participant according to the "Y's Way to Physical Fitness Evaluation Profile," appropriate copies of which form have been attached and incorpo- rated as Attachment "A" to this agreement. 2. Duration. This agreement shall commence the 21st day of May, 1991 and terminate on December 31, 1992. Either party to this agreement may terminate it by giving 30 days written notice to the other party at the addresses written below. 3. Referral of Candidates for Testing. Once each year the Chief or his designee shall refer members of his staff to the YMCA for testing mentioned under Section 1 of this agreement. Each referral shall be tested once during 1991, and once in 1992. The precise time and date of the testing of each candidate shall be by mutual agreement between the parties. Retests shall be conducted on a monthly basis as determined by the Physical Fitness Commit- tee. 4. Compensation. The City shall pay to the YMCA twenty five dollars ($25.00) per test or retest per examinee. Commencing July 1, 1991, and for each month thereafter for which YMCA conducts tests under this agreement, YMCA shall submit to the City's Finance Department at City Hall, Yakima, Washington, a bill for all tests conducted during the previous month. Compensation from the City shall be due to the YMCA on or before the 10th of each month during which billing occurs. 5. Test Scoring. Completed test scores for each examinee, within the International Association of Fire Fighters Local 469, according to Attachment "A" shall be kept confidential by the YMCA and forwarded to the Yakima Fire Department Physical Fitness Com- mittee at Fire Station No. 1, 401 North Front Street, Yakima, Washington. In the event other City employees which are not mem- bers of the International Association of Fire Fighters Local 469 1 (agr/ftnststg.jv) are tested, YMCA shall forward these scores to the Chief at the aforementioned address. 6. YMCA Staff. The YMCA shall use only such members of its staff which are competent and able to conduct the aforementioned fitness testing. Prior to the conducting of any such testing, YMCA shall screen Fire Department members which are referred to it and use the "Yakima Young Men's Christian Association Informed Consent" form and the "Yakima Young Men's Christian Association Physical Activity Readiness Questionnaire and Medical Clearance Form," true copies of which are attached and incorporated by reference herein as Attachment "B." 7. Liability. The YMCA shall be responsible for its own negligence, actions, or inactions which arise out of the perform- ance of this agreement. The City shall defend, indemnify, and hold harmless the YMCA from all liability resulting out of its perform- ance of this agreement other than YMCA's negligence, actions or inactions, in the performance of this agreement. 8. Entire Agreement. This writing represents the entire agreement between the parties. There is no other written or oral agreement between the parties with respect to the matter covered by the content of this agreement. ATTEST: BY:j ea)u2 - Karen Roberts City Clerk o aacrnO: y/ 3- i! 2 (agr/ftnststg.jv) CITY OF YAKIMA City Hall, 129 No. 2nd Street Yakima, WA 98901 BY: -:,•'\'°"4\N„ Richard A. Zais, Jr. City Manager YOUNG MEN'S CHRISTIAN ASSOCIATION OF YAKIMA, INC., A WASHINGTON CORPORATION 5 No. Naches Avenue Yakima, WA 98901 �/ BY: Title: 9 /kJ -xi -4_774i ,i-nfo LCL c'v — i )/ ATTACHMENT A THE YMCA PHYVTCAL FITNESS TEST BATTERY 113 Y's Way to Physical Fitness Physical Fitness Evaluation Profile Norms --Men 18-25 Name Dates: T1 T2 T3 Rating % ranking Resting HR % fat 3 -min step test PWC max (kgm) 1/O2max (mUkg) Flexibility Bench press Sit-ups 100 49 4 70 2350 80 26 45 60 Excellent 95 52 6 72 2275 71 22 42 54 90 55 7 78 2065 63 20 38 50 85 57 8 82 1905 59 20 34 48 Good 80 60 9 85 1795 55 19 32 46 75 61 10 88 1705 53 18 30 45 70 63 11 91 1630 51 18 28 42 Above average 65 64 12 94 1570 49 17 26 41 60 65 13 97 1515 47 17 25 40 55 67 14 101 1455 46 16 22 38 Average 50 68 15 102 1400 45 16 22 37 45 69 16 104 1350 43 15 21 36 40 71 18 107 1305 41 14 20 34 Below average 35 72 19 110 1260 39 14 17 33 30 73 20 114 1195 38 13 16 32 25 76 22 118 1135 35 12 13 30 Poor 20 79 24 121 1090 33 12 12 28 15 81 26 126 1050 31 10 9 26 10 84 28 131 975 29 9 8 24 Very poor 5 89 30 137 885 26 7 2 17 0 95 37 164 850 20 2 0 12 Actual Scores T1 T2 T3 Actual Weight Target Weight Blood Pressure T1 T2 T3 Your actual weight should be within 10% of your target weight. If your blood pressure exceeds 150/90 it is considered high. Your YMCA Medical Advisory Committee should have guidelines for when blood pressure is too high to continue fitness testing. ATTACHMENT "A" 114 Y'S WAY TO PHYSICAL FITNESS Y's Way to Physical Fitness Physical Fitness Evaluation Profile Norms—Men 26-35 Name Dates: T1 T2 T3 Rating % ranking Resting HR % fat 3 -min step test PWC max (kgm) NO2max (mL/kg) Flexibility Bench press Sit-ups 100 49 8 73 2300 70 25 43 55 Excellent 95 52 10 76 2180 64 22 40 50 90 54 12 79 1950 58 20 34 46 85 57 13 83 1820 54 19 30 45 Good 80 60 14 85 1740 52 18 29 42 75 61 15 88 1665 50 18 26 41 70 62 16 91 1600 47 17 25 38 Above average 65 64 17 94 1545 46 17 24 37 60 65 18 97 1485 44 16 22 36 55 66 19 101 1430 42 16 21 34 Average 50 68 20 103 1375 41 15 20 33 45 70 21 106 1325 40 15 18 32 40 72 22 109 1270 39 14 17 30 Below average 35 73 23 113 1225 38 13 14 30 30 74 24 116 1180 35 12 13 29 25 77 25 119 1135 34 12 12 28 Poor 20 78 26 122 1080 33 11 10 25 15 81 28 126 1020 31 10 9 24 10 84 30 130 960 28 9 5 21 Very poor 5 88 32 140 840 26 7 2 12 0 94 37 164 780 20 2 0 6 Actual Scores T1 T2 T3 Actual Weight Target Weight Blood Pressure T1 T2 T3 / / Your actual weight should be within 10% of your target weight. If your blood pressure exceeds 150190 it is considered high. Your YMCA Medical Advisory Committee should have guidelines for when blood pressure is too high to continue fitness testing. Be V A Ac Ta Bic THE YMCA PHYSICAL FITNESS TEST BATTERY 115 Y's Way to Physical Fitness Physical Fitness Evaluation Profile Norms—Men 36-45 Name Dates: T1 T2 T3 Rating % ranking Resting HR % fat 3 -min step test PWC max (kgm) VO3max (ml./kg) Flexibility Bench press Sit-ups 100 50 10 72 2250 77 24 40 50 Excellent 95 53 12 74 2055 60 21 34 46 90 56 14 81 1815 53 19 30 42 85 60 16 86 1725 49 19 28 40 Good 80 61 17 90 1640 46 17 25 37 75 62 18 94 1565 44 17 24 36 70 64 19 98 1500 42 17 22 34 Above average 65 65 20 100 1440 41 15 21 32 60 66 21 102 1375 40 15 20 30 55 68 22 105 1325 38 15 18 29 Average 50 69 23 108 1280 37 14 17 29 45 70 24 111 1235 35 13 16 28 40 73 25 113 1190 34 13 14 26 Below average 35 74 26 116 1140 33 11 13 25 30 76 26 118 1090 32 11 12 24 25 77 27 120 1045 30 11 10 22 Poor 20 80 28 124 995 28 9 9 20 15 82 29 128 945 27 9 8 18 10 86 30 132 860 25 7 5 16 Very poor 5 90 32 142 745 21 5 2 9 0 96 38 168 700 19 1 0 4 Actual Scores T1 T2 T3 Actual Weight Target Weight Blood Pressure T1 T2 T3 / / Your actual weight should be within 10% of your target weight. If your blood pressure exceeds 150/90 it is considered high. Your YMCA Medical Advisory Committee should have guidelines for when blood pressure is too high to continue fitness testing. 116 Y'S WAY TO PHYSICAL FITNESS Y's Way to Physical Fitness Physical Fitness Evacuation Profile Norms—Men 46-55 Name Oates: T1 T2 T3 Rating % ranking Resting HR % fat 3 -min step test PWC max (kgm) VO,max (ml/kg) Flexibility Bench press Sit-ups 100 50 12 78 2150 60 23 35 50 Excellent 95 53 14 81 1940 54 20 28 41 90 57 16 84 1645 47 19 24 36 85 59 18 89 1520 43 17 22 33 Good 80 60 19 93 1450 42 17 21 30 75 63 20 96 1385 40 16 20 29 70 64 21 99 1335 38 15 17 28 Above average 65 65 22 101 1285 36 15 16 26 60 67 23 103 1240 35 14 14 25 55 68 24 109 1205 35 13 13 24 Average 50 69 24 113 1165 34 12 12 22 45 71 25 115 1130 32 12 10 22 40 73 26 118 1090 31 11 10 21 Below average 35 75 27 120 1055 30 10 9 20 30 76 28 121 1020 29 10 8 18 25 79 29 124 950 28 9 6 17 Poor 20 80 30 126 935 27 8 5 16 15 83 31 130 885 26 7 4 13 10 85 32 135 830 23 6 2 12 Very poor 5 91 34 145 750 22 4 1 8 0 97 38 158 700 18 1 0 4 Actual Scores T1 T2 T3 Actual Weight Target Weight Blood Pressure T1 T2 73 / / Your actual weight should be within 10% of your target weight. If your blood pressure exceeds 150/90 it is considered high. Your YMCA Medical Advisory Committee should have guidelines for when blood pressure is too high to continue fitness testing. Name THE YMCA PHYSIC.' FITNESS TEST BATTERY 117 Y's Way to Physical Fitness Physical Fitness Evacuation Profile Norms—Men 56-65 Dates: T1 T2 T3 Rating % ranking Resting HR % fat 3 -min step test PWC max (kgm) VO2max (ml/kg) Flexibility Bench press Sit-ups 100 51 15 72 2100 58 21 32 42 Excellent 95 52 17 74 1665 49 19 24 37 90 56 18 82 1485 43 17 22 32 85 59 19 89 1400 39 17 20 29 Good 80 60 20 93 1315 38 15 18 28 75 61 21 97 1240 37 15 14 26 70 64 22 98 1195 35 13 14 24 Above average 65 65 23 100 1150 34 13 12 22 60 67 24 101 1100 33 13 10 21 55 68 24 105 1055 31 11 10 20 Average 50 69 25 109 1005 31 11 8 18 45 71 26 111 965 30 11 8 17 40 72 26 113 925 29 9 6 16 Below average 35 73 27 116 890 27 9 6 14 30 75 28 118 860 26 9 4 13 25 76 29 122 830 25 7 4 12 Poor 20 79 30 125 795 23 7 2 10 15 81 31 128 740 22 5 2 9 10 84 32 131 680 21 5 0 8 Very poor 5 88 34 136 597 18 3 0 4 0 94 38 150 590 16 1 0 2 Actual Scores T1 T2 T3 Actual Weight Target Weight Blood Pressure T1 / T2 T3 / / Your actual weight should be within 10% of your target weight. If your blood pressure exceeds 150/90 it is considered high. Your YMCA Medical Advisory Committee should have guidelines for when blood pressure is too high to continue fitness testing. 118 Y'S WAY TO PHYSICAL FITNESS Y's Way to Physical Fitness Physical Fitness Evaluation Profile Norms—Men Over 65 Name Dates: T1 T2 T3 Rating % ranking Resting HR % fat 3 -min step test PWC max (kgm) VO2max (mlJkg) Flexibility Bench press Sit-ups 100 50 15 72 1940 50 20 30 40 Excellent 95 53 17 74 1405 42 18 20 33 90 55 18 86 1235 38 17 18 29 85 58 19 89 1175 36 15 14 26 Good 80 59 20 92 1110 34 14 12 25 75 61 21 95 1045 33 13 10 22 70 62 22 97 1015 32 13 10 21 Above average 65 63 22 100 990 30 12 10 21 60 65 23 102 945 29 11 8 20 55 66 24 104 900 28 11 8 18 Average 50 69 24 109 870 26 10 6 17 45 69 25 113 840 25 9 6 16 40 70 25 114 805 25 9 4 14 Below average 35 71 26 116 765 24 8 4 13 30 73 27 119 725 22 8 4 12 25 75 28 122 695 21 7 2 10 Poor 20 77 29 126 665 21 6 2 9 15 79 30 128 610 20 5 2 8 10 83 31 133 555 18 4 0 6 Very poor 5 89 33 140 510 17 3 0 4 0 98 38 152 490 15 0 0 2 Actua! Scores T1 T2 T3 Actua! Weight Target Weight Blood Pressure T1 T2 T3 Your actual weight should be within 10% of your target weight. If your blood pressure exceeds 150/90 it is considered high. Your YMCA Medical Advisory Committee should have guidelines for when blood pressure is too high to continue fitness testing. THE YMCA PHYSICAL FITNESS TEST BATTERY Y's Way to Physical Fitness Physical Fitness Evaluation Profile Norms—Women 18-25 Name Dates: T1 T2 T3 Rating % ranking Resting HR % fat 3 -min step test PWC max (kgm) VO2max (mtlkg) Flexibility Bench press Sit -w 100 54 13 72 1830 71 27 50 55 Excellent 95 56 15 79 1640 67 25 42 48 90 60 17 83 1440 58 24 36 44 85 61 18 88 1320 54 23 32 41 Good 80 64 19 93 1235 50 22 29 38 75 65 20 97 1175 48 21 28 37 70 66 21 100 1120 46 21 25 36 Above average 65 68 22 103 1075 43 20 24 34 60 69 23 106 1030 42 20 22 33 55 70 24 110 990 41 19 21 32 Average 50 72 25 112 950 40 19 20 30 45 73 25 116 915 39 18 18 29 40 74 26 118 880 37 18 16 28 Below average 35 76 27 122 845 35 17 14 26 30 78 28 124 810 34 17 13 25 25 80 29 128 775 32 16 12 24 Poor 20 82 30 133 740 31 15 9 22 15 84 31 137 705 29 14 8 20 10 86 33 142 640 26 13 5 17 Very poor 5 90 37 149 555 22 12 2 10 0 100 43 155 500 18 8 1 4 Actual Scores 11 T2 T3 Actual Weight Target Weight Blood Pressure T1 / T2 T3 / / Your actual weight should be within 10% of your target weight. If your blood pressure exceeds 150/90 it is considered high. Your YMCA Medical Advisory Committee should have guidelines for when blood pressure is too high to continue fitness testing. 120 Y'S WAY TO PHYSICAL FITNESS Y's Way to Physical Fitness Physical Fitness Evaluation Profile Norms—Women 26-35 Name Dates: T1 T2 T3 Rating % ranking Resting HR % fat 3 -min step test PWC max (kgm) 1:1O2max (ml./kg) Flexibility Bench press Sit-ups 100 54 13 72 1800 69 26 48 54 Excellent 95 55 15 80 1440 59 24 40 42 90 59 18 86 1330 54 23 33 40 85 60 19 91 1245 51 22 29 37 Good 80 63 20 93 1180 48 21 26 34 75 64 21 97 1115 46 20 25 33 70 66 22 103 1065 43 20 22 32 Above average 65 67 23 106 1020 42 19 21 30 60 68 23 110 985 40 19 20 29 55 69 24 112 955 38 18 18 28 Average 50 70 25 116 925 37 18 17 26 45 71 26 118 885 35 18 16 25 40 72 27 121 840 34 17 14 24 Below average 35 74 29 124 805 33 16 13 23 30 76 30 127 765 31 16 12 21 25 78 31 129 730 30 15 9 20 Poor 20 80 33 131 695 28 14 8 18 15 82 35 135 655 26 14 5 16 10 84 36 141 600 25 13 2 12 Very poor 5 88 39 148 530 22 11 1 2 0 94 49 154 490 20 8 0 1 Actual Scores T1 T2 T3 Actual Weight Target Weight Blood Pressure T1 T2 T3 Your actual weight should be within 10% of your target weight. If your blood pressure exceeds 150/90 it is considered high. Your YMCA Medical Advisory Committee should have guidelines for when blood pressure is too high to continue fitness testing. Name THE YMCA PHYSICAL FITNESS I ES 1 ISA 1 1 LK T 111 Y's Way to Physical Fitness Physical Fitness Evaluation Profile Norms—Women 36-45 Dates: T1 T2 T3 Rating % ranking Resting HR % fat 3 -min step test PWC max (kgm) VO2max (mUkg) Flexibility Bench press Sit-ups 100 54 15 74 1780 66 25 46 50 Excellent 95 56 17 80 1360 53 23 32 38 90 59 19 87 1215 46 22 28 34 85 62 2G 93 1135 44 21 25 30 Good 80 63 21 97 1085 41 20 22 29 75 64 23 101 1035 39 19 21 27 70 66 24 104 980 37 19 20 26 Above average 65 68 25 106 925 36 18 18 25 60 69 26 109 880 34 17 17 24 55 70 27 111 835 33 17 14 22 Average 50 71 28 114 800 32 16 13 21 45 72 29 117 765 31 16 12 20 40 74 30 120 745 30 15 11 18 Below average 35 76 31 122 720 29 15 10 17 30 78 32 127 695 28 14 9 16 25 79 33 130 670 26 13 8 14 Poor 20 80 35 135 625 25 12 6 12 15 82 36 138 575 23 11 4 10 10 84 39 143 530 21 10 2 6 Very poor 5 88 41 146 490 19 9 1 2 0 92 48 152 470 18 6 0 1 Actual Scores TI T2 T3 Actual Weight Target Weight Blood Pressure T1 T2 T3 Your actual weight should be within 10% of your target weight. If your blood pressure exceeds 150/90 it is considered high. Your YMCA Medical Advisory Committee should have guidelines for when blood pressure is too high to continue fitness testing. 124 Y'S WAY TO PHYSICAL FITNESS Y's Way to Physical Fitness Physical Fitness Evaluation Profile Norms—Women Over 65 Name Dates: T1 T2 T3 Rating % ranking Resting HR % fat 3 -min step test PWC max (kgm) VO2max (mUkg) Flexibility Bench press Sit-ups 100 54 16 73 1190 51 22 26 36 Excellent 95 56 17 83 860 39 21 22 26 90 59 18 86 820 33 20 18 24 I 85 60 22 93 725 31 19 14 22 Good 80 62 23 97 665 30 18 13 20 75 64 25 100 640 28 18 12 18 70 66 27 104 610 27 17 11 16 Above average 65 67 28 108 585 26 17 10 15 60 68 29 114 560 25 16 9 14 55 70 30 117 540 24 15 8 13 Average 50 71 31 120 525 23 15 6 12 45 72 32 121 510 22 14 5 11 40 73 33 123 495 22 13 4 10 Below average 35 75 34 126 480 21 13 3 8 30 76 35 127 470 20 12 2 6 25 79 36 129 460 18 11 2 4 Poor 20 80 37 132 425 17 10 1 3 15 84 38 134 395 17 9 0 2 10 88 39 135 370 16 8 0 1 Very poor 5 91 40 149 340 15 6 0 0 0 96 44 151 320 14 2 0 0 Actual Scores T1 T2 T3 Actual Weight Target Weight Blood Pressure T1 T2 T3 / / Your actual weight should be within 10% of your target weight. If your blood pressure exceeds 150/90 it is considered high. Your YMCA Medical Advisory Committee should have guidelines for when blood pressure is too high to continue fitness testing. The Yakima Young Men's Christian Association Informed Consent �v Please Pnnt Name Date Address CityStatn lip Phone (Home) (Business) Birthdate Sex Height Weight Employer Occupation Emergency Contact Person Telephona STAFF ONLY RHR RBP Target HR Staff Initial 1 hereby apply for enrollment in a physical fitness testing or physical exercise program conducted by the YMCA. Before I begin the physical exercise program under the guidance and supervision of the YMCA, I agree. if required by the YMCA. to attend a YMCA physical fitness evaluation to measure my fitness level. I also agree to cooperate with and follow the instructions of the YMCA professional staff. Where the exercise program involves an individualized recommended training program, 1 agree to keep within the limits of the program. 1 understand that participation in any fitness evaluation or physical exercise program may entail certain risks. Those risks may include transient lightheadedness, fainting, chest discomfort, leg cramps and. in some cases. heart attacks or cardiac arrests. I will report any physical discomfort or problems expenenced during or atter exercise to the YMCA staff immediately. I understand the nature and components of the program for which t am applying and the risks that may be associated with physical exercise. 1 hereby consent to and voluntarily accept those risks. In the event that a medical clearance must be obtained prior to my participation in the exercise program. I agree to consult my physician and obtain written permission from my physician prior to the commencement of any exercise program. 1 further agree to hold harmless the YMCA and its staff members conducting the exercise program from any and all claims. suits. losses. or related causes of action for damages, including, but not limited to, such claims that may result from my injury or death. accidental or otherwise, during, cr arising in any way from. the exercise program. Signature of Participant Date Witness Date Class Day/Time Rev.seo 7.88 ATTACHMENT "B" Place s / T r" The Yakima Young Men's Christian Association Physical Activity Readiness Questionnaire and Medical Clearance Form Y Common sense is your best guide in answering these few questions. Please read them carefully and check the Yes or No box opposite the questions. Physical exercise always poses some risks. These questions identify some of the more serious health conditions which may increase those risks. Yes No O 0 1. Do you have or has your doctor recently (within last year) told you that you have high blood pressure? O 0 2. Are you on medication to lower your blood pressure? O 0 3. Have you ever had a heart attack? O 0 4. Have you ever had heart surgery? O 0 5. Do you have or has your doctor ever told you that you have any type of heart problems? O 0 6. Do you have any serious orthopedic (bone, back, or joint) problems that would prevent you from exercising? O 0 7. Are you pregnant? O 0 8. Do you have any reason to believe you should not engage in exercise. 1f yes, please explain_ I hereby certify that the above information is correct. Participant's Signature Date IF ANY OF THE ABOVE QUESTIONS ARE ANSWERED YES. PHYSICIAN CLEARANCE IS REQUIRED FOR PROGRAM PARTICIPATION. THEREFORE, YOU MUST HAVE YOUR PHYSICIAN COMPLETE THE FORM BELOW AND TURN IN THE FORM BEFORE BEGINNING AN EXERCISE PROGRAM. MEDICAL CLEARANCE FORM (A completed medical clearance form is only required for individuals answering "Yes" to any of the eight questions.) 1 hereby certify that, to the best of my knowledge. this person examined has no contraindication to participation in a sub -maximal exercise profile and progressive fitness program. Signature of Physician Type or Print Name Date Phona Physician's Address City Stat& 7ip