Health And Fitness Assessment Questionnaire (Vitality) (Page 4 of 4) in pdf

5.2

Please select the level of your exercise programme

Beginner (I am inactive / occasionally active)

Intermediate (I do 1-3 exercise sessions per week)

Advanced (I do more than 3 exercise sessions per week)

Terms and conditions

I confirm that all details provided by me to Virgin Life Care (Pty) limited ("Virgin Life Care") are true, accurate and complete.

I acknowledge that the information which I supply to Virgin Life Care will be relied upon and used by the biokineticist conducting this health and fitness assessment.

Should I not provide all the correct information it could be detrimental to my health by affecting the accuracy of the health report and the suitability of the exercise

programme designed for me.

I understand that I will receive a personlised report and agree that my health insurer, life insurer, medical aid scheme, health care management company and/or any

loyalty/reward programme associated with any of these entities ("the Corporate/s") may also receive a copy of my report. Virgin Life Care will not wilfully disclose

personally identifiable information to any party other than the Corporate and only if there is an agreement between Virgin Life Care and the Corporate allowing this

disclosure of information. I hereby authorise Virgin Life Care or a third party to use my personal data for research, statistical and related purposes once it has been

depersonalised.

Vitality Fitness Assessment

I do hereby consent to a health screening performed as part of the Vitality Fitness Assessment. I understand that it will include a Personal Health Review, blood

pressure, height, weight and waist circumference measurements as well as a step test or bike test, flexibility tests and sit-up and push up tests. Cholesterol and

glucose measurements can also be performed at my request for my own cost, however I am aware that Vitality points are not awarded for doing these tests. I consent

to this information being given to Vitality for points allocation and research purposes.

I acknowledge that this is a screening assessment and should any of my test results fall outside of normal parameters, I am responsible for monitoring or further

investigations that may be required.

I participate in the Health Assessment voluntarily and do not hold Discovery Vitality or the healthcare professionals liable for any damage or injury caused while doing

so.

I agree that Virgin Life Care and its members, directors, officers, employees, representatives, agents, biokineticists and independent contractors ("Other Protected

Parties") shall not be liable for any damages or loss arising out of death, injury, illness or trauma suffered by me or any other person as a result of the fitness

assessment or disclosure of my personal information, including arising due to the negligent acts (excluding gross negligence) or omissions of Virgin Life Care or any

Other Protected Party.

I and/or my estate indemnify/ies Virgin Life Care and the other Protected Parties against any claim for damages brought by any person including those arising due to

the negligent acts or omissions of Virgin Life Care or any Other Protected Party.

If one or more of these terms are found to be unenforceable, I agree that such term shall be deemed to be severable from the remainder of these terms and the remaining terms of

this agreement shall in all other respects remain in full force and effect.

Please do not sign below until you have read and understood these terms and conditions. If there is anything that you do not understand about these terms and

conditions or the assessment then please ask us for a further explanation before you sign below.

D D

M M

Y Y

DATE

I Agree (client signature)

Section 6: HEALTH MEASUREMENTS

HEALTH MEASUREMENTS (OFFICE USE ONLY)

BLOOD PRESSURE

Systolic

mmHg

Diastolic

mmHg

BODY COMPOSITION

Weight

Height

Waist

SKINFOLDS

Suprailiac

Subscapular

Triceps

Biceps

Futrex Body Fat %

AEROBIC TEST

Step Test

25 cm

Bike Test

stage 1

stage 2

stage 3

stage 4

Work (watts)

Heart rate (bpm)

1 min recovery heart rate:

Duration of test:

Distance (m)

Max HR (bpm)

Max BP (mmHg)

6MWT

1 min recovery HR (bpm)

Duration of test

1 min recovery BP (mmHg)

MUSCLE ENDURANCE

Crunches

Push-ups

FLEXIBILITY

Straight Leg Raise : Right

degrees

Sit & Reach

Left

*CHOLESTEROL (if known)

*GLUCOSE (if known)

Total Cholesterol

mmol/L

Total Glucose

*Vitality points are not allocated.

D D

M M

Y Y Y Y

Assessor's Signature

Practice Name

VLC_Vit_H&FA_questionnaire_26102011.pdf

Health And Fitness Assessment Questionnaire (Vitality) Page 4

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