INFORMED CONSENT INFORMED CONSENT FOR PARTICIPATION IN A HEALTH AND FITNESS TRAINING PROGRAM
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1 INFORMED CONSENT INFORMED CONSENT FOR PARTICIPATION IN A HEALTH AND FITNESS TRAINING PROGRAM NAME: DATE: 1. PURPOSE AND EXPLANATION OF PROCEDURE I hereby consent to voluntarily engage in an acceptable plan of personal fitness training. I also give consent to be placed in personal fitness training program activities which are recommended to me for improvement of dietary counseling, stress management, and health/fitness education activities. The levels of exercise I perform will be based upon my cardiorespiratory (heart and lungs) and muscular fitness. I understand that I may be required to undergo a graded exercise test prior to the start of my personal fitness training program in order to evaluate and assess my present level of fitness. I will be given exact personal instructions regarding the amount and kind of exercise I should do. A professionally trained personal fitness trainer will provide leadership to direct my activities, monitor my performance, and otherwise evaluate my effort. Depending upon my health status, I may or may not be required to have my blood pressure and heart rate evaluated during these sessions to regulate my exercise within desired limits. I understand that I am expected to attend every session and to follow staff instructions with regard to exercise, stress management, and other health and fitness regarded programs. If I am taking prescribed medications, I have already so informed the program staff and further agree to so inform them promptly of any changes which my doctor or I have made with regard to use of these. I will be given the opportunity for periodic assessment and evaluation at regular intervals after the start of the program. I have been informed that during my participation in the above described personal fitness training program, I will be asked to complete the physical activities unless symptoms such as fatigue, shortness of breath, chest discomfort or similar occurrences appear. At this point, I have been advised that it is my complete right to decrease or stop exercise and that it is my obligation to inform the personal fitness training program personnel of my symptoms, should any develop. I understand that during the performance of exercise, a personal fitness trainer will periodically monitor my performance and, perhaps measuring my pulse, blood pressure, or assess my feelings of effort for the purposes of monitoring my progress. I also understand that the personal fitness trainer may reduce or stop my exercise
2 H E A L T H A N D F I T N E S S P R O F E S S I O N A L S A C T I O N G U I D E program when any of these findings so indicate that this should be done for my safety and benefit. I also understand that during the performance of my personal fitness training program physical touching and positioning of my body may be necessary to assess my muscular and bodily reactions to specific exercises, as well as to ensure that I am using proper technique and body alignment. I expressly consent to the physical contact for the stated reasons above. 2. RISKS It is my understanding and I have been informed that there exists the remote possibility during exercise of adverse changes including, but not limited to, abnormal blood pressure, fainting, dizziness, disorders of heart rhythm, and in very rare instances heart attack, stroke, or even death. I further understand and I have been informed that there exists the risk of bodily injury including, but not limited to, injuries to the muscles, ligaments, tendons, and joints of the body. Every effort, I have been told, will be made to minimize these occurrences by proper staff assessments of my condition before each personal fitness training session, staff supervision during exercise and by my own careful control of exercise efforts. I fully understand the risks associated with exercise, including the risk of bodily injury, heart attack, stroke or even death, but knowing these risks, it is my desire to participate as herein indicated. 3. BENEFITS TO BE EXPECTED AND ALTERNATIVES AVAILABLE TO EXERCISE I understand that this program may or may not benefit my physical fitness or general health. I recognize that involvement in the personal fitness training sessions will allow me to learn proper ways to perform conditioning exercises, use fitness equipment and regulate physical effort. These experiences should benefit me by indicating how my physical limitations may affect my ability to perform various physical activities. I further understand that if I closely follow the program instructions, that I will likely improve my exercise capacity and fitness level after a period of 3-6 months. 4. CONFIDENTIALITY AND USE OF INFORMATION I have been informed that the information which is obtained in this personal fitness training program will be treated as privileged and confidential and will consequently not be released or revealed to any person, to the use of any information which is not personally identifiable with me for research and statistical purposes so long as same does not identify my person or provide facts which could lead to my identification. Any other information obtained, however, will be used only by the program staff to evaluate my exercise status or needs. 5. INQUIRIES AND FREEDOM OF CONSENT I have been given an opportunity to ask questions as to the procedures.
3 I have read this Informed Consent form, fully understand its terms, understand that I have given up substantial rights by signing it, and sign it freely and voluntarily, without inducement. Participant s Signature Participant s Name (Printed) Witness s Signature Date:
4 HEALTH AND MEDICAL QUESTIONNAIRE ANYFITNESS INC HEALTH & MEDICAL QUESTIONNAIRE Name: Date: Date of birth: Address: Street City State Zip Phone (Cell): (Work): address: In case of emergency, whom may we contact? Name: Phone (Cell): Relationship: (Home): Personal physician Name: Fax: Phone: Present/Past History Have you had or do you presently have any of the following? (Check if yes.) Rheumatic fever Recent operation Edema (swelling of ankles) High blood pressure Low blood pressure Injury to back or knees Seizures
5 Lung disease H E A L T H A N D F I T N E S S P R O F E S S I O N A L S A C T I O N G U I D E Heart attack or known heart disease Fainting or dizziness Diabetes High Cholesterol Orthopnea (the need to sit up to breathe comfortably) or paroxysmal (sudden, unexpected attack) or nocturnal dyspnea (shortness of breath at night) Shortness of breath at rest or with mild exertion Chest pains Palpitations or tachycardia (unusually strong or rapid beat) Intermittent claudication (calf cramping) Pain, discomfort in the chest, neck, jaw, arms, or other areas Known heart murmur Unusual fatigue or shortness of breath with usual activities Temporary loss of visual acuity or speech, or short-term numbness or weakness in one side, arm, or leg of your body Cancer Other (please describe): Family History Have any of your first-degree relatives (parent, sibling, or child) experienced the following conditions? (Check if yes.) In addition, please identify at what age the condition occurred. Heart attack Heart operation (Bypass surgery, Angioplasty, Coronary Stent placement) Congenital heart disease High blood pressure High cholesterol Diabetes Other major illness:
6 Explain checked items : Activity History 1. How were you referred to this program? (Please be specific.) 2. Why are you enrolling in this program? (Please be specific.) 3. Have you ever worked with a personal trainer before? Yes No 4. Date of your last physical examination performed by a physician: 5. Do you participate in a regular exercise program at this time? Yes No If yes, briefly describe: 5. Can you currently walk 4 miles briskly without fatigue? Yes No 6. Have you ever performed resistance training exercises in the past? Yes No 7. Do you have injuries (bone or muscle disabilities) that may interfere with exercising? Yes No If yes, briefly describe: 8. Do you smoke? Yes No If yes, how much per day and what was your age when you started? Amount per day Age 9. What is your body weight now? What was it one year ago? At age 21? 10. How tall are you? 11. Do you follow or have you recently followed any specific dietary intake plan and, in general, how do you feel about your nutritional habits?
7 12. List the medications you are presently taking. 13. List in order your personal health and fitness objectives. a. b. c. d. Thank you.
8 EXERCISE PRESCRIPTION & REFERRAL FORM PATIENT S NAME: DOB: DATE: HEALTH CARE PROVIDER S NAME: SIGNATURE: PHYSICAL ACTIVITY RECOMMENDATIONS Type of physical activity: Number of days per week: Minutes per day: Aerobic Strength REFERRAL TO HEALTH & FITNESS PROFESSIONAL Name: Phone: Address: Web Site: Total minutes per week*: *PHYSICAL ACTIVITY GUIDELINES Adults aged with no chronic conditions: Minimum of 150 minutes of moderate physical activity a week (for example, 30 minutes per day, five days a week) and muscle-strengthening activities on two or more days a week (2008 Physical Activity Guidelines for Americans). For more information, visit Follow-up Appointment Date: Notes: EXERCISE PRESCRIPTION & REFERRAL FORM PATIENT S NAME: DOB: DATE: HEALTH CARE PROVIDER S NAME: SIGNATURE: PHYSICAL ACTIVITY RECOMMENDATIONS Type of physical activity: Number of days per week: Minutes per day: Aerobic Strength REFERRAL TO HEALTH & FITNESS PROFESSIONAL Name: Phone: Address: Web Site: Total minutes per week*: *PHYSICAL ACTIVITY GUIDELINES Adults aged with no chronic conditions: Minimum of 150 minutes of moderate physical activity a week (for example, 30 minutes per day, five days a week) and muscle-strengthening activities on two or more days a week (2008 Physical Activity Guidelines for Americans). For more information, visit Follow-up Appointment Date: Notes:
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CLINIC APPLICATION. Client Information
ICNA Relief USA Shifa Free Medical Clinic 1092 Johnnie Dodds Boulevard, Suite 108 Mount Pleasant, SC 29464 Tel: (843) 352-4580 Fax: (843) 375-9063 Last Name Street Address City, State, Zip Code Home Phone
CHIEF COMPLAINT: Please number your symptoms (1 is the most severe) that you have developed since the accident.
VANCE CHIROPRACTIC PERSONAL INJURY QUESTIONAIRE (PLEASE BE VERY SPECIFIC WITH YOUR ANSWERS THANK YOU!) Last Name First Name Middle Home Phone Work Phone Street Address and Number Mailing Address if Different