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Vitality Fitness Assessment

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    Details

    Title *

    Name *

    Surname *

    ID Number *

    Discovery Membership Number

    Date of Birth *

    Sex *

    Email *

    Mobile Number *

    Medical History

    Please tick if you have ever had any of the below mentioned conditions

    Curreny symptoms

    Curent medical conditions

    Preclusions

    Consent

    I, do hereby consent to health screening as part of the Vitality Fitness Assessment.

    I understand that it will include my results from the Vitality Age assessment, medical and family history, measuring my blood pressure, height and weight, waist circumference, as well as a physical activity component consisting of a sub-maximal bike test, treadmill walk test, or an arm ergometer test, or maximal effort bike test, or maximal speed run test, as well as a strength and flexibility test.

    I acknowledge that this is a screening assessment and should any of my tests fall outside of normal parameters, I am responsible for monitoring further investigations that can be required.

    If one or more of the ‘Medical History’ or ‘Preclusions’ checkboxes above are ticked, you are advised to consult with your doctor and get clearance from the doctor before doing a fitness test.

    I participate in the Vitality Fitness Assessment voluntarily and do not hold Discovery Vitality or the healthcare professional liable for any damage or injury caused while doing so.

    I agree that Discovery Vitality and its contracted research partners may use the results from the Vitality Fitness Assessment for statistical and research purposes. Data will be anonymised.

    My participation in the Vitality Fitness assessment is voluntary and at my own risk. I am aware that under no circumstances, including as a result of its negligent acts or omissions or those of its staff, servicers, agents, contractors, partners or other persons for whom in law it may be liable, will Vitality or the biokineticist conducting this assessment be liable for any loss, injury or damage of any nature which I, my beneficiaries or any third parties may sustain as a result of my participation in this Vitality Fitness Assessment.

    *I understand that the assessment is not suitable for pregnant women and that Discovery Vitality will not be liable for any injury to myself or my unborn child should I request the bio to perform the assessment while I am pregnant.

    1. I have read and understand the practical guidelines as set out hereunder and confirm that I will comply thereto and prepare accordingly.

    2. Patients will be phoned and screened the day before consultations, and requested to take appropriate action if they are presenting with any risk symptoms or history.

    3. Patients will be stopped from entering the practice if the patient hasn't complied with proper control measures.

    4. Patients will not be allowed in the waiting room and will be requested to wait in their cars until called by the practitioner or a staff member to enter the practice.

    5. All patients will be sprayed with hand sanitiser upon entry.

    6. All patients must wear a face mask alternatively a face mask will be provided to the patient.

    7. On arrival, patients will again be screened for risk factors including the taking of a temperature.

    8. Between consultations, the necessary hygiene/cleaning protocols will be done by the practitioner and/or their staff compliment and this may cause a delay and prolong waiting periods.

    9. Patients are requested to avoid touching anything inside the practice.

    10. Patients are requested to remove any jewellery and leave same at home as it can be carriers of infections droplets.