Capetown-biokineticist.co.za

Health and Fitness
1.1 Details: Please print in capital letters using black ink and tick the relevant box(es). Membership number Cell phone number ( ) 2.1 Family history: Do you have a family history (parents or siblings) of any of the following medical conditions? before or at the age of 50 High cholesterol before or at the age of 50 Insulin dependent diabetes before or at the age of 50 High blood pressure before or at the age of 50 Non-insulin dependent diabetes before or at the age of 50 before or at the age of 50 Peripheral vascular disease before or at the age of 50 before or at the age of 50 2.2. Personal medical history: Have you suffered or do you suffer from any of these medical conditions?High cholesterol Exercise induced asthma Insulin dependent diabetes Non-insulin dependent diabetes High blood pressure Peripheral vascular disease Specialist physician Medical practitioner In the past year > 5 years ago Specific intervention? Healthy dietary habits Regular activity 2.3. Medication: Are you currently on medication for heart disease, peripheral vascular disease, cholesterol and/or blood pressure? Yes No If yes, please write your medical condition, name of medication and dosages, below: Condition: e.g. Cholesterol Medication: e.g. Lipitor Dosage: e.g. 10mg 1/day 2.4. Preclusions: Present symptoms: Do you suffer from any of these medical conditions?Chest pains while exercising Frequent fainting and/or dizzy spells Any flu-like symptoms (fever and/or muscle pains) Frequent wheezing/coughing Shortness of breath at rest or with activity Intermittent claudication Known heart murmur Unusual fatigue with usual activities Physical Injury: Do you currently suffer from any physical ailment that would preclude you from performing this assessment?Neuromuscular disease Assessor's comment (based on ACSM's risk factors for exercise testing)In your professional opinion, is the member fit to continue with this assessment? yes no 2.5. PregnancyAre you currently pregnant? yes no If yes, how many months pregnant are you? Do you have clearance from your gynaecologist to perform this assessment? yes no 3.1. Smoking status: Please tick the appropriate box relating to your smoking.
less than 3 months less than 1 year more than 15 years < 10 per day For smokers only: Please tick only one of the options that best describe your current smoking situation.
I have no intention of becoming tobacco free in the next 6 months I intend to become tobacco free in the next 6 months I am trying to become tobacco free, but I am not always successful Although I am currently using tobacco again, in the past I have been tobacco free for more than 3 months Non smoking: I confirm that I am a non-smoker and that: 1. I do not smoke and have not smoked any tobacco products, regularly or occasionally, within the last 3 months.
2. I agree to inform my insurers within 3 months of commencing smoking. I also agree to the reversal of any points that may have been awarded for being a non-smoker, if they are awarded within the same calendar year in which I commenced smoking.
3. I agree to undergo an u-cotinine test to prove my non-smoker status should my insurer request one. I understand that such requests are made randomly.
Please sign here to accept this declaration: 3.2. Alcohol use: Please make the appropriate selection relating to your weekly alcohol consumption.
I don't have any alcoholic drinks 3-4 drinks in a day, only 2-3 per month Never more than 1-2 drinks per occasion or per day 3-4 drinks in a day, 4 times per month 3 or more drinks in a day, more than once a week and/or more than 4 drinks at a time.
3.3. Sleep: Please make the appropriate selection relating to your sleeping pattern.
Undisturbed sleep Disturbed sleeping pattern, 3-4 nights per week Disturbed sleeping pattern, 1-2 nights per week Disturbed sleeping pattern, 5-7 nights per week In general, I wake up: Refreshed Unrefreshed 3.4 Stress management: Are you coping with your daily stress? No, and I have no intention of implementing coping strategies in the next 6 months No, but I intend to learn how to cope with my daily stress in the next 6 months I am trying to cope but I do not always cope successfully Yes, I have been coping with my daily stress, but for LESS than 6 months Yes, I have been coping with my daily stress for MORE than 6 months Although I am not coping well with my daily stress, in the past I have coped well for more than 3 months 3.5 Dietary assessment: Think about your eating habits over the past year or so. Approximately how often do you eat each of the following foods? Tick one box for each food.
Hamburgers or cheeseburgers Red meat, e.g. beef and mutton Fried chicken (with skin) Hot dogs, frankfurters, salami, russians, sausages Cold meats, e.g. polony, cheese/olive loaf, beef (+ fat), etc. Salad dressing, mayonnaise Margarine or butter Bacon or pork sausage Cheese or cheese spread Potato chips ("slap chips") Potato crisps, corn chips, popcorn, etc. Doughnuts, cake, cookies, puddings, etc. Fruit/vegetables/fibre Brown rice/wholewheat pasta Fruit (not counting juice) Potatoes with skin Dried beans e.g. baked beans, kidney beans, legumes Other vegetables High-fibre/bran cereal or high-fibre porridge or oat porridge Wholewheat, brown or high-fibre bread (e.g. rye) Do you currently feel that you are following a healthy diet? No, and I have no intention of following a healthy diet in the next 6 months No, but I intend to follow a healthy diet in the next 6 months I am trying to follow a healthy diet, but I am not always successful Yes, I have been following a healthy diet, but for LESS than 6 months Yes, I have been following a healthy diet for MORE than 6 months Although I am currently following a less healthy diet, in the past I have followed a healthy diet for more than 3 months physical activity assessment 4.1. Current physical activity levels: Please tick the most appropriate description of your current level of physical fitness.
4.2. Work and/or daily activities: Please tick the box that best describes your activities in the working day (e.g. office and home based) - not your leisure time physical activity.
I sit down and do not walk about much I walk about a lot, but do not carry heavy loads I mostly walk and also lift heavy loads or climb stairs I do heavy manual work and physically strain myself 4.3. Physical activity status: A typical exercise session consists of 20-30 minutes of exercise.
Over the past three months I would describe myself as having been: Inactive (please go straight to 4.4) Reasonably active - "at least 2-3 sessions per week" Occasionally active - "at least 1-4 sessions per month" Active - "at least 3-4 sessions per week" Somewhat active - "at least 1-2 sessions per week" Very active - "more than 4 sessions per week" Over the past three months, the duration of my exercise sessions and/or recreational activity has ranged between a minimum of, and a maximum of: On average, my total exercise On average, I would describe time for the week is the intensity of these sessions as <60 minutes per week Very light (seated activity) 60-90 minutes per week Light (e.g. housework) 90-120 minutes per week 2-3 hours per week 3-4 hours per week >4 hours per week 4.4. Please tick only one of the six options that best describe your current situation or what you intend to do regarding physical activity in the future.
Are you moderately physically active? No, and I have no intention of becoming moderately physically active in the next 6 months No, but I intend to become moderately physically active in the next 6 months I am trying to become moderately active, but my exercise routine is irregular Yes, I have been moderately physically active, but for LESS than 6 months Yes, I have been moderately physically active for MORE than 6 months Although I am currently inactive, in the past I have been physically active for more than 3 months exercise programme and meal plan 5.1. Please select one 12-week exercise programme.
*General Cardio + toning Lose weight & walk 5-10km Lose weight & walk 10-15km Lose weight & run 5-10km Lose weight & run 21 km Lose weight & cycle 40-60km Lose weight & cycle 80-120km B. Gain weight (muscle) C. *Stay healthy * Would you prefer to exercise in a gym or home D. *Look after health condition E. *Become generally fitter F. *Get bootcamp fit G. *Get my body back in shape Note: the sports-specific plans are outdoor-specific H. Improve my fitness for walking: I. Improve my fitness for running: J. Improve my fitness for cycling: K. Improve my fitness for swimming: L. Improve my fitness for triathlon: Sprint triathlon Standard triathlon 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) 5.3. Do you have any of the following meal preferences? Select one.
Strict vegetarian (Vegan) Vegetarian + milk, eggs, cheese Vegetarian + milk, eggs, cheese + fish Standard meal plan terms and conditions I confirm that all details provided by me to Virgin Active South Africa (Pty) Ltd ("Virgin Active") are true, accurate and complete. I acknowledge that the information which I supply to Virgin Active will be relied upon and used by the biokineticist conducting this health and fitness assessment. If I do 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 personalised 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 Active will not wilfully disclose personally identifiable information to any party other than the Corporate and only if there is an agreement between Virgin Active and the Corporate allowing this disclosure of information. I hereby authorise Virgin Active or a third party to use my personal data for research, statistical and related purposes once it has been depersonalised. I also acknowledge and agree that Virgin Active will contact me by email to confirm that I have taken part in a Health and Fitness Assessment and to request me to complete a service questionnaire.
I agree that Virgin Active 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 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 Active or any Other Protected Party.
I and/or my estate indemnify/ies Virgin Active and the other Protected Parties against any claim for damages brought by any person including those arising due to the negligent acts or omissions (excluding gross negligence) of Virgin Active 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.
I agree (client signature) health measurements Health measurements (office use only) Body composition kg Height cm Waist cm mm Subscapular mm 1 min recovery heart rate: Heart rate (bpm) Duration of test: 1 min recovery HR (bpm) 1 min recovery BP (mmHg) Duration of test cm Straight leg raise: Right *Cholesterol *Glucose Total cholesterol Assessor's signature

Source: http://www.capetown-biokineticist.co.za/pdf/fitness-assessment-questionaire-vlc.pdf