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Health and Fitness Assessment
Questionnaire (Vitality)
1.1 Details: Please print in capital letters using black ink and tick the relevant box(es).
Gender M - F Male - Female
2.1 Family History: Do you have a family history (parents or siblings) of any of the following medical conditions?
2.2. Personal Medical History: Have you suffered, or do you suffer from any of these medical conditions?
Diagnosed by?
Diagnosed when?
Specific Intervention?
2.3. Medication
Are you currently on medication for heart disease, peripheral vascular disease, cholesterol and/or blood pressure?
If yes, please write your medical condition, name of medication and dosages, below:
Condition: eg. Cholesterol
Medication: eg. Lipitor
Dosage: eg.10mg 1 / day
2.4. Preclusions
Present Symptoms: Do you suffer from any of these medical conditions?
Any flu-like symptoms (fever and/or muscle pains) Shortness of breath at rest or with activity Physical Injury: Do you currently suffer from any physical ailment that would preclude you from performing this assessment?
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? 2.5. Pregnancy
If yes, how many months pregnant are you? (e.g. 5) Do you have clearance from your gynaecologist to perform this assessment? VLC_Vit_H&FA_questionnaire_26102011pdf 3.1.Smoking Status: Please tick the appropriate box relating to your smoking
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-cotine 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.
consum I
Never more than 1 - 2 drinks per occasion or per day.
3 - 4 drinks in a day, only 2 - 3 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.
Disturbed sleeping pattern, 3-4 nights per week Disturbed sleeping pattern, 1-2 nights per week Disturbed sleeping pattern, 5-7 nights per week 3.4 Stress Management:
Are you coping with your daily stress?

No, and I have no intention to implement 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 eachfood.
Never/Once or
less than once

2-3 times
1-2 times
3-4 times
Meat/Snack
5+times per
per month
per month
Hot dogs, frankfurters, salami, Russians, sausages Cold meats, e.g. polony, cheese / olive loaf, beef (+ fat), etc.
Never/Less
about once
2-3 times per
4-6 times per
Fruit/Vegetables/Fibre
than once
Every day
Dried beans,e.g baked beans, Kidney beans, legumes 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.
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: 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:
(Minimum)
(Maximum)
On average, my total exercise
On average, I would describe the
time for the week is:
intensity of these sessions as:
0-15 minutes
0-15 minutes
<60 minutes per week
Very light (seated activity)
15-30 minutes
15-30 minutes
60-90 minutes per week
Light (eg: housework)
30-60 minutes
30-60 minutes
90-120 minutes per week
Light sweat
1-2 hours
1-2 hours
2-3 hours per week
Sweating
>2 hours
>2 hours
3-4 hours per week
Vigorous
>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.
5.1. Please select ONE 12 week exercise programme
A. Lose Weight
*
General Cardio + toning
B. Gain Weight (muscle)
C. *Stay Healthy
D. *Look after health condition

* Would you prefer to exercise in a gym or home
environment?
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:
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) 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.

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 ofthis 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.

Section 6: HEALTH MEASUREMENTS
HEALTH MEASUREMENTS (OFFICE USE ONLY)
BLOOD PRESSURE Systolic
Diastolic
Subscapular
Suprailiac
Futrex Body Fat %
Step Test
Bike Test
Work (watts)
Heart rate (bpm)
Push-ups
Crunches
Straight Leg Raise :
Sit & Reach
*CHOLESTEROL (if known)
*GLUCOSE (if known)
Total Cholesterol
Total Glucose
*Vitality points are not allocated.
Practice Name
VLC_Vit_H&FA_questionnaire_26102011.pdf

Source: http://pfn.co.za/downloads/Health%20and%20Fitness%20Assessment%20Questionnaire%20(Vitality).pdf

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