Informed Consent
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Instructions:
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Get familiar with the items explained in the form below. Read it several times and understand each item thoroughly.
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1. Purpose and Explanation - Med-Fit services involve a series of basic exercises based on your age, gender, and fitness level. The objective of each Med-Fit test is to determine your functional capacity, establish an appropriate exercise prescription, and track your progress towards your personal fitness goals. You are expected to set your own pace to whatever intensity level is comfortable for you. You may stop the Med-Fit test at any time for any reason. The Med-Fit Technician that administers your test may encourage you to slow-down, or may insist that you stop, depending on the signs of exertion or discomfort that you exhibit during your test. The general recommendation is to perform a Med-Fit test every one to three months in order to motivate and track your efforts. Participation is voluntary.
2. Attendant Risks and Discomforts - There is the possibility of certain physiological changes occurring during your Med-Fit test. These include: shortness of breath, pounding heart beats, palpitations, dizziness, fatigue, impaired coordination, and in extremely rare instances, heart attack, stroke, or death. Every effort will be made to minimize these risks by thoroughly evaluating your health status and carefully observing your performance.
3. Responsibilities of the Participant - It is important for you to disclose to the Med-Fit Technician that administers your test all the information regarding your health status and any previous experiences of heart-related symptoms, such as: shortness of breath, pain, pressure, tightness, and/or heaviness in the chest, neck, jaw, back, and/or arms. Your immediate reporting of these or any other unusual symptoms during your test is critically important. You are fully responsible for disclosing your a) past medical history, b) current heart-related medications, and c) any and all symptoms that you experience during your test.
4. Benefits to Be Expected - Your Med-Fit test will result in obtaining an accurate Med-Fit Score and an appropriate Exercise Rx. Your Med-Fit Score reflects a) your functional capacity, b) the effectiveness of your exercise program, and c) your progress towards your fitness goal. If applicable, your doctor may use your Med-Fit Score to better manage sedentary-related medical conditions in conjunction with your on-going treatment(s). Also, aggregate data will be analyzed and reported for the advancement of exercise science and lifestyle therapies.
5. Inquiries - You, your doctor, or your personal trainer are welcome to ask questions about the procedures and/or results of your Med-Fit test(s). You are encouraged to get any desired clarifications from your Med-Fit Technician. For more information, visit: www.Med-Fit.org.
Question:_________________________________________________________________________
Answer:__________________________________________________________________________
6. Use of Personal Information - The information that is obtained during your test will be treated as privileged and confidential. It will not be released or revealed to anyone. Aggregate information will be used for statistical analysis and scientific research purposes while fully protecting your identity and right to privacy. Of course, you are always free to share your Med-Fit Score and Exercise Rx with anyone you choose to do so.
7. Freedom of Consent - Your signature below acknowledges that you hereby consent to voluntarily participate in a Med-Fit test. You understand that you are free to stop the test at any time, if you so desire. You understand the procedures, as well as their attendant risks and potential discomforts, and that you had the opportunity to ask questions and get answers to your satisfaction.
Participant:____________________________________________ Date:__________
Parent/Guardian:_________________________________________ Date:__________
(Required only if Participant is <18 years old.)
Media Release: I grant to ___________________________, and to its representatives and employees, the right to take photographs and/or videos of me and my property in connection with my participation in Med-Fit services. I authorize the same, and its assigns and transferees, to copyright, use, and publish such materials, with or without my name, and for any lawful purpose, in print and/or electronically for publicity, illustration, advertising, and Web content.
Initials: Participant:________ Parent/Guardian:________ Date:__________
2. Attendant Risks and Discomforts - There is the possibility of certain physiological changes occurring during your Med-Fit test. These include: shortness of breath, pounding heart beats, palpitations, dizziness, fatigue, impaired coordination, and in extremely rare instances, heart attack, stroke, or death. Every effort will be made to minimize these risks by thoroughly evaluating your health status and carefully observing your performance.
3. Responsibilities of the Participant - It is important for you to disclose to the Med-Fit Technician that administers your test all the information regarding your health status and any previous experiences of heart-related symptoms, such as: shortness of breath, pain, pressure, tightness, and/or heaviness in the chest, neck, jaw, back, and/or arms. Your immediate reporting of these or any other unusual symptoms during your test is critically important. You are fully responsible for disclosing your a) past medical history, b) current heart-related medications, and c) any and all symptoms that you experience during your test.
4. Benefits to Be Expected - Your Med-Fit test will result in obtaining an accurate Med-Fit Score and an appropriate Exercise Rx. Your Med-Fit Score reflects a) your functional capacity, b) the effectiveness of your exercise program, and c) your progress towards your fitness goal. If applicable, your doctor may use your Med-Fit Score to better manage sedentary-related medical conditions in conjunction with your on-going treatment(s). Also, aggregate data will be analyzed and reported for the advancement of exercise science and lifestyle therapies.
5. Inquiries - You, your doctor, or your personal trainer are welcome to ask questions about the procedures and/or results of your Med-Fit test(s). You are encouraged to get any desired clarifications from your Med-Fit Technician. For more information, visit: www.Med-Fit.org.
Question:_________________________________________________________________________
Answer:__________________________________________________________________________
6. Use of Personal Information - The information that is obtained during your test will be treated as privileged and confidential. It will not be released or revealed to anyone. Aggregate information will be used for statistical analysis and scientific research purposes while fully protecting your identity and right to privacy. Of course, you are always free to share your Med-Fit Score and Exercise Rx with anyone you choose to do so.
7. Freedom of Consent - Your signature below acknowledges that you hereby consent to voluntarily participate in a Med-Fit test. You understand that you are free to stop the test at any time, if you so desire. You understand the procedures, as well as their attendant risks and potential discomforts, and that you had the opportunity to ask questions and get answers to your satisfaction.
Participant:____________________________________________ Date:__________
Parent/Guardian:_________________________________________ Date:__________
(Required only if Participant is <18 years old.)
Media Release: I grant to ___________________________, and to its representatives and employees, the right to take photographs and/or videos of me and my property in connection with my participation in Med-Fit services. I authorize the same, and its assigns and transferees, to copyright, use, and publish such materials, with or without my name, and for any lawful purpose, in print and/or electronically for publicity, illustration, advertising, and Web content.
Initials: Participant:________ Parent/Guardian:________ Date:__________