Please enable JavaScript in your browser to complete this form.Name *FirstLastAge *ID number *Sex *MaleFemaleTitle *MrMrsMsMissDrProfAdvDiscovery membership Number *Email *Do you have any of the following medical conditions *AsthmaBack Pain/ Musculoskeletal painChronic obstructive pulmonary diseaseRenal DiseaseHigh Blood PressureHigh CholesterolThyroid DiseaseClotting DisordersDiabetesHeart Disease/ Stroke/ Peripheral Disease/Cerebrovascular diseaseNo Medical ConditionsDo you take prescription medication *Yes NoHow much exercise do you do per week *Less than 150 minutes/weekmore than 150 minutes/weekHas a medical professional told you not to exercise in the last 6months *YesNoHave you had any injuries/ hospitalisation in the last 6 months *YesNoDo you experience any of the following symptoms *Pain in chest, neck, jaw, upper limb or upper back when exercisingswollen anklesabnormal heart beats/ palpitationsLong standing leg/ calf pain when exercising that is relieved by restNoneAre you pregnant or 6 weeks post pregnant *YesNoI, do hereby consent to health screening as part of the Vitality Fitness Assessment. I understand that it will include blood pressure, height, weight and waist circumference as well as a physical activity component consisting of a cardiovascular test, flexibility test and a bio movement assessment. 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. 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. *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. questions potential relation starting Signed at on 3. Preclusions (continued) You are physically inactive (ie you get less than 30 minutes of physical activity on at least 3 days a week) You have a body mass index equal or greater than 30 kg/m2 • If one or more of the phrases above is ticked, you are advised to consult your doctor before starting a vigorous-intensity exercise programme. You may begin light-to-moderate intensity exercise such as walking without/before consulting your physician, but please progress gradually with your exercise programme. • Waiver: • I understand that the answers I have given to the questions about my health may *I agree with the above terms and conditionsDate *COVID-19 pre screening questionnaire : Do you have a cough? *YESNODo you have shortness of breath? *YESNOHave you experienced recent loss of taste? *YESNOHave you experienced recent loss of smell? *YESNOAre you experiencing other flu-like symptoms *YESNOHave you had contact with a confirmed COVID-19 positive person? *YESNOI confirm the above information is correct and was completed by me with no interference or influence by any third party. *I confirmCommentSubmit
