Miller Health, occupational health and fitness

HOME	FITNESS ASSESSMENT READINESS QUESTIONAIRE

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Please complete the Fitness Assessment Readiness Questionnaire (FAR-Q), providing details of any of the injuries, illnesses, health conditions, disabilities, diseases and dysfunctions you may have or may have had.

Do you have a regular and systematic aerobic fitness program?

How many minutes of aerobic exercise do you get each week?

Yes □ No □

.............

How would you rate the intensity of your exercise?

▪	High - (running, swimming, cycling etc ) pulse rate over 120 for most of the exercise period	□

▪	Medium - (slow jog) pulse rate between 100 and 120	□

▪	Low - (walking) - pulse rate below 100	□

Do you have a regular and systematic strength training program? If yes, describe it.

.......................................................................................

Yes □ No □

Do you have a regular and systematic flexibility training program? If yes, describe it.

.......................................................................................

Yes □ No □

Describe your exercise routine for an average week.

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Have you ever had heart disease or dysfunction? If yes provide details

.........................................................................................

Yes □ No □

Are you currently on medication for blood pressure?

Yes □ No □

Are you currently on medication for adult onset diabetes?

Yes □ No □

Are you currently on medication for depression?

Yes □ No □

Do you have any muscle or joint problems which would prevent you from being involved in work or exercise of a vigorous nature?

If the answer is yes, describe the nature of the dysfunction.

.......................................................................................

Yes □ No □

Do you suffer from asthma in a way which would prevent you from being involved in continuous work of a vigorous nature?

Yes □ No □

Do you suffer from epilepsy? ............................................

Yes □ No □

Do you suffer from fainting/dizzy spells?

Yes □ No □

Is there anything at all about your health that you feel you should disclose before you participate in a corporate health program that involves a physical activity component and a fitness assessment?

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Yes □ No □

STATEMENT OF RISK

To obtain a profile of your health and fitness you will need to take part in a number of assessments, some of which involve vigorous and demanding physical activity.

¡	The activities in the test battery are safe for normal, healthy human beings, particularly those who have a regular and systematic physical training program. The people supervising the program are trained and qualified in the safe prescription and supervision of exercise

¡	Your participation in this program is voluntary. It is your choice to take part or not take part in any particular activity. If you don't want to do an exercise, don't do it. You will not be forced to do anything you don't want to do.

¡	If you are not in good shape, some of the exercises may cause you some discomfort. This is a normal response and you can choose to accept or reject the invitation to participate.

¡	If you are unable to do any of the activities; if a physician or a physical therapist, qualified and competent in the prescription of physical activity has recommended that you don't do them, then don't do them.

¡	If any of the exercises hurt while you are doing them, stop doing them immediately.

	If the person supervising the program believes that you are placing yourself at risk and asks you to stop doing an activity, you must stop doing it immediately.

¡	You will need to be aware that if you haven't exercised much in the last few years you may be a bit stiff for the next few days. This is normal.

¡	There is also a risk that you could become injured. For instance you could tear a muscle. This is an incident outside the control of the person conducting the assessment.

¡	You need to be aware that most people do not know the exact physical condition of the various key body systems. For instance you could be on the verge of a heart attack and not be aware of the seriousness of your condition. Vigorous exercise may tip you over the edge into an acute body system failure.

¡	If you believe you may be at risk of cardiac malfunction, you are strongly advised to consult your physician - who, by putting you through a range of physiological and biological assessments can determine your risk. If, in your physician's opinion the risk is too high, then you are advised not to take part, particularly in vigorous aerobic physical activity. There is less likelihood that your cardiac function will be greatly compromised in a strength and flexibility program. Cardiac risk markers include - obesity - low level of aerobic fitness - abnormal ECG - smoking - elevated blood pressure - elevated blood glucose - elevated blood cholesterol and triglycerides - elevated level of C-reactive protein - elevated level of homocysteine.

	If you have any reason to suspect that you are putting your health, particularly cardiac health) at grave risk by taking part in a vigorous physical activity program, you are strongly advised to take your physician's advice before taking part.

INDEMNITY

I understand that the information I have provided in the Fitness Assessment Readiness Questionnaire will be used by Miller Health, it's staff and its agents as a guideline to the limits of my ability to take part in the assessment program.

I understand that Miller Health and its agents will take all care and responsibility in providing me with a safe exercise and/or physical fitness assessment experience.

I understand that The people supervising the program are qualified to conduct these programs.

I understand that Miller Health and its agents cannot take responsibility for actions which are out of its control - for instance a fall, a torn muscle or a heart attack.

I have read this Statement of Risk and I am aware of the risks to my health of taking part in a vigorous physical activity and/or assessment program.

I understand that I am not being forced to take part in activity and that I am participating under my own free will.

I understand that all due care will be taken by the assessors in the administration of the tests but that there can be no guarantee that they or anyone else including myself and my personal physician, can be absolutely certain that I am capable of exercising with vigor without injuring myself or suffering from an acute body system failure. I understand that the injuries that could occur are muscle strains and sprains, asthma attack, heart attack, death ...

Subject to the terms and conditions of my organisation's workers compensation arrangements, I accept personal responsibility for undertaking these assessments.

Signed ...............................................................................................

Date ......./......../.......

Name ..................................................................................................

Age ..........

Email ...................................................................................................

Place of employment .............................................................................

Phone (w) ....................................... Phone (h) ............................................

Emergency contact person ...............................................................................

Phone (w) ....................................... Phone (h) ............................................

You, the individual, can do more for your own health and well-being than any doctor, any hospital, any drug, any exotic medical advice.

US Surgeon General

1979