Consent_20Forms_20Aug_2021,_202009

Consent_20Forms_20Aug_2021,_202009 - “,Lab Activity 1-2:...

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Unformatted text preview: “,Lab Activity 1-2: Comprehensive Medical Health Appraisal2 Name: Do you have a physician in town? Name: llIlIllllllllllllllllllIlllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllIIlllllIIlllllllllllllllllllllllllIlllllllllllllll Yes No History of Heart Disease - Have you had: I A heart attack? If so, when? Heart surgery? If so, when? Cardiac catherization? If so, when? Coronary angioplasty? If so, when? A pacemaker/ an implantable cardiac defibrillator/ a rhythm disturbance? If so, when? Heart valve disease? If so, when was it diagnosed? Heart failure? If so, when? Heart transplantation? If so, when? Congenital heart disease? If so, when was it diagnosed? Yes No Current Health Status -— Do you have: Diabetes? If so, when was it diagnosed? Asthma or other lung disease (e.g., COPD or cystic fibrosis)? If so, when was it diagnosed? o o Kidney disease? If so, when was it diagnosed? Liver disease? If so, when was it diagnosed? Thyroid disease? If so, when was it diagnosed? If you are a female, are you pregnant or do you think that you might be pregnant? Take heart medications? If so, what kind? Yes No Symptoms — Do you: Experience pain or discomfort in the chest, neck, jaw, or arms? Experience shortness of breath at rest or with mild exertion? Experience unusual fatigue or shortness of breath with usual activities? 0 i 0 Experience dizziness or fainting? Experience difficulty breathing when lying flat or when asleep? Experience ankle swelling? Experience forceful or rapid beating of the heart? Experience pain or cramping in your legs when walking short distances? Have a known heart murmur? If you answered “yes” to any of the questions above, then you are considered to be at “high risk.” This means that you will need to receive physician approval before you can participate in any fitness testing or any type of exercise in this class. (Instructor Use Only) Action taken if participant is at “high risk”: El Medical referral form completed and the student was instructed to make an appointment with his/her healthcare provider. [I No action. The student declined to artici ate in laboratory activities performed at moderate, hi ; , and maximal intensities. Yes No Cardiovascular risk factors: ' {, 3 Do you smoke, have you quit smoking within the last 6 months, or are you regularly exposed to second hand smoke? .Have you been diagnosed with high blood pressure (2140/90 mm Hg), do you take blood pressure medication, or do you not know your blood pressure? . ‘ Have you been diagnosed with high cholesterol (i.e., total cholesterol 2200 mg/dL or LDL _>_ 130 mg/dL) or low HDL (< 40 mg/dL), do you take cholesterol-lowering medication, or do you not know your cholesterol level? Has a close blood relative experienced a heart attack, heart or blood vessel surgery, or sudden death fiom a heart _ attack or stroke before age 55 (father, brother, or son) or age 65 (mother, sister, or daughter)? Have you been diagnosed with high fasting blood sugar (3100 mg/dL)? Are you physically inactive (i.e., do you participate in less than 30 minutes of moderate physical activity on at least 3 days per week for the last three months)? If you are a male, are you 45 years or older? If you are a female, are you 55 years or older, have you had a hysterectomy, or are you postmenopausal? ,Are you obese? Select “yes,” if at least one of the following apply to you: 1) you have a Body Mass Index of 30 kg/m2 or greater, 2) you are a male and your waist circumference is greater than 102 cm (40 inches), 3) you are a female and your waist circumference is greater than 88 cm (35 inches), or 4) you are more than 20 pounds overweight. IIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIllIIIIIIIIIllIIlllllllllIIIIIIIIIIIIIIIIIIIIIIIlllIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIlllIIIIIIIIIIIIIIIIIIIIIIIIIII If you answered “yes” to two or more of the questions above, but answered “no” to all questions on the first page of this document, then you are considered to be at “moderate risk.” This means that you may participate in submaximal exercise testing and moderate intensity exercise, but you will need to receive physician approval before you can participate in maximal , exercise testing or high intensity exercise. ' (Instructor Use Only) Action taken if participant is at “moderate risk”: [I Medical Referral form completed and the student was instructed to make an appointment with his/her healthcare provider. [I No action. This student has declined to‘ participate in laboratory activities requiring maximal effort or performed at a vigorous f intensi . . llllllllllllllIlllllIIllIlllllllIllllllllllIIlllllllllllIIIIIIIIIIIIIIIIllIIlIIIIIIIIllIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIllIII Other health issues that may warrant physician approval before engaging in physical activity; Have you ever been told not to exercise by a health care provider? Do you have problems with your muscles, bones, or joints? llIlIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIII O 0 Are you taking prescription medications? If so, please list: Medication Dosage I certify that the information included on this form is correct. Date Printed Name of Participant Signature of Participant Date Printed Name of Instructor Signature of Instructor _, (Instructor Use Only) Risk Status: 0 Low 0 Moderate 0 High ' 0 Diabetes 0 Heart Disease 0 Lung Disease 0 Kidney Disease 0 Liver Disease 0 Pregnant | 6 Lab Activity 1-3:, Consent Form for Participation in Exercise Testing INTRODUCTION AND PURPOSE OF EXERCISE TESTING To learn how to assess health-related physical fitness, conduct human performance tests, and prescribe exercise safely and effectively, you will be required to participate in exercise testing activities. Enrollment ‘ in this course requires your participation. However, understand that your current health status (as determined by your answers to the comprehensive medical health appraisal completed for Lab Activity 1-2) dictates the degree to which you may participate in these activities. Read this form. If there is anything you do not understand, ask questions before signing this document. PROCEDURES Depending on your health status (low, moderate, or high risk) as determined by your answers on the comprehensive medical health appraisal, you will participate in one or more of the following exercise tests: 1. Body size and composition tests (e.g., body weight, height, percent body fat with skinfold calipers, and ' waist circumferences with a tape measure); 2. Laboratory aerobic tests on a treadmill, stationary bicycle, and/or bench step with metabolic gas analysis to determine aerobic fitness, energy expenditure, and running/walking economy; Field aerobic tests (e.g., l—mile walk test and 1.5 mile run test); 4. Muscular fitness tests by: a) performing curl-ups and push-ups, b) squeezing a hand grip dynamometer, c) performing a l-repetition maximum test, d) performing hip-joint, lower back, and shoulder flexibility tests, and e) using a dynamometer to measure lower back and upper body strength. ' 5. Resting and exercise blood pressure measurements; 6. Pulmonary function tests; and 7. Anaerobic power tests by: a) jumping as high as you can (vertical jump test), b) leaping as far forward as you can (standing broad jump), c) running up a flight of stairs as fast as you can, and d) riding a stationary bike as fast as you can for 30 seconds. POTENTIAL RISKS OR DISCOMFORTS Exercise testing activities involve a few risks to your health. Please read the following and ask questions about anything you do not understand. 1. During exercise, it is normal for your heart rate and breathing rate to increase and for you to sweat. There may be, however, unforeseeable risks to exercise testing. In rare cases, people experience musculoskeletal injury, heart attack, stroke, or death during exercise. Every effort will be made to make sure that you are safe. If you experience unusual muscular pain, very fast heart rate, very slow heart rate, a pounding sensation in your chest, chest pain, pain or numbness in your arms or legs, dizziness, difficulty breathing, or fainting, then stop exercising and notify your instructor immediately. Your instructor may call 91 1, if needed. ' 2. To. ensure your safety, you must tell your instructor about your current medical health status and medical health history. 3. If you have diabetes, you must obtain physician approval before participating in the exercise testing activities, as exercise may affect your blood sugar levels. If you usually measure your blood sugar levels, then you must do this before and after the activities. 4. If you are pregnant, exercise may be dangerous to your health and the health of your fetus. If you are pregnant (or think you might be pregnant), you must obtain physician approval before participating in exercise testing activities. If you were active prior to becoming pregnant, then you may be able to perform some of the activities, but this should be determined by your doctor. You are responsible for paying your own medical bills, including those received: 1) if you are referred to a healthcare provider prior to your participation in exercise testing, and/or 2) if you seek/receive medical attention due to a complication associated with your participation in exercise testing. POSSIBLE BENEFITS By participating in exercise testing activities, you will learn how to: 1. Evaluate health-related physical fitness, health status, and health risks; 2. Conduct human performance tests; 3. Develop an effective and safe exercise and weight loss program for athletes, personal training clients, yourself, etc.; and 4. Monitor the progress of those participating in an already-established training program. Furthermore, participating in exercise testing activities will allow you to observe physiological responses to various modes of exercise, and thus, help you understand difficult concepts covered in your exercise physiology lecture class. CONFIDENTIALITY Your results will be shared among your fellow classmates and your instructor. You and your classmates will use your results to learn how to determine health status and prescribe exercise. Your instructor and the laboratory assistants may see your results when they grade assignments. The instructor and laboratory assistants will return all laboratory activities to you except Lab Activity 1-2, the comprehensive health history appraisal. This form will be kept in a secure location and not shared with anyone. It is yours and your classmates responsibility to keep confidential any information about you that was collected as part of a laboratory activity. TERMINATION OF TESTING Although enrollment in this course requires your participation, you are free to discontinue participation in any exercise testing activity at any time without penalty should you experience an unusual response to exercise (as described in the potential risks/discomfort section). In addition, the instructor may end your participation in testing without your consent if he/she believes that you may be in danger (i.e., based on physical symptoms experienced during testing such as pounding heartbeat, difficulty breathing, etc.). POINT OF CONTACT FOR FURTHER INFORMATION For questions you may have about your rights as a participant in exercise testing, contact: Laboratory Director/Instructor: Phone number: E-mail address: AUTHORIZATION “I have read and understand this consent form. Questions concerning these procedures have been answered to my satisfaction by my instructor. I agree to participate in testing. I understand that I will receive a copy of this form. I understand that enrollment in this course requires my participation. However, I understand that I may with draw from a test at any time without penalty. I also understand that my consent does not take away any legal rights in the case of negligence or other legal fault of my instructor or the facility. I further understand that nothing in this consent form is intended to replace any applicable federal, state, or local laws.” Date . Participant’s Name (Printed) ’ Signature of Participant Date Instructor’s Name (Printed) Signature of Instructor ...
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Consent_20Forms_20Aug_2021,_202009 - “,Lab Activity 1-2:...

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