Omni Bumps Consent Form

INFORMED CONSENT AND PHYSICAL ACTIVITY READINESS QUESTIONNAIRE


    Emergency contact

    Please enter an emergency contact name and phone number


    I understand the purpose of this programme is to provide safe and individualised exercise sessions to improve health and fitness.
    The programme may include:

    • Cardiovascular activity: walking, jogging, running, use of equipment, high-intensity interval training, team sports, circuit training and other such activities
    • Resistance/Strength training: bodyweight exercises, use of equipment
    • Warm up, cool down and flexibility exercises

    Potential risks:

    This programme is designed to place a gradually increasing workload on the cardiovascular and muscular systems to improve their functions. There is a risk of certain changes that may occur during or following the exercise which could affect blood pressure or heart rate and the possibility of muscle soreness.

    Potential benefits:

    Regular exercise and improved diet has a positive impact on the body. Benefits include:

    • A decreased risk of heart disease
    • A decrease in body fat
    • Improved blood pressure
    • Improved physiological function
    • Improved fitness

    The programme has been explained to me and my questions regarding the programme have been answered to my satisfaction. I understand that I can withdraw at any time. This information is treated as private and confidential.

    MEDICAL QUESTIONNAIRE

    This is designed to help us to develop a programme that is suited to your health needs. For most people, increasing the amount of physical activity or making changes to your diet will not pose a problem or hazard, however, this will allow us to minimise risk and if necessary allow you to seek medical advice before proceeding.

    Please be honest when answering the following questions. Your answers are treated as private and confidential.

    Has your doctor ever said that you have a heart condition and that you should
    only undertake physical activity recommended by a doctor?
    YesNo
    Do you feel pain in your chest when you undertake physical activity? YesNo
    In the past month, have you had chest pain when you were not doing physical
    activity?
    Do you often feel faint, have spells of severe dizziness or loss of consciousness?
    Have you ever suffered from any unusual shortness of breath at rest or with mild
    exertion?
    Do you have high or low blood pressure?
    Do you have any chronic illness or physical limitation such as asthma or
    diabetes?
    Are you on any prescribed medication?
    Do you know of any other reason that would affect your ability to take part in
    physical activity?

    Please consult your doctor before taking part in any session with Omni. Tell your doctor what questions you answered yes to on this form. You may still be able to do any activity you want as long as you start slowly and build up gradually or it may be that you need to restrict your activities to those which are safe for you. Omni takes no responsibility for injuries, illness or death as a result of underlying conditions. Please inform your instructor if you feel unwell or injured during the session.

    Please inform your coach if you have any problems or concerns.

    Photographs and filming may be taken during sessions for use by Omni and partners on social media, local press and publications.



    I Understand & Accept the Above. All the information I have given is accurate to the best of my knowledge. I will inform Omni of any changes to my health or status related to this questionnaire


    Have you filled in your questionnaire?