Informed consent form for a combined resting and exercise metabolic assessment
1. Purpose and Explanation of the Assessment
Your resting metabolic rate (RMR) is the number of calories you burn while you are resting and not exerting yourself in any way. Because RMR typically accounts for 60 to 70 percent of a person’s total daily energy expenditure, knowing your RMR can be useful when formulating an individualised nutrition and weight management plan. Before your RMR assessment, you should not participate in any strenuous exercise for 24 hours and must fast (nil by mouth other than water) for 8 hours and no alcohol for 12 hours. You will sit quietly at rest for about 15 minutes. A breathing mask will be placed over your mouth and nose and you will breathe in room air as normal. Tubes from the breathing mask are connected to a computerised device that analyzes the air you exhale.
You will perform a fitness assessment on an exercise bike. The exercise intensity will begin at a low level and may be advanced in stages depending on your fitness level. We may stop the assessment at any time because of signs of fatigue or changes in your heart rate. It is important for you to realise that you may stop when you wish because of feelings of fatigue or any other discomfort
2. Attendant Risks and Discomforts
Rarely, people feel claustrophobic and cannot tolerate wearing the breathing mask. To the best of our knowledge there are no known health risks associated with an RMR evaluation.
There exists the possibility of certain changes occurring during the assessment. These include abnormal blood pressure, fainting, irregular heart rhythm, and in rare instances, heart attack, stroke, or death. Every effort will be made to minimise these risks by evaluation of preliminary information relating to your health and fitness and by careful observations during the assessment. Emergency protocols have been established to deal with unusual situations that may arise.
3. Responsibilities of the Participant
The results of your RMR assessment may not be accurate if you did not follow the instructions for preparing for the assessment. The accuracy of your results can also be affected by certain medications, medical conditions, acute infections and, for females, pregnancy, breast feeding and menstruation. You should notify the assessment staff if you feel that any of these conditions apply to you. During the assessment you should try not to fall asleep, but should be comfortable and as relaxed as possible. You should sit still in one position while breathing normally throughout the assessment. You should immediately report any unusual feelings that are of concern to the assessment staff.
Information you possess about your health status or previous experiences of heart-related symptoms (such as shortness of breath with low-level activity, pain, pressure, tightness, heaviness in the chest, neck, jaw, back and/or arms) with physical effort may affect the safety of your fitness assessment. Your prompt reporting of these and any other unusual feelings with effort during the assessment itself is of great importance. You are responsible for fully disclosing your medical history, as well as symptoms that may occur during the assessment. You are also expected to report all medications (including non-prescription) taken recently and, in particular, those taken today, to the assessment staff.
4. Benefits to be Expected
Your RMR assessment results will be used to help formulate an individualised nutrition plan for you. However there is a lot of conflicting information available regarding eating plans so you may wish to consult with a registered dietician or nutritionist to maximise the benefits
The results obtained from the fitness assessment will assist in evaluating your cardiovascular fitness and be used to formulate an individualised exercise program for you.
RMR & Exercise
Any questions about the procedures used in the assessments or the results of your assessments are encouraged. If you have any concerns or questions, please ask us for further explanations.
6. Use of Assessment Results
RMR & Exercise
The information that is obtained during the assessments will be treated as privileged and confidential. It is not to be released or revealed to any person except your referring physician, dietician or nutritionist or trainer without your written consent. The information obtained, however, may be used for statistical analysis or scientific purposes with your right to privacy retained.
7. Freedom of Consent
I hereby consent to voluntarily engage in an RMR assessment to help formulate an individualised nutrition and/or weight management plan for me. My permission to perform this RMR assessment is given voluntarily. I do hereby waive, release and forever discharge Fit Me Up, its agents, employees, representatives, and all others from any and all responsibilities or liability for injuries or damages resulting from my participation in any activities recommended or supervised by Fit Me Up.
I hereby consent to voluntarily engage in a fitness assessment to determine my cardiovascular fitness. I acknowledge that I have either been given my physician’s permission to perform this fitness assessment or that I have decided to perform this assessment without the approval of my physician. My permission to perform this assessment is given voluntarily. I understand that I am free to stop the assessment at any point, if I so desire.
I have read this form, and I understand the assessment procedures that I will perform and the attendant risks and discomforts. Knowing these risks and discomforts, and having had an opportunity to ask questions that have been answered to my satisfaction, I consent to participate in this assessment.
I do hereby waive, release and forever discharge Fit Me Up, its agents, employees, representatives, and all others from any and all responsibilities or liability for injuries or damages resulting from my participation in any activities recommended or supervised by Fit Me Up.