Senior Fitness Consent Form

Senior Fitness Consent Form **Patient Information** Patient Name: Margaret Davies Date of Birth: 15/03/1950 Address: 14 Willow Creek Lane, Bristol, BS8 1TZ Phone Number: 07700 900345 **Physiotherapist Information** Physiotherapist Name: Dr. Eleanor Vance Clinic Name: Active Life Physiotherapy Contact Number: 0117 321 0987 **Purpose of the Fitness Programme** The purpose of this Senior Fitness Programme is to improve overall physical function, balance, strength, flexibility, and cardiovascular health, specifically tailored to reduce the risk of falls and enhance daily living activities for Ms. Davies. The programme aims to help her maintain independence and improve her quality of life through safe and effective exercises. **Description of Activities** Activities included in the programme will involve a combination of: gentle resistance training using light weights and resistance bands, balance exercises such as single-leg stands and heel-to-toe walking, flexibility exercises including stretching for major muscle groups, and low-impact cardiovascular activities like walking or stationary cycling. All exercises will be modified to Ms. Davies' current fitness level and health conditions. **Potential Risks and Benefits** * **Benefits:** Increased muscle strength, improved balance and coordination, greater flexibility, enhanced cardiovascular health, reduced risk of falls, improved mood, and increased energy levels. * **Risks:** While every effort will be made to ensure safety, potential risks include muscle soreness, sprains, strains, dizziness, or, in rare cases, more serious cardiovascular events. These risks are mitigated by careful assessment, individualised programme design, and continuous monitoring during sessions. **Patient Responsibilities** Ms. Davies agrees to: accurately report her medical history and any changes to her health status, follow all instructions given by Dr. Vance, communicate any discomfort or pain during exercises, and inform Dr. Vance of any medications she is currently taking. She also agrees to attend scheduled sessions regularly and complete any prescribed home exercises. **Confidentiality** All personal and medical information shared will be kept strictly confidential in accordance with GDPR regulations and professional ethical guidelines. **Acknowledgement and Consent** I, Margaret Davies, confirm that I have read and understood the information provided in this consent form. I have had the opportunity to ask questions, and these have been answered to my satisfaction. I understand the purpose, activities, potential risks, and benefits of the Senior Fitness Programme. I voluntarily give my consent to participate in this programme. Patient Signature: Margaret Davies Date: 1 November 2024 Physiotherapist Signature: Dr. Eleanor Vance Date: 1 November 2024