Well DNA - Activation - Novo Genomics

Health Risk Assessment (HRA)

Please Note:
This questionnaire is to be kept handy as it would help during the call that is done to get related information regarding you and your family medical history.The information would be of the person providing the Saliva/ Blood sample for the Well DNA genetic test.

Before you begin, please activate your kit.

1. Please enter your Kit ID (IHP2400XXXXX) located on the box. *

*Note: Your sample will not be processed if you do not activate your kit.

Select Your Test Package *

Silver - (Health | Fitness | Nutrition)
Gold - (Health | Fitness | Nutrition | Skin)
Platinum - (Health | Fitness | Nutrition | Medication | Skin | Sleep)

Name *

First

Last

Gender *

Male
Female

National ID / Iqama ID/ Border No. *

Date of Birth (Please enter dates according to Gregorian calendar year) *//

Blood Type *

Marital Status *

Email *

Phone *

Sample Registration Date *//

What is your Height (cm)? *

What is your Weight(kg)? *

YOUR HEALTH INFORMATION

Have you taken any Genetic Test other than WellDNA? *

Have you done any preventive health checkup? *

Personal & Family Medical History:

You need to inform Diagnosed Health Conditions, Age at the time of Diagnosis, Prescribed Medication & Relationship as shown in the example tab. The age at which the health condition was diagnosed needs to informed in both the personal & family (Father, Mother, Brothers, Sisters, Paternal & Maternal Grandparents) columns. Be sure to inform the relationship in the family while informing the health conditions.
Please Note: Diagnosed Health Conditions include diseases, deficiencies and/or allergies, as informed by your doctor.

Personal Medical History:

Diagnosed Health Condition/s *

e.g Diabetes, Blood Pressure

Age (at the time of diagnosis) *

e.g 27, 35

Prescribed Medication *

e.g Metformin

Family Medical History

Relationship *

e.g Father

Diagnosed Health Condition/s *

e.g Diabetes

Age (at the time of diagnosis) *

e.g 50

Your Nutrition Information – 24-Hour Dietary Recall

What did you eat and drink? *

How much did you consume? *

Where was your meal prepared? *

Between Breakfast and Lunch

What did you eat/drink? *

Between Breakfast and Lunch

How much did you consume? *

Between Breakfast and Lunch

What did you eat/drink? *

How much did you consume? *

Where was your meal prepared? *

After Dinner

After Dinner What did you eat/drink? *

How much did you consume? *

What time did you go to bed? *

Before 9 PM
9 PM – 11 PM
After 11 PM
Other

Have you ever taken any planned nutrition/diet? *

Do you take any non-prescribed vitamin supplements? *

If yes, please give details

Do you take any non-prescribed protein supplements? *

Your Lifestyle & Fitness Information

Do you consume alcohol? *

Do you smoke? *

Yes
No
I have quit

Are you sexually active? *

How stressed is your life? *

No Stress
Some Stress
Very Stressfull

INFORMED CONSENT FORM

PLEASE NOTE:
This is a consent to be agreed upon by the person whose saliva sample is to be tested by Novo Genomics.

Full Name *

Registration Date *//

STEP 1: SAMPLE COLLECTION

a) The Individual shall be required to provide a saliva sample (the "Sample"), as per instructions contained in the Saliva Collection Kit (the "Kit") and provided in the prescheduled instruction call (the "Instructions Call") initiated by the Individual. Along with saliva sample, blood sample may also be required to be provided by the individual as directed by Novo Genomics. In some cases, blood sample may be collected in place of saliva samples.

b) If for any reason, the Individual is unavailable to initiate the Instructions Call, Novo Genomics may at its discretion reschedule the Instructions Call on another date/time.

c) After the Instructions Call, the Individual shall be required to send the Sample to Novo Genomics

d) Indus would be sending the Sample in a de-identified/ anonymized manner to its partners for the required testing and related services.

STEP 2: HEALTH RISK ASSESSMENT

b) If for any reason, the Individual is unavailable to initiate the Instructions Call, Novo Genomics may at its discretion reschedule the Instructions Call on another date/time.

c) After the Instructions Call, the Individual shall be required to send the Sample to Novo Genomics

d) Indus would be sending the Sample in a de-identified/ anonymized manner to its partners for the required testing and related services.

STEP 3: GENETIC COUNSELLING CALL

a) The Test results provided to the Individual through mail will further be discussed only with the Individual by a genetic counsellor, through a telephonic conversation ("Genetic Counselling Call"). If the Individual would like that the genetic reports should be discussed with anyone else, then that could be done only on a written request from the Individual. In case of minors, the genetic reports will be discussed only in presence of the legal/natural guardian of the minor Individual.

b) The Genetic Counselling Call and the Instructions Call shall be recorded for internal quality and training purposes. On the basis of the Genetic Counselling Call a separate genetic counselling summary report shall be provided to the Individual.

STEP 4: FURTHER USE OF THE SAMPLE

a) After analysis, the Sample and the data derived through the Sample, health risk assessment forms, the calls and any data as may be available to Indus during the course of providing services, may be used by Novo Genomics or any third parties permitted by Novo, for further analysis and recommending tests in the future, for quality control purposes or to conduct research, studies or clinical trials and may also be published in journals and presented in conferences and seminars without revealing the Individual's identity and maintaining confidentiality.

b) For some research studies, contacting the Individual (or natural/legal guardian, in case of minors) may be required. The Individual (or natural/legal guardian, in case of minors) consents to being contacted for this purpose and understands that the Individual: – shall not be entitled to any sum of money or similar benefit if the Sample is used for such research. – shall have no right to claim on the results and outcomes of the research study including the right to claim any ownership on the data, research, publications, patents or any intellectual property resulting from the Samples.

c) Based on individuals instructions, the sample, DNA extracted from the Sample and/or the data derived through the Sample shall be banked/stored at Indus or with its partners (at the discretion of Novo Genomics)

d) The samples will not be returned to the Individual. The Individual shall have the right to request destruction of such Sample, or the information provided to Novo Genomics. However, such a request shall not entitle the Individual to a refund of the fees paid for the Tests.

GENERAL TERMS AND CONDITIONS FOR CONSENT FORM

DISCLAIMER*

These tests are designed to screen for select clinically relevant genetic variations in human genomic DNA to assess genetic risk or predisposition to various diseases and/or traits. These tests may require further confirmatory tests and advice of a qualified medical practitioner before any action is taken and Novo Genomics shall not be responsible for the same. Genetic risks are merely indicators of the genetic condition of the individual. If data indicates no substantial genetic risk for a particular disease or condition, it does not imply complete protection of that individual from that particular disease. Similarly, if data indicates a substantial genetic risk for a particular disease or condition, it does not imply certainty to develop the disease or condition. The likelihood of an individual developing a particular health condition is substantially dependent on his/her lifestyle and other factors. Genetics is only part of the picture of any individual's state of being. Also, the understanding of genetic information is rapidly evolving and at any given time Novo Genomics can only comprehend part of the picture of the role of genetics, and only a trained physician or other health care provider can assess the current state of health or disease, taking into account all the factors. Further, Novo Genomics’ services are largely dependent on the assistance provided by Novo Genomics’ partners depending upon their expertise in the relevant areas which shall cause certain variations in the Test results. Novo Genomics shall not be responsible for such variations or for the loss of your Samples or any information, due to malfunction or destruction of data servers or other catastrophic events beyond our control. The individual taking the test shall continue seeking any advice or treatment that he/she has been availing from any other qualified healthcare provider or qualified medical practitioner for any previously diagnosed ailments or disease. No part of Novo Genomics 's Services, including but not limited to the reports, instructions call, genetic counselling call are intended as a substitute for, nor does it replace professional medical advice, diagnosis, or treatment. To the maximum extent permitted by applicable law, the services of Novo Genomics are provided without warranties of any kind, whether express or implied, including, but not limited to, implied warranties of merchantability, fitness for a purpose, or non-infringement. The report generated based on processing the Sample is solely based on the associations between genetic markers and disease/traits identified at the time of sample collection in the tested individuals. Based on novel marker-disease/trait associations discovered through internal and published research, the estimated risk may be altered in future. Likewise, same raw data that is analysed by other companies could detect a different risk because each company has their own proprietary algorithms for analysing the raw data.

DISCLAIMER*

While Novo Genomics analyses a substantial number of genetic markers and their association with an individual's DNA, it is likely that some markers, for various reasons, may have not been considered that could alter the total estimated risk score. Because interpretations provided in the services of Novo Genomics, rely primarily on published studies, some interpretations may not be applicable to some individuals. Future scientific research may change the interpretation of such an individual's DNA. Novo Genomics may not be able to process the Sample if the saliva does not contain a sufficient volume of DNA or DNA that does not meet quality standards, or the results from processing do not meet Novo Genomics’ standards for accuracy. If the initial processing fails for any of these reasons, Novo Genomics shall, at its discretion, reprocess the same sample or offer to send another Kit to collect a fresh Sample at additional charge. If the fresh Sample cannot be processed due to similar reasons, Novo Genomics shall not be required to send any additional Kits.

LIMITATION OF LIABILITY

In no event shall Novo Genomics, be liable for any indirect, special, consequential, incidental or remote damages however caused, and whether based on contract, tort (including negligence), or any other theory of liability, regardless of whether Novo Genomics has been advised of the possibility of such damages. The direct liability of Indus for any and all claims arising out of the Tests shall not at any point exceed the fees paid for the Test under which the claim has arisen.
In case of implementation some law and regulation will vary or changed or cancelled at that time. Hence application and implementation of terms and conditions moderate or change or cancelled as per Saudi law.