Please Do Not Print This Document Unless You Really Need To
Studies show that trees live longer when they’re not cut down.
Please do not print this document unless you really need to.
Thank you for giving us the opportunity to provide our services to you. The following forms can be filled out by using the save as feature on your computer and sent back to us via e-mail with your name in the file name. By doing this you will help us reduce our dependence on paper and be more environmentally active.
Currently the only page that must be printed and signed is the doctors’ approval form for males 45 years of age and females 55 years of age. We prefer that you consult your doctor, but also provide a spot for you to waive that right.
Please contact us if you have any problems or questions with these forms.
Appointment Information for Lactate Threshold (LT) Testing
Lactate threshold testing should be done in a well-rested physical state. The following criteria must be adhered to prior to an LT test in order to determine accurate physiological values:
- No exercise the day of the LT test.
- No exercise the day prior to the LT test if possible. If this is not possible, then a very light bout of exercise will be acceptable. Have at least 20 hours of rest before testing.
- The LT test will preferably be after a week of recovery so that your accumulated training fatigue is low. An LT test should not be performed in a high volume and/or intensity training week.
- Treat the LT test as a very high quality training session and follow your same nutritional preparation schedule including adequately hydrating yourself. This means you should plan to be well fed within 2 hours of the appointment.
- Choose the testing modality (bike or run) in the sport that you have the most proficiency.
Items to Bring:
- Appropriate clothing and shoes for your bike or run LT test.
- Road bike or mountain bike with slick on rear if you are doing your LT test on your bike.
- Your personal heart rate monitor if you have one.
- Water bottle and recovery beverage or food.
- Your personal music CD or music player if desired.
* Shower provided in RV during summer months and changing area year round. Locker rooms at facilities for run tests.
Time Commitment:Your LT test will be scheduled for 2 hours. This includes warm-up, the test, and consultation time to interpret your results. You will notbe required to reach a maximal effort during this test.
Lactate Threshold Testing Waiver Form
Please read, check each box to show you have read and understood the waiver then agree to the signature request below.
LT Exercise Test Explanation: Athlete will perform a NON-maximal effort exercise test on his/her bike, a bike ergometer, or a motor driven treadmill approximately 30-60 minutes. After a thorough low intensity warm up, work levels will gradually increase till physiologic markers indicate a significant break from baseline data. The test can be stopped at any time should the athlete experience fatigue, shortness of breath, dizziness, chest pain or any feelings of discomfort.
Risks and Discomfort
There is some risk involved with performing an exercise test. Certain changes can occur in response to exercise including abnormal blood pressure changes, dizziness, myocardial infarction, stroke, or death. Every effort will be made to minimize these risks and emergency equipment and trained personnel are available.
Athlete Responsibilities
Information you have about your health status or previous experiences with higher intensity physical effort or testing may affect the safety of your exercise test. You are responsible for fully disclosing such information to Optimize Endurance Services.
Consent
I have asked the test administrator any question I have pertaining to this test and I understand that performance of this exercise test is completely voluntary and I am able to stop the test at any point. I hereby attest that I am in good health and my physical condition HAS BEEN VERIFIED by a licensed medical doctor, who has RELEASED ME to participate in strenuous physical activity and testing.
Waiver of EKG (Only for males 45 and females 55 years of age. See attached Physicians approval form for printing)
I understand that an EKG test will NOT be conducted and there will NOT be a physician on site during my test. I have provided, in writing, a signed consent form from my physician stating that he/she is aware that I am performing an exercise test, that there will be no physician present, that there is no contraindication to intense exercise, and that there will not be EKG monitoring during this test.
I have read and I understand the test procedures that I will perform and the associated risks and discomforts. I consent to participate in the testing.
Electronic signature completed by checking the box beside ‘I AGREE’
Participant’s Signature I AGREE Today’s Date
Participant’s Name
Optimize Endurance Services WAIVER AND RELEASE OF LIABILITY
NOTE: THIS FORM MUST BE READ AND SIGNED UNALTERED BEFORE THE PARTICIPANT IS PERMITTED TO TAKE PART IN ANY FUNCTION CONNECTED TO OPTIMIZE ENDURANCE SERVICES BUSINESS. BY CHECKING THE ‘I AGREE’ BOX BELOW, THE PARTICIPANT AFFIRMS HAVING READ AND UNDERSTOOD IT AND IS IN AGREEMENT WITH ITS CONTENTS.
IN CONSIDERATION of my involvement in the training, testing, coaching and activities performed by Optimize Endurance Services, I acknowledge, appreciate and agree that:
- RISK IS INHERENT, and in related training and discipline, including risks from the use of equipment and facilities, the risk of injury does exist, as well as the risk of damage to or loss of property; THESE RISKS INCLUDE EXTENSIVE AND SEVERE BODILY INJURY, PARALYSIS, DISMEMBERMENT, DISABILITY AND DEATH.
- I KNOWINGLY AND FREELY ASSUME ALL SUCH RISKS; both known and unknown, EVEN IF ARISING FROM THE NEGLIGENCE OF THE RELEASEES OR OTHERS;
- I willingly agree to comply with the stated and customary terms and conditions for participation. If, however, I observe any unusual or unnecessary hazard during my presence or participation, I will bring such to the attention of the nearest staff member immediately.
- I, FOR MYSELF, AND ON BEHALF OF MY HEIRS, ASSIGNS, PERSONAL REPRESENTATIVES, and NEXT OF KIN, HEREBY RELEASE, HOLD HARMLESS AND PROMISE NOT TO SUE OPTIMIZE ENDURANCE SERVICES, THEIR OFFICERS, COACHES, VOLUNTEERS, STAFF, AND SPONSORS, (“RELEASEES”) WITH RESPECT TO ANY ANDALL INJURY AND/OR LOSS ARISING FROM MY PARTICIPATION, WHETHER CAUSED BY THE NEGLIGENCE OF THE RELEASEES OR OTHERWISE, EXCEPT THAT WHICH IS THE RESULT OF GROSS NEGLIGENCE OR WANTON MISCONDUCT.
I have read this Release of Liability and Waiver Agreement, fully understand its terms, understand that I have given up substantial rights by signing it, and sign it freely and voluntarily without any inducement. Electronic signature completed by checking the box beside ‘I AGREE’
Participant’s Signature I AGREE Today’s Date Participant’s Name
FOR PARTICIPANTS OF MINORITY AGE
This is to certify that I/we as parent(s)/guardian(s) with legal responsibility for this participant, do consent and agree not only to his/her release, but also for myself/ourselves, and my/our heirs, assigns and next of kin to release and indemnify the Release from any and all Liability incident to my/our minor child’s involvement as stated above, EVEN IF ARISING FROM THE NEGLIGENCE OF THE RELEASES, to the fullest extent permitted by law.
Parent/Guardian Signature ______Date
Parent/Guardian’s Name (Printed)
Athlete Information
TODAY’S DATE AGE DATE OF BIRTH Gender: M F
NAME
ADDRESS
CITY STATE ZIPCODE
PHONE NUMBERS (H) (W) (C)
EMAIL ADDRESS
Billing Party Information (if different than above)
NAME Gender: M F
ADDRESS
CITY STATE ZIPCODE
PHONE NUMBERS (H) (W) (C)
EMAIL ADDRESS
I AGREE TO PAY IN FULLfor services at the time of service, or agree to be billed on a cyclical basis for monthly coaching and facility usage.
Participant’s Signature I AGREE
Emergency Contact Information
CONTACT 1: RELATIONSHIP:
PHONE NUMBERS (H) (W) (C)
CONTACT 2: RELATIONSHIP:
PHONE NUMBERS (H) (W) (C)
DOCTOR PHONE
HOSPITOL CHOICE MEDICATIONS WE MAY NEED TO KNOW ABOUT
ALLERGIES
EMERGENCY RELEASE: In the event of an emergency where I (or my spouse/family) cannot be contacted, I authorize Optimize Endurance Services to secure whatever medical care is necessary for the safety and well-being of my child. I will assume all costs incurred for emergency care.
Participant’s Signature I AGREE
Medical History Questionnaire
Name Date of birth AGE
Please check appropriate ‘No’ or ‘Yes’ box and provide additional details as requested.
All information is confidential.
______
Do you have or have you ever had: (List date(s)/Medications)
NO YES
High blood pressure
Heart disease
Frequent headaches
Seizure/ epilepsy
A concussion or other closed head injury? List dates:
Stayed overnight in a hospital due to a concussion or closed head Injury?
List dates:
Diabetes or high blood sugar
Anemic
Sickle cell anemia/ sickle cell trait
Lung disease
Kidney disease
Liver disease
Stomach disease (e.g.: ulcers, bleeding, etc.)
Hernia or "rupture"
Asthma or exercise induced Asthma
Do you have your inhaler with you today?
Are you allergic to any medications? (e.g.: Aspirin, penicillin, etc.) Please list:
Do you regularly take any over the counter and/or prescription medication?
(e.g.: Steroids, birth control pills, anti-inflammatory, antibiotics, topical medications, sprays/inhalers, etc.) Please give reasons
Do you regularly take any vitamins, minerals, herbs, or other supplements? Please list:
Have you ever injured the bones, ligaments, nerves or discs of your neckthat disabled you for a week or longer? List injury/dates:
Have you ever injured the bones, ligaments, nerves or discs of your upper back that disabled you or a week or longer? List injury/dates:
NO YES
Have you ever injured the bones, ligaments, nerves or discs of your low back that disabled you for a week or longer? List injury/dates:
Have you ever had a broken bone or fracture of the arms/legs?
R or L List bone/dates:
Have you ever had a shoulder injury that disabled you for a week or longer?
R or L List injury/dates:
Have you ever had shoulder surgery?
R or L what was done/why? Date:
Have you had an elbow injury that disabled you for a week or longer?
R or L List injury/dates:
Have you ever had elbow surgery?
R or L what was done/why? Date:
Have you had a wrist or hand injury that disabled you for a week or longer?
R or L List injury/dates:
Have you ever had wrist or hand surgery?
R or L what was done/why? Date:
Have you ever been told that you injured the patella, patellar tendon, or front part of your knee, cartilage/meniscus, and ligaments in your knee?
R or L List injury/dates:
Have you ever had knee surgery?
R or L what was done/why? Date:
Have you had an ankle injury that disabled you for a week or longer? Was surgery needed?
R or L List injury/dates:
Do you presently have a rod, pin, screw or plate anywhere in your body?
Where? Date:
Do you wear contact lenses while participating in your sport?
Do you wear any removable dental appliance? (Mark those which apply)
REMOVABLE RETAINER
REMOVABLE BRIDGE
REMOVABLE PLATE
Are you missing one of a set of paired organs (kidneys, eyes)?
Specify:
Are you allergic to any foods? Please list:
NO YES
Are you allergic to insect bites/stings? Please list:
Are you allergic to any trees, plants, or animals? Please list:
Do you have any other conditions you wish to make us aware?
Specify and provide details:
FEMALE ATHLETES ONLY
Are you pregnant, or do you suspect that you may be pregnant?
______
THE ABOVE QUESTIONS HAVE BEEN ANSWERED COMPLETELY AND TRUTHFULLY TO THE BEST OF MY KNOWLEDGE.
Participant’s Signature I AGREE Today’s Date
Participant’s Name
Please Print This Page only for Dr. Signature or waive right of Dr. Approval
Exercise Testing - Physicians Approval Form
(Used for individuals whose age is 45males/ 55 females)
I, Dr.______, have been informed that
______(athlete) desires to have the following exercise physiology test(s) performed with Optimize Endurance Services.
Descriptions of the tests can be found on the next page.
□Lactate Threshold test (LT)
□VO2 Max test
□Metabolic Caloric Assessment Test (MCAT)
With the below signature, I am aware of this athletes current health status and approve this athlete to participate in this/these indicated tests.
______
Physicians signature Phone Number Date
Once signed, please scan this page and send to .
If you have any questions about this form please contact: Rob Lockey, owner/operator of Optimize Endurance Services at:
Phone (303) 356-9893 or E-mail
Waive right to Physicians approval please sign and date on line below.
______
Printed Name SignatureDate
LT/MCAT Exercise Test Explanation: Athlete will perform a NON-maximal effort exercise test on his/her bike, or a motor driven treadmill approximately 30-60 minutes. After a thorough low intensity warm up, work levels will gradually increase till physiologic markers indicate a significant break from baseline data (for LT) or indirect calorimetery shows a significant move towards carbohydrate reliance (for MCAT). The test can be stopped at any time should the athlete experience fatigue, shortness of breath, dizziness, chest pain or any feelings of discomfort.
VO2 Exercise Test Explanation: The athlete will perform a MAXIMAL effort exercise test on his/her bike, or a motor driven treadmill approximately 25-35 minutes in length. After a thorough low intensity warm up, work levels will gradually increase till indirect calorimetery data show a plateau in VO2 or till volitional athlete termination. The test can be stopped at any time should the athlete experience fatigue, shortness of breath, dizziness, chest pain or any feelings of discomfort.
For all tests: Risks and Discomfort - There is some risk involved with performing an exercise test. Certain changes can occur in response to exercise including abnormal blood pressure changes, dizziness, myocardial infarction, stroke, or death. Every effort will be made to minimize these risks and emergency equipment and trained personnel are available.
Athlete Responsibilities: Information the athlete has about health status or previous experiences with higher intensity physical effort or testing may affect the safety of your exercise test. Athlete is responsible for fully disclosing such information to the ATP Center staff.
Athlete will sign a Waiver of EKG (only for males ≥45 and females ≥55 years of age) that states the following: I understand that an EKG test will NOT be conducted and there will NOT be a physician on site during my test. I have provided, in writing, a signed consent form from my physician stating that he/she is aware that I am performing an exercise test, that there will be no physician present, that there is no contraindication to intense exercise, and that there will not be EKG monitoring during this test.