1. Purpose and Explanation of the Test
You will perform a fitness test on
a cycle ergometer or a motor-driven treadmill. The
exercise intensity will begin at a low level and may be advanced in stages
depending on your fitness level. We may stop the test at any time because of
signs of fatigue or changes in your heart rate, electrocardiogram (ECG) if
recorded, or blood pressure, or symptoms you may experience. It is important
for you to realize that you may stop when you wish because of feelings of
fatigue or any other discomfort.
2. Attendant Risks and Discomforts
There exists the possibility of
certain changes occurring during the test. These include abnormal blood
pressure, fainting, irregular, fast or slow heart rhythm, and in rare
instances, heart attack, stroke, or death. Every effort will be made to
minimize these risks by evaluation of preliminary information relating to your
health and fitness and by careful observations during testing. Emergency
protocols have been established to deal with unusual situations that may arise.
3. Responsibilities of the Participant
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 test. Your prompt reporting of these and any
other unusual feelings with effort during the test itself is of great
importance. You are responsible for fully disclosing your medical history, as
well as symptoms that may occur during the test. You are also expected to
report all medications (including non-prescription) taken recently and, in particular,
those taken today, to the testing staff.
4. Benefits to be Expected
The results obtained from the
fitness test may assist in evaluating your cardiorespiratory
fitness and formulating an individualized exercise program for you.
5. Inquiries
Any questions about the procedures
used in the test or the results of your test are encouraged. If you have any
concerns or questions, please ask us for further explanations.
6. Use of Test Results
The information that is obtained
during fitness testing will be treated as privileged and confidential. It is
not to be released or revealed to any person except your referring physician
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 a fitness test to determine my cardiorespiratory
fitness. I acknowledge that I have either been given my physician's permission
to perform this cardiorespiratory fitness test or
that I have decided to perform this cardiorespiratory
fitness test without the approval of my physician. My permission to perform
this test is given voluntarily. I understand that I am free to stop the test at
any point, if I so desire.
I have read this form, and I
understand the test 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 test.
I do hereby waive, release and
forever discharge New Leaf™ Health & Fitness Products/In The Zone Fitness
and its officers, agents, employees, representatives, executors, 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 New Leaf
Health & Fitness Products/In The Zone Fitness. I do also hereby release all
of those mentioned and any others acting upon their behalf from any
responsibility or liability for any injury or damage to myself, including those
caused by the negligent act of omission of any of those mentioned or others
acting on their behalf or in any way arising out of or connected with my
participation in any activities of New Leaf Health & Fitness Products/In
The Zone Fitness.
|
___________ |
_________________________________ |
|
Date |
Signature of Client |
|
___________ |
_________________________________ |
|
Date |
Signature of Fitness Professional |