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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:
1. No exercise the day of the LT test.
2. 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.
3. 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.
4. 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.
5. Choose the testing modality (bike or run) in the sport that you have the most proficiency.
Items to Bring:
1. Appropriate clothing and shoes for your bike or run LT test.
2. Road bike or mountain bike with slick on rear if you are doing your LT test on your bike.
3. Your personal heart rate monitor if you have one.
4. Water bottle and recovery beverage or food.
5. 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 not be 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
Participant’s Name
I AGREE
Today’s Date
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:
1. 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.
2. I KNOWINGLY AND FREELY ASSUME ALL SUCH RISKS; both known and unknown, EVEN IF
ARISING FROM THE NEGLIGENCE OF THE RELEASEES OR OTHERS;
3. 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.
4. 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 AND ALL 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
PHONE NUMBERS (H)
ZIPCODE
(W)
(C)
EMAIL ADDRESS
Billing Party Information (if different than above)
NAME
Gender: M
F
ADDRESS
CITY
STATE
PHONE NUMBERS (H)
ZIPCODE
(W)
(C)
EMAIL ADDRESS
I AGREE TO PAY IN FULL for 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)
CONTACT 2:
(C)
RELATIONSHIP:
PHONE NUMBERS (H)
DOCTOR
(W)
(W)
(C)
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 neck that 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
Participant’s Name
I AGREE
Today’s Date
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 info@optimizeendurance.com.
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 rob@optimizeendurance.com
Waive right to Physicians approval please sign and date on line below.
______________________________________________________________________________
Printed Name
Signature
Date
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.