VO2 Max Form

Name *

First Name

Last Name

Phone *

(###)

###

####

Date of Test

MM

DD

YYYY

Test Method

Choose all that apply.

Treadmill

Bike

You will perform a near-threshold effort exercise test on a bike, a bike ergometer or a motor driven treadmill. The work levels will begin at a low intensity and will gradually increase throughout the test. The test can be stopped at any time should you experience fatigue, shortness of breath, dizziness, chest pain or any feelings of 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 will be available. 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 the staff. I have asked the test administer any questions 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. 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. *

Date *

MM

DD

YYYY