© 2013 by Intelligent Fitness, LLC

To Schedule An Appointment

Call 802-363-6717

e-mail intelligentfitnessvermont@gmail.com​

CLICK TO DOWNLOAD A PRINATABLE PDF OF THIS FORM

Please fill out this form prior to our appointment

 

As a way of preparing for our time together and our partnership, and to help me get you the best results possible, please initial each line of the test preparation protocol that you were able to follow.  We will discuss your questions during our appointment.

  • I have a water bottle and towel (headband optional).

  • I am illness and symptom free, and have been for at least three days before the test.

  • I am properly hydrated.  WATER only!  NO hydration drinks, coffee, or teas, etc.

  • I am caffeine free for at least 4 hours prior to the test.  It is best to be alcohol and substance free a minimum of a week prior to the test, with the exception of prescribed medications.

  • I did not partake in a strenuous workout(s) 48 hours prior to this assessment.  Ideally, no exercise in this time window is best.   My last day of exercise was: ______________ easy moderate hard (circle one).

  • I am as rested as possible and to schedule your appointment as close to your regular workout time as possible.  I normally exercise at:______(time) a.m./p.m.

  • I slept _____hours last night, normally I sleep _____ hours.

  • I am properly fed.  This means I ate familiar food a minimum of two hours to a maximum of four hours before the test.  I ate at (time): _______ a.m./p.m. and I ate the following:___________________________________________________________________________

  •       ______________________________________________________________________________________________________________

  • I am wearing my Polar T-31 transmitter for the assessment, extra transmitters available at site location.

  • Cyclists testing on personal bike, my bike is in top mechanical condition, my tires are standard size, clean, non-knobby, and inflated to 100-110p.s.i.

  • Cyclists testing on a personal bike, I understand that if a training stand skewer is installed on my bike’s rear hub it is my responsibility to make sure my original skewer is replaced properly and my bike is mounted on the Computrainer to my personal satisfaction.  I understand voluntarily that I am solely responsible for my bike.

  • Walkers/Runners, I understand how to work a treadmill and I will be shown how to stop the treadmill and hold on when necessary.

  • Men please note, facial hair should be shaved pre-test to ensure mask seal.

  • Women please note, jogbras are recommended.

  • My stress level this week (circle your rating) was a 1 (little) 2 3 4 5 (the usual) 6 7 8 9 10 (I’m maxed).

  • I understand that I can stop the test at any time and that safety is the number one concern.

  • I understand that I am entitled to a summary of my results (coaching can be purchased at an additional fee) within two weeks of the test and it is my responsibility to inform Intelligent Fitness if I have not received my summary within two weeks of the test date.  (note: you will receive a leader e-mail within two weeks of today indicating with the subject line: Results are Ready!  You MUST reply to this e-mail to release your summary in a timely manner).

  • I am wearing clothing that is comfortable and appropriate to my chosen test and I am ready to GO!

 

These guidelines help you get the most accurate, reproducible, and consistent information.  This is the first step in helping you reach your goals!  Congrats!

 

I look forward to working with you and helping you reach your personal goals.  If you have ANY questions in advance it is crucial you inform me.  Thank you!

Joey Adams   intelligentfitnessvermont@gmail.com   802-363-6717

 

GENERAL QUESTIONNAIRE

 

 

Name:______________________________ Height:__’___” Weight:______ Age:_____

 

Please answer the following questions to the best of your ability prior to your appointment:

 

  • My primary motivation for doing this appointment is:

 

 

  • My fitness goal is:

 

 

  • My most recent peak fitness was (date and reason):

 

 

  • List all current medications, supplements, herbal remedies and homeopathic remedies:

 

NOTE: If treated for pulmonary, blood pressure, psychiatric, or cardiac conditions a physician’s release is mandatory at the time of test or via e-mail in advance.  Thank you.

  • I am currently injury free.  Yes   No  Any injuries:

 

 

  • I am allergic to latex or mild soaps.  Yes   No

 

  • I am claustrophobic.  Yes  No

 

  • To the best of my knowledge I believe there is nothing that will impact my performance or ability to take this test.  Yes   No

 

  • I am currently under physician’s directives and/or restrictions. Yes   No 

If yes, my physician advises the following:

 

  • I was able to follow the test preparation protocol.  Yes  No

 

11. I last ate at _______(time) and it consisted of the following: 

 

  • My future events are (please list event(s) and dates):

 

I would like to do the following assessment(s).  Payment via cash, check or PayPal (PayPal incurs a $5 surcharge)

____VO2/AT         ____VO2/AT + RMR ____RMR

____WATTS (cyclists), or SPEED (runners) analysis add-on       

____unsure, need more information on each test

 

My signature below indicates that I understood all questions and represent full and honest disclosure. 

Signed:___________________________________________Date:______________________

office use only

 

 

ACSM Health Status Questionnaire

 

Below are 16 questions about your physical health.  Please read each questions carefully, then respond honestly and accurately.  Please answer with either a YES or NO in the space provided to the left of each question.  Your answers are totally confidential.  Please feel free to ask any questions regarding this questionnaire.

 

  • Do you have any personal history of heart disease?

  • Do you have any personal history of metabolic disease?  (e.g. thyroid, renal or liver problems)

  • If you have diabetes, have you had it for less than fifteen years?

  • If you have diabetes, have you had it for more than fifteen years?

  • Have you experienced pain or discomfort in your chest that may be due to a blood flow defeincy?

  • Have you ever experienced unusual shortness of breath during light exercise?

  • Have you had any problems with dizziness or fainting?

  • Do you ever have difficulty breathing when you stand up or during the night?

  • Do you suffer from ankle edema (i.e. swelling of the ankles)?

  • Have you ever experienced severe pain in your leg muscles during walking?

  • Do you have a known heart murmur?

  • Has anyone in your family had cardiac or pulmonary disease before they were 55 years old?

  • Have you ever been assessed as hypertensive on at least two occasions?

  • Is your serum cholesterol greater than 240mg/dl

  • Are you a cigarette smoker?

 

I have read, understood and completed this questionnaire.

 

Name:_____________________________________________________________

 

Signature:__________________________________________________________

 

Date:_______________________

 

 

AGREEMENT OF RELEASE AND WAIVER OF LIABILITY

 

I,__________________________________, hereby agree to the following:

 

  • I am voluntarily participating in the exercise testing and coaching offered by Intelligent Fitness, LLC and hosted by VASTA during which I will receive information and instruction about health and fitness. I recognize that fitness test(s) and coaching require physical exertion, which may be strenuous and may cause injury, and I am fully aware of the risks and hazards involved.

 

  • I understand that it is my responsibility to consult with a physician prior to and regarding my participation in exercise and exercise testing and coaching. I represent and warrant that I am physically fit and have no medical condition, which would prevent my full participation in a Resting Metabolic Test, Anaerobic Threshold Test, Max VO2 Test, and/or any combination of the aforementioned protocols on any exercise modality and that coaching is a recommendation.

 

  • In consideration of being permitted to participate in the assessment(s) and coaching, I agree to assume full responsibility for any risks, injuries or damages, known or unknown, which I might incur as a result of participating in the assessment(s) and coaching.

 

  • In further consideration of being permitted to participate in the assessment(s) and coaching, I knowingly, voluntarily and expressly waive any claim I may have against Intelligent Fitness, LLC, VASTA, their agents, and the manufacturer’s of the exercise equipment or the testing equipment.

 

  • By executing this Agreement, I acknowledge that the information and/or its representatives are protected by the United States copyrights and trademarks and that considerable time and investments have been incurred by Intelligent Fitness in creating the materials and information. As a condition of my receiving the materials and information from Intelligent Fitness, LLC, I agree and will not copy, reproduce, disseminate or disclose the materials and/or information to any third party and that all material, and information supplied by Intelligent Fitness, LLC will only be used exclusively for my personal information.

 

  • I, my heirs or legal representatives forever release, waive, discharge and covenant not to sue Intelligent Fitness, LLC, VASTA, their agents, and the manufacturers of the exercise equipment for any injury or death caused by negligence or others acts.

 

I have read the above release and waiver of liability and fully understand its contents.

 

     I voluntarily agree to the terms and conditions stated above.

 

  ________________________________________      ___________________________

  Signature of Participant                                                        Date

 

  ________________________________________

  Print Name

 

  ________________________________________

  Address

 

  ________________________________________

  City / State / Zip

 

  ________________________________________

  Phone #                                   Fax #

 

  ________________________________________

  E-mail Address

 

 

  ________________________________________      ______________________________

  Witness                                                                                      Date

 

Whom may we thank for this referral? ____________________________________________________

 

Do you wish to have this information shared with your personal trainer: _____yes  ____no ____n/a

If yes, trainer’s name and e-mail address:____________________________________________________________________