I hereby consent to voluntarily engage in an exercise test to determine my circulatory, respiratory, and physical fitness. It is my understanding that the information obtained will help me evaluate future physical activities and sports activities in which I may engage.

I understand and have been informed that there exists the possibility of adverse changes during the actual test. I have been informed that these changes could include abnormal blood pressure, fainting, disorders of heart rhythm, stroke, and very rare instances of heart attack or even death. I have been told that every effort will be made to minimize these occurrences by preliminary examination and by precautions and observations taken during the test. I have also been informed that emergency equipment is readily available to deal with these unusual situations should they occur. I understand that there is a risk of injury, heart attack, or even death as a result of my performance of this test, but knowing those risks, it is my desire to proceed to take the test as herein indicated.

The results of these tests may or may not benefit me. Potential benefits relate mainly to my personal motives for taking the tests, that is, knowing my exercise capacity in relation to the general population, understanding my fitness for certain sports and recreational activities, planning my physical conditioning program, or evaluating the effects of my recent physical activity habits. Although my fitness might also be evaluated by alternative means (for example, a bench step test or an outdoor running test), such tests do not provide as accurate a fitness assessment as a treadmill or bike test nor do those options allow equally effective monitoring of my responses.

I have been informed that the information obtained in the exercise tests will be treated as privileged and confidential and will consequently not be released or revealed to any person without my express written consent. I do, however, agree to the use of any information for research or statistical purposes so long as same does not provide facts that could lead to my identification. Any other information obtained, however, will be used only by Level One Training and Fitness to evaluate my exercise status or needs.

I have been given an opportunity to ask certain questions as to the procedures. I have noted these questions below along with the corresponding responses I have received.

I further understand that there are also other remote risks that may be associated with this procedure. Despite the fact that a complete accounting of all these remote risks has not been provided to me, I still desire to proceed with the test. I acknowledge that I have read this document in its entirety or that it has been read to me if I have been unable to read same. I consent to the rendition of all services and procedures as explained herein by Level One Training and Fitness.