Testing Session Information & Consent Form

This form is provided here for your reference.
You'll be asked to complete & sign it at your in-person Testing Session before participating.

ASSESSMENT INFORMATION

Our Testing Session will consist of three types of assessments described below. This form provides information about these assessments and potential risks, followed by a screening questionnaire. It is important to identify any immediate risk factors that would preclude you from participating in any assessments at this time. 

You may end your participation in any of these assessments at any time. Any assessment may be excluded or stopped if circumstances warrant doing so. As part of your Testing Session, we will confirm your personal information including age, biological sex, and bodyweight in order to properly calculate and analyze the data.

Please read the descriptions below, complete the questionnaire, then sign at the bottom prior to your participation. 

1) VO2 Max Test

Purpose & Description 

This assessment is used to assess your VO2 Max, or the maximum amount of oxygen your body can use, which is a key indicator of cardiorespiratory fitness. This is also known as a peak oxygen uptake (VO2 Peak) test as you may not elicit your maximal intake. Secondary criteria such as heart rate can be used to estimate whether a true “maximum” was likely achieved. 

The test involves cycling on a stationary bicycle at a progressively increasing workload until you are unable to continue, or until you – or the person administering the test – decide to stop it. The test begins with a brief warmup period that should feel relatively easy, then it becomes increasingly challenging. By the end, you should expect to feel very fatigued, particularly in your leg muscles. The test will typically not last longer than about 15-20 minutes including warmup and cooldown. 

During the test you will wear a portable analyzer mask that fits over your nose and mouth, which measures the amount of oxygen your body is using. You will wear a wireless strap around your chest to measure and record your heart rate. We may also measure your blood pressure using a cuff around your arm prior to testing.

For your safety, you must remain on-site with Benchmark for a minimum of 20 minutes after the completion of this test.

Potential Risks

The potential risks and discomforts associated with the VO2 Max Test are similar to those associated with any form of physical activity and in particular vigorous exercise. These include fatigue, fainting, abnormal blood pressure, irregular heart rhythm, injury, and in very rare instances, heart attack, stroke, or death. Additionally, some participants experience claustrophobia when wearing the testing mask. Every effort will be made to minimize these potential risks by evaluation of preliminary information relating to your health and fitness, and by careful observation during testing.

There are absolute and relative contraindications to VO2 Max testing. Please ensure you have no contraindication prior to undergoing your VO2 Max test. 

Contraindications to Cardiopulmonary Exercise Testing per American Heart Association (AHA) Guidelines

Absolute Contraindications

• Unstable angina or recent myocardial infarction (within two days)

• Uncontrolled cardiac dysrhythmias associated with symptoms or hemodynamic compromise

• Symptomatic severe aortic stenosis or aortic dissection

• Uncontrolled heart failure

• Acute pulmonary embolus or infarction

• Acute myocarditis, pericarditis, or endocarditis

• Acute systemic infection accompanied with symptoms

Relative Contraindications

• Moderate valvular stenosis

• Hypertrophic cardiomyopathy

• Arrhythmias

• Left main coronary artery stenosis

• Severe pulmonary or untreated severe systemic arterial hypertension

• High degree AV block

2) Dexa Body Composition Scan

Purpose & Description

This is a dual x-ray absorptiometry full body scan, that helps us better understand your body composition. It measures lean mass, fat mass (including Visceral Adipose Tissue, or “VAT”), and bone density, all important indicators of metabolic and overall health. As with all our assessments, it is a non diagnostic test. 

During the scan, you will lie still on the scanner with your legs placed comfortably in straps. The scan typically takes about 5-10 minutes. Your clothing may not include any metal (no zippers or underwire bra), and you will remove all jewelry (including piercings).

The scan involves very little radiation, approximately 0.02 millisieverts (mSV) per scan, less than that of a typical flight across the United States.

Potential Risks

While the DEXA Scan involves little radiation, any radiation exposure is associated with a slight increase in the risk of future cancer.

3) Strength, Balance & Power Tests: Grip Strength, Balance, and Vertical Jump

Purpose & Description 

Grip Strength: Grip strength serves as a proxy of overall strength, and it is a known predictor of longevity. Holding a measurement device known as a dynamometer, you will squeeze as hard as possible to measure your maximum grip strength, with up to three trials per hand.

Balance: Balance is important for daily activities, and better balance can prevent falls, which can lead to serious injury and happen more frequently as we age. To measure your balance, you will stand on one foot with your eyes open, and then with your eyes closed. You will do up to three trials on each foot.

Vertical Jump: The height of your vertical jump is an indication of lower body power (power = strength x speed). Building and maintaining power is necessary to engage in many of the sports we love, and to avoid accidental injury as we age. For this assessment, you will stand on plates that measure the force of your takeoff, and jump as high as possible. You will do up to three trials.

Potential Risks

The main risk associated with the Grip Strength, Balance, and Vertical Jump tests is injury, due to a fall or accident, or due to excessive demands on the muscles, joints, or soft tissue. Every effort will be made to minimize these potential risks by creating a safe environment for the assessment, by offering clear explanations of the proper techniques, and by careful observation during testing.

CONSENT STATEMENT

I have read the preceding information thoroughly, and answered all questions accurately. I have had the opportunity to ask questions, and my questions have been answered to my satisfaction. I acknowledge that in participating in this testing session, I am assuming all associated risks, and will not hold Benchmark Proactive Health Inc. or its directors, employees, associates, or third parties liable.

___________________________ ______________________________ ________________

Name of Participant Signature Date

____________________________ _____________________________________
Emergency Contact Name Emergency Contact Phone Number