CONSENT FORM

Seattle Pacific University Exercise Science Laboratory

For most people, physical activity should pose no significant hazard. In fact, the risk of inactivity appear to be much greater than the risks of even vigorous activity. However, the following modification of the Physical Activity Readiness Questionnaire (PAR-Q) and the AHA/ACSM Preparticipation Screening Questionnaire is helpful in identifying the small number of adults for whom physical activity may be inappropriate or who should have medical advice before exercising. Please circle any of the following that you answer affirmatively:

1. Has your doctor ever said you have heart trouble and should only exercise as directed by an MD?

2. Have you frequently, recently, or during physical activity had pain in your chest/heart?

3. Do you lose your balance because of dizziness or do you ever lose consciousness?

4. Do you have a bone or joint problem that could be aggravated by increased physical activity?

5. Has a doctor ever said your blood pressure was too high (systolic >140 mm Hg or diastolic >90 mm Hg)?

6. Has a doctor ever said that your blood cholesterol is too high (>5.2 mmol/L or >200 mg/dL), or that your HDL-cholesterol is too low (<0.9 mmol/L or <35 mg/dL)?

7. Has a doctor ever said that you have diabetes mellitus?

8. Have any of your first-degree relatives had heart attacks when younger than 55 (male) or 65 (female)?

9. Do you consider your life (occupation, transportation, and leisure) to involve only sedentary activity? On typical days, do you accumulate less than 30 minutes of activities such as walking, climbing stairs, housework, gardening, or other things that require similar or greater energy expenditure?

10. Do you have a body mass index (BMI) of 30 or higher and a waist circumference of more than 35 inches (female) or 40 inches (male)?

BMI = (weight in pounds times 700, divided by height in inches), and divided by height in inches again

11. Is there a good physical reason not mentioned here why you should not be able to safely participate in a moderate or vigorous physical activity if you want to?

According to the 1998 joint statement of the American Heart Association (AHA) and the American College of Sports Medicine (ACSM), you may reasonably engage in moderate exercise and submaximal testing without physician clearance unless you have known atherosclerotic disease or suggestive symptoms. Younger males (<45 yr) and females (<55 yr) may safely participate in vigorous activity, including maximal testing, if they are apparently healthy and have no major coronary risk factor (numbers 5-10 above).

While physical activity always presents some risks, testing is likely to cause nothing more serious than minor discomfort. Fitness evaluation provides a good foundation for individualized exercise prescription that can reasonably be expected to enhance the quality of your life.

Come to the Lab prepared to ask questions for clarification and/or sign a Consent Form affirming the following statement:

Participant's Statement

I voluntarily consent to participate in physical fitness testing and/or recommended exercise, the demands have been explained to me, and I have had opportunity to ask questions regarding procedures and other related aspects. I understand that I am free to withdraw consent and discontinue participation at any time without prejudice and that confidentiality of data and information is guaranteed.

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