Competitive Edge Performance Lab

Medical / Health Information

Name ______DOB ______

Contact Phone Number ______

Have you ever been diagnosed with ANY of the following?

Heart Condition Yes □ No □Type: ______

Cancer Yes □ No □Arthritis Yes □No □

HypertensionYes □ No □Pulmonary Disease / Asthma Yes □ No □

DiabetesYes □ No □Stomach ulcerYes □ No □

Osteoporosis Yes □No □Alcoholism / Drug AddictionYes □ No □

Kidney Disease Yes □ No □DepressionYes □ No □

Hepatitis Yes □ No □Thyroid DiseaseYes □ No □

Neurological Disease Yes □ No □TuberculosisYes □ No □

Have you experienced ANY of the following in the past year?

Fallen this yearYes □ No □Joint / Muscle swellingYes □ No □

Weight loss / gainYes □ No □Bruising easilyYes □ No □

Difficulty sleepingYes □ No □Arm / Leg swellingYes □ No □

FatigueYes □ No □Excessive bleedingYes □ No □

WeaknessYes □ No □Difficulty breathingYes □ No □

Fever/Chills/SweatingYes □ No □Regular coughYes □ No □

TremorsYes □ No □Heart racing/palpitationsYes □ No □

SeizuresYes □ No □Difficulty swallowingYes □ No □

Double visionYes □ No □Heartburn / indigestionYes □ No □

Loss of visionYes □ No □ConstipationYes □ No □

Eye rednessYes □ No □Blood in stoolsYes □ No □

Nausea / vomitingYes □ No □Difficulty urinatingYes □No □

Hearing problemsYes □ No □Difficulty holding urineYes □ No □

Skin rashYes □ No □Blood in your urineYes □ No □

Excessive StressYes □ No □Use a Walker or CaneYes □ No □

Numbness / tinglingYes □ No □

Do you have any known allergies? ______

Please describe your current exercise/physical activity routine:

Please provide an indication of exercise intensity [ HR achieved, average walking/running pace, race or event times 5K, 10K, perception of effort]:

Testing Modality Preference:TreadmillCycle Ergometer

Please list ALLprescription medications/dosages and supplements?

Cardiopulmonary Exercise Testing

Pre-test Instructions

Your CEPL lab Appointment is scheduled for: ______

Please follow these pre-test instructions to ensure a safe and effective laboratory evaluation:

  • Wear comfortable, loose fitting clothing consistent with exercise testing. Women wear a sports bra or halter top to facilitate EKG electrode placement. Wear walking, running, athletic foot wear.
  • Drink plenty of fluids over the 48-hour period preceding the test to ensure normal hydration prior to testing.
  • Maintain a diet adequate in carbohydrates several days in advance of testing.
  • You may eat a light meal 2-3 hours before testing.
  • Avoid tobacco and alcohol for at least 4 hours before testing. Avoid caffeinated drinks for 12 hours prior to testing if possible.
  • Avoid vigorous cardiovascular or resistance training, exercise, or activity the day of the test.
  • Get an adequate amount of sleep [6-8 hours] the night before the test.
  • Do not stop taking prescription medications unless this is specified by your physician.

What you may bring: towel; water bottle filled with water or sport drink; a light, quick-energy snack.

Please be prepared to give your best effort. Immediately after their first laboratory evaluation patients and athletes’ remark that they “could have given more, had a little more in me, could have gone another few minutes.” Be aware of this prior to testing. Clearly there exists’ many legitimate reasons for this including: unfamiliarity with treadmills or bicycle ergometers, the new sensation of breathing through the mouth with mask blocking the nose, and the artificial laboratory setting.

Our staff will do everything possible to care for you and exhort you to give your best effort. The level of motivation you bring to the lab is very important. The harder you work the more valuable the clinical and/or performance data we acquire. This is the reward for putting forth your best effort. We respect and admire your decision and we look forward to working with you.