Informed Consent for Fitness Test Participation

Testing objectives: In order to more safely participate in an exercise program, I hereby consent,
voluntarily, to a series of exercise tests. Each test will assist in the determination of my overall
physical fitness and will assess the following: cardiovascular fitness, body composition, muscular
fitness, and flexibility. I shall perform a cardiorespiratory assessment by walking, jogging or stepping
up and down on a step. The test may be stopped at any time because of feelings of significant fatigue
or for any other personal reason. Body composition will be determined using skinfold tests. Muscular
fitness will be assessed with sit up and push up tests. A sit-and-reach test will ascertain the flexibility
of the hip joint.
Risk and discomforts: I understand that the risks of the test procedures may include abnormal heart
rhythms, abnormal blood pressure response, fainting, and very rarely a heart attack. Every
professional effort will be made to minimize these risks through proper administration of a
completed health status questionnaire (HSQ) as well as assessment of relevant health questions and
supervision during the tests.
Responsibilities of the participant: I acknowledge that I have completed the HSQ and answered
any attendant health questions accurately. During the tests, I will report any heart-related symptom
(i.e., pain, pressure, tightness, or heaviness in the chest, neck, jaw, back, or arms) immediately. I
have reported all medications (including
nonprescription medications) taken on a regular basis, including today, to the appropriate staff
member.
Benefits to be expected: I desire to pursue these fitness tests so that I may obtain better advice
regarding my present level of cardiovascular fitness and overall physical fitness. This information
will be used to prescribe an appropriate individualized exercise program. I understand that this test
does not entirely eliminate risk in the proposed exercise program.
Inquiries: I understand that I can withdraw my consent or discontinue participation
in any aspect of the fitness testing at any time without penalty or prejudice toward me. I have
read the above statements and have had all of my questions answered to my satisfaction.
Use of medical records: I have been informed that the information obtained from the fitness tests is
privileged and confidential as described in the Health Insurance Portability and Accountability Act
of 1996. It will not be disclosed to anyone other than my physician or individuals responsible for
designing and supervising my exercise program, without my express written permission.

______Brandon K. Gentry______________ _______12/02/21_______

Signature of participant Date
(The answer to all of those questions is no.) Brandon K. Gentry 12/02/21
 Health Status Questionnaire
This questionnaire identifies adults for whom physical activity might be inappropriate or
adults who should seek physician consultation before beginning a regular physical activity
program.

Section 1 Personal and Emergency Contact Information

 Name: Brandon Gentry Date of birth: 06/25/99
Address: 5854 Hayden Cove Phone: (901)-786-3140
Physician’s name: Height: 5’11
Weight: 214 pounds
Person to contact in case of emergency Father
Name: Billy Gentry Phone: (901)-491-1972

Section 2 General Medical History

Please check the following conditions you have experienced.
Heart History
Heart attack Cardiac rhythm disturbance
Heart surgery Heart valve disease
Cardiac catheterization Heart failure
Coronary angioplasty (PTCA) Heart transplantation
Cardiac pacemaker Congenital heart disease
Symptoms
You experience chest discomfort with exertion.
You experience unreasonable shortness of breath at any time.
You experience dizziness, fainting, or blackouts.
You take heart medications.
Additional Health Issues
You have asthma or other lung disease (e.g., emphysema).
You have burning or cramping sensations in your lower legs with minimal
physical activity.
You have joint problems (e.g., arthritis) that limit your physical activity.
You have concerns about the safety of exercise.
You take prescription medications.
You are pregnant.
Section 3 Risk Factor Assessment
Risk Factors for Coronary Heart Disease
You are a man older than 45 yr.
You are a woman older than 55 yr, have had a hysterectomy, or are
postmenopausal.
You have diabetes (type 1 or type 2).
You smoke or you quit smoking within the previous 6 mo.
Your blood pressure is >140/90 mmHg.
Your blood cholesterol is >200 mg · dl–1.
You have a close male blood relative (father or brother) who had a heart attack
or heart surgery before the age of 55 or a close female blood relative (mother or
sister) who had a heart attack or heart surgery before the age of 65.
X You are physically inactive (you get <30 min of physical activity at least 3 days
per wk).
X Your waist circumference is >40 in. (101.6 cm) if you are a man or >35 in.
(88.9 cm) if you are a woman.

Section 4 Medications
Are you currently taking any medication? Yes X No
If yes, please list all of your prescribed medications and how often you take them,
whether daily (D) or as needed (PRN).

Of the medications you have listed, are there any you do not take as prescribed?

Section 5 Physical Activity Patterns and Objectives

List the type, frequency, intensity (e.g., low, moderate, strenuous), and duration of your
weekly exercise. Moderate 15-30 minutes

List your specific goals for your exercise program. 1. Exercise at moderate intensity for
30 mins, 5 days a week, for 5 weeks. 2. Take moderate walks around my neighborhood
for 20 mins, 3 days a week, for 7 weeks. 3. Jog moderately around my neighborhood for
15 mins, 2 days a week for 6 weeks.

Please inform the fitness professional immediately of any changes that occur in your
health status.
Patient Information Release Form
If you have answered yes to questions indicating that you have significant cardiac,
pulmonary, metabolic, or orthopedic problems that may be exacerbated with exercise,
you agree that it is permissible for us to contact your physician regarding your health
status.

Signature: Brandon K. Gentry Date: 12/02/21

Fitness staff signature: Date:

To be completed by fitness professional (circle one):

AHA/ACSM risk stratification: Low Moderate High Physician consent: Yes No

.)
 FITNESS ASSESSMENT DATA SHEET
Participant Name ____Brandon Gentry_________________________________________________

Gender __Male_____ Age__22____ Height__71____ in. _180.34_cm. Weight __214____lb __97.069__kg

Resting Heart Rate ___40____beats/min

Predicted Max Heart Rate: _____198_____beats/min Submax (@85%) __168_______beats/min

Goals: Lower my heart rate to improve the efficiency of my heart functioning.

MUCSULAR FLEXIBILITY CARDIORESPIRATORY TESTING

FITNESS Walk Test
Sit Ups Push Ups Sit –and- Time Heart Est Max O2 Percentile
Consumption (Rank)
Reach Rate ml/kg/min
30 25 31 24.5 180 44

mins
31
30

BODY COMPOSITION
BMI:
Metric: weight (kg) / [height (m)]2
Body Mass Index: _29.9______Classification _Overweight__ Pounds: weight (lb) / [height (in)]2 x 703

Girth Measurement: (Waist-to-Hip Ratio)

Inches Classification
Waist 41
Hips 43
Ratio 0.95 Average
 Exercise Programming
Activity Prescription

Name___Brandon Gentry_________________________________________________________________
Age___22___ Gender__Male___ Training Zone (intensity)__Moderate________
SMART Goals__1. I will exercise at moderate intensity for 30 minutes, 5 days a week, for the next 5
weeks. 2. I will take moderate walks around my neighborhood for 20 minutes, 3 days a week, for the next 7
weeks. 3. I will jog moderately around my neighborhood for 15 minutes, 2 days a week, for the next 6
weeks.__

Special Considerations

_____Coronary heart disease _____ Diabetes Mellitus _____Osteoarthritis _____Pregnancy _____ Asthma _____Pulmonary
Disease _____ Obesity _____Elderly/Chronically Ill
_____Orthopedic _________________________________________________
_____Other___________________________________________________________________________________

Warm Up__(5 min Warm Up) 1. Jogging in Place for 1 minute 2. Jumping
Jacks for 30 seconds 3. Lateral Lunges to the left for 30 seconds and to the
right for 30 seconds 4. Rotational Lunges to the left for 30 seconds and to the
right for 30 seconds 5. 2 Sets of Normal Squats for 30 seconds 5. Slide Squats
for 30 seconds __

________________________________________
Flexibility__1. Hamstring Stretch for 1 minute 2. Triceps Stretch for 1
minute altering between your left and right arm for as long as you can 3. 12
Sets of Sitting Shoulder Stretches for 5 seconds at a time (1 minute) _

__________________________________________
Cardiorespiratory
Mode of Activity:
Borg Relative
___X__Running __X___Elliptical __X___Walking _____Cycling _____ Swimming _____Sport _________
Perceived Exertion Scale

_____Other____________________________________________________________________________
Very, very light
8
9 Very light LOW INTENSITY
Duration: ____15-30 minutes___ Frequency: __2-5 days a week_____
10
11 Fairly light
12
13 Somewhat hard
Intensity: _______ low ___X____moderate _______vigorous 14 MODERATE INTENSITY
15 Hard
Exercise to maintain heart rate between _60_ and _100_BPM 16
17 Very hard
18 VIGOROUS INTENSITY
19 Very, very hard
20
 Low Intensity Exercise: ___99-118________ Heart rate
20 - 40 % VO2 max or heart rate reserve (HRR)
Moderate Intensity Exercise: ___126-150________ Heart rate
40 – 60% VO2 max or HRR (Borg 13 = 60% HRR)

Vigorous Intensity Exercise: ____152-184_______ Heart rate

>60% VO2 max or HRR (Borg 16 = 80% HRR)

Cool Down__(5 min Cool Down) 1. Walking for 3 minutes 2. Seated

Forward Bend for 1 minute 3. Standing Quadriceps Stretch for 30 seconds
using the left leg and 30 seconds using the right leg__

Muscular Fitness

Mode of Activity:
__X___Body Weight ___X__Machine Weights __X___Free Weights ______Other

Specific Exercises Load/ Intensity Repetitions Sets Frequency

Push-Ups Moderate 10 Push-Ups 2 Sets 5 Days A Week

Pull-Ups Moderate 10 Pull-Ups 2 Sets 5 Days A Week

Squat Jumps High 5 Squat Jumps 3 Sets 5 Days A Week

Back Squats High 10 Back Squats 4 Sets 5 Days A Week

Lying Leg Curls Moderate 10 Lying Leg Curls 2 Sets 5 Days A Week

Cable Face Pulls Moderate 15 Cable Face Pulls 2 Sets 5 Days A Week

Jump Rope High 20 Jumps 2 Sets 5 Days A Week

Overhead Cable Moderate 10 Overhead Cable 4 Sets 5 Days A Week

Extensions Extensions

Barbell Curls Moderate 10 Barbell Curls 3 Sets 5 Days A Week

Flexibility__1. Hamstring Stretch for 1 minute 2. Triceps Stretch for 1
minute alternating between your left and right arm for as long as you can 3. 12
Sets of Sitting Shoulder Stretches for 5 seconds at a time (1 minute) 4.
Standing Quadriceps Stretch for 30 seconds using the left leg and 30 seconds

using the right leg__

Exercise Programming
Phase One

Day Training Mode Training Effort Duration Comments

Sunday Walking/ Moderate/ 20 minutes /
Jogging Moderate 15 minutes
Monday Full-Body Moderate 30 minutes
Workout
Session
Tuesday Full-Body Moderate 30 minutes
Workout
Session
Wednesday Walking/Full- Moderate/ 20 minutes /
Week 1 Body Workout Moderate 30 minutes
Session
Thursday Full-Body Moderate 30 minutes
Workout
Session
Friday Full-Body Moderate 30 minutes
Workout
Session
Saturday Walking/ Moderate/ 20 minutes /
Jogging Moderate 15 minutes
Week 2 Sunday Walking/ Moderate/ 22 minutes /
Jogging Moderate 17 minutes
Monday Full-Body Moderate 30 minutes
Workout
Session
Tuesday Full-Body Moderate 30 minutes
Workout
Session
Wednesday Walking/Full- Moderate/ 22 minutes /
Body Workout Moderate 30 minutes
Session
Thursday Full-Body Moderate 30 minutes
Workout
Session
Friday Full-Body Moderate 30 minutes
Workout
Session
 Saturday Walking/ Moderate/ 22 minutes /
Jogging Moderate 17 minutes
Sunday Walking/ Moderate/ 24 minutes /
Jogging Moderate 19 minutes
Monday Full-Body Moderate 30 minutes
Workout
Session
Tuesday Full-Body Moderate 30 minutes
Workout
Session
Wednesday Walking/Full- Moderate/ 24 minutes /
Week 3 Body Workout Moderate 30 minutes
Session
Thursday Full-Body Moderate 30 minutes
Workout
Session
Friday Full-Body Moderate 30 minutes
Workout
Session
Saturday Walking/ Moderate/ 24 minutes /
Jogging Moderate 19 minutes
Sunday Walking/ Moderate/ 26 minutes /
Jogging Moderate 21 minutes
Monday Full-Body Moderate 30 minutes
Workout
Session
Tuesday Full-Body Moderate 30 minutes
Workout
Session
Wednesday Walking/Full- Moderate/ 26 minutes /
Week 4 Body Workout Moderate 30 minutes
Session
Thursday Full-Body Moderate 30 minutes
Workout
Session
Friday Full-Body Moderate 30 minutes
Workout
Session
Saturday Walking/ Moderate/ 26 minutes /
Jogging Moderate 21 minutes
 Summary and Activity Recommendations

This patient doesn’t have any health history. Their risk factors are that they are not regularly physically active
and their waist circumference is >40 in. Since this patient isn’t physically active on a regular basis, they do not
have a consistent exercise history.

This patient’s assessment results are that their resting heart rate is 40, their predicted max heart rate is 198
beats/min, and their submax is 168 beats/min. Their goal is to lower their heart rate to improve the efficiency of
their heart functioning. Their muscular fitness assessment for sit ups was 30 and push ups was 25. For
flexibility, the results for the sit-and-reach test were 30, 31, and 31. For cardiorespiratory testing, for the walk
test, the time was 24.5 mins, their heart rate was 180, and the est max o2 consumption was 44. The patient’s
BMI was 29.9 and their classification was overweight. Their waist was 41 inches, their hips were 43 inches and
their waist-to-hip ratio was 0.95 (average). The patient’s SMART goals are 1. To exercise at moderate intensity
for 30 minutes, 5 days a week, for the next 5 weeks. 2. Take moderate walks around my neighborhood for 20
minutes, 3 days a week, for the next 7 weeks. 3. Jog moderately around my neighborhood for 15 minutes, 2
days a week, for the next 6 weeks.

This patient’s planned exercise was to walk on Sundays, Wednesdays, and Saturdays. Jog on Sundays and
Saturdays and have full-body workout sessions on Mondays, Tuesdays, Wednesdays, Thursdays, and Fridays.
This approach was chosen to try to build a consistent and efficient way to participate in physical activity over a
period of time. This planned exercise follows the SAID principle by increasing the physical demands of the
exercise each week for the body to adapt to. The plan for follow up evaluation will be for the patient to check in
after every few weeks, to evaluate their progress and make any adjustments that might be needed.