New Jersey
Sports Medicine and Performance Lab
                           Marc Richard Silberman, MD
                               

AUTHORIZATION AND CONSENT FOR THE MAXIMUM AEROBIC POWER TEST

INFORMATION STATEMENT
As part of New Jersey Sports Medicine and Performance Lab, a fitness evaluation test will be performed.  The test is
designed to estimate and describe: 1. the maximum aerobic power (MAP) while cycling; 2. the maximum oxygen
uptake (VO2max); 3. the evolution pattern of the heart rate as power output increases; 4. the evolution pattern of blood
lactate levels as power output increases; 5. the athlete’s maximum heart rate.  Before the test you will be screened by a
physician experienced in exercise testing.  For the test, you will ride your own bicycle mounted to a Computrainer.  
Remaining seated, you will pedal at a steady cadence of 90 revolutions per minute (RPM) against a progressively higher
resistance until you can longer maintain the target cadence.  The test is a progressive and maximal test whose results
depend on your ability to go as far as possible before voluntarily stopping the test.  If you experience such symptoms as
excessive fatigue, breathlessness, chest pain, muscle pain, or any other symptoms out of your ordinary, you will stop the
test.  You can stop the test voluntarily at any time.

Blood pressure will be taken prior to the test and if elevated, the test will be postponed.  Your RPMs, heart rate,
power output in watts, blood lactate levels, and expiratory gases will be monitored during the test.

RISKS of testing include muscle injury, a remote chance of fainting and a very rare chance of abnormal heart rhythm or
heart attack, and death.

BENEFITS of testing include assessment of cycling fitness and development of power-based training zones.  The
knowledge gained from the test facilitates development of a power based training program, evaluation and monitoring of
training progress, and prevention of overtraining and injury.
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CONSENT
Your signature on the line provided below indicates:  (1) you have read, understood, and agreed to all of the above
statements; and, (2) you had an opportunity to ask questions about the exercise test, the test has been adequately
explained to you, and you have sufficient information regarding the test and its risks and benefits; and, (3) your consent
to take the exercise test is given voluntarily as you have the right not to take the test if you so choose.

I HEREBY CONSENT TO THE PERFORMANCE OF THE FITNESS TEST UNDER THE SUPERVISION OF:


_____________________________________        __________________________________
(Physician’s Name)                                                 (Patient’s Signature)

________________________________________   ____________________________________________
(Witness)                                                                  (Parent or Guardian Signature, if athlete < 18 years)

________________________________________
(Date/Time)