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Human Performance Lab Application

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About the Athlete

Name(Required)

First Last

Email(Required)

Phone(Required)

Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Sport(Required)

Triathlon

Running

Cycling

Other

Sport Participation Duration(Required)

Interest in Testing

Performance and Composition Testing

Max VO2

BRICK (Double Max VO2)

Resting Metabolic Rate (RMR)

Body Composition by Hydrostatic Weighing

Body Composition by DEXA

Reason for Evaluation(Required)

What is your reason for the evaluation?

Medical History

Hidden

Today's Date

Month

Day

Year

Age(Required)

Date of Birth

Month

Day

Year

Height(Required)

Provide in feet (ft) + inches (in) units of measurement.

Weight(Required)

Provide in pounds (lbs).

Are Your Taking any Medications?(Required)

Yes

Name and explain each medication and dose(Required)

Please include over-the-counter medications as well.

Are you under the care of a physician?(Required)

Yes

Please explain(Required)

Recent Symptoms

Please check any of the following you have experienced within the last year.

Abnormal Blood Lipids

Arthritis

Back Pain

Chest Pain

Cough on Exertion

Coughing up Blood

Fainting

Frequent or Severe Headaches

Lightheadedness

Orthopedic Problems

Rapid Heart Beats or Heart Palpitations

Shortness of Breath

Swollen Legs/Ankles

Provide additional information about your abnormal blood lipids(Required)

Provide additional information about your arthritis(Required)

Provide additional information about your back pain(Required)

Provide additional information about your chest pain(Required)

Provide additional information about your cough on exertion(Required)

Provide additional information about your coughing up blood(Required)

Provide additional information about your fainting(Required)

Provide additional information about your frequent or severe headaches(Required)

Provide additional information about your lightheadedness(Required)

Provide additional information about your orthopedic problems(Required)

Provide additional information about your rapid heart beats or palpitations(Required)

Provide additional information about your shortness of breath(Required)

Provide additional information about your swollen legs and/or ankles(Required)

Have you ever had?

Please check any of the following you have experienced.

Abnormal Heart Rhythm

Asthma

Artery Disease

Chest Discomfort

Diabetes

Epilepsy

Gout

Heart Trouble

Heart Attack

High Blood Pressure

Hospitalization

Immune Disorders (such as allergies or lupus)

Lung Disease

Osteoporosis

Rheumatic Fever

Stroke

Surgical Operations

Valve Disease (Stenosis or Regurgitation)

Varicose Veins

Provide additional information about your abnormal heart rhythm(Required)

Provide additional information about your asthma(Required)

Provide additional information about your artery disease(Required)

Provide additional information about your chest discomfort(Required)

Provide additional information about your diabetes(Required)

Provide additional information about your epilepsy(Required)

Provide additional information about your gout(Required)

Provide additional information about your heart issues(Required)

Provide additional information about your heart attack(s)(Required)

Provide additional information about your high blood pressure(Required)

Provide additional information about your hospitalization(s)(Required)

Please be sure to indicate why and when.

Provide additional information about your immune disorder(s)(Required)

Provide additional information about your lung disease(Required)

Provide additional information about your osteoporosis(Required)

Provide additional information about your rheumatic fever(Required)

Provide additional information about your stroke(Required)

Provide additional information about your operation(s)(Required)

Please include the kind of surgery and when.

Provide additional information about your valve disease(Required)

Provide additional information about your varicose veins(Required)

Joint Injury

Do you currently or have you ever had an injury (that required a visit to a physician) or surgery to any of the following joints? If so, check all that apply below.

Ankle

Back

Elbow

Hand

Hip

Knee

Muscle Injuries or Tendonitis

Neck

Shoulder

Wrist

Provide additional information about your ankle injury(Required)

Provide additional information about your back injury(Required)

Provide additional information about your elbow injury(Required)

Provide additional information about your hand injury(Required)

Provide additional information about your hip injury(Required)

Provide additional information about your knee injury(Required)

Provide additional information about your muscle injury or tendonitis(Required)

Provide additional information about your neck injury(Required)

Provide additional information about your shoulder injury(Required)

Provide additional information about your wrist injury(Required)

Limited Range of Motion(Required)

Do you have any condition or past injuries that limit the range of motion of your muscles or joints, spinal column or any other part of your body which may be aggravated by exercise?

Yes

Provide additional details about your limited range of motion(Required)

Broken Bones(Required)

Have you ever broken a bone?

Yes

Provide additional details about your broken bone(s)(Required)

Vehicle Accident, Fall, or Lifting Injuries(Required)

Were you ever injured as a result of a vehicle accident, a fall, or lifting an object (that required a visit to a physician)?

Yes

Provide additional details about your injuries(Required)

Head Injury(Required)

Have you ever suffered a head injury?

Yes

Provide additional details about your head injuries(Required)

Current Smoker?(Required)

Do you currently smoke?

Yes

Former Smoker?(Required)

Did you previously smoke?

Yes

When did you quit?(Required)

Please provide an estimate for when you quit smoking.

Smoking Duration(Required)

For how many years did you smoke previously?

How many?(Required)

How many cigarettes did you smoke per day?

When did you start?(Required)

Please provide an estimate for when you started smoking.

How many?(Required)

How many cigarettes do you smoke per day?

How often?(Required)

How often do you smoke?

Breathing Discomfort During Activity(Required)

Do you have any pain, discomfort, or shortness of breath with activity?

Yes

Provide explain what you feel during activity(Required)

Caffeine(Required)

Do you drink coffee and/or other caffeinated beverages?

Yes

How much?(Required)

How Often?(Required)

Alcohol(Required)

Do you drink alcoholic beverages?

Yes

How many drinks?(Required)

How many drinks do you consume per week?

Type of beverage?(Required)

Please specify your preferred type of alcoholic beverage (wine, beer, spirits).

Family Health History

Family members ever had?

Please check any of the following symptoms or health-related procedures that your blood-relatives (i.e. parents, siblings, grandparents) have experienced.

Anemia

Asthma

Cancer

Degenerative Bone or Joint Disease

Diabetes

Heart Attack

Heart Disease

Heart Surgical Operations

High Blood Pressure

High Cholesterol

Stroke

Sudden Death

Thyroid Disorder

Who in your family experienced anemia?(Required)