New Client Form

Thank you for booking your service with Project Blue! If you are new, below is a form to help us get to know you! If you are a returning customer, please fill out the form and update anything that has changed. For the safety of all our clients, please take a few minutes to complete the form prior to your appointment. This will help us better tailor our services to your needs.

First name

Last name

Multi-line address

Country/Region

Address

City

Zip / Postal code

Birthday

Month

Day

Year

Phone

Emergency Contact (Name, Relationship, Phone, Email)

Athletic History (Sport, Years Involved, Frequency)

Current FTP (cyclists) / FTPa (runners)

Max Power/Pace for 30 Seconds

Cyclists, please input the details about your bike setup so we can prepare the Wahoo Bike Pro to match your specifications.

Type of Clipless Pedals

Saddle Height - vertical distance from center of bottom bracket to top of seat (cm or inches, please specify)

Saddle Setback - horizontal distance from center of bottom bracket to saddle reference point (cm or inches, please specify)

Handlebar Height/Stack - vertical distance from center of bottom bracket to center of handlebar (cm or inches, please specify)

Handlebar Distance/Reach - horizontal distance from center of bottom bracket to center of handlebars (cm or inches, please specify)

Crank Arm Length (mm)

The following information is related to your current and past health. Please complete as accurately as possible. If a required section does not apply to you, please mark as "NA."

Allergies

Alcohol Use (amount & frequency)

Tobacco History (amount & frequency)

Illicit Drug Use (name, amount, frequency)

Current Vitamins / Supplements (name, amount, frequency)

Current Medications (name, amount, frequency)

Psychological History

Anxiety

Depression

Claustrophobia

Neurological History

History of Stoke

History of Seizures

Any numbness or tingling in the body

Chronic Headaches

Metabolic History

Diabetes

High Cholesterol

Thyroid Disorder

Obesity

History of Hospitalizations (provide why & year)

Surgical History (provide type of surgery & year)

VO2 Max, Lactate, and Sweat Testing Informed Consent

Purpose: I agree to strenuous activity for physiological testing which can include wearing a tight fitting mask and/or blood lactate tested using a finger-prick or ear-prick method to provide information about my metabolic response during exercise.

Risks: For lactate testing, I understand that blood lactate testing involves a small finger-prick or ear-prick, which may cause minor discomfort, brief pain, slight bleeding, bruising, skin irritation, or infection at the site. There is a small risk of allergic reaction to any adhesives, gauze, or bandages uses on your skin. These risks are generally mild and temporary. For VO2 Max or Resting Metabolic Rate testing I agree to wear a tight fitting mask while exercising or while at rest which may cause temporary discomfort.

Benefits: The primary benefit is obtaining personalized data about my physiologic response during exercise, which may help inform training, nutrition, and recovery strategies.

Confidentiality: I consent to my test data being kept confidential in accordance with applicable privacy laws. Results will only be shared with me and Project Blue staff for the purpose of providing the service. Results may be shared with other persons if written notice is given.

No Diagnosis or Medical Advice: I acknowledge that VO2 Max, lactate, and sweat testing are screening tools and not diagnostic medical tests. Project Blue staff are not interpreting results as a medical diagnosis. I understand that the test is for informational purposes only and does not replace a formal medical evaluations.

Follow-up Responsibility: I agree that if I have any concerns about my results or health, I will follow up with Project Blue staff and/or consult my own medical professional for further assessment or care.

Emergency Protocols: I understand that in the rare event of critical values or critical events during testing, I may require immediate medical attention. In such cases, emergency devices (such as automated external defibrillator) or emergency services (such as an ambulance) will be used in life saving situations. Any associated costs will be my responsibility or covered by my personal insurance.

I give Project Blue permission to perform VO2 Max testing, lactate testing, and/or sweat analysis testing based on the above informed consent.

Our notice of Privacy Practices provides information about how we may use or disclose protected health information. This can be seen on our website (https://www.projectblue-optimization.com)

The notice contains a patient’s rights section describing your rights under the law. You ascertain that by your signature that you have reviewed our notice before signing this consent. The term of the notice may change, if so, you will be notified at your next visit to update your signature/date.

You have the right to restrict how your protected health information is used and disclosed for treatment, payment or healthcare operations. We are not required to agree with this restriction, but if we do, we shall honor this agreement. The HIPAA (Health Insurance Portability and Accountability Act of 1996) law allows for the use of the information for treatment, payment or healthcare operations.

By signing this form, you consent to our use and disclosure of your protected healthcare information and potentially anonymous usage in a publication. You have the right to revoke this consent in writing, signed by you. However, such a revocation will not be retroactive.

By signing this form, please check to verify consent of:

Protected health information may be disclosed or used for treatment, payment, or healthcare operations.

The practice reserves the right to change the privacy as allowed by law.

The practice has the right to restrict the use of the information but the practice does not have to agree to those restrictions.

The patient has the right to revoke this consent in writing at any time and all full disclosures will then cease.

The practice may condition receipt of treatment upon execution of this consent.

I consent to the use of photography & video taken of me during my time at Project Blue. Photography and video may be used for social media, marketing, and printed material of Project Blue and I understand there will be no financial compensation and no time limits associated with when the images or video can be used.

By signing below, I confirm that I have read, understood, and completed this form to the best of my ability. I agree that I am testing on a voluntary means and can stop at any time. If any information is missing or additional information is needed I will notify Project Blue and/or one of it’s providers.

If you have any questions or concerns prior to signing this form please contact Project Blue for further explanation.

Signature

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Date

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