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Consent Form for Exercise Treadmill Testing
I authorize Edward J. Lind M.D. to perform an exercise treadmill test (stress test). Possibility of other procedures
As a result of having this test, I understand there is a possibility I may need other urgent procedures that were
unanticipated. I consent to the performance of any additional procedures determined to be in my best interest
and where delay might cause additional harm. Other medical personnel
I understand that other qualified practitioners may be chosen to help with this procedure. I understand that
physicians in training (residents), medical students, nurses and medical assistants may assist with or perform
portions of the test under the direct supervision of the doctor.
Purpose of the test
I understand the purpose of this test to be:
□ To rule out coronary artery disease as the cause of symptoms I am having.
□ To screen for the presence of silent coronary artery disease due to my risk factors.
□ Other:_____________________________________________________________ Risks of having the test
I understand that the risk of serious complication is very rare. However, there are risks involved with the test,
however rare, including: Musculoskeletal trauma, fatigue, dizziness or fainting, chest discomfort or heart
pounding, shortness of breath, slow or rapid heart rhythms, abnormal heart rhythms, low or high blood pressure,
congestive heart failure, stroke, heart attack, shock, cardiac arrest and death. The risk of serious complication is
estimated as 2 or 3 cases every 10,000 tests performed. Alternative tests
I understand that the alternative to having this test is to have NO TEST. There are more invasive tests. There are
more sophisticated tests. They are not used routinely as screening tests.
By signing below I state that I am at least 18 years of age. I have read or have had explained to me the contents
of this form and I agree to receive the care, treatment or service as listed on or implied by this consent. I have
been given a chance to ask questions, and all of my questions have been answered.
Patient's printed name Patient's signature Date:________/_______/_______ ________________________________________ Witness signature
Exercise Treadmill Test Preparation
An exercise treadmill test is performed to help diagnose heart disease, monitor blood pressure response to exercise and
determine your exercise tolerance. WHAT TO EXPECT
• You will be asked to sign a consent form giving permission for the test.
• The skin on your chest where the electrodes will be placed will first be
prepared with abrasive lotion. Male patients: your chest will be partially shaved.
This is done to ensure the electrodes make good contact, so we can accurately
monitor your heart’s rhythm.
• You will then walk on the treadmill. The physician will watch the monitor for
any changes that may indicate heart disease or rhythm problems.
• Your blood pressure will be checked frequently during the test.
• The test will take approximately 30 minutes. Risks
Stress tests are generally safe. Some patients may have chest pain or may faint or collapse. A heart attack or dangerous irregular rhythm is rare.
Persons who are likely to have such complications are usually already known to have a weak heart, so they are
not given this test. WHAT YOU NEED TO DO TO PREPARE FOR THE TEST
If you’re scheduled for an Exercise Treadmill Test, follow these guidelines: Diet
• Nothing to eat four hours prior to the procedure.
• No caffeine products the morning of the procedure. Please understand that this means no coffee, colas, diet colas, energy
No nicotine the morning of the test; chewing tobacco, smoking, nicotine gum, inhaler or patch.
• Take your prescribed medications unless directed not to do so by our office.
Bring a list of medications with you.
• If you are on a Beta Blocker (you will find a list of beta-blockers below) do not take them the night before or the day of
• If you are diabetic and taking insulin, please get specific instructions. In general when fasting, you will be asked to take
your normal dose of Levemir or Lantus, but do not take
your Humalog, Novolog, or Apidra. Please bring a snack with
you to have after the test ( i.e. cheese and crackers, or your favorite).
. If you are unsure of the directions given to you, please call our office. Clothing
• Wear shorts, comfortable slacks or sweatpants.
• Please do not wear pantyhose.
• Wear tennis shoes or comfortable walking shoes. Smoking
Again, no smoking the morning of the procedure.
Questions about your Exercise Treadmill Test? Call 316-689-0776.
Fossil Rim Wildlife Center Ph: 254-897-2960, Fax Number: 254-898-4091 PLEASE FILL OUT A FORM FOR EACH CHILD. CHILD INFORMATION LAST NAME___________________FIRST NAME_________________ AGE ____ DOB _______M/F___ PARENT INFORMATION LAST NAME _____________________________ FIRST NAME ______________________________ Relationship to Child _______________________ Primary Contact Num
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