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Treadmill Consent

The document provides consent for a treadmill exercise test. It outlines that the test will involve gradually increasing exertion on a treadmill to assess heart health and determine an appropriate treatment plan and activity level. Risks of the test like abnormal blood pressure, fainting, heart rhythm issues, and rare instances of heart attack or stroke are acknowledged. Emergency equipment will be on hand and the doctors are authorized to treat any unforeseen conditions. Patient information will be kept confidential.

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Ron Buchheit
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626 views1 page

Treadmill Consent

The document provides consent for a treadmill exercise test. It outlines that the test will involve gradually increasing exertion on a treadmill to assess heart health and determine an appropriate treatment plan and activity level. Risks of the test like abnormal blood pressure, fainting, heart rhythm issues, and rare instances of heart attack or stroke are acknowledged. Emergency equipment will be on hand and the doctors are authorized to treat any unforeseen conditions. Patient information will be kept confidential.

Uploaded by

Ron Buchheit
Copyright
© Attribution Non-Commercial (BY-NC)
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as DOC, PDF, TXT or read online on Scribd
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_____________________________________________________________________________________

CONSENT FOR TREADMILL EXERCISE TEST

I authorize and consent for A. Amiry, M.D., M. Fortsas, M.D., R. Sharma, M.D., J.
Pinto, M.D., or J. Robbins M.D. to perform a procedure known as a stress test or stress
echocardiogram. I have been informed to my satisfaction that this test is being performed
to assist in determining the cause of my discomfort, the state of my heart and circulation
and to assist my doctor in forming an appropriate plan for treatment and my activity
level.

The test, which I will undergo, will be performed on a treadmill with the amount of effort
increasing gradually. This increase in effort will continue until symptoms such as fatigue,
shortness of breath or chest discomfort may appear which would indicate me to stop.

During the performance of the test my blood pressure, pulse and electrocardiogram will
be monitored. I recognize that during the test the possibility if certain changes exist.
They include abnormal blood pressure, fainting, disorders of heart beat (increase heart
beat, decrease heart beat or ineffective) and very rare instances of a heart or stoke.

Every effort will be made to minimize them by the preliminary examination and by
observation during the test. Emergency equipment is available to deal with unusual
situations which may arise.

I therefore authorize the doctor to treat my unforeseen condition which may arise. I
know that I may terminate the procedure at any time for any reason.

The information which is obtained will be treated as privileged and confidential and will
not be released or revealed to any person without my written consent. I have read the
foregoing and I understand it. In addition, any questions have been answered to my
satisfaction.

PATIENT ___________________________________________ DATE ____/____/____

WITNESS ___________________________________________DATE ____/____/____

Revised 07/2008

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