Consent Form for Tredmill Excercise Testing
Exercise testing measures the performance and capacity of the heart, lungs and blood vessels. In many cases, the test is carried out to assist in making a diagnosis of coronary artery disease. Other uses of the test include evaluating a patient’s capacity to undertake certain physical activities, the planning of an appropriate training program, assessment of prognosis in patients with heart disease and the effect of medical treatment, angioplasty or surgery on symptoms. Before being tested you will be questioned and examined by a doctor and a resting electrocardiogram will be recorded prior to performing exercise.
The testing consists of walking on a treadmill and the speed and gradient of the treadmill will be increased every three minutes. The test is eventually stopped if and when you develop symptoms such as fatigue, breathlessness, tired legs, chest pain or other symptoms. Throughout the test a doctor will be present and your pulse, blood pressure and electrocardiogram will be monitored. If there is any change in any of these observations, which concerns the doctor, he or she may stop the test immediately. Your pulse, blood pressure and electrocardiogram will continue to be monitored for sometime after the test has been stopped. If at any time during the test you are feeling unwell in any way, report the symptom immediately.
Clinical exercise stress testing is usually performed in patients with known or suspected coronary artery disease. While every effort is made to minimize the risks of the procedure, there is a small but definite risk of complications which you should be aware of. Please also be aware that emergency equipment and trained personnel are available to deal with any complications that may arise. Serious potential complications include the possibility of a major disturbance of heart rhythm requiring resuscitation, the development of heart failure or prolonged angina (heart pain) or the development of a heart attack. The risk of one of these occurring is approximately 2 or 3 in 10,000 tests. Unfortunately, there is also a very small risk of death occurring as a result of an exercise test. The chance of this in the average patient is approximately 1 in 10,000 although the risks of both complications and of death may be higher in patients who are already known to have severe coronary disease. The doctor performing the test is well aware of these risks and will have taken them into account before deciding to recommend the study. Please feel free to discuss these issues prior to agreeing to undergo the exercise stress test.
Before proceeding with the test we need your signed consent. Before signing the consent form, please feel free to ask any questions you have about exercise stress testing and about any risks.
I have read this form and had the opportunity to ask questions. I understand the test and I have been made aware of the risks involved. I consent to participate in this stress test.