AUTHORIZATION FOR AND CONSENT TO EXERCISE STRESS TEST
AUTHORIZATION FOR AND CONSENT TO
EXERCISE STRESS TEST
INFORMATION STATEMENT AND INFORMED CONSENT
| Your physicians have determined that an exercise
stress test may be beneficial in the diagnosis and evaluation of your medical
condition. Stress testing is designed to evaluate the functional perforrnance
of your heart, lungs and blood vessels, especially the coronary arteries.
Before the stress test, you will be screened by a physician experienced
in stress testing and a resting electrocardiogram will be recorded. You
will then be asked to walk on a treadmill (or pedal a bicycle or exercise
on some other device) with gradual increases in exertion until the amounts
of fatigue, breathlessness, chest pain and/or other symptoms are such that
you feel you should stop. If you feel you should stop the test, notify
the medical personnel administering the test so that the test can be terminated.
Your blood pressure and electrocardiogram will be monitored during the test. In some instances blood may be drawn for testing. RISKS of stress testing include occasional changes in the rhythm of the heart beats and the possibility of excessive changes in blood pressure. There is a remote chance of fainting and an even more remote chance of a heart attack (about 1 in 10,000). BENEFITS of testing include semi-quantitative assessment of work capacity and appraisal of cardiac disorders that may contribute to impaired capacity. The knowledge gained from the stress test facilitates better diagnosis of your medical condition and makes possible more accurate treatment and prognosis. CONSENT Your signature on the line provided below indicates: (1) you have read, understood and agreed to all of the above statements; (2) you have had an opportunity to ask questions about the stress test, the test has been adequately explained to you, and you have sufficient information regarding the test, its risks and benefits; and (3) your consent to take the stress test is given voluntarily as you have the right not to take the test if you so choose. 1 hereby consent to the performance of the stress test on me under the supervision of:
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