Exercise Stress Test Consent Form
Exercise Stress Test Consent Form
Exercise Stress Test Consent Form
PROCEDURE
Your doctor has referred you for an exercise stress test. The exercise stress test will evaluate your heart and
vascular systems response to exercise. It will help diagnose blocked arteries in the heart (coronary artery
disease), assess abnormal heart beats, and check pacemaker function.
You will be connected to an electrocardiograph (ECG), which records your heart beat, and a blood pressure
monitor. Your heart will be exercised or stressed by walking on a treadmill. The speed and slope of the
treadmill will increase every three minutes. Exercise intensity may be high. The test will be stopped if you
have significant chest pain, become very tired or very short of breath.
Your heart rate, electrocardiogram and blood pressure will be monitored during and after the test. If you feel
unwell or experience any symptoms you should tell the doctor or technician immediately.
Please note that this test is not 100% accurate and a negative result does not guarantee you do not have
heart disease.
CONSENT
I, (print name) _____________________ (date of birth), have
read and fully understood the above information regarding the test procedure and associated risks. I hereby
consent to undergoing the procedure of an exercise stress test to be performed at the Gold Coast Heart
Centre.
I also consent to such further treatment measures as may be deemed necessary during the course of the
procedure.
STC1 10.11.10