Heart of Australia Pty Ltd
Level 1, 109 Honour Avenue, Chelmer QLD 4068
P:
07 3162 5310 F: 07 3077 7153
E: reception@heartofaustralia.com
W: www.heartofaustralia.com.au


Exercise Stress Test - Patient Consent Form

Explanation of the tests

You will perform a graded exercise stress test. The work levels will be advanced in stages in order to increase your heart rate until a medically recognised end-point is reached. During the performance of the test, your heart, blood pressure, and electrocardiogram will be under surveillance by the physician, who will be present throughout the test.

Risks and discomforts

There exists the possibility of complications occurring during the exercise test that could include abnormal blood pressure, a disturbance in the heart beat, and in very rare instances, a heart attack. To minimize these conditions, your electrocardiogram and overall response to the exercise will be closely monitored.

Benefits to be expected

The results obtained from the exercise test should assist your physician in the diagnosis of your illness or in evaluation of what types of activities you might carry out with minimal risk.

Inquiries

Any questions about the procedures used in the exercise stress test are welcome. If you have any doubts or questions, please ask us for further explanations.

Freedom of consent

Your participation in this exercise test is voluntary. You are free to deny consent if you so desire. I understand the test procedures that I will perform and I consent to participate in this test. I do hereby give my consent the Doctor to administer the treatment and test referred to above. If at any time during the test I have discomfort or pain, I will tell the testing physician or technologist in charge.


Draw signature|Type signatureClear
Draw signature|Type signatureClear