NOTE: This is information only, the PDF version is what you want to print out, sign, and bring with you.
Georgia state law guarantees that you have both the obligation and the right to make decisions concerning your health care. Your Provider can provide you with necessary information, but as you are aware, as a member of the health care team, you must enter into the decision making process. This form has been designed to acknowledge your acceptance of treatment recommended by your Provider.
EXPLANATION OF THE EXERCISE STRESS TEST: You will perform a graded exercise stress test on a treadmill. The work levels will be advanced in stages in order to increase your heart rate, until a medically recognized end-point is reached. During the performance of the test, your heart rate, blood pressure, and electro cardiogram will be monitored continually though out the test.
PURPOSE OF THE EXERCISE STRESS TEST: By creating an environment where exercise may be observed, increasing stress on the heart can reveal coronary problems that may not be apparent when the body is at rest. While not perfect, the stress test is the best initial practical coronary test.
RISKS: There exists the possibility of complications occurring during the exercise testing, which could include abnormal blood pressure, disturbance in the heart rhythm, and in rare instances heart attack or even death or injury from falling off the treadmill. Medications, additional medical procedures or hospitalization may be required. To minimize these complications your electrocardiogram and overall response to exercise will be closely monitored. It is important for you to communicate if you experience pain or difficulty or feel unwell during the test.
BENEFITS: The results obtained from the exercise test should assist your provider in the diagnosis of symptoms, or in the evaluation of what types of activities you might carry out with minimal risk.
INQUIRIES: Any questions about the procedure used in the exercise stress test are welcome and encouraged. If you have doubts or questions, please ask for further explanation.
FREEDOM OF CONSENT: Your participation in this exercise is voluntary - you are free to deny consent if you desire.
PREPARATION FOR THE EXERCISE STRESS TEST: Avoid eating, drinking, or smoking three hours before the test. Wear loose, comfortable clothing suitable for exercise, including comfortable walking shoes. This test should last approximately 30 minutes.
By singing the consent form, you will be implying that you understand the purpose, risks and benefits of the exercise stress test, and that you also understand the alternatives, including not having the test, and the consequences of those alternatives. You will be consenting to participate freely to this test. If at any time during the test you have discomfort or pain, you understand that it is your responsibility to inform the testing technician in charge immediately and I will do so.