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Microsoft word - exercise stress echo consent form - treadmill.doc

You have been booked to have an
EXERCISE STRESS ECHO (Treadmill)
at Hearts West
Purpose of the test
Exercise stress echocardiography (ESE) is used to measure how your heart
responds to stress, under medically supervised conditions. The test gives us very
important information, which we perform ESE if you have suspected coronary
artery disease, or if we know you have coronary artery disease but we need more
information.
The test itself
An echocardiogram is ultrasound of the heart. Images of the heart will be taken at
rest, along with an ECG recording. Continuous ECG recordings will be made until
the end of the test. You will then begin to walk on a treadmill at a speed and tilt set
by the computer. It starts slowly, and throughout the test we will monitor your ECG,
pulse rate and blood pressure. The treadmill will increase in speed and tilt every
three minutes. The test will finish if you reach the limit of your exercise capacity or
earlier if decided by the doctor. It is important that you let the doctor know if you
develop chest pain or other symptoms. As soon as exercise finishes, you will be
asked to lie down on the bed as quickly as possible, and ultrasound images of your
heart will be taken immediately while your heart is at peak heart rate. Further
images and ECG tracings will be recorded as your heart returns to its resting state.
The equipment used is the latest state-of-the-art echocardiography equipment. We
are committed to performing the highest quality service possible.
Risks associated with the test
The risks of exercise ECG testing are approximately the same as sudden
unaccustomed exercise. We carefully control the amount of exercise, and take into
account any medical problems you may have. Despite this, there is the small risk
you may develop heart rhythm abnormalities, and an even smaller risk you may
have a heart attack precipitated by the exercise. We are equipped with all
necessary resuscitation facilities, and all staff involved are trained to deal with any
complications that may arise.
Consent to the test
By signing below you are consenting to undergo exercise ECG testing, and
understand the purpose of the test, the test itself, and any risks associated with the
test.
Signature

If you have any questions regarding the test, or would like more information please
call our office on 9391 1234

FEE PAYABLE ON DAY OF TESTING:

(Medicare
$339.20)
BETA BLOCKERS ARE TO BE CEASED
PRIOR TO STRESS TESTING

AM APPOINTMENT –
last dose 2 days prior
PM APPOINTMENT - last dose am day prior
ANSELOL (atenolol)
ATEHEXAL (atenolol)
BARBLOC (pindolol)
BETALOC (metoprolol)
BICOR (bisoprolol fumarate)
CARDOL (sotalol hydrochloride)
CORBETON (oxprenolol)
DERALIN (propanolol)
DILATREND (carvedilol)
GENRX ATENOLOL (atenolol)
GENRX METOPROLOL (metoprolol)
INDERAL (propanolol)
LOPRESOR (metoprolol)
METOHEXAL (metoprolol)
METOPROLOL-BC (metoprolol)
METROL (metoprolol)
MINAX (metoprolol)
NOTEN (atenolol)
SOTAHEXAL (hexal)
TENORMIN (atenolol)
TENSIG (atenolol)
TOPROL (metoprolol)
VISKEN (pindolol)

Source: http://www.playford.biz/pdfs/Exercise%20stress%20Echo%20consent%20form%20-%20Treadmill.pdf

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