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)
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You have been booked to have an