ATS Pulmonary Function Laboratory Manual

chapter  19

Appendix 19.2  Example of Informed Consent for Exercise Testing

To determine your cardiopulmonary response to exercise, you are being asked to voluntarily agree to engage in an exercise test. The information obtained will be used to help your doctor understand more about any problems related to your heart or lungs. The test will measure your tolerance of exercise until fatigue, breathlessness, chest discomfort, other symptoms occur, or a specific period time expires, which will stop the test. The test, including the electrocardiogram (ECG) and blood pressure will be monitored by a physician and precautions for your safety will be observed. Risks of the testing procedure are minimal and complications from the test are rare, but they do include the following: fainting, falling, irregularities of heart beat, and, very rarely, heart attack or death (less than 1 in 10,000 cases). Physical injury can occur because of the unfamiliarity with the equipment on the part of the patient. Every effort will be made to explain the nature of the exercise equipment prior to starting the test. Professional staff will be present and necessary equipment available for emergency treatment if any problems should arise. I have read and fully understand the above and voluntarily consent toperformthis exercise test at the ___________ hospital. Patient signature: _______________________  Date: Witness: Physician supervising the test:

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