Northwest Primary Care, Inc
Clyde, Ohio 43410
INFORMED CONSENT FOR A HEALTH RELATED EXERCISE TEST
Date:_______________________
Explanation of the Exercise Test. You will perform an exercise test on a motor-driven treadmill. The exercise intensity will begin at a level you can easily accomplish and will be advanced in stages depending on your fitness level. We may stop the test at any time because of personal feelings of fatigue of discomfort.
Risks and Discomforts. There exists the possibility of certain changes occurring during the test.. They include abnormal blood pressure, fainting, disorders of heart beat, and in rare instances , heart attack, stroke, or death. Every effort will be made to minimize these risks by evaluation of preliminary information relating to your health and fitness and by observation during testing. Emergency equipment and trained personnel are available to deal with unusual situations that may arise.
Responsibilies of the Participant. Information you possess about your health status or previous experiences of unusual feelings with physical effort may affect the safety and value of your exercise test. Your prompt reporting of feelings with effort during the exercise test itself are also of great importance. You are responsible to fully disclose such information when requested by the testing staff.
Benefits to be expected.The results obtained from the exercise test may assist in the diagnosis of your illness or in evaluation of what type of physical activities you might do with low risk of harm.
Inquiries. Any questions about the procedures used in the exercise test or in the estimation of functional capacity ar encouraged. If you have any doubts or questions, please ask us for further explanations .
Freedom of Consent.Your permission to perform this exercise test is voluntary. You are free to deny consent or stop the test at any point, if you so desire.
Recognizing that complications can occure and that unforseen conditions may be encountered, I further authorize and consent to such additional services as may be deemed reasonable or appropriate.
It is understood by me that the practice of medicine and surgery is not an exact science and I acknowledge that no guarantees have been made to me as to the results of this testing or other medical procedures.
I have read and understand this consent form before signing it.
Signed in my presence on:
_____________ at _____________ _____________________________________________
Date Time Patient or legal guardian signature
_______________________________ _____________________________________________
Witness Relationship or status of legal representative
_______________________________
Signature of Physician.