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ONLINE FORMS
Informed Consent for Exercise Nuclear Stress Testing
After completing this form, please print, sign and bring it with you to your
appointment.
Click Here to download the PDF.
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Your physician has ordered an exercise stress test with nuclear imaging. An exercise stress ordinarily consists of walking and/or jogging on a motorized treadmill until your heart rate reaches a point sufficiently rapid for proper diagnosis and evaluation of your heart and circulation. By using nuclear imaging with exercise the presence of coronary artery disease can be more accurately assessed.
An intravenous line will be inserted into your arm. An initial scan will be performed. You will be attached to a cardiac monitor and an ECG will be taken. During and after the performance of physical exercise, your ECG will be monitored and blood pressure measured and recorded. You will be encouraged to report any symptoms you develop, including chest pain, shortness of breath, dizziness, or weakness which might indicate a need to stop the test. A repeat scan will then be performed.
The testing will include performing a radioactive isotope scan in conjunction with the stress test. A small amount of the isotope will be injected into an arm vein at the appropriate time. The heart will then be scanned using a special camera. The amount of radioactive isotope injected is small and according to current scientific knowledge, free of hazard, except during pregnancy. You understand that if you are or may be pregnant or are breast feeding, you should not undergo this test procedure because of possible adverse effects to the fetus or baby.
Exercise testing has been associated with the following risks: fatigue, shortness of breath, lightheadedness, fainting, chest discomfort, leg cramps and irregular heartbeats (too slow or too rapid). Like any stress test, there is also a small risk of heart attack, cardiac arrest or death; the laboratory personnel are trained to administer any emergency care necessary.
Participant’s Statement
I have read this consent form, discussed the procedure and I have been given the opportunity to ask questions, which have been answered to my satisfaction.
I have been fully informed of the above described procedure with its risks and benefits, and I hereby consent to the procedure set forth.
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DATE:
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PHYSICIAN OR PHYSICIAN ASSISTANT |
Female Patients
I hereby attest that I am not
pregnant or currently breast feeding
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DATE:
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WITNESS: |
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PHYSICIAN OR PHYSICIAN
ASSISTANT |
Pioneer Valley Cardiology
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Pioneer Valley Cardiology
299 Carew Street
Suite 310
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