Gov. W.

Pascual Avenue, Brgy Catmon, Malabon City

CONSENT FORM FOR TREADMILL STRESS TESTING

I, ___________________________________, __ years old authorize Dr. _____________
and such for work assistants as she/he may designate to administer and conduct exercise test.
This is to measure my fitness for work and/or to evaluate the effectiveness of my current
therapy.

I understand that I will walk, jog and run on a motor driven treadmill. During the
performance of my physical activity, my electrocardiogram will be monitored and my blood
pressure will be measured and recorded until I attain a predetermined end point corresponding
to moderate exercise stress, or become distressed in any way of the above occurs first.

Every effort will be made to conduct the test in such a way as to minimize discomfort
and risk. However, I understand that just as with other types of diagnostics tests, there are
potential risks (approximately 2-3 per 10,000) associated with exercise test. I further
understand that the laboratory is properly equipped for such situations and that the
professional personnel are trained to administer any emergency care necessary. I voluntary
accept the risk associated with the above procedure.

PAHINTULOT
Ako si ___________________________, edad ____ ay nagbibigay pahintulot kay
Dr. __________ at sa kanyang mga assistant na kaniyang inatasan magbigay ng exercise stress
test. Itong test ay gagawin upang masukat ang aking kakayahang magtrabaho at upang makita
kung gaano ka-epektibo ang kasalukuyan kong panggagamot.

Naiintindihan ko na ako ay lalakad at tatakbo sa isang treadmill na pinapatakbo ng isang

motor. Habang ako ay nageehersisyo ang aking electrocardiogram end point na katapat ng
isang katamtamang pag-ehersisyo o kaya ako man ay mahirapan o magpakita ng abnormal na
kilos na maaring ikabahala ng doktor.

Sa abot ng makakaya, gagawin ang test sa paraang mabawasan ang hindi ninanais na
pakiramdam at posibleng delikadong mangyari. Datapwat, naiintindihan ko na gaya ng ibang
diagnostic test, may mga posibleng delikadong mangyari rin na kasama sa “exercise test”.
Naiintindihan ko rin na ang laboratory ay may kakayahan sa ganuong mga pangyayari at ang
mga propesyonal na tauhan ay sinasanay sa “emergency care” kung ito ay kailanganin.
Tinatanggap ko ang posibleng delikadong mangyari na kasama sa “procedure” na ito.

PETSA: ______________

LAGDA: _____________

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