ATS Pulmonary Function Laboratory Manual

chapter  14

Appendix 14.1  Example of Informed Consent for Exercise Challenge Test

To determine the nature and severity of your pulmonary disease, you are being asked to voluntarily agree to engage in an exercise test. The test will be conducted on an appropriate exercise device (e.g., treadmill). You will be asked to wear a nose clip and we will monitor your heart, blood pressure, and oxygen saturation. The exercise intensity will be increased until you are at about 80% of your maximum and we will ask you to continue to exercise for about 10 minutes. We will have you blow into a spirometer to measure your lung function before and several times after the exercise period. The information obtained will be used to help your doctor understand more about the effect of exercise on your breathing. The test including the electrocardiogram (ECG) and blood pressure will be monitored by a trained pro- fessional and precautions for your safety will be observed. Risks of the testing procedure are modest and complications from the test are rare. But they do include the fol- lowing: fainting, falling, irregularities of heartbeat, wheezing and shortness of breath, 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 to perform this exercise test at the ________ ___________________________________________________________________ hospital/clinic. Patient Name (Print) _______________________________________________________________________ Patient or legal guardian signature ____________________________________________________________ Date ____________________________________________________________________________________ Witness __________________________________________________________________________________ Physician supervising the test _________________________________________________________________

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