Stress Test Appointment GetWell Health System Name* First NameLast Name Phone Number* example@example.com Email* example@example.com Gender* MaleFemaleOther Date of Birth* -Month -DayYearDate Address* Street Address Street Address Line 2 CityState / Province Postal / Zip Code Emergency Contact Number* Please enter a valid phone number. Relationship* First NameLast Name Back Next Medical History Primary Care Physician Cardiologist (if any): Do you have any of the following? Chest painShortness of breathPalpitationsDizziness or faintingHigh blood pressureDiabetesHigh cholesterolPrevious heart attackHeart surgery or stentsStrokeThyroid issuesLung conditionsKidney diseaseOther List any current medications: Any allergies? YesNo Lifestyle Information Do you smoke? YesNo Do you drink alcohol? YesNo Exercise Level: RarelyModerateRegular Reason for Stress Test Chest discomfortShortness of breathIrregular heartbeatFatiguePre-surgical evaluationDoctor’s recommendation Pre-Test Checklist (Patient to Confirm) I have avoided caffeine for 24 hoursI have not eaten a heavy meal in the last 3 hoursI am wearing comfortable shoes and clothingI took my medications as advisedI informed the technician of any recent symptoms Submit Should be Empty:
