*Filled by officers

No Reg :
Height :

Weight :

Have you ever been or are suffering from any of the following circumstances :
No.
1.
2.
3.
4.
5.
6.
7.
8.
9.
10.

Choice
Yes
No

Question

Heart attack / chest pain / palpitations in the last 6 months.

Currently in treatment /control with a cardiologist.
A history of cardiac arrest or a history of heart rhythm
disorders.
Had a congenital heart disorder or a family history of heart
disease.
A disturbance in the lower limbs that block to run for more
than 6 minutes.
A history of blood pressure / blood pressure exceeds
180/110 mmHg.
The existence of a positive history of previous ischemic
Treadmill.
Severe renal disease (advanced stage of kidney
dysfunction).
Diabetic.
Smoking.
*Select one by giving a check ( )

INFORMED CONSENT
I, the undersigned
Name
Date of birth
Position
Company

:
:
:
:

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States are willing to follow the treadmill test, and have filled the data in the right
earnest. It is also willing to perform treadmill directed at clinic / hospital equipment that
is more complete, if it turns out that there are risks to me large enough.
Balikpapan,..2013

(........................................)