Buffalo Concussion Treadmill/Bike Test
Patient Name
*
First Name
Last Name
Date
*
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Safety Considerations. I am comfortable performing this exercise in the clothing and shoes I am wearing.
*
Yes
No
Absolute Contraindications
Recent Heart Attack
*
Yes
No
High-Risk Unstable Angina
*
Yes
No
Uncontrolled Cardiac Arrhythmias
*
Yes
No
Severe Aortic Stenosis
*
Yes
No
Uncontrolled Heart Failure
*
Yes
No
Acute Pulmonary Embolism / Infarction
*
Yes
No
Acute Myocarditis / Pericarditis
*
Yes
No
Acute Aortic Dissection
*
Yes
No
Relative Contraindications
Left Main Coronary Stenosis
*
Yes
No
Moderate Stenotic Valvular Heart Disease
*
Yes
No
Electrolyte Abnormalities
*
Yes
No
Blood Pressure Systolic > 200 mmHg
*
Yes
No
Blood Pressure Diastolic > 110 mmHg
*
Yes
No
Tachyarryhthmias / Bradyarrhythmias
*
Yes
No
Hypertrophic Cardiomyopathy
*
Yes
No
Mental / Physical Impairment with Inability to Exercise
*
Yes
No
High-Degree Atrioventricular Block
*
Yes
No
Terminating the Test
Maximum Exertion (RPE Score > 17.5)
Experimenter Notes Rapid Progression of Symptoms
Symptom Exacerbatioon > 2 Points
Patient Reports Inability to Continue Test
Patient Signature
*
Date
*
/
Month
/
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
C 2022 First Care Concussion Clinic, LLC
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