PATIENT’S NAME: _______________________________________________________

APPOINTMENT DATE AND TIME: __________________________________________

PLACE: The Guild Building, 825 Washington Street, Norwood, Suite #290

INFORMATION FOR PHARMACOLOGIC STRESS PATIENTS

A pharmacologic stress test has been ordered for you by your physician that does not require you to exercise on a treadmill. The following instructions should be followed prior to your stress test:

1. DIET: Do NOT eat or drink anything for six (6) hours prior to the exam. Avoid all food and beverages containing caffeine for 48 hours prior to the exam. This includes all coffee, decaffeinated coffee, tea, soda and chocolate. You will be able to eat after the first part of the test.

2. MEDICATIONS: Take all of your medicines with a little water, as directed, unless otherwise specified by your physician. Medications containing Theophylline should be avoided 48 hours prior to your exam. If you take a beta blocker (Atenolol, Metoprolol, Tenormin, Toprol, Inderal), please do NOT take your morning dose but bring it with you. If you are taking any of the following medicine, please check with your physician.

Acacin No Doz Theo-24 Theovent longacting

Areofate Norgesic Theobid duracap Therclear LA

Bronkodyl Norgesic Forte Theochron Theox

Cafergot Quibron (all forms) TheoDur T-PHYL

Constant-t Respbid Theolair-SR Trimatene (tablets)

Elixophyline SR Slobid Theobid Theo-Organidin Uniphyl

Esgic Slo-Phylline Theophylline SR Wigraine

Excedrin Suslaire Theo-Sav

Fiorinal Synalgos-DS Theospan duracap

Fiorivet Tedral SA Theo-stat

ALWAYS INFORM YOUR PHYSICIAN IF YOU ARE HOLDING YOUR MEDICATIONS.

3. A list of all medications with dosages is needed. For your convenience, we have left space at the bottom of this page for this information.

4. Above, all try not to be apprehensive or worry about this test. Relaxation is best for you and for the accuracy of the test.

5. A tracing agent will be administered via IV and imaging will be done after the stress portion of the test as

well as two to four (2-4) hours later.

6. Plan to be at the office for one and a half hours (1 ½ hours) for the first portion of the test. You may leave the office for two to four (2-4) hours and then return for 30 minutes. You will be able to eat after the stress portion of the test.

Medication and dosage: ________________________________________________________________

IF YOU ARE UNABLE TO KEEP THIS APPOINTMENT, 24 HOUR NOTICE MUST BE GIVEN. PLEASE CALL 781-255-0561.

Rev: 02/02 Approved: WDD