Exercise Stress Test Report (Pediatric)

Pediatric Exercise Stress Test / CPET Diagnostic Report

(Use this template for pediatric treadmill ECG stress testing and/or cardiopulmonary exercise testing. If information was not assessed or is unavailable, document "Not performed" or "Not assessed" rather than omitting. Omit CPET sections entirely if gas exchange was not measured.)

Administrative Information

Patient: [Patient name]; MRN: [Medical record number]; DOB: [Date of birth]; Age at test: [Age]; Sex: [Sex]

Anthropometrics: Height: [Height in cm]; Weight: [Weight in kg]; BMI: [BMI] (If any anthropometric value is missing, note: "Anthropometrics incomplete; percent-predicted values may be unavailable.")

Test date/time: [Date and time]; Test modality: [Exercise ECG Stress Test / CPET / Combined ECG+CPET]

Referring clinician: [Referring clinician name and credentials]; Interpreting clinician: [Interpreting clinician name and credentials]

Clinical Indication and History

Indication and clinical question: [Referral reason and specific clinical question]

Targeted history: [Pertinent cardiac diagnosis, relevant prior cardiac testing and results, baseline activity level and sports participation] (Include only details relevant to the indication.)

Medications affecting HR/rhythm: [List relevant medications and whether held] (Include beta-blockers, stimulants, antiarrhythmics, and other rate-limiting agents if applicable; state "None" if no relevant medications.)

Consent: Consent obtained. (Note assent if applicable for older children/adolescents.)

Baseline Status

Contraindication screening: [No contraindications identified / Concerns identified with mitigation: (specify)]

Resting vitals and rhythm: HR: [Resting HR] bpm; BP: [Resting BP] mmHg; SpO2: [Resting SpO2]% [or "Not monitored"]; Rhythm: [Baseline rhythm]

Baseline ECG findings relevant to interpretation: [None / Baseline ST-T abnormalities / Conduction abnormalities / Paced rhythm / Other: (specify)] (Note if ischemia assessment may be limited by baseline abnormalities.)

Protocol and Technique

Exercise modality: [Treadmill / Cycle ergometer]; Protocol: [Bruce / Modified Bruce / Ramp / Other: (specify)]

• ECG monitoring: Continuous ECG with 12-lead captures at baseline, each stage, peak, and throughout recovery.
• Blood pressure measurements: Baseline, during exercise [every 3 minutes / per stage], and recovery.
• Pulse oximetry: [Used / Not used]
• Gas exchange (CPET): [Mouthpiece / Face mask]; Averaging interval: [Breath-by-breath with X-second averaging]; Maximal effort criteria: [RER threshold and/or secondary criteria] (Include only if CPET was performed; otherwise state "Gas exchange not measured.")

Results

Test Summary

• Total exercise time: [mm:ss]
• Peak workload achieved: [Treadmill stage, speed, and grade / Cycle peak watts and cadence]
• Estimated peak METs: [Value / Not calculated]
• Reason for termination: [Fatigue / Symptoms / Arrhythmia / Achieved target HR / Other: (specify)]
• Test adequacy: [Maximal / Submaximal]; Peak HR [value] bpm ([percent] predicted); Peak RER [value] (if CPET); Peak RPE [value]

Hemodynamic Response

• Heart rate: Rest [value] bpm; Peak [value] bpm ([percent] predicted); 1-minute HR recovery: [value] bpm
• Blood pressure: Rest [value] mmHg; Peak [value] mmHg; Recovery [value] mmHg — Response: [Normal / Blunted / Exaggerated / Hypotensive]
• Oxygen saturation: Rest [value]%; Nadir during exercise [value]% [or "Not monitored"]

Symptoms and Effort

• Symptoms during exercise: [None / Chest pain / Palpitations / Dizziness / Dyspnea / Fatigue / Leg pain / Wheeze / Other] (Include timing of onset if present.)
• Peak perceived exertion: [RPE value and scale used]
• Recovery: [Symptoms resolved / Symptoms persisted / Intervention required]

ECG and Arrhythmia Findings

• Rhythm during exercise and recovery: [Description]
• Arrhythmias: [None / Type: (specify)] — Frequency: [Isolated / Frequent]; Complexity: [Single / Couplets / Runs]; Onset timing: [Stage or HR]; Duration: [Duration]; Symptom correlation: [Present / Absent]; Recovery: [Resolved / Persisted]
• ST-segment changes: [Absent / Present] — Lead distribution: [Leads]; Magnitude: [mm]; Morphology: [Upsloping / Horizontal / Downsloping] (State if interpretation limited by baseline abnormalities.)
• Early termination due to ECG finding: [No / Yes: (specify)]

Cardiopulmonary Exercise Testing (CPET) Variables

(Include this section only if gas exchange was measured; omit entirely otherwise.)

• Peak VO2: [value] mL/kg/min ([percent] predicted)
• Ventilatory anaerobic threshold (VAT): [value] mL/kg/min ([percent] of peak VO2)
• Peak RER: [value]
• VE/VCO2 slope: [value]
• Peak O2 pulse: [value] mL/beat ([percent] predicted)
• Reference equation: [Name/source of pediatric reference equation]

(If percent-predicted values cannot be calculated, state the reason and report absolute values.)

Interpretation

Adequacy of test: [Maximal / Submaximal] effort based on [objective criteria: peak RER, peak HR % predicted, RPE].

Technical limitations: [None / Limitations: (specify)] (e.g., baseline ECG abnormalities limiting ischemia assessment, incomplete BP measurements, suspected mask leak.)

Exercise capacity: [Normal / Above average / Below average / Severely reduced] relative to age and body size norms. (Anchor to peak VO2 % predicted if CPET performed; otherwise reference protocol time and estimated METs.)

Hemodynamic response: Chronotropic response [normal / attenuated / exaggerated] with peak HR [value] bpm ([percent] predicted). Blood pressure response [normal / blunted / exaggerated / hypotensive].

ECG/Arrhythmia: [No exercise-induced arrhythmia / Exercise-induced arrhythmia present: (type and clinical significance)]. Ischemia: [Absent / Present / Non-diagnostic: (reason)].

Overall Impression:

• [Summary statement on test adequacy and exercise capacity]
• [Summary statement on arrhythmia/ECG findings]
• [Summary statement on hemodynamic response]

(Provide 2–4 statements ordered by clinical importance.)

Recommendations

• [Further testing or imaging if indicated]
• [Medication or management adjustments if indicated]
• [Follow-up interval and clinic/provider]
• [Activity guidance pending further evaluation if applicable]

(Omit items that do not apply.)

Return-to-Play Considerations

(Include this section only when the test was performed to inform sports participation; omit otherwise.)

Final eligibility requires clinical correlation and shared decision-making with the patient/guardian and care team.

• Risk-relevant test findings: [Summary of findings relevant to sport participation risk]
• Participation statement: [No exercise-test findings that independently mandate restriction / Temporary restriction pending further evaluation: (specify) / Restriction recommended due to high-risk findings: (specify)]
• [Sport- or intensity-specific guidance if applicable]

Signature

Interpreting clinician: [Name, credentials] — [Signature] — [Date and time]