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Six Minute Walk Test (6MWT) Recording Form: Patient ID: Family Name: Given Name(s) : Date of Birth: Sex: M F I

This document contains forms and instructions for conducting two six-minute walk tests, which measure a patient's functional capacity by recording vital signs and distance walked over six minutes. The forms include spaces for patient information, date and time, use of mobility aids or oxygen, and monitoring of vital signs, distance walked, and limiting factors during the tests.

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dina
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75 views2 pages

Six Minute Walk Test (6MWT) Recording Form: Patient ID: Family Name: Given Name(s) : Date of Birth: Sex: M F I

This document contains forms and instructions for conducting two six-minute walk tests, which measure a patient's functional capacity by recording vital signs and distance walked over six minutes. The forms include spaces for patient information, date and time, use of mobility aids or oxygen, and monitoring of vital signs, distance walked, and limiting factors during the tests.

Uploaded by

dina
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as DOCX, PDF, TXT or read online on Scribd
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(Affix patient label here)

Patient ID:
Family name:
Given name(s):
Date of birth: Sex: M F I

Six Minute Walk Test (6MWT) recording form


Medical history checked
Medical clearance provided for the patient to participate in exercise testing
Contraindications to 6MWT:
Resting heart rate > 120 beats / min after 10 minutes rest (relative contraindication)
Systolic blood pressure > 180 mm Hg +/- diastolic blood pressure > 100 mm Hg (relative contraindication)
Resting SpO2 < 85% on room air or on prescribed level of supplemental oxygen
Physical disability preventing safe performance
No contraindications identified
6MWT 1 Date: Time:
Supplemental Oxygen Mobility Aid

Time BP SpO2 HR RPE Distance walked Rests / comments


mins
Rest

Recovery
1

Total distance: Symptom recovery: HR recovery:


Limiting factor:
Was test terminated? No Yes If yes: when?
6MWT Termination Criteria: Intolerable dyspnoea, unrelieved by rest
Chest pain or angina-like symptoms Persistent SpO2 <85% (Note: pending clinical
Heart rate > Predicted HR max. presentation)
Evolving mental confusion, light-headedness or Abnormal gait pattern (leg cramps, staggering, ataxia)
incoordination Other clinically warranted reason
Physical or verbal severe fatigue

1
Medical history checked
Medical clearance provided for the patient to participate in exercise testing
Contraindications to 6MWT:
Resting heart rate > 120 beats / min after 10 minutes rest (relative contraindication)
Systolic blood pressure > 180 mm Hg +/- diastolic blood pressure > 100 mm Hg (relative contraindication)
Resting SpO2 < 85% on room air or on prescribed level of supplemental oxygen
Physical disability preventing safe performance
No contraindications identified
6MWT 2 Date: Time:
Supplemental Oxygen Mobility Aid

Time BP SpO2 HR RPE Distance walked Rests / comments


mins
Rest

Recovery
1

Total distance: Symptom recovery: HR recovery:


Limiting factor:
Was test terminated? No Yes If yes: when?
6MWT Termination Criteria: Intolerable dyspnoea, unrelieved by rest
Chest pain or angina-like symptoms Persistent SpO2 <85% (Note: pending clinical
Heart rate > Predicted HR max. presentation)
Evolving mental confusion, light-headedness or Abnormal gait pattern (leg cramps, staggering, ataxia)
incoordination Other clinically warranted reason
Physical or verbal severe fatigue

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