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Student Heart Screening History Questionnaire

Thank you for submitting the Parent Consent form. Please complete the screening history below to complete this process.

Email address of person completing this form*

First Name*

Last Name*

Birthday*

Height*

Weight*

Gender*

1. Has it been more than two years since you had a physical exam that included a blood pressure reading and listening to your heart?*

2. Have your parents or has a physician ever told you that you have a heart murmur?*

3. Has a physician ever suggested that you not participate in athletic competition?*

4. Have you had chest pain/pressure, dizziness or racing or “skipped beats” at rest or with exercise?*

5. Have you ever fainted or passed out during exercise or after having been frightened or surprised?*

6. Have you ever fainted or passed out after exercise?*

7. Have you ever been told that you have high blood pressure, high cholesterol or diabetes?*

7a. If yes, which one(s)?

8. Have you ever been diagnosed with unexplained seizures or exercise-induced asthma?*

9. Do you use or have you ever used cocaine, anabolic steroids, or other drugs?*

10. Do you use tobacco products?*

11. Do you drink energy drinks?*

12. Has anyone in your family had sudden, unexpected death before age 45?*

13. Has anyone in your immediate family had unexplained fainting or seizures?*

14. Has a physician diagnosed anyone in your family with an abnormally thickened heart, weakened heart or Marfan syndrome?*

15. What sport(s) do you plan on playing (if applicable)?*

Name of student signing*

Name of parent signing*

* Required information

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