ATHLETE CARDIOVASCULAR RISK VIDEO QUESTIONNAIRE ATHLETE CARDIOVASCULAR RISK VIDEO QUESTIONNAIRE IntroductionWhy should you be concerned with answering these scary questions? Sure, heart problems and their complications including death are rare in young athletes. But what if the causes of these conditions and their complications were known and we knew their warning signs? Your parents, relatives and coaches would like you to be able to play sports safely. Modern medicine has made tools available for screening and treating heart conditions so why not take advantage of them? The first step in doing so is to watch these videos and answer these questions as best you can. Studies have shown us that they can be clues for recognizing the first signs of heart conditions. Your answers to these questions will be summarized for you to take to your annual screening for participation in organized sports with some suggestions for your doctor or organization to consider prior to sports participation. Even if you don’t have any of these symptoms now, you now know that if they ever occur, they should be reported. Please share this resource with your teammates.Name: First Last Email Sex: Male Female DOB: MM slash DD slash YYYY Height: in units such as 6ft 1 inchSport(s): Previous or referring family doctor: School: ATHLETIC CARDIOVASCULAR HEALTH HISTORY:Watch the videos and answer the questions. Not all questions have videos. Have you ever had discomfort, pain, tightness, or pressure in your chest during exercise? Yes No Have you ever passed out or nearly passed out DURING or AFTER exercise? Yes No Do you ever get so out of breath that you can't continue to exercise even though your peers aren't tired or short of breath yet? Yes No Have you ever felt like your heart was racing, fluttering, or beating abnormally, DURING or AFTER exercise? Yes No Have you ever seen a doctor for a heart problem before? Yes No Has a doctor ever ordered testing for your heart, such as an EKG/ECG, x-ray, Echocardiogram, MRI or an exercise test? Yes No Has a doctor ever told you not to play sports before? Yes No Have you ever had an unexplained seizure? Yes No Do you take any performance supplements or energy drinks? Yes No FAMILY HISTORY INFORMATION:Is your PARENT or GUARDIAN helping to complete this form? Yes No Has any family member died suddenly or unexpectedly? Yes No Check if any of these have occurred in your family: Unexplained Car Accidents While Being the Driver A Competent Swimmer Drowning Sudden Infant Death Syndrome Other Unusual or Unexpected Death Has any family member have inherited disease of the heart such as the following? Yes No Check if any of these have occurred in your family: Hypertrophic Cardiomyopathy Long QT syndrome Brugada Syndrome Right Ventricular Cardiomyopathy Valvular or Vascular Heart Disease - including bicuspid aortic valve, mitral valve prolapse or aortic dilation NameThis field is for validation purposes and should be left unchanged.