ATHLETE CARDIOVASCULAR RISK VIDEO QUESTIONNAIRE

ATHLETE CARDIOVASCULAR RISK VIDEO QUESTIONNAIRE

Introduction

This form was completed on the California Chapter of the ACC website using the Levine Videos for the four major CV risk questions. You should keep a copy with your family medical records and give a copy as part of your annual Pre-participation exam from your family physician and/or school.
Name:
Sex:
MM slash DD slash YYYY
Height:
School:
Ethnicity:

ATHLETIC CARDIOVASCULAR HEALTH HISTORY:

Watch the videos and answer the questions. Not all questions have videos, only the first four. Please use the play button in the middle of the video to view and to stay within the questionnaire.
Have you ever had discomfort, pain, tightness, or pressure in your chest during exercise?
Have you ever passed out or nearly passed out DURING or AFTER exercise?
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?
Have you ever felt like your heart was racing, fluttering, or beating abnormally, DURING or AFTER exercise?
Have you ever seen a doctor for a heart problem before?
Has a doctor ever ordered testing for your heart, such as an EKG/ECG, x-ray, Echocardiogram, MRI or an exercise test?
Has a doctor ever told you not to play sports before?
Have you ever had an unexplained seizure?
Do you take any performance supplements or energy drinks?

FAMILY HISTORY INFORMATION:

A PARENT or GUARDIAN helped me complete this form
A family member(s) died suddenly or unexpectedly
The following have occurred in your family:
Family member(s) had/have an inherited disease of the heart:
MM slash DD slash YYYY
This field is for validation purposes and should be left unchanged.

 

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