ATHLETE CARDIOVASCULAR RISK VIDEO QUESTIONNAIRE ATHLETE CARDIOVASCULAR RISK VIDEO QUESTIONNAIRE IntroductionThis 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: First Last Email Sex: Male Female DOB: MM slash DD slash YYYY Height: Feet Inches Sport(s): Previous or referring family doctor: School: Grade School High School College Other Name of School: Ethnicity: African American Hispanic Caucasian Other 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? 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:A PARENT or GUARDIAN helped me complete this form Yes No A family member(s) died suddenly or unexpectedly Yes No The following 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 Family member(s) had/have an inherited disease of the heart: Hypertrophic Cardiomyopathy Inherited Valve Disease: Bicuspid Aortic Disease, Mitral Valve Prolapse Marfan's Syndrome, Aortic Dilatation Arrhythmogenic Right Ventricular Cardiomyopathy Catecholaminergic Polymorphic Ventricular Tachycardia Long QT Syndrome Brugada Syndrome Yes: but I do not know the name or it is not listed No: There are no Inherited Heart Diseases in my Family Enter the date:(Required) MM slash DD slash YYYY NameThis field is for validation purposes and should be left unchanged.
