ATHLETE CARDIOVASCULAR RISK VIDEO QUESTIONNAIRE

ATHLETE CARDIOVASCULAR RISK VIDEO QUESTIONNAIRE

Introduction

Why 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:
Sex:
MM slash DD slash YYYY
in units such as 6ft 1 inch

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?
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:

Is your PARENT or GUARDIAN helping to complete this form?
Has any family member died suddenly or unexpectedly?
Check if any of these have occurred in your family:
Has any family member have inherited disease of the heart such as the following?
Check if any of these have occurred in your family:
This field is for validation purposes and should be left unchanged.

 

X