Cardiac Risk Questionnaire for Young Athletes (CRQA) Getting StartedAllergiesGeneral Questions First NameLast NameEmailPhone/MobileDate Of BirthMonthDayYearDate of Questionnaire CompletionSex assigned at birth (F, M, or intersex) Male Female Intersex Prefer not to discloseHow do you identify your gender? (F/M/Other)Please Enter Your HeightFeetInchesWeight (lbs)BMIBelt Size (inches)AgeMajor Sport- Select -Baseball/softballBasketballBoxingCrewCross countryDistance runningField hockey/LacrosseFootball (line)Football (other than line)GolfGymnasticsHiking/ClimbingIce HockeyOrienteeringOtherRacket sportSoccerSpeed WalkingSwimmingTennisTrack and fieldVolleyballWater poloWeightliftingWrestlingSport details (other sports, training habits/patterns)School/Organization or Team that you play for:PreviousNextHave You Had Covid-19? Yes NoHave you received any immunizations against COVID-19 Yes NoIf Yes, How many shots have you had? 1 Shot 2 shots 3 Shots More than 3 ShotsDate of bivalent (updated) vaccine (if applicable)Please List Any Past and Current Medical ConditionsHave You Ever Had Surgery? If Yes, Please List All Past Surgical ProceduresMedicines and Supplements: List all current prescriptions, over the counter medicines, and supplements (herbal and nutritional)Do You Have Any Allergies? Yes NoPlease list any medicinal allergies you have (if applicable)Please list any specific food allergies (if applicable)Please list any specific pollen allergies (if applicable)Please list any specific stinging insect allergies (if applicable)PreviousNextOver the last two weeks, how often have you been bothered by any of the following problems:Feeling nervous, anxious, or on edge? Not At All Several Days Over Half the Days Nearly Every DayNot being able to stop or control worrying? Not At All Several Days Over Half the Days Nearly Every DayLittle Interest or Pleasure in Doing Things? Not At All Several Days Over Half the Days Nearly Every DayFeeling Down, Depressed or Helpless? Not At All Several Days Over Half the Days Nearly Every DayDo You have any concerns that you would like to discuss with your provider? Yes NoHas a doctor ever denied or restricted your participation in sports for any reason? Yes NoDo you have any ongoing medical conditions or recent illness? If so, please identify belowHave you ever passed out or nearly passed out during or after exercise? (Please watch the video below) Yes No (English) (Spanish)Have you ever had discomfort pain tightness or pressure in your chest during exercise? (Please watch the video below) Yes No Don't know (English) (Spanish)Does your heart ever race or flutter in your chest or skip irregular beats during exercise? (Please watch the video below) Yes No Don't know (English) (Spanish)Do you get light-headed or feel shorter of breath than your friends during exercise? (Please watch the video below) Yes No Don't know (English) (Spanish)Has a doctor ever told you that you have high blood pressure, a heart murmur, or any other heart problems? Yes NoHave you ever had a heart test such as an electrocardiogram (ECG), MRI or echocardiogram? Yes NoHave you ever had a seizure? Yes NoHas any family member has any family member or relative died of heart problems or had an unexpected or unexplained sudden death before age 50 including drowning or unexplained car crash? Yes NoDoes anyone in your family before age 50 have a genetic heart problem or a history of heart disease? e.g. Hypertrophic or any cardiomyopathy(HCM), Arrhythmogenic right ventricular dysplasia(ARVC),Paroxysmal Ventricular tachycardia(PSVT) or Long QT syndrome(LQTS) If yes please list the family member (i.e mother, father, brother, sister etc)SelectMotherFatherSisterBrotherHas anyone in your family had a pacemaker or an implanted defibrillator before age 50? Yes No Don't know Previous Submit Form
