Heart Health Questionnaire for Young Athletes

Parents, please assist your child in completing this form.

Please correct the errors described below.

Patient Name

Do you get chest pain, discomfort, tightness or pressure related to exercise or physical activity?

Yes No

Have you had unexplained syncope (passing out) or near syncope (nearly passing out)?

Yes No

Do you get excessive or unexplained shortness of breath, fatigue or palpitations associated with exercise or physical activity?

Yes No

Have you ever been diagnosed with COVID-19?

Yes No

Have you ever been diagnosed with a heart murmur or high blood pressure?

Yes No

Have you ever been restricted from participating in sports or other physical activities?

Yes No

Has your doctor ever told you that you have heart problems? If so, check all that apply:

Heart murmur

High cholesterol

Heart infection

High blood pressure

No heart problems

Other

If other, please explain:

Has a doctor ever ordered a test for your heart?

Yes No

If so, what test and why?

Has any close relative died of heart problems or had an unexpected or unexplained sudden death before age 50?

Yes No

Does any close relative have hypertrophic or dilated cardiomyopathy, Marfan syndrome, long QT syndrome, or any clinically significant arrhythmia?

Yes No

Do you have any specific knowledge of genetic cardiac conditions in the family?

Yes No

Please add details as needed:

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