• Children's Healthcare of Atlanta

    Pediatric Sudden Cardiac Death Risk Assessment Form

    Ask these questions (or have parents complete for your review) at periodic times during well child visits: neonatal, preschool, before/during middle school and before/during high school

  • DATE OF BIRTH*
     / /
    2 digit month, 2 digit day, 4 digit year

  • Patient History Questions: Tell me about any of these in your child

  • Has your child fainted or passed out DURING or AFTER exercise, emotion or startle?*
  • Has your child ever had extreme shortness of breath during exercise?*
  • Has your child had extreme fatigue associated with exercise (different from other children)?*
  • Has your child ever had discomfort, pain or pressure in his chest during exercise?*
  • Has a doctor ever ordered a test for your child's heart?*
  • Has your child ever been diagnosed with an unexplained seizure disorder? or exercise-induced asthma not well controlled with medication?*

  • Family History Questions: Tell me about any of these in your family

  • Are there any family members who had a sudden, unexpected, unexplained death before age 50? (including SIDS, car accident, drowning, others) or near drowning*
  • Are there any family members who died suddenly of "heart problems" before age 50?*
  • Are there any family members who have had unexplained fainting or seizures?*

  • Are there any relatives with certain conditions, such as:

  • Enlarged Heart: Hypertrophic cardiomyopathy (HCM)*
  • Dilated cardiomyopathy (DCM)*
  • Heart Rhythm problems: Long QT syndrome (LQTS)*
  • Short QT syndrome*
  • Brugada syndrome*
  • Catecholaminergic ventricular tachycardia*
  • Arrhythmogenic right ventricular cardiomyopathy (ARVC)*
  • Marfan syndrome (aortic rupture)*
  • Heart attack, age 50 or younger*
  • Pacemaker or implanted defibrillator*
  • Deaf at birth (congenital deafness)*
  • Date*
     / /
    2 digit month, 2 digit day, 4 digit year

  • Visit www.choa.org/heart for more information. If we can help you with any screening questions contact the Cardiac Call Center at 404-256-2593 (800-542-2233) or info@kidsheart.com.

    Children need Children'sR ©2008 Children's Healthcare of Atlanta Inc. All rights reserved.

  • CGI-P: Conners' Global Index - Parent Version

    By C. Keith Conners, Ph.D.
  • Gender*

  • Child's Birthdate:

  • Today's Date:

  • Instructions: Below are a number of common problems that children have. Please rate each item according to your child's behavior in the last month. For each item, ask yourself, "How much of a problem has this been in the last month?", and mark the best answer for each item. If none, not at all, seldom, or very infrequently, you would mark "NOT TRUE AT ALL". If very much true, or it occurs very often or frequently, you would mark "VERY MUCH TRUE". You would mark "JUST A LITTLE TRUE" or "PRETTY MUCH TRUE" for ratings in between. Please respond to all the items.

     

  • Restless or overactive*
  • Excitable, impulsive*
  • Fails to finish things he/she starts*
  • Inattentive, easily distracted*
  • Temper outbursts*
  • Fidgeting*
  • Disturbs other children*
  • Demands must be met immediately - easily frustrated*
  • Cries often and easily*
  • Mood changes quickly and drastically*
  •  
  • Should be Empty: