Cardiac Checklist
Please answer the following questions by marking "yes" if you have experienced the symptom. Mark "no" if you have not experienced the symptom.
Patient's Name
*
First Name
Last Name
Patient's Date of Birth
*
-
Month
-
Day
Year
Date
Shortness of breath with exercise (more than other children of the same age) in the absence of an alternate explanation (e.g. asthma, sedentary lifestyle, obesity)
*
Yes
No
Poor exercise tolerance (in comparison with other children) in the absence of an alternate explanation (e.g. asthma, sedentary lifestyle, obesity)
*
Yes
No
Fainting or seizures with exercise, startle or fright
*
Yes
No
Palpitations brought on by exercise
*
Yes
No
Back
Next
Personal or Family History: (in first or second degree relatives) of non-ischemic heart disease such as:
Long QT syndrome or other familial arrhythmias
*
Yes
No
Wolff-Parkinson-White Syndrome
*
Yes
No
Cardiomyopathy
*
Yes
No
Heart Transplant
*
Yes
No
Pulmonary Hypertension
*
Yes
No
Unexplained motor vehicle collisions or drowning
*
Yes
No
Implantable Defibrillator
*
Yes
No
Submit
Should be Empty: