Cardiac History Form printable pdf download

COMMACK PUBLIC SCHOOLS

COMMACK, NEW YORK

Cardiac History Form

MANDATORY for all students entering grades 7 and 10 and for all students participating in athletics.

Student’s Name __________________________________________________Date of Birth __________________Age _____

Address ____________________________________________________________________________________________

Home Phone ___________________________ Cell Phone ________________________________ Male _____ Female _____

Parent’s/Guardian’s Name _______________________________________________________________________________

Name, Address and Phone Number of Primary Care Physician/Pediatrician: __________________________________________

___________________________________________________________________________________________________

1. Has your child ever had chest pain or discomfort? If yes, please describe YES ⁭ NO ⁭ _______________________________

___________________________________________________________________________________________________

2. Has your child ever passed out or almost passed out? If yes, please describe YES ⁭ NO ⁭ ____________________________

___________________________________________________________________________________________________

3. Has your child ever been short of breath or experienced fatigue with exercise? If yes, please describe YES ⁭ NO ⁭ __________

___________________________________________________________________________________________________

4. Has your child ever been told he/she has a heart murmur? If yes, please describe YES ⁭ NO ⁭ __________________________

___________________________________________________________________________________________________

5. Has your child ever had high blood pressure? If yes, please describe YES ⁭ NO ⁭ __________________________________

___________________________________________________________________________________________________

6. Has anyone in your family died before the age of 50? If yes, please describe YES ⁭ NO ⁭ _____________________________

___________________________________________________________________________________________________

7. Has anyone in your family died before the age of 50 due to heart disease? If yes, please describe YES ⁭ NO ⁭ _____________

__________________________________________________________________________________________________

8. Do you know of any relatives less than 50 that are disabled with heart disease? If yes, please describe YES ⁭ NO ⁭ _________

____________________________________________________________________________________________________

9. Do you know of any family members with the following heart diseases: Cardiomyopathy, Long-qt Syndrome, Marfan Syndrome,

Arrhythmogenic Right Ventricular Dysplasia, Anomalous Coronary Artery, Catecholmanigeric Polymorphic Ventricular, Arrythmias

Tachychardia (CPVT)? ? If yes, please describe YES ⁭ NO ⁭ (Please circle any applicable)

If yes, please describe YES ⁭ NO ⁭ __________________________________

10. Is your child currently on any medication?

Name of person completing form:_________________________________________ Relationship to Child __________________

Signature:_________________________Date/Time____________

Form Reviewed by (Commack UFSD) _______________________________ ___________________________ ____________

Name

Signature

Date

FOR PHYSICIAN USE ONLY:

1. Heart Murmur YES ⁭ NO 2. Marfan Syndrome Physical Stigmata YES ⁭ NO ⁭ Brachial Artery Blood Pressure (sitting position) _________

Physician’s Signature: ______________________________________Date Time ___________________

Cardiac History Form