PARENT INFORMATION: ENTER IN PRIMARY SECTION ABOVE
|
|
|
75-100 Parent Volunteers Are Needed
|
Interested in volunteering at this screening? No experience necessary, training provided!
*
|
|
|
*
|
If yes, please complete your student’s registration and then return to the home page to complete the volunteer registration located at the upper-left corner.
|
STUDENT INFORMATION
|
One Student Per Registration
|
|
|
Student First Name
*
|
(limit your response to 200 characters)
|
|
Student Last Name
*
|
(limit your response to 200 characters)
|
|
Student Gender
*
|
|
|
Student Race
*
|
|
|
Student Date of Birth
*
|
(MM/DD/YY)
Example: 04/19/99
|
|
Student ID Number
*
|
|
|
Student Weight in Pounds
*
|
Number only. Example: 133
|
|
Student Height
*
|
|
|
I grant permission for my child to be photographed:
*
|
This permits my child to be photographed and/or appear in recording of this event for any legitimate purpose.
|
|
Does your student participate on a sports team at school or outside of school?
*
|
|
|
If your student plays more than one sport, which sport does your student play most intensely?
*
|
|
HEALTH QUESTIONS ABOUT THE STUDENT
|
|
|
|
1. Does the student have any previously diagnosed heart disease?
*
|
Includes: Anonmalous Coronary Artery, Aortic Aneurysm, Arrhythmogenic Right Ventricular Dysplasia Cardiomyopathy (ARVD/C), Brugada Syndrome, Chagas Disease, Congenital Heart Disease, Coronary Artery Disease (CAD), Dilated Cardiomypathy, Hypertrophic Cardiomyopathy (HCM), Long QT Syndrome, Marfan Syndrome, Non-Compaction Cardiomyopathy, Rheumatic Heart Disease, Valvular Heart Disease, Wolff-Parkinson-White Syndrome (WPW)
|
|
If "yes" please indicate condition:
*
|
|
|
If "yes" are you followed by a physician for this heart condition?
*
|
|
|
If you are not followed by a physician for this heart condition, why not?
|
(limit your response to 200 characters)
|
|
2. Does the student have any ongoing medical illnesses?
*
|
|
|
If "yes" what illness?
*
|
(limit your response to 200 characters)
|
|
Are you followed by a physician for this ongoing medical illness?
*
|
|
|
If you are not being followed by a physician for this ongoing medical illness, why not?
*
|
(limit your response to 200 characters)
|
|
3. Does the student take any medications other than birth control?
*
|
|
|
What medication(s)?
|
(limit your response to 200 characters)
|
HEART HEALTH QUESTIONS ABOUT PARENTS & SIBLINGS
|
(Consult a knowledgeable family member)
|
|
|
Are you able to answer family health history questions?
*
|
|
|
|
For a variety of reasons, your child’s health history may not be known to you. If you are unable to fully answer these questions, please answer this and subsequent health history questions with a “no” answer.
|
|
1. Has the student's parent or sibling died suddenly from a heart problem before the age of 50?
*
|
|
|
If "yes" what relative and from what heart condition?
*
|
(limit your response to 200 characters)
(Mother, Father, Sister, Brother only)
|
|
2. Has the student's parent or sibling died suddenly for an unknown reason before the age of 50?
*
|
Includes death for any reason including sudden infant death syndrome (SIDS), unexplained car accident, or drowning.
|
|
If "yes" what relative and what reason?
*
|
(limit your response to 200 characters)
(Mother, Father, Sister, Brother only)
|
|
3. Does the student's parent or sibling have a genetic heart condition?
*
|
Includes: Hypertrophic Cardiomyopathy, Dilated Cardiomyopathy, Long QT Syndrome, Marfan Syndrome or other Heart Rhythm problems.
|
|
If "yes" what relative?
*
|
(limit your response to 200 characters)
(Mother, Father, Sister, Brother only)
|
|
If "yes" your family member has what specific genetic heart condition?
*
|
|