Pediatric Sudden Cardiac Death Risk Assessment Form
| Patient history questions: Tell me about any of these in your child… | Yes | No |
| Has your child fainted or passed out during or after exercise, emotion, or startle? | ||
| Has your child ever had extreme shortness of breath and/or discomfort, pain, or pressure in his or her chest during exercise? | ||
| Has your child had extreme fatigue associated with exercise (different from other children)? | ||
| 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 crash, 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: HCM | ||
| Dilated cardiomyopathy | ||
| Heart rhythm problems: LQTS | ||
| Short QT syndrome | ||
| Brugada syndrome | ||
| Catecholaminergic ventricular tachycardia | ||
| Arrhythmogenic right ventricular cardiomyopathy | ||
| Marfan syndrome (aortic rupture) | ||
| Heart attack, age 50 or younger | ||
| Pacemaker or implanted defibrillator | ||
| Deaf at birth (congenital deafness) | ||
| Please explain more about any “yes” answers here: | ||
| Parent signature: | ||
| Physician signature: | ||
| Date: |
| Patient history questions: Tell me about any of these in your child… | Yes | No |
| Has your child fainted or passed out during or after exercise, emotion, or startle? | ||
| Has your child ever had extreme shortness of breath and/or discomfort, pain, or pressure in his or her chest during exercise? | ||
| Has your child had extreme fatigue associated with exercise (different from other children)? | ||
| 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 crash, 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: HCM | ||
| Dilated cardiomyopathy | ||
| Heart rhythm problems: LQTS | ||
| Short QT syndrome | ||
| Brugada syndrome | ||
| Catecholaminergic ventricular tachycardia | ||
| Arrhythmogenic right ventricular cardiomyopathy | ||
| Marfan syndrome (aortic rupture) | ||
| Heart attack, age 50 or younger | ||
| Pacemaker or implanted defibrillator | ||
| Deaf at birth (congenital deafness) | ||
| Please explain more about any “yes” answers here: | ||
| Parent signature: | ||
| Physician signature: | ||
| Date: |
Ask these questions (or have parents complete for your review) at periodic times during well-child visits (neonatal, preschool, before or during middle school, and before or during high school).