Name:____________________________

DOB:____________________________

Email:____________________________
ATHLETE MEDICAL SCREENING FORM
Has your athlete ever:
..passed out DURING exercise, emotion, or startle? Y N

..passed out AFTER exercise? Y N

..had extreme fatigue associated with exercise (different from peers)? Y N

..ever had unusual or extreme shortness of breath during exercise? Y N

..ever had discomfort, pain, or pressure in his/her chest during exercise or complained of his/her heart “racing or Y N
skipping beats?”

..ever had a doctor identify high blood pressure, high cholesterol, a heart murmur, or a heart infection? Y N
(If “yes,” check which one[s]) _____________________________________

..ever had a test ordered by a doctor on their heart? Y N

..ever been diagnosed with an unexplained seizure disorder or exercise-induced asthma? Y N

..used cocaine or strong stimulants more than once Y N

Family History Questions: Has any family member...

..had a sudden, unexpected death before age 50 (including from sudden infant death syndrome [SIDS], car accident, Y N
drowning, or others)?

..died suddenly of “heart problems” before age 50? Y N

..had unexplained fainting or seizures? Y N

..been identified with certain conditions such as: Y N

Hypertrophic cardiomyopathy (HCM) Y N

Dilated cardiomyopathy (DCM) Y N

Aortic rupture or Marfan syndrome Y N

Coronary artery atherosclerotic disease Y N

heart attack, age 50 years or younger Y N

Arrhythmogenic right ventricular cardiomyopathy Catecholaminergic polymorphic v. tachycardia Y N

Long QT syndrome , Short QT syndrome , Brugada syndrome Y N

Pacemaker or implanted cardiac defibrillator Y N

Primary pulmonary hypertension Congenital deafness (deaf at birth) Y N

Heart of the Valley Pediatric Cardiology

5933 Coronado Lane, Suite 1 F, Pleasanton, CA 94588
Phone 925 416-0100 Fax 925 397-2193 email: amaxwell@heartofthevalley.us

Pleasanton Brentwood Fremont Tracy San Mateo

 CONSENT AND DISCLAIMER
Dear Parent:

This test is a screen for the underlying causes of sudden cardiac death in athletes. See the
accompanying tri-fold brochure for background and additional details of the screen. Screening of
athletes for causes of sudden cardiac death is routine if not mandatory in most European countries.
It is mostly unavailable and completely voluntary in the US. The screening offered by this practice
is adapted from the program that is used in Italy with great success. Please read the following
important points about the screening program.

1) The screen consists of the screening questionnaire and an ECG. The success of the screen depends on the
accuracy and completeness of the questionnaire and of follow-up answers to questions asked by the screening doctor.
This accuracy and completeness is the responsibility of the athlete and the parent.
2) As all screening tools, even under the best circumstances it is not perfect and it does not catch all causes. In
Italy, the screening program was able to reduce the incidence of sudden cardiac death to 1/6th of the rate without
screening. This means, in a typical population of 100,000 screened athletes, each year one athlete who passed the
screen would still be expected to die suddenly. However, this is an improvement compared to no screening where 6
athletes would be expected to die suddenly each year.
3) Just as a screening tool does not catch all causes, sometimes it detects issues that appear to be of concern, but,
with further testing, are shown not to be of concern (These are called false positive screens). Thus, sometimes
additional costs are incurred for what ultimately turns out to be nothing serious. In Italy, 9% of athletes required
additional studies, usually an echocardiogram, before risk could be better assessed.
4) Insurance companies do not currently cover the cost of screening. They will cover the cost most of the time if
there are any positive responses on the screening questionnaire or the screening ECG and your doctor believes it is
important to have this further evaluated by a pediatric cardiologist.
5) It is very important to understand that, once a person is identified to be at increased risk of sudden cardiac
death, the risk is only reduced by some sort of intervention. Often this involves restriction from competitive sports. In
Italy, 2% of all those screened were restricted from sports even though it is estimated that only 1 in 10 of those
restricted athletes had a truly high risk of sudden cardiac death. Thus, you may be advised to consider restriction
unnecessarily (You may be a false positive even after additional testing). All effort will be taken to minimize false
positives through additional testing performed by the pediatric cardiologist.
6) Because this is a voluntary screen, agreeing to an intervention or restriction from competition is also a
voluntary decision on the part of the athlete and parents. The screening doctor will not act to enforce restrictions and
will not notify the school or your doctor. It will be up to the athlete and parent to decide how to act on the
information. However, if the athlete or parent discuss the results with their doctor or pediatric cardiologist, they may
choose to withhold sports clearance either with the available results or until further testing is performed.
7) Notification of these results is via email only. The ECG and interpretation of risk is sent via a password
protected PDF file. Be sure to put the email address to which you wish the results sent on the questionnaire.
8) The cost of this screen is $50.

I am the legal guardian of this athlete and have read this important information about this test and
agree to this athlete being tested.

______________________________ ________________ ____________________________

Athlete Name Date of Birth Sport

______________________________ ________________ ____________________________

Parent Signature Date Email
______________________________
Parent Name
Heart of the Valley Pediatric Cardiology

5933 Coronado Lane, Suite 1 F, Pleasanton, CA 94588

Phone 925 416-0100 Fax 925 397-2193 email: amaxwell@heartofthevalley.us

Pleasanton Brentwood Fremont Tracy San Mateo