Cardiac Sports Screening Form

The physicians of ORP feel it is important to screen our patients for cardiac disease. This is especially important in adolescent patients who will
participate in sports. This screening tool helps us to identify patients who may need further evaluation by a cardiologist.
Oberlin Road Pediatrics Cardiovascular Screening Form
Patients 12 years and older need to have the following questionnaire completed
and reviewed by a physician.
Has your child ever fainted or passed out during or after exercise, emotion or startle?
___Yes ___No
Has your child ever had extreme shortness of breath during exercise?
___Yes ___No
Has your child had extreme fatigue with exercise (different from other children)?
___Yes ___No
Has your child had discomfort, pain, or pressure in his/her chest during exercise?
___Yes ___No
Has your doctor ever ordered a test for your child’s heart?
___Yes ___No
Has your child ever been diagnosed with an unexplained seizure disorder?
___Yes ___No
Has your child ever been diagnosed with exercise-induced asthma not well-controlled
with medication?
___Yes ___No
Has your child ever had palpitations during exercise or during the recovery phase?
___Yes ___No
Family History
Please indicate if any relatives (including: parents, siblings, grandparents, aunts, uncles, and cousins)
have any of the below conditions). When answering, please indicate if it is on the maternal or paternal
side (eg. Maternal Grandfather or Paternal Aunt, etc.).
Sudden death (any reason) under age 50 years of age:
Sudden cardiac death under 50 years of age:
Prolonged QT syndrome:
Arrhythmia (irregular heart rhythms):
Brugada Syndrome:
Heart attack under 50 years of age:
Congenital deafness: