Cardiac Screening

In: Science

Submitted By lm2015
Words 470
Pages 2
Please fill in the both sides of this form
For Office Use Only
Payment
Received: Questionnaire
Checked: Info box ticked: Consent
Signed:
Seen By Doctor: Follow-up Required: Yes No
Additional Notes:

Result: Patient ID no (for office use only):

Full Name:

Date of Screening:

Parents names if under 16:

Personal Details
Home (correspondence) address: Doctors name and Address:

POSTCODE: POSTCODE:
Phone Number: Phone Number:
E-mail:
Date of Birth: Age: Gender: Main Sport(s):
Have you had an ECG test before? If so, when and where?
Are you taking any medication: If so, please describe?

Ethnicity (please tick the appropriate box)
White Mixed Black Asian Other
British  White and Black Caribbean  Caribbean  Indian  Chinese 
Irish  White and Black African  East African  Pakistani  Filipino 
Turkish /Cypriot  White and Asian  West African  Bangladeshi  Vietnamese 
Greek /Cypriot  North African  Other 
If other, please state your ethnic origin:

Height ……….cm Weight ………..Kg Blood Pressure ………./……….mmHg

1. Have you ever fainted?
During Exercise Yes / No How recently did this occur? If yes, please describe the circumstances
Following Exercise Yes / No How recently did this occur?
Unrelated to exercise Yes / No How recently did this occur?

2. Do you experience dizzy turns?
During Exercise Yes / No How recently did this occur? If yes, please describe the circumstances
Following Exercise Yes / No How recently did this occur?
Unrelated to exercise Yes / No How recently did this occur?

3. Do you experience palpitations? (palpitations are a fluttering in your chest that you can notice whilst resting)
Yes / No If yes, how recently and please describe the circumstances

4. Do you experience chest pain,…...

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