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* 1. Full name:

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* 2. Date of birth: (DD/MM/YYYY)

Date

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* 3. Gender:

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* 4. Address:

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* 5. Phone number:

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* 6. Email address:

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* 7. Height (cm):

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* 8. Weight (kg):

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* 9. What is your ethnicity? (Please select all that apply.)

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* 10. Please give the name, address and contact details of your nominated doctor or GP

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* 11. I consent to undergoing the Cardiogenics cardiac screening tests which will include blood pressure tests and electrocardiogram (ECG) and may include a cardiac ultrasound (echocardiogram).

YOUR PERSONAL HISTORY - Have you ever experienced any of the following?

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* 12. Do you have any medical problems?

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* 13. Do you take regular medication?

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* 14. Do you have any allergies?

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* 15. Have you ever had an anaphylactic reaction?

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* 16. Do you suffer from chest pain, chest heaviness or tightness during or following exercise?

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* 17. Do you feel more short of breath or tire more easily during exercise when compared to your team-mates?

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* 18. Have you ever fainted or blacked out during or after exercise or had an unexplained fainting episode?

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* 19. Have you ever experienced dizzy turns during or after exercise?

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* 20. Do you have palpitations? (Racing heartbeat or unexpected, fast or irregular heartbeat)

Have you ever been told that you have:

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* 21. A heart murmur 

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* 22. A heart infection

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* 23. High blood pressure

YOUR FAMILY HISTORY - Please confirm details with relatives where possible.
Have either of your parents, brothers or sisters suffered from:

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* 24. Heart attack or sudden unexplained death aged 50 or less?

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* 25. Heart rhythm problems requiring pacemaker or other treatment?

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* 26. Angina, heart pain under the age of 50 years?

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* 27. Any heart condition such as cardiomyopathy, long QT syndrome or been diagnosed with Marfan's syndrome?

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* 28. Any additional relevant details:

You have been asked to fill out this medical questionnaire on your own behalf. This questionnaire has been devised to aid in identification of young people who currently engage in competitive sport, but who could be at risk of suffering a serious cardiac event. This is not a common occurrence. The number of events can however be reduced by careful evaluation of symptoms and family history.
No screening system can guarantee 100% accuracy. If you answer “Yes” to any of these questions, you may be required to undertake further tests or referred to a Physician for further investigation. It is very important that you answer these questions honestly. You must however be aware that it is possible that as a result of this process you could potentially be disqualified from participation in your chosen sport.

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* 29. I confirm that I have read and understood the above information, and that the information I have given is accurate to the best of my knowledge.

You can read the Cardiogenics Data Protection Policy Statement here

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