Pediatric Sudden Cardiac Death Risk Assessment Form

Are there any relatives with certain conditions, such as:

Enlarged Heart: Hypertrophic cardiomyopathy (HCM)*

YesNo

Dilated cardiomyopathy (DCM)*

YesNo

Heart Rhythm problems: Long QT syndrome (LQTS)*

YesNo

Short QT syndrome*

YesNo

Brugada syndrome*

YesNo

Catecholaminergic ventricular tachycardia*

YesNo

Arrhythmogenic right ventricular cardiomyopathy (ARVC)*

YesNo

Marfan syndrome (aortic rupture)*

YesNo

Heart attack, age 50 or younger*

YesNo

Pacemaker or implanted defibrillator*

YesNo

Deaf at birth (congenital deafness)*

YesNo

Please explain more about any "yes" answers here:

Parent Signature

Date*

Date

Please print your name

What is your relationship to the patient?

Visit www.choa.org/heart for more information. If we can help you with any screening questions contact the Cardiac Call Center at 404-256-2593 (800-542-2233) or info@kidsheart.com.

Child's Name*

Gender*

MF

Child's Birthdate:

Month*

Day*

Year*

Age*

School Grade*

Parent's Name*

Today's Date:

Month*

Day*

Year*

Instructions: Below are a number of common problems that children have. Please rate each item according to your child's behavior in the last month. For each item, ask yourself, "How much of a problem has this been in the last month?", and mark the best answer for each item. If none, not at all, seldom, or very infrequently, you would mark "NOT TRUE AT ALL". If very much true, or it occurs very often or frequently, you would mark "VERY MUCH TRUE". You would mark "JUST A LITTLE TRUE" or "PRETTY MUCH TRUE" for ratings in between. Please respond to all the items.

Restless or overactive*

NOT TRUE AT ALL (Never, Seldom)JUST A LITTLE TRUE (Occasionally)PRETTY MUCH TRUE (Often, Quite a Bit)VERY MUCH TRUE (very Often, Very Frequent)

Excitable, impulsive*