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, heaviness or tightness?
During Exercise Yes / No If yes, please describe the circumstances
Following Exercise Yes / No
Unrelated to exercise Yes / No

5. Do you feel that you are more breathless or more easily tired than your team mates?
Yes / No If yes, please describe the circumstances

6. Is there a family history of (please tick):
High Blood Pressure □ High Cholesterol □ Diabetes □

7. Is there a family history of heart disease in anyone under the age of 50?
Yes / No If yes, how are they related to you, what is the diagnosis? Please state the age of onset

8. Has anyone died suddenly in your family under the age of 50?
Yes / No If yes, how were they related to you? Please describe the circumstances and at what age did the death occur

9. Approximately, how many days per week are you physically active (playing sport)? ……………

10. On average, how many hours per week are you physically active (playing sport)? ………..........

11. If you are competitive athlete what sports do you play and at what level?

e.g. International, A (main sport)………………………. Level: ………………………………….
National, County,
Club, Other B. ……………………………………. Level: ………………………………….

C. ……………………………………. Level: ………………………………….

12. How long (for how many years) have you been participated in sport? …………