Should Athletes be Screened Better for Heart Defects?

By
Margaret Anne Rich

A Research Project Proposal
Submitted to the Graduate School of
Northwestern State University of Louisiana
In partial fulfillment of the requirements for the
Master of Science in Health and Human Performance
With concentration in Sport Administration

April 2013

Abstract
The purpose of this study is to determine if college athletes that are predisposed to heart defects develop a heart defect during their athletic career. The researcher will conduct a causal comparative study to prove that college athletes that are predisposed to heart defects develop one during their athletic career. The study will examine college athletes that are predisposed to heart defects and do not realize they are at risk for possible development of a heart defect during their athletic career. Knowing an athlete’s family and medical history could help prevent a great deal of possible health conditions. Athletes have a higher risk of developing a higher risk if they are predisposed. There are athletes that do not realize that they are predisposed to heart defects and that they could develop one.

Table of Contents Introduction 5 Background 5 Theoretical Framework 6 Statement of the problem. 6 Research question. 6 Purpose for the study. 7 Significance 7 Limitations of the Study 7 Definitions of Terms 8 Arrhythmias 8 Athletic Career 8 Electrocardiogram 8 Hypertrophic cardiomyopathy: 8 Sudden Cardiac Death: 8 Review of Related Literature 9 What is causing the sudden death of young athletes? 9 Successful Prevention 10 Role of NCAA 11 Summary 12 Methodology 13 Design 13 Setting and Participants 13 Data Collection 14 Treatment of the Data 14 Implications for Future Research 15 References 16 Appendix A 16 Appendix B 21 Appendix C 22

Introduction
Background
Sudden cardiac death of young athletes is becoming more and more known. There is a variety of reasons as to what is causing this to happen. Most of them are caused by a young athlete going into cardiac arrest. The things causing the cardiac arrest are Hypertrophic cardiomyopathy (HCM), Arrhythmias, Coronary Artery Abnormalities, Long QT Syndrome (LQTS), Myocarditis, and Ruptured aortic aneurysm or Marfan’s Syndrome. There is also a very rare cause called commotion cordis. This blow to the chest could trigger ventricular fibrillation if it strikes at the exact wrong time. “According to the Minneapolis Heart Institute Foundation, a leading center for research in the field, there are more than 30 identified causes of sudden death in athletes” (Ramnarace, 2011). .
Student athletes have to get physicals every year. During the physicals they screen an athlete’s heart and lungs. As with most things there are some university’s that cannot afford to pay for better screening. “The cost of adding an ECG to the screening program has been a central argument against its routine use” (Wheeler, Heidenreich, Froelicher, Hlatky, & Ashley, 2010, pp. 276-286)
The NCAA has taken every precaution necessary and they have a fact sheet for student athletes that explain heart disease in student-athletes and sudden cardiac death. The main way that the NCAA is protecting their athletes from sudden cardiac death or any type of catastrophic incident is they have a set of guidelines that they follow. “Sudden cardiac death during sports is often the first and definitive manifestation of an underlying cardiovascular disease, which usually has a silent clinical course” (Corrado, Basso, Schiavon, Pelliccia, & Thiene, 2008, pp. 1981-1989). Heart defects are becoming more common in college athletes than people realize. There are ways that team physicians screen their athletes and there are a few occasions where the physicals that are given have to be taken further with other preventative measures. The NCAA has done everything in its power to make sure that they have guidelines and plans in case sudden cardiac death does happen.
Theoretical Framework
When it comes to the safety of college student athletes, there is a list of people who try to take as good of care of them as they can. Sometimes, things do not work out the way that people think they should. Most student athletes do not realize the different risks they take when they step out on the field or court. There are some student athletes that do not ever have to worry about these risks. Unfortunately there are some student athletes that have to learn about these risks the hard way when they lose a team mate to sudden cardiac death.
Statement of the problem. A growing concern and problem with student athletes to day is different cardiac problems. All athletes come from different backgrounds, geological and health wise, within the past several years there have been more and more sudden deaths caused by different heart defects that do not show up on an athlete’s physical. There are many different dynamics and causes of heart defects. They can pop up without any family history and without any warning. Family dynamics can help majorly when trying to diagnose an athlete with a heart defect and prevent them from sudden cardiac death. With these thoughts in mind should student athletes be screened better for different heart defects?
Research question. College student athletes put themselves at risk every day. Most do not realize that they put themselves at a greater risk than others. Thus, the researcher poses the question: Should athletes that are predisposed to a heart defect be checked differently throughout their college career to see if they have developed a defect?
Purpose for the study. A causal-comparative study will be conducted to determine if athletes that are predisposed to heart defects develop a heart defect during their athletic career. It will show what the different types of heart defects that do not show up on a routine physical done yearly. With more athletes are suffering from sudden cardiac death, more precautions should be taken with athletes that are predisposed to heart defects. The results from this study will show that there are more student athletes that do not know they are predisposed to heart defects than those that are not.
Significance
The idea behind the study is to show that there are athletes predisposed to heart defects based on their genealogy and genetics and do not know about it. The way that athletes are screened for heart defects cannot show that they have a possible life threatening heart defect.
One method involves the use of a cardiologist and a test being run on the athletes’ heart. If, through this study, the researcher finds that there is a relationship between athletes predisposed to heart defects and those athletes that develop a heart defect during their athletic career, there is a possibility that more athletes’ lives could be extended.
Limitations of the Study
The design used in this study is a basic causal-comparative design. There will be two groups in this study. The experimental group will be college student athletes predisposed to heart defects based on genealogy and genetics. The control group will not be predisposed to heart defects and do not display any symptoms of having one. The dependent variable in this study is the heart defect. Once the athletes are split up into the two classes they can start to run EKG’s on the on the athletes with known heart defects and the ones that are predisposed to them. The limitations of this study are that the athletes are self-reporting symptoms and knowing the health history of their family. Based on the 2013 Louisiana Medicare Fee Schedule times 200%, college’s need to be prepared to pay somewhere in the range of $160-$250 for an EKG per athlete. Questions of validity and reliability in the study will be answered by adhering to the standards set by the team physician, head athletic trainer, and NCAA regulations.
Definitions of Terms
In order for the reader to have a basic understanding of this proposal, the following terms are defined:
Arrhythmias: An arrhythmia is an abnormal rhythm, mainly from a change in electrical impulses, in a person’s heart. (About Arrhythmias)
Athletic Career: Athletic career is comprised of Athletes who compete in team sports, such as football, hockey, baseball or basketball, get their training by participating on high school, college or club teams. (McKay, n.d.) Electrocardiogram: Electrocardiogram, also known as EKG, is a test measures electrical activity in a person’s heart. (Electrocardiogram) Hypertrophic cardiomyopathy: Hypertrophic Cardiomyopathy, also known as HCM, is associated with thickening of the heart muscle, most commonly at the septum between the ventricles, below the aortic valve. (Heart Disease and Hypertrophic Cardiomyopathy)
Sudden Cardiac Death: Sudden Cardiac Death, also known as SCD, is an unexpected death due to cardiac causes occurring in a short time period, which is generally within 1 h of symptom onset, in a person with known or unknown cardiac disease. (Sovari, MD)

Review of Related Literature The purpose of this review of related literature is to examine the different steps and ideas for what can be done to prevent sudden cardiac death in student athletes. With this sudden cardiac death in student athletes epidemic on the rise precautions need to start being done to prevent it. The American Academy of Orthopaedic Surgeons states that additional testing and/or consultations should be done. They also say that modification or preclusion of activity, screening evaluation for prevention of illness in family members, and emergency action plans for all practices and competitions should be put into place.

What is causing the sudden death of young athletes? Sudden cardiac death of young athletes is becoming more and more known. There is a variety of reasons as to what is causing this to happen. Most of them are caused by a young athlete going into cardiac arrest. The things causing the cardiac arrest are Hypertrophic cardiomyopathy (HCM), Arrhythmias, Coronary Artery Abnormalities, Long QT Syndrome (LQTS), Myocarditis, and Ruptured aortic aneurysm or Marfan’s Syndrome. There is also a very rare cause called commotion cordis. This blow to the chest could trigger ventricular fibrillation if it strikes at the exact wrong time. “According to the Minneapolis Heart Institute Foundation, a leading center for research in the field, there are more than 30 identified causes of sudden death in athletes” (Ramnarace, 2011). Dr. Wesley Covitz states hypertrophic cardiomyopathy accounts for half of sudden cardiac deaths a year. HCM is the second most cause of sudden death. HCM is caused when the myocardium becomes abnormally thick. This makes it harder for the heart to pump blood. “Hypertrophic cardiomyopathy, while usually not fatal in most people, is the most common cause of heart-related sudden death in people under 30” ("Sudden Death in Young," 2011). Since most athletes have an enlarged heart it is easy to see why this is possible to happen. Arrhythmias are abnormal heart rhythms. “Arrhythmia and conduction alterations are common in the trained athlete and recommendations for their evaluations are available” (Baggish & Wood, 2011, pp. 2723-2735). The most common type of arrhythmia is called ventricular fibrillation. If it is left untreated death can occur in a matter of minutes. One way that physicians are treating people who have HCM is an implantable cardioverter-defibrillator. This is similar to a pacemaker and if something were to happen it delivers electrical shock to restore a person’s normal heart beat.
Successful Prevention Student Athletes have to get physicals every year. During the physicals they screen an athlete’s heart and lungs. The team physician checks to see if the athlete has a heart murmur. If they hear a murmur they do not clear them for play and send them to a Cardiologist to get checked out. The best way for a cardiologist to screen for hypertrophic cardiomyopathy or most heart defect is to have an electrocardiogram (EKG). The EKG “shows a 3-D view of the heart...” (O’Connor, 2012). It can show if there is thickening within the walls of the heart. This is called HCM.
Better Screenings As with most things there are some university’s that cannot afford to pay for better screening. “The cost of adding an ECG to the screening program has been a central argument against its routine use” (Wheeler, Heidenreich, Froelicher, Hlatky, & Ashley, 2010, pp. 276-286). There are some schools that can afford to pay for the proper screening but do not want to pay for it. “In some areas, high schools offer student athletes EKGs at deeply discounted rates” (O’Connor, 2012). This unfortunately is not true in every state or region. The “Cost-effectiveness calculations for the inclusion of ECG in the preparticipation screening of athletes will differ significantly depending on the incidence rate used” (Harmon, Asif, Klossner, & Drezner, 2011, pp. 1594-1600).
Role of NCAA The NCAA has a fact sheet for student athletes that explain heart disease in student-athletes and sudden cardiac death. The motto on the fact sheet for when athletes report their symptoms is “Put pride aside: Don’t diagnose yourself” (A Fact Sheet for Student-Athletes, n.d.).. The main way that the NCAA is protecting their athletes from sudden cardiac death or any type of catastrophic incident is they have a set of guidelines that they follow. It consists of ten different steps and is has been revised several times. The steps are definition of a catastrophic incident, a management team, immediate action plan, chain of command/role delineation, criminal circumstances, away contests responsibilities, phone list and flow chart, incident report, notification process, and assistance to visiting team’s catastrophic incident as host institution. The first step the NCAA defines a catastrophic incident as the sudden death of a student-athlete, coach or staff member from any cause, or disabling and/or quality of life altering injuries. When talking about a management team the NCAA compiles the team of “one or more than the following: director of athletics, head athletic trainer, university spokesman, director of athletic communications and university risk manager” (NCAA, 2008). The management team works together to communicate all important information to family members, coaches, teammates, staff, the institution, and media. The third step is the immediate action plan. The immediate action plan is first call 9-1-1, then starts CPR, if applicable use an AED, and continue until the EMS arrive. The chain of command/role delineation outlines the responsibility each person as to what needs to be done with the aftermath of a catastrophe. The people involved in this are athletic administrators, university administrators, and support services personnel. The NCAA has an outline for athletic departments to collaborate with university, state, and local police when there is any type of catastrophic event. In the event that a catastrophic event happens during an away game the NCAA says for a university to have an individual to represent the university and stay behind with the athlete. All emergency contact information should be provided for each athlete that is traveling. They should also travel with a phone number for the university’s legal counsel and the NCAA catastrophic injury service. The next step is to write an incident report chronologically of how the event happened. After that begins the notification process. The athletic director, head athletic trainer, or head coach should contact the parent or guardian of the athlete. The last step is to make sure that the home team is always prepared for a catastrophic event, and in the event that the visiting team have one occur, be prepared to offer assistance.
Summary
“Sudden cardiac death during sports is often the first and definitive manifestation of an underlying cardiovascular disease, which usually has a silent clinical course” (Corrado, Basso, Schiavon, Pelliccia, & Thiene, 2008, pp. 1981-1989). . Heart defects are becoming more common in college athletes than people realize. There are ways that team physicians screen their athletes. There are a few occasions where the physicals that are given have to be taken further. The NCAA has done everything in their power to make sure that they have guidelines and plans incase sudden cardiac death does happen.

Methodology
A causal-comparative study will be conducted for the purpose of figuring out if athletes that are predisposed to heart defects develop a heart defect during their athletic career. In this chapter the following issues related to the proposed study will be addressed: design, setting and participants, data collection, and treatment of data. Also, implications for future research will be examined.
Design
The method of research that will be used is a causal-comparative study. McGraw-Hill defined a causal-comparative research attempts to determine the cause or consequences of differences that already exist between or among groups of individuals.. This study is mainly focused on the relationship between two or more people and how it affects the person contract and correlation.
This type of research will be used because the causal-comparative study can be done because it seeks to identify the factor that leads to a difference (Gay, Mills, & Airasian, 2012, pp. 227-236). The limitations of a causal-comparative study are that the experimenter has limited control and only relations are established. There is caution during interpretation because a cause-effect relationship cannot be established.
Setting and Participants
The target population for this study includes all college student athletes in Louisiana predisposed to heart defects. The accessible population is student athletes at Northwestern State University. The study's sample will be a stratified sample that consists of student athletes who get yearly routine physicals and are not diagnosed with HCM. All athletes will receive their routine yearly physical. Through family history forms, trainers will decide and figure out which athletes need to be screened for different types of heart defects. Athletes’ parents will have a letter to sign clearing their child for play and care by the team physician (Appendix A). IRB approval will need to be obtained prior to beginning this study.
Data Collection
The design used in this study is a basic causal-comparative design. There will be two groups in this study. The experimental group will be college student athletes predisposed to heart defects based on genetics and genealogy. The control group with be college student athletes not predisposed to heart defects and do not show symptoms of a heart problem. The dependent variable in this study is the heart defect.
The instrument used to collect the data is the physical form (Appendix B) and history form (Appendix C). The physical form is what is used at the college level based off of the NCAA guidelines, and the history form is there to get an athlete’s family history.
EKG’s will be performed on predisposed athletes who show symptoms of heart problems and athletes that show symptoms of heart problems. Additionally, EKG’s will be run on athletes who are predisposed with no symptoms. The control group will not have EKG’s run since they are so costly. The college should be prepared to pay between $160 to $250 per athlete, based on the 2013 Louisiana Medicare Fee Schedule times 200%.
Questions of validity and reliability in the study will be answered by the standards set by the team physician, head athletic trainer, and NCAA regulations.
From these results, this study will attempt to determine if there if athletes predisposed to heart defects develop a heart defect during their athletic career.
Treatment of the Data
The causal comparative data will be analyzed using a t-test to find significant differences in the group of college student athletes predisposed to heart defects based on genetics and genealogy and the group of college student athletes not predisposed to heart defects and do not show symptoms of a heart problem.
Implications for Future Research The researcher hopes to report a relationship between athletes predisposed to heart defects and those athletes that develop a heart defect during their athletic career. Based on findings outlined in the previous chapter, heart defects are becoming more common in athletes. Should the findings of this study suggest that there is a relationship athletes predisposed to heart defects and those athletes that develop a heart defect during their athletic career then further research/testing should be considered by using other strategies.

References

A Fact Sheet For Student-Athletes [Fact sheet]. (n.d.). Retrieved from NCAA website: http://www.ncaa.org/wps/wcm/connect/public/ncaa/health+and+safety/cardiac+homepage/resources/cardiac+fact+sheet+for+student+athletes About Arrhythmias. (n.d.). Retrieved from American Heart Association: http://www.heart.org/HEARTORG/Conditions/Arrhythmia/AboutArrhythmia/About-Arrhythmia_UCM_002010_Article.jsp Baggish, A. L., & Wood, M. J. (2011). Athlete's Heart and Cardiovascular Care of the Athlete:Scientific and Clinical Update. Circulation, 123, 2723-2735. Catastrophic Incident in Athletics. (2008). In NCAA (Ed.), NCAA Guidelines (pp. 16-17). Corrado, D., Basso, C., Schiavon, M., Pelliccia, A., & Thiene, G. (2008). Pre-Participation Screening of Young Athletes for Prevention of Sudden Cardiac Death. Journal of the American College of Cardiology, 52(24), 1981-1989.

Covitz, W. (2012, June 28). Screening for Heart Defects in Young Athletes. Retrieved from Wake Forest Baptist Health website: http://www.wakehealth.edu/Health-Central/Screening-for-Heart-Defects-in-Young-Athletes/

Electrocardiogram. (n.d.). Retrieved from WebMD: http://www.webmd.com/heart-disease/electrocardiogram

Gay, L. R., Mills, G. E., & Airasian, P. (2012). Causal-Comparative Research. In Educational Research: Competencies for Analysis and Applications (10th ed., pp. 227-236). Boston, MA: Pearson.

Harmon, K. G., Asif, I. M., Klossner, D., & Drezner, J. A. (2011). Incidence of Sudden Cardiac Death in National Collegiate Athletic Association Athletes. Circulation, 123, 1594-1600.

Heart Disease and Hypertrophic Cardiomyopathy. (n.d.). Retrieved from WebMD: http://www.webmd.com/heart-disease/guide/hypertrophic-cardiomyopathy

Heart Disease in Student Athletes [Fact sheet]. (n.d.). Retrieved from NCAA website: http://www.ncaa.org/wps/wcm/connect/public/ncaa/health+and+safety/cardiac+homepage/resources/overview+of+heart+disease+in+student+athletes

January 2013 Medicare Physician's Fee Schedule-Louisiana Locality 99. (2013, January). Retrieved from Novitas-Solutions: https://www.novitas-solutions.com/partb/reimbursement/phy-fee/la/pdf/2013/la9913.pdf

Main Points [Fact sheet]. (n.d.). Retrieved from How to Design and Evaluate Research in Education website: http://highered.mcgraw-hill.com/sites/0072981369/student_view0/chapter16/main_points.html

McKay, D. R. (n.d.). Athlete: Career Information. Retrieved from About Career Information website: http://careerplanning.about.com/od/occupations/p/athlete.htm

O'Connor, A. (2012, April 30).Should Young Athletes be Screened for Heart Risk.Retrieved from NY Times.com website: http://well.blogs.nytimes.com/2012/04/30/heart-risk-in-athletes-is-gaining-attention/?pagewanted=print

Ramnarace, C. (2011, March 8). 7 Ways to Protect Your Young Athlete from Sudden Cardiac Death. Retrieved from Everyday Health website: http://www.everydayhealth.com/heart-health/0108/ways-to-protect-your-young-athlete-from-sudden-cardiac-death.aspx

Selected Issues in Injury and Illness Prevention and the Team Physician: A Consensus Statement.(n.d.). American Academy of Orthopaedic Surgeons, 1-21. Retrieved from http://www.aaos.org/about/papers/advistmt/1031.asp

Sovari, MD, A. A. (n.d.). Sudden Cardiac Death. Retrieved from Medscape Reference: http://emedicine.medscape.com/article/151907-overview Sudden death in young people-Heart problems often blamed. (2011, May 19). Retrieved from Mayo Clinic website: http://www.mayoclinic.com/health/sudden-death/HB00092/METHOD=print

Wheeler, M. T., Heidenreich, P. A., Froelicher, V. F., Hlatky, M. A., & Ashley, E. A. (2010). Cost Effectiveness of pre-participation Screening for Prevention of Sudden Cardiac Death in Young Athletes. Ann Intern Med, 152(5), 276-286.

Appendix A
Athletic Program Liability Release and Waiver
Notice: This document contains important terms and conditions which affect your legal rights. PLEASE READ CAREFULLY

1. I am aware that playing or practicing in any type of sport or athletics can be a dangerous activity involving many risks of injury. I understand that the dangers and risks of playing or practicing any type of sport or athletics include, but are not limited to, death, paralysis, dismemberment, and serious injury or impairment to other aspects of my body, general health and well-being.
2. I understand that the risk of injury inherent in any sport or athletic activity depends in part upon the general health and physical condition or limitations of the individual participant. I have been examined by and consulted with my personal physician, or a physician or other health care professional employed by Northwestern State University, in order to determine whether and to what extent I am fit to participate in such activities. I certify that I am aware of no health-related reasons or problems which preclude or restrict my participation in athletic activities. I understand that any physical examination performed by the Northwestern State University Athletic Training Department is necessarily limited in scope and should not be deemed a substitute for a comprehensive physical examination performed by my personal physician. I understand that Northwestern State University recommends that all students regularly visit their personal physician to monitor their general health.
3. I have weighed the dangers inherent in participating in sports activities, the risks presented by my own health and physical condition, and my personal desire to participate in sports activities. I have concluded that the risks inherent in my participation, both in general and as affected by my individual health and physical condition, are acceptable.
4. In consideration of and return for the services, facilities and other assistance provided to me by Northwestern State University in my association (or proposed association) with a Northwestern State University athletic team or program, and for Bentley University permitting me to engage in all activities related to the team, I;
A. voluntarily assumes all risks associated with my participation;
B. waive any right to make a claim or demand against Northwestern State University, its trustees, agents, servants, employees, and its athletic staff (collectively, the “University”) arising out of my participation;
C. on behalf of myself and my heirs, release the University from any and all liability, claims, causes of action or demands of any kind or nature whatsoever which might arise by or in connection with my participation;
D. agree to defend, indemnify and hold harmless the University from and against any and all liability, claims, causes of action or demands of any kind or nature whatsoever which might arise by or in connection with my participation.
5. I am of sound mind and body. I have carefully read the foregoing document. I understand its contents, I am aware that by signing this document I am giving up legal rights and it is my intent to do so. I sign this document of my own free will and violation and with full appreciation of the consequences of doing so.
Signature: _____________________________________________ Dated: ____________
Print name: ____________________________________________

I/We are the parents/legal guardians of . He/She has my/our permission to participate in athletic programs at Northwestern State University. I/We have carefully read the foregoing document and understand its terms and effects. I/We agree to be bound by it and by the expressed desires of my/our son/daughter/ward.
Signature: _____________________________________________ Dated: ____________
Print name: ____________________________________________

Appendix B
Northwestern State University
Athletic Physical Examination Form

Date ___/___/____ Sex M / F Sport ___________________

Athlete Name ___________________________ _____________________________ ______ Last First Mid. In.

Age _____ DOB ___/___/____ HT _____ WT _____ B/P ____/____ Pulse _____

Regular Medications ____________________________________________________________________

Allergic Reactions ______________________________________________________________________

Surgeries _____/__________________ _____/___________________ Year Body Part Year Body Part

Fractures _____/__________________ _____/___________________ Year Body Part Year Body Part

Pre-existing Conditions ____________________________________________________________________________________________________________________________________________________________

Cleared Comments
EENT ______ __________________________________________________
Heart ______ __________________________________________________
Lungs ______ __________________________________________________
Abdomen ______ __________________________________________________
Hernia ______ __________________________________________________
Neurological ______ __________________________________________________
Orthopedic ______ __________________________________________________
Recommended for Participation YES NO

Comments ____________________________________________________________________________________________________________________________________________________________

_____________________________________ ___/___/____
Physician Signature Date

Appendix C
Athlete Family History Form
Demographics
Name: ______________________________________________ Sport: _____________
Date of Birth: ___________________ Gender: Male Female
Personal History
Please check any of the conditions that you currently have or have had in the past. General | Yes | No | | General | Yes | No | Fever or Chills | | | | Double, failing vision | | | Recent weight change | | | | Dry eyes | | | Fatigue | | | | Pain or light sensitivity | | | Heat or cold intolerance | | | | Cardiovascular | | | Recent changes in mood | | | | High blood pressure | | | Head and Neck | | | | High Cholesterol | | | Swelling in neck | | | | Diabetes | | | Prolonged hoarseness | | | | Heart Failure | | | Frequent sore throat | | | | Heart Murmur | | | Pain or stiffness in neck | | | | Heart skips beats | | | Skin | | | | Heart beats too fast | | | Rash, dryness, itching | | | | Passing out spells | | | Ears, Nose, Mouth | | | | Feet, ankle or leg swelling | | | Nose bleeds | | | | Short of breath at rest | | | Sinus Problems | | | | Short of breath with exercise | | | Hearing loss | | | | Problems sleeping | | | Eyes | | | | Frequent Urination | | | Abdominal pain | | | | Stomach ulcer | | | Lungs | | | | Endocrine | | | Wheezing | | | | Night sweats | | | Asthma | | | | Excessive thirst | | | Musculoskeletal | | | | Psychiatric | | | Arm or leg weakness | | | | Depression | | | Leg cramps | | | | Anxiety | | | Inflammatory disease (i.e. psoriasis) | | | | Nervous breakdown | | | Neurologic | | | | Alcohol Problem | | | Light head or dizziness | | | | Drug Problem | | | Convulsions or seizures | | | | Physical, verbal, sexual abuse | | | Numbness or tingling | | | | | | | Frequent headaches | | | | | | | Concussions | | | | | | | Genitourinary | | | | | | | Burning or painful urination | | | | | | | Blood in urine | | | | | | | Bladder infections | | | | | | | Kidney stones | | | | | | | Irregular menses (female only) | | | | | | | Gastrointestinal | | | | | | | Rectal bleeding | | | | | | | Blood in stool | | | | | | | Loss of appetite | | | | | | | Heartburn or indigestion | | | | | | | Difficulty swallowing | | | | | | | Nausea or vomiting | | | | | | |
Please include any other conditions you would like to discuss with our team physician: __________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

Past Medical History
List all medical problems for which you are currently or previously been treated. Include hospital visits, surgeries and ALL DISEASES/ILLNESS YOU HAVE BEEN DIAGNOSED WITH

Condition | Year | | Condition | Year | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | |

Medications
List type and amount of medication you use on a regular basis. Include prescription, over- the- counter, birth control, hormones, vitamins, herbs, nutritional supplements, and recreational drugs

Medication | Dosage/Frequency | Reason for Taking | Started: mo/yr | | | | | | | | | | | | | | | | | | | | | | | | | | | | |

Allergies
List any allergy and type of reaction (include medications, food, season; environmental (i.e. cats, dogs, latex, smoke, etc.)

No known Drug Allergies

Allergy to Description of Reaction | Allergy to Description of Reaction | | | | | | | | | | | | |

Family History
Please complete as much of this section as possible.

Medical Condition | Mom | Dad | Sister | Brother | Daughter | Son | GrandparentsMGF/MGMPGF/PGM | Comments | Indicate approximate age disease first identified: | | High Blood Pressure | age | age | age | age | Age | age | age | | High Lipids | age | age | age | age | Age | age | age | | High Cholesterol | age | age | age | age | Age | age | age | | Diabetes (type 1/type2) | age | age | age | age | Age | age | age | | Heart Attack | age | age | age | age | Age | age | age | | Heart Failure | age | age | age | age | Age | age | age | | Heart surgery/stent/balloon | age | age | age | age | Age | age | age | | Angina (heart pain) | age | age | age | age | Age | age | age | | Leg circulation problem | age | age | age | age | Age | age | age | | Failing kidneys | age | age | age | age | Age | age | age | | Stroke | age | age | age | age | Age | age | age | | Smoking | age | age | age | age | Age | age | age | | Dementia/ Alzheimer’s | age | age | age | age | Age | age | age | | Alcoholism | age | age | age | age | Age | age | age | | Arthritis | age | age | age | age | Age | age | age | | Birth Defects | age | age | age | age | Age | age | age | | Hearing Problems | age | age | age | age | Age | age | age | | Sudden Death | age | age | age | age | Age | age | age | | Genetic Diseases | age | age | age | age | Age | age | age | | Age & L=LivingD=Deceased | Mom | Dad | Sister | Brother | Daughter | Son | GrandparentsMGF __________MGM _________PGF ___________PGM __________ | Comments | *MGF=Maternal Grandfather, MGM=Maternal Grandmother, PGF=Paternal Grandfather, PGM=Paternal Grandmother |

Please include any other details related to your family history or concerns you would like to discuss with our team physician: ____________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________