Cardiac Screening Questionnaire Spam protection, skip this field ID Number To be completed by staff member. Full Name Date of Birth Month January February March April May June July August September October November December Day 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 Year 1910 1911 1912 1913 1914 1915 1916 1917 1918 1919 1920 1921 1922 1923 1924 1925 1926 1927 1928 1929 1930 1931 1932 1933 1934 1935 1936 1937 1938 1939 1940 1941 1942 1943 1944 1945 1946 1947 1948 1949 1950 1951 1952 1953 1954 1955 1956 1957 1958 1959 1960 1961 1962 1963 1964 1965 1966 1967 1968 1969 1970 1971 1972 1973 1974 1975 1976 1977 1978 1979 1980 1981 1982 1983 1984 1985 1986 1987 1988 1989 1990 1991 1992 1993 1994 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013 2014 2015 2016 2017 2018 2019 2020 2021 2022 2023 2024 2025 2026 2027 2028 2029 2030 2031 2032 2033 2034 2035 2036 2037 2038 2039 2040 Ethnicity Have you ever been told that you have a heart condition? Yes No If yes, please provide details. Have you ever been told you have high blood pressure, diabetes or a high cholesterol? Yes No If yes, please provide details. Do you currently / or have you ever experienced chest pain whilst exercising or post exercise? Yes No If yes, please provide details. Do you currently or have ever smoked? Yes No If yes, please provide details. Do you currently / or have you ever experienced breathlessness whilst exercising or post exercise? Yes No If yes, please provide details. Do you currently / or have you ever experienced dizziness or have collapsed whilst exercising or post exercise? Yes No If yes, please provide details. Do you currently / or have you ever experienced palpitations whilst exercising or post exercise? Yes No If yes, please provide details. Has any family member or close relative died suddenly of a heart problem or had any unexpected or unexplained sudden death before the age of 50yrs (including drowning, unexplained car accident or sudden infant death syndrome)? Yes No If yes, please provide details. Has any family member or close relative ever had a heart attack, stent or coronary bypass operation under the age of 50yrs? Yes No If yes, please provide details. Has any family member or close relative been diagnosed with: Cardiomyopathy, Marfan Syndrome, Long QT syndrome, short QT syndrome, Brugada syndrome or Ventricular Tachycardia? Yes No If yes, please provide details. How many hours a week do you spend exercising? What sports / exercise do you participate in on a regular basis? Please list any medication you currently take.