Pre-Screening Questionnaire and Consent Form

Pre-Screening Questionnaire and Consent Form

Pre-Screening Questionnaire and Consent Form

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ECHO SCREENING QUESTIONNAIRE AND CONSENTThis form must be completed before your test. If you are under the age of 18, yourParent or Legal Guardian must assist you with completing the form <strong>and</strong> must also sign it.Today’s Date:_____________Patient Name: ______________________________________ Date of Birth:______________Address:______________________________________________________________Emergency Contact, Name & Number:_______________________________________Physician Name_________________________________________________________Physician Phone Number_________________________________________________PLEASE ANSWER the following questions by circling the appropriate answer:1. Have you ever been under the care of a cardiologist/heart doctor? Yes / No2. Have you ever been told that you have high blood pressure? Yes / No3. Have you ever stopped, or significantly slowed down, during anactivity for any of the following reasons:a. You felt faint or dizzy Yes / Nob. You had chest pain Yes / No4. Have you ever passed out or lost consciousness? Yes / No5. Do you ever feel overly tired during or after exercising? Yes / No6. Has your heart beat ever been too fast to count? Yes / No7. Does your heart ever skip beats during activity? Yes/No8. Have you had trouble breathing for any reason in the past 12 months? Yes/No

CONSENT:I consent to the performance of a cardiac diagnostic screening test. I underst<strong>and</strong> what thetest consists of, <strong>and</strong> that the test result may be an indicator of a potential medicalabnormality <strong>and</strong> does not constitute a complete medical exam on which I can rely. Tounderst<strong>and</strong> the result of this screening, <strong>and</strong> to obtain a diagnosis of a medical problem, Iunderst<strong>and</strong> that I must see a physician for a complete medical exam. I underst<strong>and</strong> thatthe test results will be mailed to the address above, <strong>and</strong> that any critical results will becommunicated to me <strong>and</strong>/or the emergency contact identified above via telephone.Signature: _________________________________________ Date:_____________________Patient or Parent/Legal Guardian if under 18Printed Name:_______________________________________Parent/Legal Guardian

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