The questionnaire below must be completed by each participant:
Heart Screening Questionnaire
Date of birth______/_____/__________
Name of parent or guardian___________________________________
Please circle yes or no to the following questions.
• Do you smoke? Yes/No
• Do you take alcohol? Yes/No
• Have you had an ECG test before? Yes/No
• Are you taking any medication? Yes/No
• Do you have any allergies? Yes/No
1. Has a doctor ever advised you not to participate in sport due to a heart problem? Yes/No.
2. Do you have any heart conditions? Yes/No
3. Are you taking any drugs for your heart? Yes/No
4. Have you ever fainted during or after exercise? Yes/No
5. Have you ever been dizzy during or after exercise? Yes/No
6. Have you ever had chest pains during or after exercise? Yes/No
7. Do you tire more quickly than your friends during exercise? Yes/No
8. Have you ever been told that you have:
High blood pressure? Yes/No
Heart infection? Yes/No
Heart Murmur? Yes/No
9. Have you ever had heart tests carried out by a doctor? Yes/No
10. Have you ever had very rapid heart beating that has begun and ended for no apparent reason? Yes/No
11. Has anyone in your family died before the age of fifty from a heart condition for which no cause was found? Yes/No
12. Has there ever been an incident of drowning/near drowning in your family?
13. Has there ever been an incident of single car collision in your family?
14. Have you ever suffered from any kind of electric shock?
15. Have you ever taken or are you currently taking any form of illegal drugs or stimulants?
16. Are you involved in regular exercise or training? Yes/No
Please explain: ACTIVITY. NO. OF SESSIONS. TOTAL HOURS/WEEK
________________ _________________ ___________________
17. Please tick one box to show which of these best describes you.
I am…..White Black-Caribbean Black-African
Black-other (write in)………………
Height _____________cm Weight______________kg BMI_________________
Blood pressure: Right: Left:
Resting ECG performed Inspiration ? Expiration ?
Please read carefully and sign the declaration below:
I declare that the questions answered by me have been answered honestly; to the best of my knowledge and that the information provided by me is factually correct and accurate, to the best of my knowledge.
I understand that failure to provide accurate and honest information could jeopardise the accuracy of the cardiac risk screening and prevent a true assessment result being provided to me.
I agree to take full personal and financial responsibility for any further referral required* following review of my ECG by the Cardiologist.
I declare that I understand that no form of cardiac risk/heart screening can provide a guarantee that I could or will not suffer from a cardiac event, at some time in my life, following this screening and that the results of this screening represent my cardiac health on this date —– of (month) —– in —–(year).
I declare that all aspects of the cardiac screening have been explained to me and I am aware of the process both during and following the screening.
Further referral and review by a cardiologist will be advised to any participant whose ECG shows signs of abnormality. This is vital as the screening does not include Clinical Review by a Cardiologist.
Tick to agree above term ?
Signature of Participant: ——————————————————-.
Signature of Screening Nurse: ————————————————.
Date: ————————– Time: ————————————–.
The benefits of health screening can be felt by both the employer and the employee alike. Health screening is an effective way of increasing employee morale, and leads to reduced sickness and levels of absenteeism.
Smoking Cessation Programmes, Carbon Monoxide Lung Analysis, Cardiovascular Risk Assessment, Alcohol Awareness/Risk Assessment, Spirometry, Celiac Testing, Weight and Stress Management.