Psychiatry ADHD Cardiac Questionnaire Form

Name*

First Last

Email*

Date of Birth*

Current Medications

Please list your current medications, including any health supplementations or natural food supplements

Have you or anyone in your family ever lost consciousness or fainted?*

Yes
No

Have you or anyone in your family ever lost consciousness or fainted DURING or AFTER EXERCISE?*

Yes
No

Have you ever had chest pain, chest discomfort, or shortness of breath DURING EXERCISE?*

Yes
No

Have you ever had an unexplained, noticeable change in exercise tolerance, where you became tired for no reason?*

Yes
No

Have you ever had palpitations of the heart, heart racing without reason, or extra or skipped heart beats?*

Yes
No

Have you ever had a heart murmur OTHER THAN an innocent/benign heart murmur, or history of any other heart problem?*

Yes
No

Have you ever had high blood pressure, high cholesterol, or a heart infection?*

Yes
No

Has a doctor ever ordered a test for your heart such as an ECG or echocardiogram?*

Yes
No

Have you or anyone in your family ever had a seizure?*

Yes
No

Have you ever had rheumatic fever, or disease of the heart valves?*

Yes
No

Has anyone in your family died suddenly for no apparent reason, for example, by drowning, or a car accident, or by just dropping over?*

Yes
No

Has anyone in your family under age 50 died suddenly from a cardiac cause or had a heart attack?*

Yes
No

Has anyone in your family under age 40 ever required resuscitation– for example, fainting and needing someone to revive him or her?*

Yes
No

Has anyone in your family died suddenly during exercise?*

Yes
No

Has anyone in your family had abnormal rhythms of the heart, cardiomyopathy or problems with the heart muscle, Wolff-Parkinson-White syndorme, long QT syndrome, or any other heart syndrome?*

Yes
No

Is there anyone in the family with Marfan syndrome?*

Yes
No

Comments

Please explain all “YES” answers here, or note any other concerns you have about your heart health or that of family members