8. Has a doctor ever told you that you have any heart problems? If so, check all that apply:
High blood pressure High cholesterol ___
Kawasaki disease ___
A heart murmur ___
A heart infection ___
Other: _____________________
9. Has a doctor ever ordered a test for your heart? (For example, ECG/EKG, echocardiogram)
10. Do you get lightheaded or feel more short of breath than expected during exercise?
11. Have you ever had an unexplained seizure?
12. Do you get more tired or short of breath more quickly than your friends during exercise?
HEART HEALTH QUESTIONS ABOUT YOUR FAMILY
Yes No
Yes No
Yes No
13. Has any family member or relative died of heart problems or had an unexpected or unex-
plained sudden death before age 50 (including drowning, unexplained car accident, or sud-
den infant death syndrome)?
14. Does anyone in your family have hypertrophic cardiomyopathy, Marfan syndrome, ar-
rhythmogenic right ventricular cardiomyo pathy, long QT syndrome, short QT syndrome, Bru-
gada syndrome, or catecholaminergic polymorphic ventricular tachycardia?
15. Does anyone in your family have a heart problem, pacemaker, or implanted defibrillator?
16. Has anyone in your family had unexplained fainting, unexplained seizures, or near
drowning?
BONE AND JOINT QUESTIONS
17. Have you ever had an injury to a bone, muscle, ligament, or tendon that caused you to
miss a practice or a game?
18. Have you ever had any broken or fractured bones or dislocated joints?
19. Have you ever had an injury that required x-rays, MRI, CT scan, injections, therapy, a
brace, a cast, or crutches?
20. Have you ever had a stress fracture?
21. Have you ever been told that you have or have you had an x-ray for neck instability or
atlantoaxial instability? (Down syndrome or dwarfism)
22. Do you regularly use a brace, orthotics, or other assistive device?
23. Do you have a bone, muscle, or joint injury that bothers you?
24. Do any of your joints become painful, swollen, feel warm, or look red?
25. Do you have any history of juvenile arthritis or connective tissue disease?
MEDICAL QUESTIONS
26. Do you cough, wheeze, or have difficulty breathing during or after exercise?
27. Have you ever used an inhaler or taken asthma medicine?
28. Is there anyone in your family who has asthma?
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