SADS School Risk Assessment 

Parents, answer these questions (or have your child’s doctor help complete them) every few years at these times: preschool, before/during middle school, before/during high school, and before participating in organized sports. You download a printable form HERE

Patient History Questions
Yes No
Has your child fainted or passed out DURING exercise, emotion or startle?
Has your child fainted or passed out AFTER exercise?
Has your child had extreme fatigue associated with exercise (different from other children)?
Has your child ever had unusual or extreme shortness of breath during exercise?
Has your child ever had discomfort, pain or pressure in his chest during exercise?
Has a doctor ever ordered a test for your child’s heart?
Has your child ever been diagnosed with an unexplained seizure disorder?
Family History Questions

Are there any family members who had an unexpected, unexplained death before age 50?

   (include SIDS, car accident, drowning, others)

Are there any family members who died of heart problems before age 50?
Are there any family members who have had unexplained fainting or seizures?
Are there any relatives with certain conditions such as:
Hypertrophic cardiomyopathy (HCM)
Dilated cardiomyopathy (DCM)
Aortic rupture or Marfan syndrome
Arrhythmogenic right ventricular cardiomyopathy
Long QT syndrome (LQTS)
Short QT syndrome
Brugada syndrome
Catecholaminergic ventricular tachycardia
Primary pulmonary hypertension
Pacemaker
Congenital deafness
Please explain more about any “yes” answers here: