Youth Heart Screening Required forms

To complete your screening, parents and youth must COMPLETE and PRINT this packet. Follow the directions below, and scroll down for more information about the screening event.

Health History Form and Screening Waiver

This is a fillable PDF. You can choose to fill it out online AND PRINT, or simply PRINT IT and fill it out by hand with a black pen. 
PRINT THE FORM SINGLE SIDED ONLY

Each screening participant needs their own completed form. Youth under 18 will not be screened without a parent signature and contact information on the waiver. (Youth with a signed waiver do not need a parent in attendance.)

  1. Click on the button below, download and save the form to your laptop or desktop computer
  2. Once downloaded, to complete online, open the PDF with Adobe Acrobat Reader DC – it will not work if you use Preview  (If needed, download Adobe for free for PC and Mac)
  3. Complete pages 1, 2, 3 and 4 (skip Staff Only pages) then pages 7 and 8 by clicking on the bubbles or type in the information.
  4. Once completed, click SAVE before closing and printing the document
  5. Print the entire 8-page form SINGLE SIDED and bring it with you to the screening
  6. Once printed, you must sign the waiver on page 7

If you encounter a problem, or you cannot print the form, we have blank forms for you at the screening. If this is necessary, please review the forms in advance so you will be prepared to complete them at the screening. You can also simply print the form at home and fill in the bubbles by hand. See you there!

Download form

What To Expect

Who Can Be Screened
This free heart screening is for youth ages 12 to 25 only. On the day of the screening, participants must be at least 12 years old, and not older than 25.

If the participant is already being followed by a cardiologist, they are not eligible to be screened, as this event is meant to identify undetected heart conditions.

Screening Does Not Replace PPE
This screening is a specific evaluation of the heart that is not included in pre-participation physicals (PPE) required for sports programs—it does not fulfill the requirement for a PPE. We do not sign PPE forms, so please complete your PPE with your primary care provider.

Safety
By registering for the screening, you are agreeing to adhere to current health and safety guidelines, particularly with regard to COVID-19. As such, ONE parent or guardian will be allowed to accompany the youth through the screening. Other precautions may include social distancing and hand sanitizer provided by EPSAL. Masks may be required so please bring one.

What To Wear
On the day of the screening, participants should wear a t-shirt and sweat pants or sport shorts. Girls should wear a sports bra. Girls will be asked to remove the t-shirt but will keep the sports bra on at all times.

Privacy
All girls will be screened by female volunteers in an area separate from boys. We want to assure you that participants’ confidentiality, privacy and individual modesty will be respected throughout all aspects of the program. Multiple screening tables are in one large space. A private screening space is available upon request for any participant.

What the Screening Includes
The screening is completely painless and non-invasive (no needles or x-ray exposure) and consists of:

  1. Review of Participant Medical Questionnaire & Cardiac Risk Assessment
  2. ECG screening (Small patches with a mild latex-free adhesive will be placed on the chest, legs and arms. Electrodes are attached to the patches and the heart’s electrical activity is recorded)
  3. Some participants may also have a limited echocardiogram (ultrasound) of their heart

National Pilot
We are participating in a national study of SCA in youth that requires participants to complete a scanable medical questionnaire at the screening event. (You’ll note on the form all information is depersonalized to protect your privacy.) We highly encourage you to opt in to the simple followup process on page 6 of the waiver. Your participation will significantly contribute to future sudden cardiac arrest prevention standards of care.

Results of Your Screening
You will consult with a cardiologist at the screening about your cardiac risk assessment and screening results and be advised of any follow-up needed with your medical provider. If you do not have a medical provider, please alert our team. Organizations like 2-1-1 San Diego connects people with health services.

A simple ECG can identify about two-thirds of heart abnormalities associated with Sudden Cardiac Arrest. Our ECG devices report a potential ~2% false positive rate that may be discovered during follow-up testing. EPSAL’s clinical team makes every effort to insure quality screening outcomes.

At the screeing you will be given a copy of your ECG report. (Echocardiogram reports are not available). We urge you to add this to your youth’s medical record as a baseline. If you need to request a copy, we keep records for one year. Use the REQUEST ECG button at epsavealife.org/contact.

This screening does not substitute for a regular on-going relationship with a primary care physician, who is attuned to your medical history and any changes in health status. No screening can identify 100% of the individuals at risk for a sudden cardiac event.

We encourage you to continue to have yearly physicals and to contact your medical provider with any concerns or changes in your health, particularly the warning signs and risk factors you’ve commented on in the screening packet. New American Academy of Pediatrics guidelines recommend regular heart screening for youth.

See our Heart Screening Fact Sheet for more information.