SMART HEARTS CARDIAC RISK ASSESSMENT ACTIVITY "*" indicates required fields Step 1 of 2 50% As part of Smart Hearts Don’t Miss A Beat, this cardiac risk assessment activity is designed to help you become more familiar with warning signs, risk factors and family history that should be reported to your medical practitioner so they can better assess your heart. When you document important information about how you feel and medical issues that have arisen in your family, it gives your physician a better opportunity to provide you with the right preventative care. This is not meant to be medical advice or a diagnosis. It is only a learning tool that will help you become your own heart health advocate as well as be more aware of heart health in your future family. Answering Yes or Unsure to any questions does not mean you have a heart condition, but it’s something your doctor’s office should be aware of, so be sure to the results you will receive after you complete this assessment with your medical provider and discuss your answers.Name* First Last Email* Your HistoryPlease consider these questions relative to anything you’ve experienced, even if it was once, but especially if you’ve experienced it repeatedly.Have you ever fainted or passed out DURING exercise/activity, emotion or startle?* Yes No Unsure Have you ever fainted or passed out AFTER exercise/activity?* Yes No Unsure Do you experience extreme fatigue associated with exercise/activity (different from your friends and teammates)?* Yes No Unsure Have you ever had unusual or extreme shortness of breath during exercise/activity?* Yes No Unsure Have you ever had discomfort, pain or pressure in chest during exercise/activity?* Yes No Unsure Have you ever complained of a racing heart or “skipping beats”?* Yes No Unsure Have you ever been diagnosed with an unexplained seizure disorder or exercise/activity-induced asthma?* Yes No Unsure Have you ever been diagnosed with any form of heart/cardiovascular disease or a heart condition?* Yes No Unsure Have you ever been diagnosed with any form of heart/cardiovascular disease or a heart condition?* Yes No Unsure Have you ever been diagnosed with any form of heart/cardiovascular disease or a heart condition?* Yes No Unsure Do you drink energy drinks?* Yes No Do you smoke or vape?* Yes No Family HistoryIt’s best to talk with a parent or guardian or older family member who may know more about the heart health of your extended family. These questions apply to your parents, sisters and brothers, grandparents, aunts and uncles and cousins.Are there any family members who had a sudden, unexpected or unexplained death before age 50? (including SIDS/Sudden Infant Death Syndrome, car accident, drowning, passing away in sleep)* Yes No Unsure Are there any family members who had a sudden, unexpected or unexplained death before age 50? (including SIDS/Sudden Infant Death Syndrome, car accident, drowning, passing away in sleep)* Yes No Unsure Are there any family members who have had unexplained fainting or seizures?* Yes No Unsure Are there any family members who are disabled due to “heart problems” under the age of 50?* Yes No Unsure Has anyone in your family been diagnosed with a heart condition under the age of 50?* Yes No Unsure Does any family member have and pacemaker or implanted cardiac defibrillator (ICD)?* Yes No Unsure Has anyone in your family had genetic testing for heart disease?* Yes No Unsure I have no way of knowing about my family’s heart history* Yes, I have been able to ask older family members. No, I do not have access older family members or relatives.
