Download Athletic-Heart-Screening-Information-Packet

February 3, 2017
Dear Parents,
St. Anthony’s Memorial Hospital in conjunction with the Andrew Gobczynski Big Heart Foundation
is providing a free heart screening for high school athletes on Saturday, March 25, 2017, from 8:00
a.m. to 12:00 p.m. at Prairie Heart Institute at St. Anthony’s in Effingham. This painless and harmless
screening is intended to detect undiagnosed heart problems, which in the heat of competition could
injure your child. Please note it is not a complete cardiac work up.
This free service, which is being offered to high school-aged sophomores and junior/senior athletes
who have not already participated, may detect heart abnormalities. Although most detected
abnormalities are minor, some could be quite significant and require treatment. I encourage you to
allow your child to participate in this valuable program. If you have any questions about the heart
screening, please feel free to contact me at school.
The program requires athletes to complete a history and physical form specifically targeted to detect
at-risk athletes along side a physician assessment. In addition, blood pressure screenings and
electrocardiograms will be performed which can detect athletes with dangerous electrical
abnormalities of the heart.
Please take a few moments to fill out the registration form, student participation and parental approval
form, and the history worksheet. Please fill the forms out in detail, leaving nothing blank, and do
not forget to sign the forms. Students who present with forms that are not completely filled out will
not be allowed to participate.
Bring completed forms with you on the day of the event.
For more information please visit www.stanthonyshospital.org and search for Big Heart Foundation
Heart Screening.
Thank you for your concern and cooperation.
Sincerely,
Athletic Director
Athletic Heart Screening
March 25, 2017 Registration Form
Name: __________________________________________________________________
Address: ________________________________________________________________
City: _____________________________ State: _________ Zip: _________________
Home Phone: ______________________ Cell Phone: ___________________________
Social Security Number: ___________________________________________________
Student
Y _____
N _____
Sex
M _____
F _____
Date of Birth: _______________________________
Name of School: __________________________________________________
WE MUST HAVE THE INFORMATION LISTED BELOW
Family Physician: _________________________________________________________
Physician Address: ________________________________________________________
City: _____________________________ State: _________ Zip: _________________
Name of Parents: _________________________________________________________
Address: ________________________________________________________________
City: _____________________________ State: _________ Zip: _________________
Athletic Heart Screening
Student Participation and Parental Approval
There are 3 forms with this packet that must be completed and returned.
We can schedule your child for this event only if all forms are complete.
Name of Student (please print) _____________________________________________
Name of School (please print) ______________________________________________
The opportunity to participate in this limited cardiac screening program is entirely voluntary
on my part.
Signature of Student ___________________________________ Date ______________
I hereby give my consent for the above-named student to participate in a limited cardiac
screening designed to identify undiagnosed abnormalities of the heart which could lead to
sudden cardiac death in young athletes. The screening is offered free of charge and in good
faith. I understand that the screening will be done at Prairie Heart Institute at St. Anthony’s in
Effingham and results will be interpreted by a physician. If further testing is required due to
abnormal test results, I understand that I am responsible for contacting my child’s physician
(listed below) concerning follow-up testing and am responsible for the costs of those tests.
Name of Family Physician (please print) ______________________________________
Signature of Parent _____________________________________ Date ______________
Big Heart Foundation Heart Screening
History Worksheet
Student Name ___________________________________________________________
Age _______
Height _______
Weight ________ LBS
Sex:
Male
Female
School ________________________________ Sports ___________________________
Health History (cardiac related) please circle Yes or No in the questions below.
YES
NO
Problems with heart/blood pressure
YES
NO
Chest pain with exercise?
YES
NO
Dizziness or fainting with exercise?
YES
NO
Any surgeries? If yes, what kind ________________________________
___________________________________________________________________
Family History (cardiac related) please circle Yes or No in the question below.
YES
NO
Has a family member died suddenly at less than 50 years of age of causes
other than an accident?