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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?