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Section 1: School Info
School
*
- Select a value -
Lake Forest HS 10/11/2023 Screening
Student ID
*
Section 2: Student Info
Student First Name
*
Student Last Name
*
Gender at Birth
*
Male
Female
Date of Birth
*
Jan
Feb
Mar
Apr
May
Jun
Jul
Aug
Sep
Oct
Nov
Dec
Month
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
Day
1993
1994
1995
1996
1997
1998
1999
2000
2001
2002
2003
2004
2005
2006
2007
2008
2009
2010
2011
2012
2013
Year
Race
*
African-American
Asian
Caucasian
Hispanic
Native American
Pacific Islander
Other
Section 3: Student Medical Info
Height
*
- Select a value -
4ft-6in
4ft-7in
4ft-8in
4ft-9in
4ft-10in
4ft-11in
5ft-0in
5ft-1in
5ft-2in
5ft-3in
5ft-4in
5ft-5in
5ft-6in
5ft-7in
5ft-8in
5ft-9in
5ft-10in
5ft-11in
6ft-0in
6ft-1in
6ft-2in
6ft-3in
6ft-4in
6ft-5in
6ft-6in
6ft-7in
6ft-8in
6ft-9in
6ft-10in
6ft-11in
7ft-0in
Weight (pounds)
*
Does the student have any previously diagnosed heart disease?
*
No
Yes
Please indicate condition
*
- Select a value -
Anomalous Coronary Artery
Aortic Aneurysm
Arrhythmogenic Right Ventricular Dysplasia Cardiomyopathy (ARVD/C)
Brugada Syndrome
Chagas Disease
Congenital Heart Disease
Coronary Artery Disease
Dilated Cardiomyopathy
Hypertrophic Cardiomyopathy
Long QT Syndrome
Marfan Syndrome
Non-Compaction Cardiomyopathy
Rheumatic Heart Disease
Valvular Heart Disease
Wolff-Parkinson-White Syndrome (WPW)
Other
Other Heart Disease
*
Does the student have any ongoing medical illnesses?
*
No
Yes
What Illness?
*
Does the student take any medications other than birth control?
*
No
Yes
What medication(s)?
*
Has your student ever tested positive for COVID-19?
*
No
Yes
Has your student received the COVID-19 vaccine?
N/A
Yes
No
This information is utilized by our cardiologist to interpret the EKG and determine diagnosis.
Additional Comments
Section 4: Parent/Guardian Info
Parent/Guardian Email
*
Parent/Guardian First Name
*
Parent/Guardian Last Name
*
Parent/Guardian Phone
*
Parent/Guardian Address
Address 1
*
Address 2
City
*
State
*
- Select -
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
--
Armed Forces (Americas)
Armed Forces (Europe, Canada, Middle East, Africa)
Armed Forces (Pacific)
American Samoa
Federated States of Micronesia
Guam
Marshall Islands
Northern Mariana Islands
Palau
Puerto Rico
Virgin Islands
ZIP code
*
Section 5: Waivers & Releases
I grant permission for my child to be photographed
*
No
Yes
Agree
*
I understand that my child's participation in HeartSmart EKG is intended to identify heart abnormalities, which may affect her/his health during physical activity. I assume all risks associated with my child's participation in the cardiac screening. As a result of the screening, I may be advised to seek follow-up testing or treatment for my child with a physician. Physician encounters and future tests are not considered part of the screening and thus may incur cost. All such risks being known and appreciated by me, and having read this waiver, I hereby for myself, child, heirs, executors, and administrators waive any and all claims of any kind or nature, I may have against the Max Schewitz Foundation, NorthShore University HealthSystems,
[current-user:field-school]
, and any and all individuals associated with this screening, and their heirs, representatives, and successors, and assigns for any and all injuries suffered by me or my children in connection with this screening. I understand de-identified health information collected, including the EKG and echo results, may be used in cardiac research. I understand that usual and accepted standards will be used to keep my child's health information confidential.
Section 6: Account Security
E-mail address
*
A valid e-mail address. All e-mails from the system will be sent to this address. The e-mail address is not made public and will only be used if you wish to receive a new password or wish to receive certain news or notifications by e-mail.
Password
*
Confirm password
*
Provide a password for the new account in both fields.
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