This form is recommended by pediatric cardiologists at the Children’s Sibley Heart Center. It can be used by any healthcare provider at any time for patients from birth to age 21.
Download the pediatric cardiac risk assessment form:
Many of the children at risk for sudden cardiac death will have symptoms at some time that could be discovered on periodic review history. This form educates parents about potential risk factors.
Some conditions that can put a child or adolescent at risk for sudden cardiac arrest can affect the child before adolescence, and not all children will receive pre-participation physicals. Therefore, the Children’s cardiologists recommend a periodic history, using this form at least four times during the well-child continuum, to identify those children as early as possible so referral and treatment can be timely.
- During the newborn period (for pertinent family history)
- During physicals for children ages 6 to 8
- During the middle school years
- During high school, especially for nonathletes and those playing community sports
- Whenever episodes of unexplained fainting, near-fainting or seizure activity occur
High school athletes should complete an annual pre-participation evaluation (PPE), both history and physical exam, before the season starts. The PPE form is endorsed by the American Academy of Pediatrics, Children's, the Georgia High School Association and several sports medicine associations.
Contact the Cardiac Call Center at 404-256-2593 or 800-542-2233 if you have any questions.