SADS Foundation :: Sudden Arrhythmia Death Syndromes Foundation

If you would like to receive a free informative packet about sudden death and LQTS, register with us today. We use information about your condition (& your family's) to help us with the statistics about SADS conditions. We do not sell or give your personal contact information to any other organization.

Personal

First name *

Last Name *

Address *

City *

State *

Zip Code *

Contact Phone 1 *

CellHomeWorkOther

Contact Phone 2

CellHomeWorkOther

Email Address *

Why are you contacting the SADS Foundation?

Recent fainting episodeSudden deathHistory of SADS in familyRecent diagnosis of heart rhythm disorderHave family/friend diagnosedNetwork with other familiesInterested in genetic testingInterested in volunteering with SADSInterested in doing a fundraiser with SADSInterested in more information on a SADS conditionInterested in learning more about medication
to avoid with LQT Syndrome or Brugada
SyndromeOther

How did you hear about the SADS Foundation?

My doctorFamily/FriendWWW

Facebook/TwitterRadio/TV/Newspaper/Magazine

Other

 

Would you like information from the SADS Foundation?

(Check all that apply)

NewsletterEnewsletterLiterature ReviewInformation Packet

Family Information

Which, if any, medical condition do you or the diagnosed person have?

Medical condition: (Please choose only one.)

Long QT SyndromeCPVTBrugada SyndromeHCMARVDOther

Symptoms: (check all that apply)

SyncopePalpitationsSeizureCardiac Arrest

Current Treatment: (check all that apply)

BetablockerOther medicationICDPacemakerNoneOther

Genetic Testing

Have you heard about genetic testing?

YesNo

If yes, and you’ve had a genetic test, what were your results? (e.g. LQT I, LQT II, etc):

Has there been a recent death in your family?

YesNo

If you answered "yes" above, what is the relationship of the deceased individual to you?

Do you have children?

YesNo

Other comments or questions

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IMPORTANT: The SADS Foundation is committed to the privacy of your personal information. The information you give us will be used only by us, and will not be shared, sold, or released. Only combined, non-identifying statistics will ever be made public.