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Family Registration

Thank you for registering with The SADS Foundation. With this form you can let us know what further information you would like to receive and ask any questions you might have. If you have a SADS condition yourself or in your family, please continue on to begin the Pedigree Project to help you and your doctor understand how it affects your family, and help to identify any other family members who may need screening. Your answers here also help us support and encourage vital research in the scientific community to help end SADS. All of your information is kept confidential and will not be released to 3rd parties – see our privacy policy for more information.

First Name *:

Last Name*:

Address *:

City *:

State *:

Zip Code *:

Contact Phone 1 *:

Phone Type:

Contact Phone 2 *:

Phone Type:

Email Address *:

Reason for contacting the SADS Foundation, please select all that apply:

Recent fainting episode:

Sudden death:

History of SADS in family:

Recent diagnosis of heart rhythm disorder:

Have family friend diagnosed:

Network with other families:

Interested in genetic testing:

Interested in volunteering with SADS:

Interested in doing a fundraiser with SADS:

Interested in more information on a SADS condition:

Interested in learning more about medication to avoid with LQT Syndrome or Brugada:

Other:

If selecting other, please describe here:

How did you hear about the SADS Foundation? Select all that apply

My doctor:

Family/Friend:

WWW:

Name of website:

Facebook/Twitter:

Radio/TV/Newspaper/Magazine:

(If selected, please specify):

Other:

If selecting other, please describe here):

What information would you like from the SADS Foundation? Select all that apply.

Newsletter:

Enewsletter:

Literature Review:

Information Packet:

Do you have a SADS condition in your family? Select all that apply

Long QT Syndrome:

CPVT:

Brugada_Syndrome:

HCM:

ARVD:

Other:

If selecting other, plese describe here:

If you or a family member have experienced symptoms, please select all that apply.

Syncope:

Palpitations:

Seizure:

Cardiac Arrest:

Other, please describe:

What treatment have you received? Select all that apply

Betablocker:

Other Medication:

ICD:

Pacemaker:

None:

Other:

If selecting other, please describe here:

Other information:

Have you had genetic testing?:

YesNo

If yes, 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? (e.g. husband, wife, child etc...):

Do you have children?:

YesNo

Family Registration

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