Family Registration

Welcome, and 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.

Your Contact Information

First Name*:	Last Name*:
Street Address*:	Email Address*:
City*:	State*:	Zip Code*:
Country*:
Phone Number:	Phone Type:

*Have you been diagnosed with a SADS condition?:

YesNo

If not you, list the immediate family member who has been diagnosed (or is being tested)::

If diagnosed, which condition?: LQT Short QT CPVT Brugada Timothy's Syndrome WPW ARVD JLNS HCM ATS Other Unknown None
If you selected LQT, what type is it:
If you selected other condition, please specify:

At what age was a SADS diagnosis made?:

Have you been genetically tested for a SADS condition?:

YesNo

What were your results?:

If you have LQTS, what is your QTc?:

Has your entire immediate family been genetically tested?:	YesNo
Have you told your extended family members?:	yesNo
*If you have children, do you have a school care plan in place?:	YesNoNA
*Do you have an Automatic External Defibrillator (AED)?:	YesNo
Have you notified local hospitals/ERs of your condition?:	YesNo

Symptoms (Select all that apply):

What are the current treatment methods? (Select all that apply): None Beta blockers Mexiletine Flecainide Quinidine Calcium blocker Heart transplant Potassium Fish oil ICD Pacemaker Sympathectomy Denervation Other
If you selected other, please specify:

How many people in your immediate and extended family are living with a SADS condition?:

How many people in your immediate/extended family have symptoms, but not a diagnosis?:

Family/Loved Ones Diagnosed

Name:	Date of Birth:	Gender: MF
Relationship:	Diagnosis:

Name:	Date of Birth:		Gender: MF
Relationship:	Diagnosis:

Name:	Date of Birth:	Gender: MF
Relationship:	Diagnosis:

Name:	Date of Birth:	Gender: MF
Relationship:	Diagnosis:

Sudden Death of Family/Loved Ones

Has there been a recent death in your immediate family?:

YesNo

Name:	Relationship:	Gender: MF
Date of Birth:	Date of Death:	Cause of Death:

Name:	Relationship:	Gender: MF
Date of Birth:	Date of Death:	Cause of Death:

How did you hear about the SADS Foundation?:

What information, if any, would you like from the SADS Foundation? Select all that apply:

		eNewsletter:			Literature Review:
		Newsletter:			Information Packet:

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