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Family Registration
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. 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:
Home
Cell
Work
Have you been diagnosed with a SADS condition?:
Yes
No
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?:
Yes
No
What were your results?:
If you have LQTS, what is your QTc?:
Has your entire immediate family been genetically tested?:
Yes
No
Have you told your extended family members?:
yes
No
If you have children, do you have a school care plan in place?:
Yes
No
NA
Do you have an Automatic External Defibrillator (AED)?:
Yes
No
Have you notified local hospitals/ERs of your condition?:
Yes
No
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:
M
F
Relationship:
Diagnosis:
Name:
Date of Birth:
Gender:
M
F
Relationship:
Diagnosis:
Name:
Date of Birth:
Gender:
M
F
Relationship:
Diagnosis:
Name:
Date of Birth:
Gender:
M
F
Relationship:
Diagnosis:
Sudden Death of Family/Loved Ones
Has there been a recent death in your immediate family?:
Yes
No
Name:
Relationship:
Gender:
M
F
Date of Birth:
Date of Death:
Cause of Death:
Name:
Relationship:
Gender:
M
F
Date of Birth:
Date of Death:
Cause of Death:
How did you hear about the SADS Foundation?:
Physician
Family
Friend
WWW
Social Media (Facebook, Twitter, etc.)
Event/Meeting
Other
What information, if any, would you like from the SADS Foundation? Select all that apply:
eNewsletter:
Newsletter:
Information Packet:
Other comments or questions:
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Warning Signs
Family history of unexpected, unexplained sudden death under age 40.
Fainting or seizure during exercise, excitement or startle.
Consistent or unusual chest pain &/or shortness of breath during exercise.