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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.


First Name *:
Last Name*:
Address:
City *:
State/Province:
Zip/Postal 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
Other comments or questions:

Family Registration

Online Community

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Warning Signs