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Family Registration
Welcome, and thank you for registering with The SADS Foundation! Please feel free to ask any questions you have and also let us know what further information you might want. By registering with SADS you help us to personalize and improve our services to you and your family. We also can use your deidentified information to encourage vital research in the scientific community to help stop 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
*= required fields
First Name*:
Last Name*:
Street Address*:
Email Address*:
City*:
State*:
Zip Code*:
Country*:
Phone Number:
Phone Type:
Home
Cell
Work
*Condition Connection - choose all that apply (hold down shift key to choose more than one):
Choose all that apply
I am affected
My child is affected
My spouse/partner is affected
Another family member is affected
I lost someone who was affected
I am a medical professional
Other/Prefer not to respond
*SADS Condition - Please select all that apply:
Please Select
ARVD/ARVC
Brugada Syndrome
CPVT
HCM
LQTS Type 1
LQTS Type 2
LQTS Type 3
LQTS other
SQTS
Timothy Syndromes
WPW
Unknown, seeking diagnosis
Other condition
Other/Prefer not to respond
If you selected other condition, please specify:
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
Family/Loved Ones Diagnosed
Name:
Date of Birth:
Gender:
M
F
Relationship:
Diagnosis:
Please Select
ARVD/ARVC
Brugada Syndrome
CPVT
HCM
LQTS Type 1
LQTS Type 2
LQTS Type 3
LQTS other
SQTS
Timothy Syndromes
WPW
Unknown, seeking diagnosis
Other condition
Other/Prefer not to respond
Genetic testing?:
Yes
No
Name:
Date of Birth:
Gender:
M
F
Relationship:
Diagnosis:
Please select
ARVD/ARVC
Brugada Syndrome
CPVT
HCM
LQTS Type 1
LQTS Type 2
LQTS Type 3
LQTS other
SQTS
Timothy Syndromes
WPW
Unknown, seeking diagnosis
Other condition
Other/Prefer not to respond
Genetic testing?:
Yes
No
Name:
Date of Birth:
Gender:
M
F
Relationship:
Diagnosis:
Please select
ARVD/ARVC
Brugada Syndrome
CPVT
HCM
LQTS Type 1
LQTS Type 2
LQTS Type 3
LQTS other
SQTS
Timothy Syndromes
WPW
Unknown, seeking diagnosis
Other condition
Other/Prefer not to respond
Genetic testing?:
Yes
No
Name:
Date of Birth:
Gender:
M
F
Relationship:
Diagnosis:
Please select
ARVD/ARVC
Brugada Syndrome
CPVT
HCM
LQTS Type 1
LQTS Type 2
LQTS Type 3
LQTS other
SQTS
Timothy Syndromes
WPW
Unknown, seeking diagnosis
Other condition
Other/Prefer not to respond
Genetic testing?:
Yes
No
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?:
Please select
Physician
Family
Friend
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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.