MGH CARDIOVASCULAR SCREEN

A.) Targeted Personal History

Yes

No

Comment

1.) Previously detected cardiac disease (congenital or acquired; heart murmur)

2.) Syncope, dizziness (particularly with exercise)

3.) Chest pain, Shortness of breath, exercise intolerance

4.) Palpitations, heart racing, frequent skipped beats

B.) Family Cardiovascular History

1.) Sudden or unexplained death or event requiring resuscitation (children, young adults)

2.) Early onset cardiac disease (MI < 35 yrs old, cardiomyopathy)

3.) Arrhythmias (e.g., Wolf-Parkinson-White)

4.) Long QT syndrome

C.) Data

Blood pressure, heart rate normal

A positive response does not negate the use of medications; however, if suggestive of cardiovascular disease, it recommended to refer the child to a primary care physician or pediatric specialist (e.g. cardiology) for further assessment.

References:

1. "American Academy of Pediatrics/American Heart Association clarification of statement on cardiovascular evaluation and monitoring of children and adolescents with heart disease receiving medications for ADHD: May 16, 2008." J Dev Behav Pediatr 29(4): 335.

2. Gutgesell, H., D. Atkins, et al. (1999). "AHA scientific statement: Cardiovascular monitoring of children and adolescents receiving psychotropic drugs." Journal of the American Academy of Child and Adolescent Psychiatry 38(8): 979-982.

3. Vetter, V. L., J. Elia, et al. (2008). "Cardiovascular Monitoring of Children and Adolescents With Heart Disease Receiving Stimulant Drugs. A Scientific Statement From the American Heart Association Council on Cardiovascular Disease in the Young Congenital Cardiac Defects Committee and the Council on Cardiovascular Nursing." Circulation.

Made available with permission from Timothy Wilens, M.D. This form has not been modified.