Sunil N. Lalla, M.D. PA, Bharti Lalla, M.D. FAAP

BHARTI LALLA, MD

First Name * Last Name * Date of Birth: * Date of Completion: * Has a doctor over denied or restricted your participation in sports for any reason? * Have you ever spent the night in the hospital ? * Have you ever had surgery ? * Have you ever passed out or nearly passed out DURING or AFTER exercise ? * Have you ever had dizziness or pressure in your chest during ecercise ? Does your heart ever race or skip beats (irregular beats) during execise ? * Has a doctor ever told you thar you have any heart problems ? If so, check all that apply? Has a doctor ever ordered a test for your heart ? (for exmple ECG/EKG, Echocardiogram) * Do you have lightheaded or feel more short of breath than expected during exercise? * Have you ever has an unexplained seizure ? * Do you get more tired or short of breath more quickly than your friends during exercise ? * Has any family member or relative died of heart problems or had an unexpected or unexplained sudden death before age 50(including drowning, unexplained car accident or sudden infant death syndrome? * Does anyone in your family have hypertrophic cardiomyopathy, marfan syndrome,arrhythmogenic right ventricular cardiomyopathy, long QT syndrome, short QT syndrome, Brugada syndrome, or catecholaminergic polymorphic ventricular trachycardia? * Does anyone in your family have a heart problem, pacemaker or implanted defibrillator ? * Has anyone in your family had unexplained fainting, unexplained seizures or near drowing ? * Have you ever had an injury to a bone, muscle, ligament or tendon that caused you to miss a practice or game ? * Have you ever had any broken or fractured bones or dislocated joints ? Have you ever had an injury that required x-rays, MRI, CT scan, injections, therapy, a brace, a cast or crutches ? * Have you ever had a stress fracture ? * New Field53 * Do you regularly use a brace, orthotics, or other assistive devices ? * Do youhave a bone, muscle or joint injury that bothers you ? * Do any of your joints become painful,swollen, feel warm or look red ? * Do you have any history of juvenile arthrits or connective tissue disease ? * Do you cough, wheeze, or have difficulty breathing during or after exercise? * Have you ever used an inhaler or taken asthma medicine? * Is there anyone in your family who has asthma? * Were you born without or are you missing a kidney, an eye, a testicle( males), your spleen, or any other organ * Do you have groin pain or a painful bulge or hernia in the groin area? * Have you had infectious mononucleosis(mono) within the last month? * Do you have any rashes, pressure sores, or any other skin problems? * Have you had a herpes or MRSA skin infection? * Have you ever had a head injury or concussion? * Have you ever had a hit or blow to the head that caused confusion, prolonged headache, or memory problems? * Do you have history of seizure disorder? * Do you have headaches with exercise? * Have you ever had numbness, tingling, or weakness in your arms or legs after being hit or falling? * Have you ever been unable to move your arms or legs after being hit or falling? * Have you ever become ill while exercising in the heat? * Do you get frequent muscle cramps when exercising? * Do you or someone in your family have sickle cell trait or disease? * Have you had any problems with your eye or vision? * Have you had any eye injuries? * Do you wear glasses or contact lenses? * Do you wear protective eyewear, such as goggles or a face shield? * Do you worry about your weight? * Are yoo trying to or has anyone recommended that you lose or gain weight? * Are you on a special diet or do you avoid certain types of food? * Have you ever had an eating disorder? * Do you have any concerns that you would like to discuss with a doctor? * FEMALES ONLY Have you ever had a menstrual period? * How old were you when you had your first menstrual period? * How many periods have you had in the last 12 months? *