Test your ECG – step 1

Your name (* marks mandatory fields)

Your surname *

Your Email *

Confirm your Email *

Country of origin *
---AfghanistanAngolaAlbaniaAndorraUnited Arab EmiratesArgentinaArmeniaAntigua and BarbudaAustraliaAustriaAzerbaijanBurundiBelgiumBeninBurkina FasoBangladeshBulgariaBahrainBahamasBosnia and HerzegovinaBelarusBelizeBolivia, Plurinational State ofBrazilBarbadosBrunei DarussalamBhutanBotswanaCentral African RepublicCanadaSwitzerlandChileChinaCôte d'IvoireCameroonCongo, the Democratic Republic of theCongoColombiaComorosCape VerdeCosta RicaCubaCyprusCzech RepublicGermanyDjiboutiDominicaDenmarkDominican RepublicAlgeriaEcuadorEgyptEritreaSpainEstoniaEthiopiaFinlandFijiFranceMicronesia, Federated States ofGabonUnited KingdomGeorgiaGhanaGuineaGambiaGuinea-BissauEquatorial GuineaGreeceGrenadaGuatemalaGuyanaHondurasCroatiaHaitiHungaryIndonesiaIndiaIrelandIran, Islamic Republic ofIraqIcelandIsraelItalyJamaicaJordanJapanKazakhstanKenyaKyrgyzstanCambodiaKiribatiSaint Kitts and NevisKorea, Republic ofKuwaitLao People's Democratic RepublicLebanonLiberiaLibyaSaint LuciaLiechtensteinSri LankaLesothoLithuaniaLuxembourgLatviaMoroccoMonacoMoldova, Republic ofMadagascarMaldivesMexicoMarshall IslandsMacedonia, the former Yugoslav Republic ofMaliMaltaMyanmarMontenegroMongoliaMozambiqueMauritaniaMauritiusMalawiMalaysiaNamibiaNigerNigeriaNicaraguaNetherlandsNorwayNepalNauruNew ZealandOmanPakistanPanamaPeruPhilippinesPalauPapua New GuineaPolandKorea, Democratic People's Republic ofPortugalParaguayQatarRomaniaRussian FederationRwandaSaudi ArabiaSudanSenegalSingaporeSolomon IslandsSierra LeoneEl SalvadorSan MarinoSomaliaSerbiaSouth SudanSao Tome and PrincipeSurinameSlovakiaSloveniaSwedenSwazilandSeychellesSyrian Arab RepublicChadTogoThailandTajikistanTurkmenistanTimor-LesteTongaTrinidad and TobagoTunisiaTurkeyTuvaluTanzania, United Republic ofUgandaUkraineUruguayUnited StatesUzbekistanSaint Vincent and the GrenadinesVenezuela, Bolivarian Republic ofViet NamVanuatuSamoaYemenSouth AfricaZambiaZimbabwe

ID or SSN identification number *

Date of birth * (DD.MM.YYYY)

Weight (kg) *

Height (cm) *

Associated conditions and diseases

Hypertension *
---NoYes - under 5 yearsYes - 5 years or more

Diabetes *
---NoInsulin dependentInsulin independent

Valvular heart disease *
---Noneaortic stenosis or insufficiencymitral stenosis or insufficiency

Ischemic heart disease - myocardial infarction *
---NoYes

Congenital heart disease * (if any please specify, if none, write 'none')

Certain confirmed syndromes of any disease * (if none, write 'none')

Drug usage (if any, please specify, if none, write 'none')

Are you engaged in professional sports * (if yes, which sport and for how long, if no write 'no')

Existence of a positive family history of sudden cardiac death * (if yes, please write down which family member, if no write 'none')

Who fills in the questionnaire *

Personally
Medical doctor