Test your ECG – step 1


Your name (* marks mandatory fields)

Your surname *

Your Email *

Confirm your Email *

Country of origin *

ID or SSN identification number *

Date of birth * (DD.MM.YYYY)

Weight (kg) *

Height (cm) *

Associated conditions and diseases

Hypertension *

Diabetes *

Valvular heart disease *

Ischemic heart disease - myocardial infarction *

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 *

 

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