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 Physician's first name Physician's surname Specialty Hospital I Have obtained the consent of the patient Supported card issuers: