Endurance Athlete Cardiovascular Risk Assessment
Personal Information
Name
Date of Birth
Age
Gender
Male
Female
Other
Sport & Training History
Primary Sport
Years of Endurance Training
Average Weekly Training Hours
Medical History
Family History of Cardiovascular Disease
Yes
No
Personal History of Heart Conditions
Yes
No
Other Medical Conditions
Symptoms & Alarming Events
Have you experienced any of the following?
History of Fainting, Chest Pain, or Palpitations during Exercise
Yes
No
Lifestyle Factors
Smoking Status
Never
Former
Current
Alcohol Consumption (drinks/week)
Brief Dietary Description
Vital Signs
Blood Pressure (mmHg)
Resting Heart Rate (bpm)
Recent Cardiac Evaluation
Type of Evaluation
ECG
Echocardiogram
Stress Test
Other
Date of Evaluation
Key Findings