Please consider and answer the following questions. We will contact you to schedule a screening within 48 hours of submitting this form. You can also call 918.592.0999 to schedule a screening. You must have JavaScript enabled to use this form. Contact Information Name Address City State - None -AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarshall IslandsMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Marianas IslandsOhioOklahomaOregonPalauPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirgin IslandsVirginiaWashingtonWest VirginiaWisconsinWyoming Zip Code Phone Number Email Address Have you been told you have a heart murmur? Yes No Have you had rheumatic fever? Yes No Have you had an infection in one or more of your heart valves? Yes No Do you have a history of heart valve disease in your family? Yes No Do you have swelling of feet or ankles? Yes No Do you have palpitations/irregular heart beat? Yes No Do you have shortness of breath, with physical activity or at rest? Yes No Do you have history of passing out? Yes No Do you have any chest pain? Yes No Submit
