Table 3.

Massachusetts General Hospital Cardiovascular Screen^a,b

Cardiovascular History	Yes	No	Comment
Personal history
Congenital or acquired cardiac disease	☐	☐
Coronary artery disease	☐	☐
Chest pain	☐	☐
Palpitations	☐	☐
Shortness of breath	☐	☐
Dizziness	☐	☐
Syncope	☐	☐
Family history (< 30 years of age)
History of early myocardial infarction	☐	☐
History of cardiac death	☐	☐
History of significant arrhythmias	☐	☐
History of long QT syndrome	☐	☐
Objective
Baseline (off medication) blood pressure and heart rate within normal limits	☐	☐

^aCopyright Timothy E. Wilens, MD. Published with permission.

^bIf positive on an item, recommend referral to primary care physician or cardiology for further assessment prior to initiating medication.