| Today's Date: |
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| Date your SCAD occurred: |
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| Your Name |
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| Your sex |
FemaleMale |
| Email Address (optional) |
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| Your age when SCAD occurred: |
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| Did your SCAD occur during exertion or at rest? Please describe. |
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| Level of fitness when SCAD occurred? i.e. very fit, overweight, active, sedentary, etc. |
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| If female, were you on your period, or post partum at the time of your SCAD? Please state which, and if post-partum, how long after childbirth did it occur. |
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| How would you describe your stress level at the time of your SCAD? |
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| What medications were you on at the time of your SCAD? |
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| Any other major medical issues prior to your SCAD? |
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| Were you on birth control at the time of your SCAD? |
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| Any history of heart disease, cardiac risk factors, or family history of heart disease? |
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| Any history of anemia, auto-immune or connective tissue disorders? |
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| How were you treated for the initial SCAD? ie. stents, surgery, only medicine |
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| What medicine are you on now? |
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| Have you been tested for any connective tissue disorders since your SCAD? |
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| Describe any strange side effects you have noticed since your SCAD. |
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| How did you find this website?: |
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