Get the free Form: Sudden Cardiac Arrest (CA Dept of Education)

California Department of EducationUpdated March 2018Parent/Guardian and Pupil Sudden Cardiac Arrest Warning Signs and Symptoms Information and Acknowledgment Form On July 1, 2017, Assembly Bill 1639,

How to fill out form sudden cardiac arrest

How to fill out form sudden cardiac arrest

1. To fill out the form for sudden cardiac arrest, follow these steps:
2. Begin by writing your personal information, such as your name, address, and contact details.
3. Next, provide any relevant medical information, including your medical history, current medications, and known allergies.
4. Include details about any previous incidents of sudden cardiac arrest, if applicable.
5. Fill in the date and time of the incident, along with any known triggers or factors that may have led to the cardiac arrest.
6. Describe the symptoms you experienced during the episode, such as chest pain, shortness of breath, or loss of consciousness.
7. Add any information about the response and treatment received, such as CPR or defibrillation.
8. Finally, sign and date the form to certify the accuracy of the information provided.

Who needs form sudden cardiac arrest?

1. The form for sudden cardiac arrest is typically needed by individuals who have experienced or have a high risk of experiencing sudden cardiac arrest. This includes people with a history of heart disease, heart conditions, or those who have survived a previous cardiac arrest. Additionally, individuals who are at risk due to family history, certain medications, or lifestyle factors may also need to fill out this form. It is important for individuals who fall into these categories to have their medical information documented to ensure appropriate and timely medical intervention in case of a cardiac event.

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