This is a pre-registration form for the Johns Hopkins ARVD Patient Registry based in Baltimore, Maryland. This form will also be used to determine the eligibility of newly diagnosed individuals for the North American ARVD Registry based in Tucson, Arizona, (also referred to as The Multidisciplinary Study of Right Ventricular Dysplasia).

You will be contacted by either Kathy Gear or Crystal Tichnell, MGC about the process of confirming your diagnosis and completing your registration.

Name:


Address:


City:


State:   ZIP: 

Country:


Tel:


E-Mail:


Join ARVD Mailing List:
yes  no

How old is the patient?

Date of Birth:

Your ARVD Physician:
(doctor's name, hospital, city)



Date of Diagnosis: (month & year)



Method of Diagnosis (select all that apply):
MRI
Echocardiogram
Other (please specify)



Family History of ARVD?
yes  no


Family History of Sudden Death?
yes  no


Other Affected Family Members?
(family member's name and relation to patient)



Current Treatment (select all that apply):

Pharmacological Therapy
(please specify)


Implantable Defibrillator
(please specify model and/or brand)


Other
(please specify)



Additional Comments:


Registry Coordinator May Contact Me for Additional Information:
yes  no