LettertoParticipantsnottakingExam

OMB#: 0925-0216

Exp. 12/2007        

Public reporting burden for this collection of information is estimated to average 20 minutes per response, including the time for reviewing instructions, searching existing data sources, gathering and maintaining the data needed, and completing and reviewing the collection of information. An agency may not conduct or sponsor, and a person is not required to respond to, a collection of information unless it displays a currently valid OMB control number. Send comments regarding this burden estimate or any other aspect of this collection of information, including suggestions for reducing this burden, to: NIH, Project Clearance Branch, 6705 Rockledge Drive, MSC 7974, Bethesda, MD 20892-7974, ATTN: PRA (0925-0216). Do not return the completed form to this address.

 

OMB#: 0925-0216

Exp. 12/2007   

ID#:

Dear ,

We would like to update the health information that we have on file for you at the Framingham Heart Study. As a participant in the Heart Study, it is important that we have information regarding diagnoses for any significant heart disease, vascular disease, stroke or cancer since we last examined you.

Please complete the enclosed medical history update form. Also, please sign and complete the consent form with the names of physicians and hospitals you have listed on the medical update form. This procedure will give us permission to obtain the necessary information from the physicians and hospitals where you may have received care. Please inform us if there is any name, address or telephone number change.

If you have questions, please don’t hesitate to call Maureen Valentino, participant coordinator, at 1-508-935-3417 or 1-800-854-7582, extension 417.

Thank you for your help.

Sincerely,

Daniel Levy, M.D.

Director

Framingham Heart Study

To Whom It May Concern:

I hereby authorize _________________________________________________

_________________________________________________

_________________________________________________

to release to the Framingham Heart Study

73 Mt. Wayte Avenue

Framingham, MA 01702

The following protected health information my medical record.

Patient Name: Date of Birth:

Address:

,

Disclose the following information for dates from to 2/5/2021.

Face Sheet	CT Scan (Head)
Discharge Summary	MRI/MRA (Head/Neck)
ER Report	Lab Reports – Cardiac Enzymes
Admission Notes	Consults (Cardiac & Neuro)
Progress Notes	Cardiac Catheterization
Operative Report	Exercise Tolerance Test
Pathology Report	Nursing Home Notes
Chest X-Ray	Notes near time of death
EKGs (All)	Other _______________________
Echocardiogram	____________________________

The purpose for this disclosure is research.

The information disclosed under this authorization will not be redisclosed to anyone but the researchers conducting this study, except as required by law.

I understand I may revoke this authorization at any time by requesting such of the above referenced physician/hospital in writing. If I do it will not have any effect on actions that the hospital/physician took before it received the revocation.

This authorization expires at the end of the research study.

Date: _______________________ Signed: _____________________________

For Office Use Only

TYPE |___|___|	1=TELEPHONE 2=MAILER 3=ONSITE BONE STUDY 4=ONSITE EBCT 88=OTHER
INTERVIEWER |___|___|___|		DATA ENTRY |___|___|___|1 |___|___|___|2

ID

DATE OF LAST EXAM OR UPDATE

NAME

ADDRESS and PHONE (if changed _______________________________________________

since last exam/update)

_______________________________________________

SOCIAL SECURITY NUMBER |___|___|___| - |___|___| - |___|___|___|___|

DATE COMPLETED |___|___| - |___|___| - |___|___|

1. a. First, please tell us who is completing this form:

 Framingham Heart Study (FHS) participant whose name is above (Go to question 3)  Spouse

• Family member other than spouse

(Relationship) ______________________________

Go to 1.b.

 Friend

 Health care provider for FHS participant

 Other __________________________

If other than participant, please answer the following questions.

b. Name ________________________________________

c. How long have you known the participant?

|___|___| years |___|___| months

d. Are you currently living in the same household with the participant?

 yes  no

e. How often did you talk with the participant during the prior 11 months? Check one.

 Almost every day

• Several times a week

• Once a week

• 1 to 3 times per month

• Less than once a month

• Unknown / N/A

2. Have you noticed that he/she has had any memory problems or change in personality?

 yes  no

Specifically: ______________________________________________________

If response to #2 “yes”:

Has there been a diagnosis of dementia or Alzheimer’s Disease made by a doctor?

 yes  no

to whom should we send a consent form to be signed so that we can obtain medical records?

name: ___________________________________________________

address: ___________________________________________________

relationship: _______________________________________________

Please go on to the next page

3. Since the date of the last Framingham Heart Study exam or update on the top of Page 1 of the Medical History Update form, have you seen a doctor or been hospitalized?

 yes  no If yes, did you have any of the following problems?

a. Heart Problems, such as:

Yes No (Mark yes or no for each question)

  Chest pain, angina or angina pectoris

  Heart attack or myocardial infarction or MI

  Heart failure or congestive heart failure or CHF

  Heart catheterization or cardiac catheterization

  Heart bypass operation or coronary bypass surgery or CABG

  Procedure to unblock narrowed blood vessels to your heart

muscles (PTCA, coronary angioplasty, or coronary stent)

  Other heart problem (pacemaker, valve problem, aorta surgery, rhythm problem, atrial fibrillation, ventricular tachycardia).

(Specify) _________________________________________________

b. Circulatory Problems, such as:

Yes No (Mark yes or no for each question)

  Stroke, TIA (transient ischemic attack), sudden paralysis, vision

loss, inability to speak

  Procedure to unblock narrowed blood vessels in your neck

(carotid endarectomy, carotid angioplasty).

  Poor blood circulation or blocked or narrowed blood vessels to the legs or feet, (claudication, peripheral arterial disease, gangrene)

  Amputation of part of a leg or toes, because of poor circulation or gangrene.

  Blood clot or embolism in leg or lung.

  Other circulatory problem.

(Specify) __________________________________________________

Since the date of the last Framingham Heart Study exam or update on the top of Page 1 of the Medical History Update form, have you seen a doctor or been hospitalized for the following:

c. Other Neurological Problems

Yes No (Mark yes or no for each question)

  Memory problems

  Other neurological problems such as Parkinson’s, multiple sclerosis,

seizures, head injury

Specify problem _________________________________________

  Have you had an MRI scan of your brain other than for the Framingham

Heart Study?

Name of MRI Facility ____________________________________

Date of MRI |___|___| - |___|___| - |___|___|

d. Other Problems

Yes No (Mark yes or no for each question)

Diabetes If yes, please list medications you take for diabetes

______________________________________________________

  Cancer (Specify type) ____________________________________

Physician ______________________________________________

Place where biopsy performed______________________________

______________________________________________________

______________________________________________________

  Fracture, broken bone (Specify including hip, back, arm, leg, pelvis,

collarbone, foot, toe and others)_____________________________

  Other (Specify problem) __________________________________

Please go on to the next page

4. Since the date of your last Framingham Heart Study exam or update on the top of Page 1 of the Medical History Update form, have you been admitted to a HOSPITAL or gone to an EMERGENCY ROOM or seen a PHYSICIAN for other than a routine examination?

 yes (if yes, please give details)  no (go to question 5 on the next page)

Date |___|___| - |___|___| - |___|___|

Type* _______________________________________________________ _____

Reason** _______________________________________________________ _____

Hospital Name _____________________________ Doctor’s Name _____________________________

Address __________________________________ Address __________________________________

_________________________________________ __________________________________________

Date |___|___| - |___|___| - |___|___|

Type* _______________________________________________________ _____

Reason** _______________________________________________________ _____

Hospital Name _____________________________ Doctor’s Name _____________________________

Address __________________________________ Address __________________________________

_________________________________________ __________________________________________

Date |___|___| - |___|___| - |___|___|

Type* _______________________________________________________ _____

Reason** _______________________________________________________ _____

Hospital Name _____________________________ Doctor’s Name _____________________________

Address __________________________________ Address __________________________________

_________________________________________ __________________________________________

* Type ** Reason

1. Overnight admission 1. Heart problems

2. Emergency room visit 2. Stroke or transient ischemic attack (TIA), sudden paralysis, vision loss, inability

3. Day Surgery/Procedure to speak

4. M.D. visit 3. Broken, crushed or fractured bones

4. Cancer or malignant tumor

5. Circulation problem, or blood clots

6. Other reasons (Please specify)

Nursing Home/Rehabilitation Admissions.

5. Have you stayed overnight as a patient in a nursing home, rehabilitation center or transitional care unit (TCU) since the date of your last Framingham Heart Study exam or update on the top of page 1?

 yes  no (if no, go to Question 8.)

6. Please list the name and location of the nursing home or rehabilitation center and the date

you were admitted.

Nursing home/Rehab Center name: __________________________________________

Street address: ___________________________________________________________

City/State/Zip Code _______________________________________________________

Date you entered the nursing home/rehabilitation center |___|___| - |___|___| - |___|___|

7. Were you an overnight patient in a nursing home, rehabilitation center or transitional care unit (TCU) at any other time since your last exam?

 yes  no

Nursing home/Rehab Center name: __________________________________________

Street address: ___________________________________________________________

City/State/Zip Code _______________________________________________________

Date you entered the nursing home/rehabilitation |___|___| - |___|___| - |___|___|

Marital Status.

8. What is your current marital status? Please check one

 married  widowed  divorced  separated

 single, never married  living with partner

Health Status. (Questions 9 and 10 to be filled out only by the participant.)

9. In general, how is your health now?

 Excellent

 Fair

 Poor

 Good

 Don’t know

10. Compare your health to most people your own age. Would you say your health is?

 Better

 Worse than most people

 About the same

 Don’t know

Primary Care Physician

11. Please list the name and address of your primary care physician.

Name _____________________________________________

Address ____________________________________________

___________________________________________________

you might be sent a consent form to sign so that we may obtain your medical records.