17 survey

OMB#: 0925-0216

Expiration Date: xx/xxxx

Public reporting burden for this collection of information is estimated to average 10 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.

Physician’s Name	Participant’s Name:
Physician's Mailing Address	Exam Date:
	DOB:
	ID:

________________________________________________________________________

The Heart Study evaluation focuses on cardiovascular disease and is NOT a comprehensive exam. Our research exam does NOT take the place of regular check-ups with a complete physical examination. The following tests are done on a routine basis: Lipids, Glucose, Pulmonary Function, Ankle-brachial BP. Abnormal findings for non-invasive C-V tests will be forwarded separately.

BLOOD PRESSURE:	FIRST READING	SECOND READING
Systolic Blood Pressure
Diastolic Blood Pressure
ECG DIAGNOSIS:
SUMMARY OF SIGNIFICANT HISTORY AND PHYSICAL EXAM:
1. No history or physical exam findings to suggest cardiovascular disease.

OMB No = 0925-0216 4/30/2001 ------------------------------------

HEART STUDY PHYSICIAN

EXAMINATION REPORT OMB NO=0925-0216 03-08-2010

OMNI Group 1 Exam #

Physician’s Name	Participant’s Name:
Physician's Mailing Address	Exam Date:
	DOB:
	ID:

________________________________________________________________________

The Heart Study evaluation focuses on cardiovascular disease and is NOT a comprehensive exam. Our research exam does NOT take the place of regular check-ups with a complete physical examination. The following tests are done on a routine basis: Lipids, Glucose, Pulmonary Function, Ankle-brachial BP. Abnormal findings for non-invasive C-V tests will be forwarded separately.

BLOOD PRESSURE:	FIRST READING	SECOND READING
Systolic Blood Pressure
Diastolic Blood Pressure
ECG DIAGNOSIS:
SUMMARY OF SIGNIFICANT HISTORY AND PHYSICAL EXAM:
1. No history or physical exam findings to suggest cardiovascular disease.

OMB No = 0925-0216 4/30/2001 ------------------------------------

HEART STUDY PHYSICIAN

The Framingham Heart Study

LABORATORY

LABORATORY TEST RESULTS

OMB NO=0925-0216 03-08-2010

P ARTICIPANT INFORMATION

PaRTICIPANT Name: Study ID: Exam #: Exam Date:

BLOOD TESTS

(FILL IN APPROPRIATE VALUES)

TEST	VALUE mg/dl		Date of Birth
Total cholesterol:			Comments:
HDL cholesterol:
Triglyceride (fasting):
Glucose (fasting):
Serum Creatinine:

RESULTS REPORTED

P HYSICIAN NAME: PHONE: FAX:

PHYSICIAN ADDRESS:

C ONTACT: TECH INITIALS: DATE PHONED: DATE faxed:

please be advised that laboratory testing at the Framingham Heart Study is done for research purposes only. blood test results provide a guide to participants and their physicians. Framingham Heart Study laboratory results should not be used in place of regular clinical care and should be repeated for confirmation.

if you have any questions please contact our laboratory at 508-935-3408.

The Framingham Heart Study

LABORATORY

LABORATORY TEST RESUlts

OMB NO=0925-0216 03-08-2010

P ARTICIPANT INFORMATION

PaRTICIPANT Name: Study ID: Exam #: Exam Date:

BLOOD TESTS

(FILL IN APPROPRIATE VALUES)

TEST	VALUE		Date of Birth
wbc	10^3/ul		Comments:
RBC	10^6/ul
Hemoglobin	g/dl
hematocrit	%
Platelet Count	10^3/ul

RESULTS REPORTED

P HYSICIAN NAME: PHONE: FAX:

PHYSICIAN ADDRESS:

C ONTACT: TECH INITIALS: DATE PHONED: DATE faxed:

please be advised that laboratory testing at the Framingham Heart Study is done for research purposes only. blood test results provide a guide to participants and their physicians. Framingham Heart Study laboratory results should not be used in place of regular clinical care and should be repeated for confirmation.

if you have any questions please contact our laboratory at 508-935-3408.

Letter Date______________ Exam Date____________

OMB No= 0925-0216 Exp. 04/30/2011

___________________________

A report of your recent examination at the Framingham Heart Study has been

forwarded to your doctor or health care provider:

________________________________________________________

The examination you had at the Heart Study does not take the place of a medical check-up you would get from your doctor and cannot identify all serious heart and health conditions.

Any clinical abnormalities requiring that you see your physician are listed below. Some results from tests obtained during your visit are not immediately available; any abnormalities that may have important health and treatment implications will be sent directly to your doctor.

________________________________________________________________

________________________________________________________________

________________________________________________________________

________________________________________________________________

We look forward to seeing you again and appreciate your support. Your participation in the Framingham Heart Study makes possible our efforts to identify the causes of heart disease and stroke and ways of preventing or treating them.

Thank you for your continuing support.

Sincerely,

Daniel Levy, MD

Medical Director

Framingham Heart Study Examiner____________________