Download:
pdf |
pdfOMB #: 0925–0216
Expiration Date: xx/xxxx
Public reporting burden for this collection of information is estimated to average
65 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 (09250216). Do not return the completed form to this address.
EXAM 32
«ID»
«LName», «FName»
Form A
OMB #: 0925–0216
1 Date: xx/xxxx
Expiration
Numerical Data (Anthropometry)
|__|
Check here if whole page is blank.
|__|__|__|
Reason why___________________________________
Technician Number.
Basic Information
Check Protocol Modification ONLY if there was one and document it in Comment section
|__|
Marital Status (1=Single, 2=Married, 3=Widowed, 4=Divorced, 5=Separated)
|__|
Site of Exam (0=Heart Study, 1=Nursing home, 2=Residence, 3=Other, 9=Unk.)
|__|__|__|
Weight (to nearest pound, 999=Unk.)
if not FHS
protocol
fill
|__|
Protocol modification for weight (check if Yes)
|__|
Method used to obtain weight, if not FHS protocol or field
visit with portable scale (1=recorded in NH chart, 2=Other
write in _________________________________________)
|__|__|*|__|__|*|__|__|__|__|
|__|__|*|__|__|
Date weight obtained (99/99/9999=Unk.) if not Exam date
Height (inches, to next lower 1/4 inch, 99/99=Unk.)
|__|
88/88=field visit
Protocol modification for height. (check if Yes)
Comments on all protocol modifications:
________________________________________________________________________________________
________________________________________________________________________________________
________________________________________________________________________________________
__________________________________________________________________________________________________________
TECH01
Version 1
05-13-2012
OMB NO=0925-0216
11/30/2013
EXAM 32
|__|
«ID»
«LName», «FName»
Check here if whole page is blank.
|__|__|__|
Form A
OMB #: 0925–0216
2 Date: xx/xxxx
Expiration
Reason why___________________________________
Technician Number.
EXAM 32 Procedures Sheet
|__|
|__|
|__|
|__|
|__|
|__|
|__|
|__|
ECG
Physician Medical History (Tech. Medical History, off-site)
Observed Physical Performance
CES-D, 10-item
MMSE
Physical function: Katz, Rosow-Breslau, Nagi, IADL
Leisure Time Cognitive and Physical Activities
Height
8=not done due to offsite visit
|__|
|__|
Weight
Socio-demographic, Nursing (Community) Services Use
0=No
1=Yes
9=Unk.
Adverse Events
|__|__|__|
Technician ID#
|__|
Was there an adverse event in clinic/offsite exam that does not require further
medical evaluation? (0=No, 1=Yes, 9=Unk.)
Comments:____________________________________________________________
|__|
Was a FHS physician contacted during the offsite examination due to medical
concern? (0=No, 1=Yes, 9=Unk.)
(offsite exam only)
Comments:____________________________________________________________
Exit Interview
|__|__|__|
Technician ID
|__|
Procedure Sheet Review
|__|
Referral Sheet Review
|__|
Left Clinic with all belongings 8=n/a, offsite
|__|
Feedback
0=No
0=No feedback, 1=Positive feedback,
2=Negative feedback, 3=Other
1=Yes
Comments_____________________________________________________
______________________________________________________________
______________________________________________________________
Your exam today was for research purposes only and is not designed to make a medical
diagnosis. The exam cannot identify all serious heart and health issues. It is important
that you continue regular follow-up with your physician or health care provider.
TECH02
Version 1
05-13-2012
OMB NO=0925-0216
11/30/2013
EXAM 32
|__|
«ID»
OMB #: 0925–0216
«LName», «FName»
Form A
3 Date: xx/xxxx
Expiration
Observed performance. Part 1 Technician Administered
Check here if whole page is blank.
|__|__|__|
Reason why___________________________________
Technician Number
HAND GRIP TEST Measured to the nearest kilogram
Right hand
Trial 1
99=Unk.
|__|__|
Trial 2
99=Unk.
|__|__|
Trial 3
99=Unk.
|__|__|
Left hand
Trial 1
99=Unk.
|__|__|
Trial 2
99=Unk.
|__|__|
Trial 3
99=Unk.
|__|__|
|__|
Check if this test not completed or not attempted.
|__|
If not attempted or completed, why not?
1=Physical limitation, 2=Refused, 3=Other ____________________write in, 9=Unk.
PHYSICAL FUNCTION TEST 10 seconds stand
Side by Side
Was this test completed? Held for 10 seconds (0=No, 1=Yes, 8=N/A, 9=Unk.)
Number of seconds held if less than 10 99.99=Unk.
If not attempted or completed, why not?
1=Physical limitation
3=Other ____________________write in
2=Refused
9=Unk.
Semi-Tandem
Was this test completed? Held for 10 seconds (0=No, 1=Yes, 8=N/A, 9=Unk.)
Number of seconds held if less than 10 99.99=Unk.
If not attempted or completed, why not?
1=Physical limitation
3=Other ____________________write in
2=Refused
9=Unk.
Tandem
Was this test completed? Held for 10 seconds (0=No, 1=Yes, 8=N/A, 9=Unk.)
Number of seconds held if less than 10 99.99=Unk.
If not attempted or completed, why not?
1=Physical limitation
3=Other ____________________write in
2=Refused
9=Unk.
|__|
|__|__|*|__|__|
|__|
|__|
|__|__|*|__|__|
|__|
|__|
|__|__|*|__|__|
|__|
TECH03
Version 1
05-13-2012
OMB NO=0925-0216
11/30/2013
EXAM 32
«ID»
«LName», «FName»
Form A
OMB #: 0925–0216
4 Date: xx/xxxx
Expiration
Observed performance. Part 2 Technician Administered
|__|
Check here if whole page is blank.
|__|__|__|
Reason why___________________________________
Technician Number
Repeated Chair Stands
Time to complete five stands in seconds (99.99=Unk.)
|__|__|*|__|__|
If less than five stands, enter the number (9=Unk.)
|__|
IF OFFSITE visit, Chair height (in inches, 99*99=Unk.)
|__|__|*|__|__|
|__|
Check if this test not completed or not attempted.
|__|
If not attempted or completed, why not?
1=Physical limitation, 2=Refused, 3=Other _______________________write in, 9=Unk.
Measured Walks
Course in meters. OFFSITE ONLY
|__|
3m
(check one)
Walking aid used: (0=No aid, 1=Cane, 2=Walker, 3=Other, 9=Unk.)
|__|
4m
|__|
First Walk
Walk time (in seconds, 99.99=Unk.)
|__|
|__|__|*|__|__|
Check if this test not completed or not attempted.
|__|
If not attempted or completed, why not?
(1=Physical limitation, 2=Refused, 3=Other ____________________write in, 9=Unk.)
Second Walk
Walk time (in seconds, 99.99=Unk.)
|__|
|__|__|*|__|__|
Check if this test not completed or not attempted.
|__|
If not attempted or completed, why not?
(1=Physical limitation, 2=Refused, 3=Other ____________________write in, 9=Unk.)
Quick Walk
Walk time (in seconds, 99.99=Unk.)
|__|
|__|__|*|__|__|
Check if this test not completed or not attempted.
|__|
If not attempted or completed, why not?
(1=Physical limitation, 2=Refused, 3=Other ____________________write in, 9=Unk.)
TECH04
Version 1
05-13-2012
OMB NO=0925-0216
11/30/2013
EXAM 32
«ID»
«LName», «FName»
Form A
OMB #: 0925–0216
5 Date: xx/xxxx
Expiration
Mini-Mental State Exam
|__|
Check here if whole page is blank.
Reason why___________________________________
Read Script: I’m going to ask some questions that require concentration and memory. Some
questions are more difficult than others and some will be asked more than one time.
|__|__|__|
Technician Number
Write all responses on exam form
(score 1 point for each correct response)
SCORE CORRECT
No Try=6, Unk.=9
0 1 2 3 6
9
What Is the Date Today? (Month, day, year, correct score=3)
0 1
6
9
What Is the Season?
0 1
6
9
What Day of the Week Is it?
0 1
2 3 6
9
What Town, County and State Are We in?
0 1
6
9
What Is the Name of this Place?
(any appropriate answer all right, for instance my home, nursing home, street address, heart
study...max score=1)
0 1
6
9
What Floor of the Building Are We on?
0 1
2 3 6
9
I am going to name 3 objects. After I have said them I want you to repeat
them back to me. Remember what they are because I will ask you to name
them again in a few minutes: Apple, Table, Penny
|__|__|__|__|__|
Now I am going to spell a word forward and I want you to spell it backwards.
The word is world. W-O-R-L-D.
Please Spell it in Reverse Order.
(Letters Are Entered and Scored Later)
Score as:
0 1 2 3
6
9
66666=Not administered for reason unrelated to cognitive status
00000=Administered, but couldn’t do
99999=Unk.
What are the 3 objects I asked you to remember a few moments ago?
TECH05
Version 1
05-13-2012
OMB NO=0925-0216
11/30/2013
EXAM 32
«ID»
«LName», «FName»
Form A
OMB #: 0925–0216
6 Date: xx/xxxx
Expiration
Mini-Mental State Exam
|__|
Check here if whole page is blank.
Reason why___________________________________
Write all responses on exam form.
(score 1 point for each correct answer)
SCORE CORRECT
No Try=6, Unk.=9
0 1
6
9
What Is this Called? (Watch)
0 1
6
9
What Is this Called? (Pencil)
0 1
6
9
Please Repeat the Following: "No Ifs, Ands, or Buts." (Perfect=1)
0 1
6
9
Please Read the Following & Do What it Says (performed=1, code 6 if low vision)
0 1
6
9
Please Write a Sentence (code 6 if low vision)
0 1
6
9
Please Copy this Drawing (code 6 if low vision)
0 1 2 3 6
9
Take this piece of paper in your right hand, fold it in half with both hands,
and put in your lap (score 1 for each correctly performed act, code 6 if low vision)
0=No, 1=Yes,
2=Maybe, 9=Unk
Factor Potentially Affecting Mental State Testing
0
1
2
9
Illiterate or low education
0
1
2
9
Poor eyesight
0
1
2
9
Poor hearing
0
1
2
9
Depression / possible depression
0
1
2
9
Other
TECH06
Version 1
05-13-2012
OMB NO=0925-0216
11/30/2013
EXAM 32
«ID»
«LName», «FName»
Form A
OMB #: 0925–0216
7 Date: xx/xxxx
Expiration
Mini-Mental State Exam
Sentence and Design Handout for Participant
PLEASE WRITE A SENTENCE
_________________________________________________________________________________
_________________________________________________________________________________
_________________________________________________________________________________
PLEASE COPY THIS DESIGN
Version 1
05-13-2012
OMB NO=0925-0216
11/30/2013
EXAM 32
Version 1
«ID»
«LName», «FName»
05-13-2012
Form A
OMB #: 0925–0216
8 Date: xx/xxxx
Expiration
OMB NO=0925-0216
11/30/2013
EXAM 32
«ID»
«LName», «FName»
Form A
OMB #: 0925–0216
9 Date: xx/xxxx
Expiration
Socio-demographics
|__|
Check here if whole page is blank.
|__|__|__|
Reason why___________________________________
Technician Number for Socio-demographics
Socio-demographics
|__|
Where do you live? (0=Private residence, 1=Nursing home, 2=Other institution,
such as: assisted living or retirement community, 9=Unk.)
|__|
Does anyone live with you? (0=No, 1=Yes, 9=Unk.)
Code Nursing Home Residents as NO to these questions
If Yes
If 0 or 9, skip down
|__|
Spouse
|__|
Children
0=No
1=Yes
9=Unk.
|__|
Other Relatives
|__|
Are you Currently doing volunteer or community work? (0=No, 1=Yes.)
|__|
Do you have health insurance other than Medicare or Medicaid? (0=No,
1=Yes, 9=Unk.)
** Proxy may NOT be used to help complete this section **
|__|
In general, how is your health now: (1=Excellent, 2=Good, 3=Fair, 4=Poor, 9=Unk)
|__|
Compare your health to most people your own age:
(1=Better, 2=About the same, 3=Worse than most people your own age, 9=Unk.)
|__|
As I get older, things are: (1= Better than I thought they’d be, 2=About the same that I
thought they’d be, 3= Worse, 9=Unk.
TECH07
Version 1
05-13-2012
OMB NO=0925-0216
11/30/2013
EXAM 32
«ID»
«LName», «FName»
Form A
OMB #: 0925–0216
10 Date: xx/xxxx
Expiration
Instrumental Activities of Daily Living (Lawton IADL)
(Not administered to nursing home residents)
|__|
Check here if whole page is blank.
Reason why___________________________________
Instructions: Use the prompt cards when asking these questions .If code=2 –write in definition of “some help”
|__|__|
1. Can you use the phone:
01
02
03
|__|__|
2. Can you get to places out of walking distance:
01
02
03
|__|__|
completely unable to do any housework
with some help
without help (performs light daily tasks – dishwashing, bed making, etc).
resides in assisted living facility, does not do
6. Can you do your own handyman work:
01
02
03
88
|__|__|
completely unable to prepare meals (needs meals prepared and served)
with some help (heat and serve prepared meals)
without help (plans, prepares, serves meals)
resides in assisted living facility, does not do
5. Can you do your own housework :
01
02
03
88
|__|__|
completely unable to do any shopping
with some help (needs to be accompanied on any shopping trip)
without help
resides in assisted living facility, does not do
4. Can you prepare your own meals:
01
02
03
88
|__|__|
completely unable to travel unless special arrangements are made (taxi or car with human assistance)
with some help (when assisted or accompanied by another)
without help (travels independently: drives car, public transportation or use of taxi)
3. Can you go shopping for groceries :
01
02
03
88
|__|__|
completely unable to use the phone
with some help
without help (operates phone on own initiative, looks up, dials number, etc.)
completely unable to do any handyman work
with some help
without help
resides in assisted living facility, does not do
7. Can you do your own laundry:
01
02
03
88
completely unable to use the laundry
with some help (such as using laundry service)
without help (does personal laundry completely)
resides in assisted living facility, does not do
|__|__|
8.
|__|__|
8.
A.
01
02
B.
01
02
03
|__|__|
8.
C.
01
02
03
|__|__|
Do you take medicines or use any medications:
Yes
Go to question 8B
No
Go to question 8C
Do you take your own medicines:
completely unable to take own medicine
with some help (if someone prepares it or reminds you)
without help (in the right doses at the right time)
If you had to take medicine, could you do it:
completely unable to take own medicine
with some help (if someone prepares it or reminds you)
without help (in the right doses at the right time)
9. Can you manage your own money:
01
02
03
completely unable to manage own money
with some help (manages day-to-day purchases, needs help with banking, major purchases)
without help
TECH08
Version 1
05-13-2012
OMB NO=0925-0216
11/30/2013
EXAM 32
«ID»
«LName», «FName»
Form A
OMB #: 0925–0216
11 Date: xx/xxxx
Expiration
Self-Reported Physical Function.
|__|
Check here if whole page is blank.
Reason why___________________________________
Note: If the participant is unable to answer the Nagi & Rosow-Breslau questions, Proxy may answer these questions.
|__|__|__|
Technician Number for Rosow-Breslau and Nagi Quest.
Nagi Questions
For each thing tell me whether you have
(0) No Difficulty
(1) A Little Difficulty
(2) Some Difficulty
(3) A Lot Of Difficulty
(4) Unable To Do
(5) Don't Do On MD Orders or Institutional Orders
(6) Unable to Assess Difficulty Because Not Done as Part of Daily Activities
(9) Unk.
|__|
Pulling or pushing large objects like a living room chair
|__|
Either stooping, crouching, or kneeling
|__|
Reaching or extending arms below shoulder level
|__|
Reaching or extending arms above shoulder level
|__|
Either writing, or handling or fingering small objects
|__|
Standing in one place for long periods, say 15 minutes
|__|
Sitting for long periods, say 1 hour
|__|
Lifting or carrying weights under 10 pounds (like a bag of potatoes)
|__|
Lifting or carrying weights over 10 pounds (like a very heavy bag of groceries)
|__|
|__|
if NO
then
|__|
if NO
then
|__|
if NO
then
Rosow-Breslau Questions
Are you able to do heavy work around the house, like shoveling
snow or washing windows, walls, or floors without help?
0=No, unable to do
Are you able to walk half a mile without help? (About 4-6 blocks)
Are you able to walk a quarter of a mile without help?
(About 2-3 blocks)
Are you able to walk up and down stairs to the second floor
without any help?
|__|
|__|
1=Yes, able
2=Does not do
9=Unk.
Are you able to climb up 10 steps without help?
Do you drive now? (0=No, 1=Yes, 9=Unk)
|__|
Reason for not driving now (1=Health, 2=Other non-health reason, 3=never
licensed, 9=Unk.)
TECH09
Version 1
05-13-2012
OMB NO=0925-0216
11/30/2013
EXAM 32
«ID»
«LName», «FName»
Form A
OMB #: 0925–0216
12 Date: xx/xxxx
Expiration
Self-Reported Physical Function.
|__|
Check here if whole page is blank.
|__|__|__|
Reason why___________________________________
Technician Number for Physical Function
Katz: Activities of Daily Living
During the Course of a Normal Day, can you do the following activities independently or do you need help from
another person or use special equipment or a device?.
(0=No help needed, independent, 1=Uses device, independent, 2=Human assistance needed, minimally
dependent, 3=Dependent, 4=Do not do during a normal day, 9=Unk.)
|__|
Dressing (undressing and redressing) Devices such as: velcro, elastic laces.
|__|
Bathing (including getting in and out of tub or shower) Devices such as: bath chair, long
handled sponge, hand held shower, safety bars.
|__|
Eating Devices such as: rocking knife, spork, long straw, plate guard.
|__|
Transferring( getting in and out of a chair) Devices such as: sliding board, grab bars, special
seat.
|__|
Toileting Activities (using bathroom facilities and handle clothing) Devices such as: special
toilet seat, commode.
|__|
Bladder Continence (ask if person has "accidents"; code=5 if use special products) Devices
such as: external catheter, drainage bags, ileal appliance, protective devices.
|__|
Bowel Continence (ask if person has "accidents") (code=5 if use special products) Devices
such as: suppositories, bedpan, regular enemas, colostomy.
|__|
Walking on Level Surface about 50 Yards Devices such as: cane, crutches, or walker.
|__|
Walking up and down One Flight Stairs Devices such as: handrail, cane.
TECH10
Version 1
05-13-2012
OMB NO=0925-0216
11/30/2013
EXAM 32
«ID»
«LName», «FName»
Form A
OMB #: 0925–0216
13 Date: xx/xxxx
Expiration
Activities Questions.
|__|
Check here if whole page is blank.
|__|__|__|
Reason why___________________________________
Technician Number for Activities Questions
Use of Nursing and Community Services
|__|
|__|
if yes,
check all
services
|__|
|__|
if yes
then
Have you been admitted to a nursing home (or skilled facility) since your last exam or
medical history update?
(0=No, 1=Yes, 9=Unk.)
Since your last exam, have you been visited by a nursing service, or used home,
community, or outpatient programs?
(0=No, 1=Yes, 9=Unk.)
|__|
Home health aides
|__|
Homemaker visits
|__|
Visiting Nurses
|__|
Other (write in)_______________________________________________
Are you in bed or a chair for most or all of the day (on the average)?
(0=No, 1=Yes, 9=Unk.)
Do you need a special aid (wheelchair, cane, walker) to get around?
(0=No, 1=Yes, 9=Unk.)
If yes, which of the following equipment do you use?
|__|
Cane or walking stick
|__|
Wheelchair
|__|
Walker
|__|
Other (Write in )_____________________________
0=No
1=Yes, always
2=Yes, sometimes
9=Unk.
TECH11
Version 1
05-13-2012
OMB NO=0925-0216
11/30/2013
EXAM 32
«ID»
«LName», «FName»
Form A
OMB #: 0925–0216
14 Date: xx/xxxx
Expiration
Falls and Fractures
|__|
Check here if whole page is blank.
|__|__|__|
|__|
Technician Number for Falls and Fractures
Since your last exam have you accidentally fallen and hit the floor or ground?
(code as no if during sports activity)
(0=No, 1=Yes, 2=Maybe, 9=Unk)
if yes,
fill
|__|
Reason why___________________________________
How many times did you fall in the past year?
|__|__|
(99=Unk.)
Since your last exam or medical history update have you broken any bones?
(0=No, 1=Yes, 2=Maybe, 9=Unk.)
If 1 or 2,
fill
|__|__|
Location of 1st fracture
|__|__|
Location of 2nd fracture
|__|__|
Location of 3rd fracture
Location Fracture Code
1. Clavicle (collar bone)
2. Upper arm (humerus) or elbow
3. Forearm or wrist
4. Hand
5. Back (If disc disease only, code as no)
6. Pelvis
7. Hip
8. Leg
9. Foot
10. Other (specify)____________________________
TECH12
Version 1
05-13-2012
OMB NO=0925-0216
11/30/2013
EXAM 32
«ID»
«LName», «FName»
OMB #: 0925–0216
15 Date: xx/xxxx
Expiration
Form A
Leisure Time Cognitive and Physical Activities
|__|
Check here if whole page is blank.
|__|__|__|
Reason why___________________________________
Technician Number for Leisure time activities.
During the past year, how often have you participated in the following leisure time
activities?
Questions to be answered
Never
Circle best answer for each
question
Daily
(7 days per
week)
Several
days per
week
Once
weekly
Monthly
(2-6 days per
week)
(1 day per
week)
(once a
month)
Occasionally Unk.
(< once a
month)
1. Reading books/newspapers
0
1
2
3
4
5
9
2. Writing for pleasure
0
1
2
3
4
5
9
3. Doing crossword puzzles
0
1
2
3
4
5
9
4. Playing board games or cards
0
1
2
3
4
5
9
5. Participating in organized
group discussions
0
1
2
3
4
5
9
6. Group exercises
0
1
2
3
4
5
9
7. Housework
0
1
2
3
4
5
9
8. Playing musical instruments
0
1
2
3
4
5
9
OMB NO=0925-0216
11/30/2013
TECH13
Version 1
05-13-2012
EXAM 32
«ID»
«LName», «FName»
Form A
OMB #: 0925–0216
16 Date: xx/xxxx
Expiration
CES-D Scale
|__|
Check here if whole page is blank.
|__|__|__|
Reason why___________________________________
Technician Number for CES-D Scale
The next questions ask about your feelings. For each of the following statements, please say if
you felt that way during the past week.
Circle best answer for each question
DURING THE PAST WEEK
Rarely or
Some or a Occasionally
none of the
little of the
or moderate
time
time
amount of time
(less than 1 day) (1-2 days)
(3-4 days)
Most or all
of the time
(5-7 days)
I was bothered by things that usually don’t bother me.
0
1
2
3
I had trouble keeping my mind on what I was doing.
0
1
2
3
I felt that everything I did was an effort.
0
1
2
3
I felt depressed.
0
1
2
3
I felt hopeful about the future.
0
1
2
3
I felt fearful.
0
1
2
3
My sleep was restless.
0
1
2
3
I was happy.
0
1
2
3
I felt lonely.
0
1
2
3
I could not “get going”
0
1
2
3
TECH14
Version 1
05-13-2012
OMB NO=0925-0216
11/30/2013
EXAM 32
«ID»
«LName», «FName»
Form A
OMB #: 0925–0216
17 Date: xx/xxxx
Expiration
Proxy form
|__|
if yes,
fill
Proxy used to complete this exam (0=No, 1=Yes, 1 proxy, 2=Yes, more than 1 proxy, 9=Unk)
Proxy Name ___________________________________________________________
Relationship (1=1st Degree Relative(spouse, child), 2=Other Relative,
|__|
3=Friend, 4=Health Care Professional, 5=Other, 9=Unk.
|__|__|*|__|__| How long have you known the participant? (Years, months; 99.99=Unk)
example: 3m=00*03
Are you currently living in the same household with the participant? (0=No,
|__|
1=Yes, 9=Unk)
How often did you talk with the participant during the prior 11 months?
|__|
(1=Almost every day, 2=Several times a week, 3=Once a week, 4=1 to 3 times per
month, 5=Less than once a month, 9=Unk.)
Proxy Name ___________________________________________________________
Relationship (1=1st Degree Relative(spouse, child), 2=Other Relative,
|__|
3=Friend, 4=Health Care Professional, 5=Other, 9=Unk.
|__|__|*|__|__| How long have you known the participant? (Years, months; 99.99=Unk)
example: 3 m=00*03
Are you currently living in the same household with the participant? (0=No,
|__|
1=Yes, 9=Unk)
How often did you talk with the participant during the prior 11 months?
|__|
(1=Almost every day, 2=Several times a week, 3=Once a week,
4=1 to 3 times per month, 5=Less than once a month, 9=Unk.)
TECH15
Version 1
05-13-2012
OMB NO=0925-0216
11/30/2013
EXAM 32
Version 1
«ID»
«LName», «FName»
05-13-2012
Form A
OMB #: 0925–0216
18 Date: xx/xxxx
Expiration
OMB NO=0925-0216
11/30/2013
EXAM 32
«ID»
«LName», «FName»
Form A
OMB #: 0925–0216
19 Date: xx/xxxx
Expiration
Date of exam
_____/_____/_____
Framingham Heart Study
Cohort Exam 32
Summary Sheet to Personal Physician
Blood
Pressure
First Reading
Second Reading
Systolic
Diastolic
ECG Diagnosis ______________________________________________________________________
___________________________________________________________________________________
Summary of Findings__________________________________________________________________
____________________________________________________________________________________
____________________________________________________________________________________
____________________________________________________________________________________
____________________________________________________________________________________
____________________________________________________________________________________
____________________________________________________________________________________
____________________________________________________________________________________
____________________________________________________________________________________
____________________________________________________________________________________
__________________________
Examining Physician
The Heart Study examination is not comprehensive and does not take the place of a routine physical
examination.
Version 1
05-13-2012
OMB NO=0925-0216
11/30/2013
EXAM 32
Version 1
«ID»
«LName», «FName»
05-13-2012
Form A
OMB #: 0925–0216
20 Date: xx/xxxx
Expiration
OMB NO=0925-0216
11/30/2013
EXAM 32
«ID»
«LName», «FName»
Form A
OMB #: 0925–0216
21 Date: xx/xxxx
Expiration
Referral Tracking
|__|
Check here if whole page is blank.
Reason why_____________________________________
Was further medical evaluation recommended for this participant?
if yes fill below 0=No, 1=Yes, 9=Unk.
||
RESULT
Reason for further evaluation:
(Check ALL that apply).
|| Blood Pressure
result ______/_______
mmHg
______/_______
mmHg
SBP or DBP
Phone call > 200 or >110
Expedite > 180 or >100
Elevated > 140 or >90
Write in abnormality
|| ECG abnormality _____________________________________________________
|__| Clinic Physician identified medical problem_________________________________
|| Other ________________________________________________________________
Method used to inform participant of need for further medical evaluation
(Check ALL that apply)
|__|
Face-to-face in clinic
|__|
Phone call
|__|
Result letter
|__|
Other
Method used to inform participant’s personal physician of need for further
medical evaluation (Check ALL that apply)
|__|
Phone call
|__|
Result letter mailed
|__|
Result letter FAX’d (inform staff if Fax needed)
|__|
Other
Date referral made: _____/____/________
ID number of person completing the referral: __________
Notes documenting conversation with participant or participant’s personal physician:_________________
_____________________________________________________________________________________
REF1
Version 1
05-13-2012
OMB NO=0925-0216
11/30/2013
EXAM 32
Version 1
«ID»
«LName», «FName»
05-13-2012
Form A
OMB #: 0925–0216
22 Date: xx/xxxx
Expiration
OMB NO=0925-0216
11/30/2013
EXAM 32
«ID»
«LName», «FName»
Form A
OMB #: 0925–0216
23 Date: xx/xxxx
Expiration
Medical History—Hospitalizations, ER Visits, MD Visits
DATE ______________
Cohort Exam32
DATE of last exam «Lastexamdate»
DATE of last health update «Evdate»
Health Care
Since your last exam or health update
|__|__|__|
1st Examiner ID _________________________ 1st Examiner Name
Hospitalizations (not just E.R.) (0=No; 1=yes, hospitalization, 2=yes, more than 1
|__|
hospitalization, 9=Unk.)
|__|
E.R. Visits (0=No; 1=Yes, 1 visit, 2=Yes, more than 1 visit, 9=Unk.)
|__|
Day Surgery (0=No, 1=Yes, 9=Unk.)
Major illness with visit to doctor (0=No, 1=Yes, 1 visit; 2=Yes, more than 1 visit;
|__|
9=Unk)
|__|
Check up by doctor or other health care provider? (0=No, 1=Yes, 9=Unk.)
|__|__| |__|__| |__|__|__|__| Date of this FHS exam (Today's date - See above)
MM
DD
YYYY
Medical Encounter
Month/Year
(of last visit)
Name & Address of Hospital or
Office
Doctor
MD01
Version 1
05-13-2012
OMB NO=0925-0216
11/30/2013
EXAM 32
«ID»
«LName», «FName»
Form A
OMB #: 0925–0216
24 Date: xx/xxxx
Expiration
Medical History—Medications
Since your last exam
(0=No, 1=Yes, now, 2=Yes, not now,
9=Unk.)
|__|
Have you taken medication for the treatment of hypertension? (high blood pressure)
|__|
Have you taken medication for the treatment of high blood cholesterol or high
triglycerides?
|__|
Have you taken medication for the treatment of high blood sugar or diabetes?
Aspirin use
|__|
If yes,
fill
Take aspirin regularly? (0=No, 1=Yes, 9=Unk)
|__|__|
Number of aspirins taken regularly (99=Unk.)
|__|
Aspirin frequency- number taken regularly (0=Never, 1=Day, 2=Week
3=Month, 4=Year, 9=Unk)
|__|__|__|
Usual dose (write in mgs, 999=Unk.)
Examples: 081=baby,160=half dose, 250=
like in Excedrin , 325=usual dose,
500=extra strength
MD02
Version 1
05-13-2012
OMB NO=0925-0216
11/30/2013
EXAM 32
«ID»
«LName», «FName»
Form A
OMB #: 0925–0216
Expiration Date: xx/xxxx
25
Medical History – Prescription and Non-Prescription Medications
Copy the name of medicine, the strength including units, and the total number of doses per day/week/month/year. Include vitamins and minerals.
Medication Name
Strength
(Print first 20 letters)
EXAMPLE:
S A M P L
E
D R U G
(include mg, IU,
etc)
N A M E
100
mg
Route
Number per
1= oral, 2=topical,
3=injection,
4=inhaled,
5=drops,6=nasal
88=other
#
1
1
(circle one)
day/week/month/year
1 / 2 / 3 / 4
DWMY
0
Check if
OTC med
Medication bag with medications brought to exam or med
**List medications taken regularly in past month/ongoing medications**
bottles/packs used by examiner to complete form? (0=No 1=Yes) Code ASPIRIN ONLY on screen MD02.
PRN 0=no,
1=yes,9=Unk.
|__|
DWMY
DWMY
DWMY
DWMY
DWMY
DWMY
DWMY
DWMY
DWMY
DWMY
Continue on the next page
MD03
Version 1
05-13-2012
OMB NO=0925-0216
11/30/2013
«LName», «FName»
Form A
26
Medical History – Prescription and Non-Prescription Medications
EXAMPLE:
Strength
Route
(Print first 20 letters)
(include mg, IU, etc)
1= oral, 2=topical,
3=injection,
4=inhaled,
5=drops,6=nasal
88=other
#
1
1
S A M P L
E
D R U G
N A M E
100
mg
MD04
Version 1
05-13-2012
OMB NO=0925-0216
11/30/2013
Number per
(circle one)
day/week/month/year
1 / 2 / 3 / 4
0
.
Medication Name
OMB #: 0925–0216
Expiration Date: xx/xxxx
Check if
OTC med.
«ID»
PRN 0=no,
1=yes, 9-Unk
EXAM 32
DWMY
DWMY
DWMY
DWMY
DWMY
DWMY
DWMY
DWMY
DWMY
DWMY
DWMY
DWMY
DWMY
DWMY
DWMY
DWMY
EXAM 32
«ID»
«LName», «FName»
Form A
OMB #: 0925–0216
27 Date: xx/xxxx
Expiration
Medical History–Blood Pressure, Smoking
Blood Pressure
(first reading)
Systolic
BP cuff size
|__|__|__|
to nearest 2 mm Hg
999=Unk.
|__|
0=pediatric,1=regular adult,
2=large adult, 3= thigh, 9=Unk.
Diastolic
Protocol modification
|__|__|__|
to nearest 2 mm Hg
999=Unk.
|__|
0=No, 1=Yes, 9=Unk.
write in _____________________
Smoking
|__|
Have you smoked cigarettes regularly since your last exam?
if yes fill
|__|__|
0=No,
1=Yes, now,
2=Yes, not now,
9=Unk.
How many cigarettes do/did you smoke a day?
(01=one or less, 99=Unk.)
MD05
Version 1
05-13-2012
OMB NO=0925-0216
11/30/2013
EXAM 32
«ID»
«LName», «FName»
Form A
OMB #: 0925–0216
28 Date: xx/xxxx
Expiration
Medical History –Alcohol Consumption.
Now I will ask you questions regarding your alcohol use.
Do you drink any of the following beverages at least once a month?
(0=no, 1=yes, 9=Unk.)
|__|
Beer
|__|
Wine
||
Liquor/spirits
What is your average number of servings in a typical week or month since your last exam?
(999=Unk.)
Code alcohol intake as EITHER weekly OR monthly as appropriate.
Beverage
Per week
Per month
Beer (12oz bottle, glass, can)
|__|__|__|
|__|__|__|
Wine (red or white, 4oz glass)
||||
||||
Liquor/spirits (1oz cocktail/highball)
||||
||||
|__|
Check if over past year participant drinks less than one alcoholic drink of any type per
month.
MD06
Version 1
05-13-2012
OMB NO=0925-0216
11/30/2013
EXAM 32
«ID»
«LName», «FName»
Form A
OMB #: 0925–0216
29 Date: xx/xxxx
Expiration
Medical History—Respiratory Symptoms. Part 1
Cough
(0=No, 1=Yes, 9=Unk.)
|__|
Do you usually have a cough? (Exclude clearing of the throat)
||
Do you usually have a cough at all on getting up or first thing in the
morning?
If YES to either question above answer the following:
|__|
Do you cough like this on most days for three consecutive months or
more during the past year?
|__|__|
How many years have you had this cough? (# of years.)
Phlegm
1=1 year or less
99=Unk
(0=No, 1=Yes, 9=Unk.)
|__|
Do you usually bring up phlegm from your chest?
||
Do you usually bring up phlegm at all on getting up or first thing in the
morning?
If YES to either question above answer the following:
|__|
Do you bring up phlegm from your chest on most days for three
consecutive months or more during the year?
|__|__|
How many years have you had trouble with phlegm? (# of years)
Wheeze
1=1 year or less
99=Unk
(0=No, 1=Yes, 9=Unk.)
In the past 12 months…
|__|
if yes,
fill
all
Have you had wheezing or whistling in your chest at any time?
|__|
How often have you had this wheezing or whistling?
0=Not at all 1=MOST days or nights 2=A few days or nights a WEEK
3=A few days or nights a MONTH 4=A few days or nights a YEAR 9=Unk.
|__|
Have you had this wheezing or whistling in the chest when you had
a cold?
|__|
Have you had this wheezing or whistling in the chest apart from
colds?
|__|
Have you had an attack of wheezing or whistling in the chest that
had made you feel short of breath?
MD07
Version 1
05-13-2012
OMB NO=0925-0216
11/30/2013
EXAM 32
«ID»
«LName», «FName»
Form A
OMB #: 0925–0216
30 Date: xx/xxxx
Expiration
Medical History—Respiratory Symptoms. Part 2
Nocturnal chest symptoms
In the past 12 months…
(0=No, 1=Yes, 9=Unk.)
|__|
Have you been awakened by shortness of breath?
|__|
Have you been awakened by a wheezing/whistling in your chest?
|__|
Have you been awakened by coughing?
if yes,
fill
all
How often have you been awakened by coughing?
|__|
0=Not at all 1=MOST days or nights 2=A few days or nights a WEEK
3=A few days or nights a MONTH 4=A few days or nights a YEAR 9=Unk.
Shortness of breath
|__|
if yes,
fill
all
(0=No, 1=Yes, 9=Unk.)
Are you troubled by shortness of breath when hurrying on level ground or walking up a slight
hill?
|__|
Do you have to walk slower than people of your age on level ground because of shortness
of breath?
|__|
Do you have to stop for breath when walking at your own pace on level ground?
|__|
Do you have to stop for breath after walking 100 yards (or after a few minutes) on level
ground?
|__|
Do you/have you needed to sleep on two or more pillows to help you breathe (Orthopnea)?
|__|
Have you since last exam had swelling in both your ankles (ankle edema)?
|__|
Have you been told by your doctor you had heart failure or congestive heart failure?
if yes,
fill
Name of doctor ______________________________________________________
Date of visit |__|__|*|__|__|*|__|__|__|__|
|__|
if yes,
fill
99/99/9999=Unk.
Have you been hospitalized for heart failure?
Name of hospital ______________________________________________________
Date of visit |__|__|*|__|__|*|__|__|__|__|
99/99/9999=Unk.
Examiner Opinion
|__|
0=No,1=Yes
2=Maybe, 9=Unk.
First examiner believes CHF
Comments________________________________________________________________________________
__________________________________________________________________________________________
MD08
Version 1
05-13-2012
OMB NO=0925-0216
11/30/2013
EXAM 32
«ID»
«LName», «FName»
Form A
OMB #: 0925–0216
31 Date: xx/xxxx
Expiration
Medical History—Heart
|__|
Any chest discomfort since last exam or medical history update?
(0=No, 1=Yes, 2=Maybe, 9=Unk.)
(please provide narrative comments in addition to checking the appropriate boxes)
if yes,
fill
and below
|__|
Chest discomfort with exertion or excitement
(0=No, 1=Yes, 2=Maybe, 9=Unk.)
|__|
Chest discomfort when quiet or resting
(0=No, 1=Yes, 2=Maybe, 9=Unk.)
Chest Discomfort Characteristics (must have checked box at top of table)
|__|__|*|__|__|__|__|
Date of onset
mo/yr, 99/9999=Unk.
|__|__|__|
Usual duration (min)
1=1 min or less, 900=15 hrs or more, 999=Unk.
|__|__|__|
Longest duration (min)
1=1 min or less, 900=15 hrs or more, 999=Unk.
|__|
Location
0=No, 1=Central sternum and upper chest,
2=L up per Quadrant, 3=L lower ribcage, 4=R chest,
5=Other, 6=Combination, 9=Unk.
|__|
Radiation
0=No, 1=Left shoulder or L arm, 2=Neck,
3=R shoulder or arm, 4=Back, 5=Abdomen,
6=Other, 7=Combination, 9=Unk.
|__|__|__|
Frequency
(number in past month)
999=Unk.
|__|__|__|
Frequency
(number in past year)
999=Unk.
|__|
Type
1=Pressure, heavy, vise, 2=Sharp, 3=Dull, 4=Other,
9=Unk
|__|
Relief by Nitroglycerine in <15 minutes
|__|
Relief by Rest in <15 minutes
|__|
Relief Spontaneously in <15 minutes
|__|
Relief by Other cause in <15 minutes
0=No
1=Yes,
8=Not tried
9=Unk.
MD09
Version 1
05-13-2012
OMB NO=0925-0216
11/30/2013
EXAM 32
«ID»
«LName», «FName»
Form A
OMB #: 0925–0216
32 Date: xx/xxxx
Expiration
Medical History—Heart (Continued)
Have you since your last exam been told by doctor you have/had a heart attack or
myocardial infarction? (0=No, 1=Yes, 2=Maybe, 9=Unknown)
|__|
if yes,
fill
Name of doctor ______________________________________________________
Date of visit |__|__|*|__|__|*|__|__|__|__|
|__|
99*99*9999=Unk.
Have you been hospitalized for heart attack?
if yes,
fill
Name of hospital ______________________________________________________
Date of visit |__|__|*|__|__|*|__|__|__|__|
99*99*9999=Unk.
CHD First Opinions
|__|
Angina pectoris in interim
|__|
0=No,
1=Yes,
2=Maybe,
9=Unk.
Angina pectoris since revascularization procedure
|__|
Coronary insufficiency in interim
|__|
Myocardial infarct in interim
Comments_____________________________________________________________________________
______________________________________________________________________________________
______________________________________________________________________________________
______________________________________________________________________________________
MD10
Version 1
05-13-2012
OMB NO=0925-0216
11/30/2013
EXAM 32
«ID»
«LName», «FName»
Form A
OMB #: 0925–0216
33 Date: xx/xxxx
Expiration
Medical History—Atrial Fibrillation/Syncope
|__|
if yes,
fill
Have you been told you have/had a heart rhythm problem called atrial fibrillation? (0=No,
1=Yes, 2=Maybe, 9=Unk.)
|__|__|*|__|__|*|__|__|__|__|
|__|
Date of first episode (99/99/9999=Unk.)
ER/hospitalized or saw M.D. (0=No, 1=Hosp/ER, 2=Saw M.D., 9=Unk.)
Hospitalized at:___________________________________________
M.D. seen: _______________________________________________
Have you fainted or lost consciousness since your last exam?
|__|
if yes,
fill all
(If due to stroke skip to screen 11)
If event immediately preceded by head injury, or accident code 0=No
Code: 0=No, 1=Yes,
2=Maybe, 9=Unk.
|__|__|__|
Number of episodes in the past two years
(999=Unk.)
|__|__|*|__|__|__|__|
Date of first episode
(mo/yr, 99/9999=Unk.)
|__|__|__|
Usual duration of loss of consciousness
(minutes, 999=Unk.)
|__|
Did you have any injury caused by the event? (0=No, 1=Yes, 2=Maybe, 9=Unk.)
|__|
if yes,
fill
ER/hospitalized or saw M.D. (0=No, 1=ER/Hosp., 2=Saw M.D., 9=Unk.)
Hospitalized at: _______________________________________
M.D. seen: ___________________________________________
Syncope First Opinions
|__|
|__|
Syncope (0=No, 1=Yes, 2=Maybe, 3=Presyncope, 9=Unk.)
|__|
Cardiac syncope
|__|
Vasovagal syncope
|__|
Other-Specify: ______________________
0=No,
1=Yes,
2=Maybe,
9=Unk.
Seizure Disorder (0=No, 1=Yes, 2=Maybe,, 9=Unk.)
Comments ______________________________________________________________________________
_______________________________________________________________________________________
_______________________________________________________________________________________
_______________________________________________________________________________________
_______________________________________________________________________________________
MD11
Version 1
05-13-2012
OMB NO=0925-0216
11/30/2013
EXAM 32
«ID»
«LName», «FName»
Form A
OMB #: 0925–0216
34 Date: xx/xxxx
Expiration
Medical History—Cerebrovascular Disease
Cerebrovascular Episodes in Interim
|__|
Sudden muscular weakness
|__|
Sudden speech difficulty
|__|
Sudden visual defect
|__|
Sudden double vision
0=No,
1=Yes,
2=Maybe,
9=Unk.
|__|
Sudden loss of vision in one eye
|__|
Sudden numbness, tingling
if yes,
fill
|__|
if yes,
fill
|__|
Numbness and tingling is positional
|__|__| * |__|__| * |__|__|__|__|
Date
___________________________
|__|
if yes,
fill
|__|
0=No,1=Yes,
2= Maybe,9=Unk.
Head CT scan OTHER THAN FOR THE FHS
99/99/9999=Unk.
Place
Head MRI scan OTHER THAN FOR THE FHS
0=No,1=Yes,
2= Maybe,9=Unk.
|__|__| * |__|__| * |__|__|__|__|
Date
99/99/9999=Unk.
___________________________
Place
Seen by neurologist(write in who and when below)
___________________________________________________________
0=No,
|__|
Have you been told by a doctor you had a stroke or TIA
(transient ischemic attack, mini-stroke)?
1=Yes,
|__|
Have you been told by a doctor you have Parkinson Disease?
2=Maybe,
|__|
Have you been told by a doctor you have memory problems, dementia or
Alzheimer’s disease?
9=Unk.
|__|
Do you feel or do other people think that you have memory problems that
prevent you from doing things you’ve done in the past?
Comments:________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
MD12
Version 1
05-13-2012
OMB NO=0925-0216
11/30/2013
EXAM 32
«ID»
«LName», «FName»
Form A
OMB #: 0925–0216
35 Date: xx/xxxx
Expiration
Medical History—Cerebrovascular Disease Continued
Details for "Serious" Cerebrovascular Event in Interim
|__|
Examiner's opinion that TIA or stroke took place in interim
(0=No, 1=Yes, 2=Maybe, 9=Unk.)
if yes or
maybe
fill all
|__|__|*|__|__|__|__|
|__|__|*|__|__|*|__|__|
|__|
Date (mo/yr, 99/9999=Unk.)
Observed by_________________________
Duration (use format days/hours/mins, 99/99/99=Unk.)
Hospitalized or saw M.D. (0=No, 1=Hosp.2=Saw M.D, 9=Unk)
Name________________
Address______________________________
Neurology First Opinions
|__|
Stroke in Interim
|__|
TIA
|__|
Dementia
|__|
Parkinson Disease
|__|
Other, Specify: __________________
0=No,
1=Yes,
2=Maybe,
9=Unk.
Comments________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
MD13
Version 1
05-13-2012
OMB NO=0925-0216
11/30/2013
EXAM 32
«ID»
«LName», «FName»
Form A
OMB #: 0925–0216
36 Date: xx/xxxx
Expiration
Medical History--Peripheral Arterial Disease
Peripheral Arterial Disease
|__|
Are you able to walk 50 feet without help? (0=Able to walk 50 feet without help, 1=Needs help,
2=Can’t walk, 9=Unknown)
|__|
Do you get discomfort in either leg on walking? (0=No, 1=Yes, 9=Unk.)
if yes,
fill
Does this discomfort ever begin when you are standing still or sitting?
(0=no, 1=yes, 9=Unk)
When walking at an ordinary pace on level ground, how many city blocks
until symptoms develop (1=1 block or less, 99=Unk.) where 10 blocks=1
mile, code as no if more than 98 blocks required to develop symptoms
|__|
|__|__|
Left
Right
Claudication symptoms
|__|
|__|
Discomfort in calf while walking
|__|
|__|
Discomfort in lower extremity (not calf) while walking
Write in site of discomfort_____________________________________
0=No, 1=Yes, 9=Unk.
|__|
Occurs with first steps (code worse leg)
|__|
After walking a while.
|__|
Do you get the discomfort when you walk up hill or hurry?
|__|
Does the discomfort ever disappear while you are still walking?
What do you do if you get discomfort when you are walking?
Check ONLY ONE box below
1=stop
2=slow down
3=continue at same pace
9=Unk.
|__|__|__|
|__|__|
Time for discomfort to be relieved by stopping (minutes)
(000=No relief with stopping, 999=Unk.)
Number of days/month of lower limb discomfort
(1=1 day/month or less, 99=Unk.)
MD14
Version 1
05-13-2012
OMB NO=0925-0216
11/30/2013
EXAM 32
«ID»
«LName», «FName»
Form A
OMB #: 0925–0216
37 Date: xx/xxxx
Expiration
Medical History--Peripheral Arterial Disease Continued
|__|
if yes,
fill
Since your last exam have you been told you have intermittent claudication or peripheral artery
disease? (0=No, 1=Yes, 2=Maybe, 9=Unk.)
Name of doctor ______________________________________________________
Date of visit |__|__|*|__|__|*|__|__|__|__|
|__|
if yes,
fill
Have you been hospitalized for intermittent claudication or peripheral artery disease?
(0=No, 1=Yes, 2=Maybe, 9=Unk.)
Name of hospital ______________________________________________________
Date of visit |__|__|*|__|__|*|__|__|__|__|
PAD First Opinions
|__|
0=No, 1=Yes,
2=Maybe,
9=Unk.
Intermittent Claudication
Comments________________________________________________________________________________
_________________________________________________________________________________________
_________________________________________________________________________________________
MD15
Version 1
05-13-2012
OMB NO=0925-0216
11/30/2013
EXAM 32
«ID»
«LName», «FName»
Form A
OMB #: 0925–0216
38 Date: xx/xxxx
Expiration
Venous Disease and Second Blood Pressure
Venous Disease
|__|
Since your last exam have you had a Deep Vein Thrombosis
(blood clots in legs or arms)
|__|
Since your last exam have you had a Pulmonary Embolus
0=No,
1=Yes,
9=Unk.
(blood clots in lungs)
Blood Pressure
(second reading)
Systolic
BP cuff size
|__|__|__|
to nearest 2 mm Hg
999=Unk.
|__|
0=pediatric,1=regular adult,
2=large adult, 3= thigh, 9=Unk.
Diastolic
Protocol modification
|__|__|__|
to nearest 2 mm Hg
999=Unk.
|__|
0=No, 1=Yes, 9=Unk.
write in _____________________
Comments on Protocol modification
_________________________________________________________________________________________
_________________________________________________________________________________________
_________________________________________________________________________________________
MD16
Version 1
05-13-2012
OMB NO=0925-0216
11/30/2013
EXAM 32
«ID»
«LName», «FName»
Form A
OMB #: 0925–0216
39 Date: xx/xxxx
Expiration
Medical History-- CVD Procedures
Since your last exam or health history update did you have any of the
following cardiovascular procedures?
0=No, 1=Yes
2=Maybe, 9=Unk.
|__|
if yes
fill
|__|
Cardiovascular Procedures
(if procedure was repeated code only first and provide narrative)
Heart Valvular Surgery
|__|__|__|__| Year done (9999=Unk)
Exercise Tolerance Test
if yes
fill
|__|
|__|__|__|__| Year done (9999=Unk)
Coronary arteriogram
if yes
fill
|__|
|__|__|__|__| Year done (9999=Unk)
Coronary artery angioplasty or stent
if yes
fill
|__|
|__|__|__|__| Year done (9999=Unk)
Coronary bypass surgery
if yes
fill
|__|
|__|__|__|__| Year done (9999=Unk)
Permanent pacemaker insertion
if yes
fill
|__|
|__|__|__|__| Year done (9999=Unk)
Carotid artery surgery or stent
if yes
fill
|__|
|__|__|__|__| Year done (9999=Unk)
Thoracic aorta surgery
if yes
fill
|__|
|__|__|__|__| Year done (9999=Unk)
Abdominal aorta surgery
if yes
fill
|__|
|__|__|__|__| Year done (9999=Unk)
Femoral or lower extremity surgery
if yes
fill
|__|
|__|__|__|__| Year done (9999=Unk)
Lower extremity amputation
if yes
fill
|__|
|__|__|__|__| Year done (9999=Unk)
Other Cardiovascular Procedure (write in below)
if yes
fill
|__|__|__|__| Year done (9999=Unk) Description______________________________________
Comments:___________________________________________________________________________
_____________________________________________________________________________________
MD17
Version 1
05-13-2012
OMB NO=0925-0216
11/30/2013
EXAM 32
«ID»
«LName», «FName»
Form A
OMB #: 0925–0216
40 Date: xx/xxxx
Expiration
Cancer Site or Type
|__|
Check
ALL that
apply
Since your last exam or health update have you had a cancer or a tumor?
(0=No and skip to MD19 (next screen); If 1=Yes, 2=Maybe, 9=Unk. please continue)
Site of Cancer or Year First
Tumor
Diagnosed
Maybe
Benign
cancer
Check ONE
1
2
3
Cancer
|__|
Esophagus
|__|
|__|
|__|
|__|
Stomach
|__|
|__|
|__|
|__|
Colon
|__|
|__|
|__|
|__|
Rectum
|__|
|__|
|__|
|__|
Pancreas
|__|
|__|
|__|
|__|
Larynx
|__|
|__|
|__|
|__|
|__|
|__|
|__|
Trachea/Bronchus/
Lung
|__|
Leukemia
|__|
|__|
|__|
|__|
Skin
|__|
|__|
|__|
|__|
Breast
|__|
|__|
|__|
|__|
Cervix/Uterus
|__|
|__|
|__|
|__|
Ovary
|__|
|__|
|__|
|__|
Prostate
|__|
|__|
|__|
|__|
Bladder
|__|
|__|
|__|
|__|
Kidney
|__|
|__|
|__|
|__|
Brain
|__|
|__|
|__|
|__|
Lymphoma
|__|
|__|
|__|
|__|
|__|
|__|
|__|
|__|
Other/Unk.
______________
Diagnostic biopsy done?
if yes fill ___ - ___
-______ Date
Hosp./office
name_________________________
Name Diagnosing
M.D.
City of M.D.
(0=No, 1=Yes, 9=Unk.)
Location of biopsy_________________________________________
Address
(city/state)_________________________________________
Comment (If participant has more details concerning tissue diagnosis, other hospitalization, procedures, and treatments)
__________________________________________________________________________________________
__________________________________________________________________________________________
MD18
Version 1
05-13-2012
OMB NO=0925-0216
11/30/2013
EXAM 32
«ID»
«LName», «FName»
Form A
OMB #: 0925–0216
41 Date: xx/xxxx
Expiration
Electrocardiograph--Part I
|__|__|__|
Examiner ID Number
|__|
if Yes, fill out
rest of form
_________________________________ Examiner Last
Name
ECG done (0=No, 1=Yes)
Rates and Intervals
|__|__|__|
|__|__|__|
|__|__|__|
|__|__|__|
|__|__|__|__|
Ventricular rate per minute (999=Unk.)
P-R Interval (milliseconds) (999=Fully Paced, Atrial Fib, or Unk.)
QRS interval (milliseconds) (999=Fully Paced, Unk.)
Q-T interval (milliseconds) (999=Fully Paced, Unk.)
QRS angle (put plus or minus as needed) (e.g. -045 for minus 45 degrees, +090 for plus 90, 9999=Fully
paced or Unk.)
Rhythm--predominant
|__|
0 or 1 = Normal sinus, (including s.tach, s.brady, s arrhy, 1 degree AV block)
3 = 2nd degree AV block, Mobitz I (Wenckebach)
4 = 2nd degree AV block, Mobitz II
5 = 3rd degree AV block / AV dissociation
6 = Atrial fibrillation / atrial flutter
7 = Nodal
8 = Paced
9 = Other or combination of above (list)_____________________________________
Ventricular conduction abnormalities
|__|
if yes,
fill
|__|
|__|
IV Block (0=No, 1=Yes, 9=Fully paced or Unk.)
|__|
Pattern (1=Left, 2=Right, 3=Indeterminate, 9=Unk.)
||
Complete (QRS interval=.12 sec or greater)(0=No, 1=Yes, 9=Unk.)
|__|
Incomplete (QRS interval = .10 or .11 sec) (0=No, 1=Yes, 9=Unk.)
Hemiblock (0=No, 1=Left Ant, 2=Left Post, 9=Fully paced or Unk.)
WPW Syndrome (0=No, 1=Yes, 2=Maybe, 9=Fully paced or Unk.)
Arrhythmias
|__|
|__|
|__|__|
Atrial premature beats (0=No, 1=Atr, 2=Atr Aber, 9=Unk.)
Ventricular premature beats (0=No, 1=Simple, 2=Multifoc, 3=Pairs, 4=Run, 5=R on T,
9=Unk)
Number of ventricular premature beats in 10 seconds (see 10 second rhythm strip,
99=Unk.)
MD19
Version 1
05-13-2012
OMB NO=0925-0216
11/30/2013
EXAM 32
«ID»
«LName», «FName»
Form A
OMB #: 0925–0216
42 Date: xx/xxxx
Expiration
Electrocardiograph-Part II
Myocardial Infarction Location
|__|
Anterior
|__|
Inferior
|__|
True Posterior
(0=No,
1=Yes,
2=Maybe,
9=Fully paced or Unk.)
Left Ventricular Hypertrophy Criteria
|__|
R > 20mm in any limb lead
(0=No,
|__|
R > 11mm in AVL
|__|
R in lead I plus S 25mm in lead III
1=Yes,
9=Fully paced, Complete LBBB or Unk)
Measured Voltage
*|__|__|
R AVL in mm (at 1 mv = 10 mm standard) Be sure to code these voltages
*|__|__|
S V3 in mm (at 1 mv = 10 mm standard) Be sure to code these voltages
R in V5 or V6-----S in V1 or V2
|__|
R 25mm
|__|
S 25mm
|__|
R or S 30mm
|__|
R + S 35mm
|__|
Intrinsicoid deflection .05 sec
|__|
S-T depression (strain pattern)
|__|
|__|
|__|
|__|
|__|
|__|
0=No,
1=Yes,
9=Fully paced, Complete LBBB or Unk
Hypertrophy, enlargement, and other ECG Diagnoses
Nonspecific S-T segment abnormality (0=No, 1=S-T depression, 2=S-T flattening,
3=Other, 9=Fully paced or Unk.)
Nonspecific T-wave abnormality
(0=No, 1=T inversion, 2=T flattening, 3=Other,
9=Fully paced or Unk.)
U-wave present
(0=No, 1=Yes, 2=Maybe, 9=Paced or Unk.)
Atrial enlargement
(0=None, 1=Left, 2=Right, 3=Both, 9=Atrial fib. or Unk.)
RVH
(0=No, 1=Yes, 2=Maybe, 9=Fully paced or Unk.; If complete RBBB present,
RVH=9)
LVH
(0=No, 1=LVH with strain, 2=LVH with mild S-T Segment Abn, 3=LVH by
voltage only, 9=Fully paced or Unk., If complete LBBB present, LVH=9)
Comments and
Diagnosis______________________________________________________________________________________
_______________________________________________________________________________________________
_______________________________________________________________________________________________
MD20
Version 1
05-13-2012
OMB NO=0925-0216
11/30/2013
EXAM 32
«ID»
«LName», «FName»
Form A
OMB #: 0925–0216
43 Date: xx/xxxx
Expiration
Clinical Diagnostic Impression.
Non Cardiovascular Diagnoses First Examiner Opinions
|__|
Diabetes Mellitus
|__|
Prostate disease
|__|
Renal disease (specify)___________________
|__|
Emphysema
|__|
Chronic bronchitis
0=No,
|__|
Pneumonia
1=Yes,
|__|
Asthma
2=Maybe,
|__|
Other pulmonary disease
9=Unk.
|__|
Gout
|__|
Degenerative joint disease
|__|
Rheumatoid arthritis
|__|
Gallbladder disease
|__|
Other non C-V diagnosis (for cancer, see special screen)
8=Female
Comments CDI Other
Diagnoses______________________________________________________________________________
_______________________________________________________________________________________
_______________________________________________________________________________________
_______________________________________________________________________________________
_______________________________________________________________________________________
Continue Comments on the next page→
MD21
Version 1
05-13-2012
OMB NO=0925-0216
11/30/2013
EXAM 32
«ID»
«LName», «FName»
Form A
OMB #: 0925–0216
44 Date: xx/xxxx
Expiration
Continue from MD21
Comments CDI Other
Diagnoses______________________________________________________________________________
_______________________________________________________________________________________
_______________________________________________________________________________________
_______________________________________________________________________________________
_______________________________________________________________________________________
_______________________________________________________________________________________
_______________________________________________________________________________________
_______________________________________________________________________________________
_______________________________________________________________________________________
MD22
Version 1
05-13-2012
OMB NO=0925-0216
11/30/2013
| File Type | application/pdf |
| Author | pandeym |
| File Modified | 2013-09-17 |
| File Created | 2013-04-11 |