Public reporting burden for this collection of information is estimated to average 90 or 60 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.
Name: [lastname], [firstname]DOB: [dob]Age: [age] Sex: [sex] Date of last exam: [lastexamdate]
Date of last medical health update: [lastmhudate]
Date of this FHS exam (today's date)
Year of this FHS exam
Site Heart Study
Nursing home Residence Other
IDTYPE 2 - NOS
3 - Gen 3
72 - Omni Gen 2 (FHS idtype)
ID
(FHS ID (4-digit))
Participant's last name
Participant's first name
Date of birth
Year of birth
Age (in years)
Sex Male
Female
Date of last exam
Year of last exam
Date of last medical health update
Date of last medical information:
Page 2 of 2
Participant Information
Name: [lastname], [firstname]DOB: [dob]Age: [age] Sex: [sex] Date of last exam: [lastexamdate]
Date of last medical health update: [lastmhudate]
1st Examiner ID
Since you last provided medical information ([lastmedinfodate]) have you had any of the following?
Hospitalizations (not just E.R.)? No
Yes Unknown
If "Yes"
Hospitalization #1 Reason
Year
(9999 = Unknown)
DATE details (e.g. 10/2, April, Summer, August-Nov., Unknown etc.)
Name of hospital
Location of hospital
Have you had another hospitalization? No Yes
Unknown
Hospitalization #2 Reason
Year
(9999 = Unknown)
DATE details (e.g. 10/2, April, Summer, August-Nov., Unknown etc.)
Name of hospital
Location of hospital
Have you had another hospitalization? No Yes
Unknown
Hospitalization #3 Reason
Page 2 of 7
Year
(9999 = Unknown)
DATE details (e.g. 10/2, April, Summer, August-Nov., Unknown etc.)
Name of hospital
Location of hospital
Have you had another hospitalization? No Yes
Unknown
Hospitalization #4 Reason
Year
(9999 = Unknown)
DATE details (e.g. 10/2, April, Summer, August-Nov., Unknown etc.)
Name of hospital
Location of hospital
If participant has had more than 4 hospitalizations, provide details in "Additional comments" below.
E.R. visits only? No
Yes Unknown
If "Yes"
E.R. Visit #1 Reason
Year
(9999 = Unknown)
DATE details (e.g. 10/2, April, Summer, August-Nov., Unknown etc.)
Name of hospital
Location of hospital
Have you had another E.R. visit? No
Yes Unknown
E.R. Visit #2 Reason
Year
(9999 = Unknown)
DATE details (e.g. 10/2, April, Summer, August-Nov., Unknown etc.)
Name of hospital
Have you had another E.R. visit? No
Yes Unknown
E.R. Visit #3 Reason
Year
(9999 = Unknown)
DATE details (e.g. 10/2, April, Summer, August-Nov., Unknown etc.)
Name of hospital
Location of hospital
Have you had another E.R. visit? No
Yes Unknown
E.R. Visit #4 Reason
Year
(9999 = Unknown)
DATE details (e.g. 10/2, April, Summer, August-Nov., Unknown etc.)
Name of hospital
Location of hospital
If participant has had more than 4 E.R. visits, provide details in "Additional comments" below.
Day surgery? No
Yes Unknown
If "Yes"
Day Surgery #1 Reason
Year
(9999 = Unknown)
DATE details (e.g. 10/2, April, Summer, August-Nov., Unknown etc.)
Name of hospital/doctor
Location of hospital/doctor
Have you had another day surgery? No Yes
Unknown
Day Surgery #2
Year
(9999 = Unknown)
DATE details (e.g. 10/2, April, Summer, August-Nov., Unknown etc.)
Name of hospital/doctor
Location of hospital/doctor
Have you had another day surgery? No Yes
Unknown
Day Surgery #3 Reason
Year
(9999 = Unknown)
DATE details (e.g. 10/2, April, Summer, August-Nov., Unknown etc.)
Name of hospital/doctor
Location of hospital/doctor
Have you had another day surgery? No Yes
Unknown
Day Surgery #4 Reason
Year
(9999 = Unknown)
DATE details (e.g. 10/2, April, Summer, August-Nov., Unknown etc.)
Name of hospital/doctor
Location of hospital/doctor
If participant has had more than 4 day surgeries, provide details in "Additional comments" below.
Major illness with visit to doctor? No
Yes Unknown
If "Yes"
Major Illness #1 Reason
Year
(9999 = Unknown)
DATE details (e.g. 10/2, April, Summer, August-Nov., Unknown etc.)
Name of doctor
Location of doctor
Have you had another major illness with visit to No
doctor? Yes
Unknown
Major Illness #2 Reason
Year
(9999 = Unknown)
DATE details (e.g. 10/2, April, Summer, August-Nov., Unknown etc.)
Name of doctor
Location of doctor
Have you had another major illness with visit to No
doctor? Yes
Unknown
Major Illness #3 Reason
Year
(9999 = Unknown)
DATE details (e.g. 10/2, April, Summer, August-Nov., Unknown etc.)
Name of doctor
Location of doctor
Have you had another major illness with visit to No
doctor? Yes
Unknown
Major Illness #4 Reason
Year
(9999 = Unknown)
DATE details (e.g. 10/2, April, Summer, August-Nov., Unknown etc.)
Name of doctor
Location of doctor
If participant has had more than 4 major illnesses, provide details in "Additional comments" below.
Check up by doctor or other health care provider? No Yes
Unknown
If "Yes"
Check Up #1 Reason
Year
(9999 = Unknown)
DATE details (e.g. 10/2, April, Summer, August-Nov., Unknown etc.)
Name of doctor
Location of doctor
Have you had another check up by doctor or other No
health care provider? Yes
Unknown
Check Up #2 Reason
Year
(9999 = Unknown)
DATE details (e.g. 10/2, April, Summer, August-Nov., Unknown etc.)
Name of doctor
Location of doctor
Have you had another check up by doctor or other No
health care provider? Yes
Unknown
Check Up #3 Reason
Year
(9999 = Unknown)
DATE details (e.g. 10/2, April, Summer, August-Nov., Unknown etc.)
Name of doctor
Location of doctor
Have you had another check up by doctor or other No
health care provider? Yes
Unknown
Check Up #4 Reason
Year
(9999 = Unknown)
DATE details (e.g. 10/2, April, Summer, August-Nov., Unknown etc.)
Name of doctor
Location of doctor
If participant has had more than 4 check ups, provide details in "Additional comments" below.
Medical Encounters
Gen 3, NOS, Omni 2 Cohort Exam 3
Page 1 of 2
FHS_IDTYPE_ID
Date of last medical health update: [lastmhudate]
Do you take aspirin REGULARLY? No Yes
Unknown
If "Yes" to taking aspirin REGULARLY
Usual dose of aspirin? 081mg Baby
160mg Half
250mg e.g. Excedrin 325mg Usual
500mg Extra strength Other
Unknown
If dose of Aspirin is 'Other'
(Dose in mg )
How many aspirin?
(99=unknown)
How often do you take [numaspirin] ([doseaspirin]) Day
aspirin? Week
Month Year Unk
High blood pressure or hypertension
Have you been TOLD by your doctor you have high blood No pressure or hypertension? Yes
Unknown
Are you CURRENTLY taking medication for high blood No
pressure or hypertension? Yes
Unknown
High blood cholesterol or high triglycerides
Have you been TOLD by doctor you have high blood No
cholesterol or high triglycerides? Yes Unknown
Are you CURRENTLY taking medication for high blood No
cholesterol or high triglycerides? Yes Unknown
High blood sugar or diabetes
Page 2 of 2
Have you been TOLD by doctor you have high blood No
sugar or diabetes? Yes
Unknown
Are you CURRENTLY taking medication for high blood No
sugar or diabetes? Yes
Unknown
Are you CURRENTLY taking medication for No
cardiovascular disease? (for example angina/chest Yes
pain, heart failure, atrial fibrillation/heart rhythm Unknown abnormality, stroke, leg pain when walking,
peripheral artery disease)
Additional comments for Aspirin and Medication Treatment Questions
Page 1 of 2
FHS_IDTYPE_ID
Name: [lastname], [firstname]DOB: [dob]Age: [age] Sex: [sex] Date of last exam: [lastexamdate]
Date of last medical health update: [lastmhudate]
In the past month have you taken any prescription No
and/or non prescription as directed by HCP? Yes, as directed by HCP Unknown
Medication bag with medications brought to exam? No Yes
Medication name #1
Medication name #2
Medication name #3
Medication name #4
Medication name #5
Medication name #6
Medication name #7
Medication name #8
Medication name #9
Medication name #10
Are there any medications that you could not find on No
the list? Yes
Medication (new) name #1
Medication (new) name #2
Medication (new) name #3
Medication (new) name #4
Medication (new) name #5
Page 2 of 2
Are you taking any over the counter products i.e. No
vitamins, supplements, plant extracts, alternatives? Yes Unknown
Check all OTC you are taking: Vitamins
Supplements Plant extracts Alternatives Other
Comment on vitamins
Comment on supplements
Comment on plant extracts
Comment on alternatives
Comment on other over the counter products
Additional comment for Prescription and Non-Prescription Medications in Last Month
M05 Female Repro Pregnancy
FHS_IDTYPE_ID
Gen 3, NOS, Omni 2 Cohort Exam 3
Page 1 of 4
Name: [lastname], [firstname]DOB: [dob]Age: [age] Sex: [sex] Date of last exam: [lastexamdate]
Date of last medical health update: [lastmhudate]
Participant is male. Select "Save and go to Next Form".
Since your last exam have you taken or used birth No
control pills, shots, or hormone implants for birth Yes, now
control or medical indications (not post menopausal Yes, not now
hormone replacement)? Unk.
Have you ever tried to become pregnant for >=1 year No without becoming pregnant? Yes
Unk.
Have you been pregnant since last exam? No Yes Unk.
If "Yes",
Number of pregnancies?
During any of these pregnancies, were you told you No
had high blood pressure or hypertension? Yes Unk.
During any of these pregnancies, were you told you No
had eclampsia, pre-eclampsia (toxemia)? Yes Unk.
During any of these pregnancies, were you told you No
had high blood sugar or diabetes? Yes Unk.
Have you had any births since your last exam? No Yes
If "Yes",
Number of live births since last exam
Now, I would like to ask you about how much each of your children weighed at birth and whether you breastfed.
Full term? < 37 weeks
=>37 weeks Unk.
Birth weight (pounds)
Birth weight (ounces)
Did you breast feed ( include expressed breast milk)? No Yes Unk.
If yes, how long? < 6 weeks
6 to 11 weeks
3 to 6 months
>6 months Unk.
Full term? < 37 weeks
=>37 weeks Unk.
Birth weight (pounds)
Birth weight (ounces)
Did you breast feed (include expressed breast milk)? No Yes Unk.
If yes, how long? < 6 weeks
6 to 11 weeks
3 to 6 months
>6 months Unk.
Baby #4
Full term? < 37 weeks
=>37 weeks Unk.
Birth weight (pounds)
Birth weight (ounces)
Did you breast feed (include expressed breast milk)? No Yes Unk.
If yes, how long? < 6 weeks
6 to 11 weeks
3 to 6 months
>6 months Unk.
Full term? < 37 weeks
=>37 weeks Unk.
Birth weight (pounds)
Birth weight (ounces)
Did you breast feed (include expressed breast milk)? No Yes Unk.
If yes, how long? < 6 weeks
6 to 11 weeks
3 to 6 months
>6 months Unk.
Full term? < 37 weeks
=>37 weeks Unk.
Birth weight (pounds)
Birth weight (ounces)
Did you breast feed (include expressed breast milk)? No Yes Unk.
If yes, how long? < 6 weeks
6 to 11 weeks
3 to 6 months
>6 months Unk.
Female Repro - Pregnancy
Name: [lastname], [firstname]DOB: [dob]Age: [age] Sex: [sex] Date of last exam: [lastexamdate]
Date of last medical health update: [lastmhudate]
Participant is male. Select "Save and go to Next Form".
What is the best way to describe your periods? 1=Not stopped
(Check the BEST answer - only one.) 2=Stopped due to pregnancy, breast feeding, hormonal contraceptive
3=Stopped due to low body weight, exercise, medication or health conditions
4=Stopped for less than 1 year (perimenopausal) 5=Stopped for 1 year or more
6=Stopped but now have periods induced by hormones (Check the BEST answer - only one.)
For option 3 above, write in cause.
For option 4 above, write in number of months since
last period. (99=Unknown)
For option 6 above, write in number of months period stopped before hormones started.
When was the first day of your last menstrual period
month ? (88=period stopped for more than 1 year or using postmenopausal hormones, 99=Unknown)
When was the first day of your last menstrual period
day ? (99=Unknown, 88=period stopped for more than 1
year or using postmenopausal hormones)
When was the first day of your last menstrual period
year ? (9999=Unknown, 8888=period stopped for more than 1 year or using postmenopausal hormones)
How many periods have you had in past 12 months?
(99=Unknown, 88=periods stopped for more than 1 year or using postmenopausal hormones)
Age when periods stopped. If periods now induced by hormones, code age when periods naturally stopped. (00=not stopped, 99=Unknown)
Was your menopause natural or the result of surgery, Still menstruating chemotherapy, or radiation? Natural
Surgical Chemo/radiation Other
Unknwon
Page 2 of 2
Have you since your last exam taken hormone No
replacement therapy (estrogen/progesterone) or a Yes, now selective estrogen receptor modulator (such as evista Yes, not now or raloxifene)? Unk.
Since your last exam have you had a hysterectomy No
(uterus/womb removed)? Yes
Unk.
If yes, age at hysterectomy?
(99=Unknown)
If yes, date of surgery (month)
(99=Unk.)
If yes, date of surgery (year)
(9999=Unk.)
Since last exam have you had an operation to remove No one or both of your ovaries? Yes
Unk.
If yes, age when ovaries removed?
(If more than one surgery, use age at last surgery. 99=Unk )
If yes, number of ovaries removed? One ovary Two ovaries
Unknown number of ovaries Part of an ovary
(If more than one surgery, use age at last surgery. 99=Unk )
Female Repro - Menopause
Name: [lastname], [firstname]DOB: [dob]Age: [age] Sex: [sex] Date of last exam: [lastexamdate]
Date of last medical health update: [lastmhudate]
Cigarettes
Since your last exam have you smoked cigarettes No
regularly? Yes
Unknown
If "Yes"
Have you smoked cigarettes regularly in the last No
year? (No means less than 1 cigarette a day for 1 Yes
year.) Unknown
Do you smoke cigarettes (as of 1 month ago)? No Yes
Unknown
How many cigarettes do you smoke per day now?
(99 = Unknown)
Questions below refer to "whole lifetime"
On the average of the entire time you smoked, how
many cigarettes did you smoke per day? (99 = Unknown)
How old were you when you first started regular
cigarette smoking? (99 = Unknown)
If you have stopped smoking cigarettes completely,
how old were you when you stopped? (00 = Not stopped, 99 = Unknown)
When you were smoking, did you ever stop smoking No
for > 6 months? Yes
Unknown
If "Yes"
For how many years in total did you stop smoking
cigarettes? (1 = 6 months - 1 year, 99 = Unknown)
Page 2 of 2
Since your last exam have you regularly smoked a pipe No or cigar? Yes
Unknown
If "Yes"
Do you smoke a pipe or cigar now? No Yes
Unknown
E-cigarettes are battery-powered and produce vapor instead of smoke. Have you ever tried an e-cigarette? No
Yes
Refused to answer Don't know
If "Yes"
Have you ever been a regular user of e-cigarettes No
(at least once per week)? Yes
Refused to answer Don't know
If "Yes"
How long did you use e-cigarettes? (# of years)
(99 = Unknown)
How many days per week, on average, did you use
e-cigarettes while you were a regular user? (1 = 1 day or less per week, 9 = Unknown)
In the past 5 days, including today, on how many 0 days
days did you smoke an e-cigarette? 1 day 2 days
days
days
days
Refused to answer Don't know
Smoking
Name: [lastname], [firstname]DOB: [dob]Age: [age] Sex: [sex] Date of last exam: [lastexamdate]
Date of last medical health update: [lastmhudate]
Now I will ask you questions regarding your alcohol use.
Do you drink beer at least once a month? (serving 12 No
oz. bottle, glass, can) Yes
Unknown
If "Yes"
Do you drink beer at least once week? No Yes
Unknown
If "Yes"
Number of beers per week
(999 = Unknown)
If "No"
Number of beers per month
(999 = Unknown)
Do you drink wine at least once a month? (serving red No or white, 4oz. glass) Yes
Unknown
If "Yes"
Do you drink wine at least once a week? No Yes
Unknown
If "Yes"
Number of glasses of wine per week
(999 = Unknown)
If "No"
Number of glasses of wine per month
(999 = Unknown)
Do you drink liquor/ spirits at least once a month? No
(serving 1 oz. cocktail/ highball) Yes
Unknown
If "Yes"
Do you drink liquor/ spirits at least once per week? No Yes
Unknown
If "Yes"
Page 2 of 2
Number of drinks per week
(999 = Unknown)
If "No"
Number of drinks per month
(999 = Unknown)
At what age did you stop drinking alcohol?
(000 = Not stopped, 888 = Never drinker, 999 = Unknown)
Over the past year, on average, on how many days per
week did you drink an alcoholic beverage of any type? (0 = No days, 1 = 1 day or less, 9 = Unknown)
Over the past year, on a typical day when you drink,
how many drinks do you have? (0 = No drinks, 1 = 1 or less, 99 = Unknown)
What was the maximum number of drinks you had in a 24
hour period during the past month? (0 = No drinks, 1 = 1 or less, 99 = Unknown)
Since your last exam has there been a time when you No
drank 5 or more alcoholic drinks of any kind almost Yes
daily? Unknown
Over the past year, does participant drink less than No
one alcoholic drink of any type per month? Yes
Alcohol Consumption
Name: [lastname], [firstname]DOB: [dob]Age: [age] Sex: [sex] Date of last exam: [lastexamdate]
Date of last medical health update: [lastmhudate]
Cough
In the past 12 months . . .
Do you usually have a cough? (Exclude clearing of the No throat) Yes
Unknown
Do you usually have a cough at all on getting up or No
first thing in the morning? Yes
Unknown
If "Yes" to either of 2 questions directly above
Do you cough like this on most days for three No
consecutive months or more during the past year? Yes Unknown
How many years have you had this cough? (# of years)
(1 = 1 year or less, 99 = Unknown)
In the past 12 months . . .
Do you usually bring up phlegm from your chest? No Yes
Unknown
Do you usually bring up phlegm at all on getting up No
or first thing in the morning? Yes
Unknown
If "Yes" to either of 2 questions directly above
Do you bring up phlegm from your chest on most days No for three consecutive months or more during the year? Yes
Unknown
How many years have you had trouble with phlegm? (# of years) (1 = 1 year or less, 99 = Unknown)
Page 2 of 2
In the past 12 months . . .
Have you had wheezing or whistling in your chest at No
any time? Yes
Unknown
If "Yes"
How often have you had this wheezing or whistling? MOST days or nights
A few days or nights a WEEK
A few days or nights a MONTH A few days or nights a YEAR Unknown
Have you had this wheezing or whistling in the chest No
when you had a cold? Yes
Unknown
Have you had this wheezing or whistling in the chest No
apart from colds? Yes
Unknown
Have you had an attack of wheezing or whistling in No
the chest that made you feel short of breath? Yes Unknown
Name: [lastname], [firstname]DOB: [dob]Age: [age] Sex: [sex] Date of last exam: [lastexamdate]
Date of last medical health update: [lastmhudate]
Sleep Related Symptoms (days/ nights)
Since your last exam . . .
On average how many nights a week did you snore? Never
Rarely (1-2 nights/week)
Occasionally (3-4 nights/week) Frequently (5 or more nights/week) I don't know
Unknown
On average, how many nights a week do you snort, Never
gasp, or stop breathing while you are asleep? Rarely (1-2 nights/week) Occasionally (3-4 nights/week) Frequently (5 or more nights/week) I don't know
Unknown
On average, how many days a week have you had Never
excessive (too much) daytime sleepiness? Rarely (1-2 nights/week) Occasionally (3-4 nights/week) Frequently (5 or more nights/week) I don't know
Unknown
Since your last exam . . .
Have you been awakened by shortness of breath? No Yes
Unknown
Have you been awakened by a wheezing/ whistling in No
your chest? Yes
Unknown
Have you been awakened by coughing? No Yes
Unknown
If "Yes"
How often have you been awakened by coughing? MOST days or nights
A few days or nights a WEEK
A few days or nights a MONTH A few days or nights a YEAR Unknown
Since your last exam . . .
Are you troubled by shortness of breath when hurrying No on level ground or walking up a slight hill? Yes
Unknown
If "Yes"
Do you have to walk slower than people of your age No
on level ground because of shortness of breath? Yes Unknown
Do you have to stop for breath when walking at your No
own pace on level ground? Yes
Unknown
Do you have to stop for breath after walking 100 No
yards (or after a few minutes) on level ground? Yes Unknown
Do you/ have you needed to sleep on two or more No
pillows to help you breathe (Orthopnea)? Yes Unknown
Have you had swelling in both your ankles (ankle No
edema)? Yes
Unknown
Have you been told by your doctor that you had heart No
failure or congestive heart failure? Yes Unknown
If "Yes"
Have medical encounter details been entered on M01? No
Yes
If "No"
Name of doctor
Location of doctor
Date of visit - year
(9999 = Unknown)
DATE details (e.g. 10/2, April, Summer, August-Nov., Unknown etc.)
Have you been to a hospital/ E.R. for heart failure? No Yes
Unknown
If "Yes"
Have medical encounter details been entered on M01? No
Yes
If "No"
Name of hospital
Location of hospital
Date of hospitalization - year
(9999 = Unknown)
DATE details (e.g. 10/2, April, Summer, August-Nov., Unknown etc.)
First Examiner believes CHF No
Yes Maybe Unknown
Sleep Apnea and CHF Opinion
Name: [lastname], [firstname]DOB: [dob]Age: [age] Sex: [sex] Date of last exam: [lastexamdate]
Date of last medical health update: [lastmhudate]
Systolic (to nearest 2 mm Hg)
Diastolic (to nearest 2 mm Hg)
BP cuff size Pedi
Regular adult Large adult Thigh Unknown
Protocol modification No
Yes Unknown
If "Yes"
Comments for Protocol modification
Blood Pressure 1st MD Reading
Name: [lastname], [firstname]DOB: [dob]Age: [age] Sex: [sex] Date of last exam: [lastexamdate]
Date of last medical health update: [lastmhudate]
Since you last provided medical information No
([lastmedinfodate]) have you experienced any chest Yes
discomfort? (Please provide narrative comments in Maybe
addition to completing the appropriate questions.) Unknown If "Yes" or "Maybe"
Chest discomfort with exertion or excitement No Yes
Maybe Unknown
Chest discomfort when quiet or resting No Yes
Maybe Unknown
Chest Discomfort Characteristics
Date of onset - year
(2002-2021)
DATE details (e.g. 10/2, April, Summer, August-Nov., Unknown etc.)
Usual duration (minutes)
(1 = 1 min or less, 900 = 15 hrs or more, 999 = Unknown)
Longest duration (minutes)
(1 = 1 min or less, 900 = 15 hrs or more, 999 = Unknown)
Location No
Central sternum and upper chest Left upper quadrant
Left lower ribcage Right chest
Other Combination Unknown
Radiation No
Left shoulder or left arm Neck
Right shoulder or right arm, Back
Abdomen Other Combination Unknown
Number of episodes of chest pain in past month
(999 = Unknown)
Number of episodes of chest pain in past year
(999 = Unknown)
Type Pressure, heavy, vise
Sharp Dull Other Unknown
Relief by nitroglycerin in < 15 minutes
No Yes Not tried Unknown
Relief by rest in < 15 minutes
Relief spontaneously in < 15 minutes
Relief by other cause in < 15 minutes
Since you last provided medical information No
([lastmedinfodate]) have you been told by a doctor Yes
you had a heart attack, myocardial infarction or Maybe
angina? Unknown
If "Yes" or "Maybe"
Have medical encounter details been entered on M01? No
Yes
If "No"
Name of doctor
Location of doctor
Date of visit - year
(2002-2021)
DATE details (e.g. 10/2, April, Summer, August-Nov., Unknown etc.)
Since you last provided medical information No
([lastmedinfodate]) have you been to a hospital/ E.R. Yes
for a heart attack, myocardial infarction or angina? Maybe Unknown
If "Yes" or "Maybe"
Have medical encounter details been entered on M01? No
Yes
If "No"
Name of hospital
Location of hospital
Date - year
(2002-2021)
DATE details (e.g. 10/2, April, Summer, August-Nov., Unknown etc.)
Angina pectoris No
Yes Maybe Unknown
If "Yes" or "Maybe"
Angina pectoris since revascularization procedure No Yes
Maybe Unknown
Coronary insufficiency No
Yes Maybe Unknown
Myocardial infarct No
Yes Maybe Unknown
Chest Discomfort and CHD Opinion
Gen 3, NOS, Omni 2 Cohort Exam 3
Page 1 of 3
FHS_IDTYPE_ID
Name: [lastname], [firstname]DOB: [dob]Age: [age] Sex: [sex] Date of last exam: [lastexamdate]
Date of last medical health update: [lastmhudate]
Atrial Fibrillation
Since your last exam or medical history update....
Have you been told you have/had atrial fibrillation? No Yes
Maybe Unknown
Have medical encounter details been entered on M01? Yes
No
If "No"
Date of first episode - year
DATE details (e.g. 10/2, April, Summer, August-Nov., Unknown etc.)
ER/hospitalized or saw M.D. No
Hosp/ER Saw M.D.
Unk.
Name of the hospital (write Unk. if unknown)
Name of M.D. (write Unk. if unknown)
Syncope
Have you fainted or lost consciousness? No Yes
Maybe Unknown
Number of episodes in the past two years
(999=Unknown)
Date of first episode (month)
(99=Unknown)
Date of first episode (year)
(9999=Unknown)
Usual duration of loss of consciousness (minutes)
(999=Unk., 1=1 min or less)
Did you have any injury caused by the event? No Yes
Maybe Unknown
(999=Unk., 1=1 min or less)
ER/hospitalized or saw M.D. No
Hosp/ER Saw M.D.
Unk.
(999=Unk., 1=1 min or less)
Name of the hospital (write Unk. if unknown)
Name of M.D. (write Unk. if unknown)
Have you had a head injury with loss of No
consciousness? Yes
Maybe Unknown
Have medical encounter details been entered on M01? Yes
No
If "No",
Date of serious head injury with loss of consciousn.
- year (9999=Unknown)
DATE details (e.g. 10/2, April, Summer, August-Nov., Unknown etc.)
Have you had a seizure? No
Yes Maybe Unknown
Have medical encounter details been entered on M01? Yes
No
If "No",
Date of most recent seizure - year
(9999=Unknown)
Are you being treated for a seizure disorder? No Yes
Maybe Unknown
Syncope First Examiner Opinion
Syncope (needs second opinion) No
Yes Maybe
Presyncope Unk.
Cardiac syncope No
Yes Maybe Unknown
Vasovagal syncope No
Yes Maybe Unknown
Other syncope No
Yes Maybe Unknown
Specify:
Atrial Fibrillation Syncope Syncope Opinion
Name: [lastname], [firstname]DOB: [dob]Age: [age] Sex: [sex] Date of last exam: [lastexamdate]
Date of last medical health update: [lastmhudate]
Cerebrovascular Disease
Since you last provided medical information ([lastmedinfodate]) have you had . . .
Sudden muscular weakness Sudden speech difficulty Sudden visual defect Sudden double vision
Sudden loss of vision in one eye Sudden numbness, tingling
No Yes Maybe Unknown
If "Yes" or "Maybe"
Numbness and tingling is positional No Yes
Maybe Unknown
HEAD CT scan OTHER THAN FOR THE FHS No
Yes Maybe Unknown
If "Yes" or "Maybe"
Have medical encounter details been entered on M01? No
Yes
If "No"
Name of facility
Location of facility
Date - year
(2002-2021)
DATE details (e.g. 10/2, April, Summer, August-Nov., Unknown etc.)
HEAD MRI scan OTHER THAN FOR THE FHS No
Yes Maybe Unknown
If "Yes" or "Maybe"
Have medical encounter details been entered on M01? No
Yes
If "No"
Name of facility
Location of facility
Date - year
(2002-2021)
DATE details (e.g. 10/2, April, Summer, August-Nov., Unknown etc.)
Seen by neurologist No
Yes Maybe Unknown
If "Yes" or "Maybe"
Have medical encounter details been entered on M01? No
Yes
If "No"
Name of neurologist
Location of neurologist
Date - year
(2002-2021)
DATE details (e.g. 10/2, April, Summer, August-Nov., Unknown etc.)
Have you been told by a doctor you had a stroke or TIA (transient ischemic attack,
mini-stroke)?
No Yes Maybe Unknown
Have you been told by a doctor you have Parkinson's disease?
Have you been told by a doctor you have memory problems, dementia or Alzheimer's disease?
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?
Do you feel your memory is becoming worse?
TIA or stroke took place No
Yes Maybe Unknown
If "Yes" or "Maybe"
Date of TIA or stroke - year
(2002-2021)
DATE details (e.g. 10/2, April, Summer, August-Nov., Unknown etc.)
Observed by
Duration - number of days
(99 = Unknown)
Duration - number of hours
(0 - 23, 99 = Unknown)
Duration - number of minutes
(0 - 59, 99 = Unknown)
Hospitalized or saw MD No
Hosp/ER Saw MD Unknown
Have medical encounter details been entered on M01? No
Yes
If "No"
Name of hospital
Location of hospital
Name of doctor
Location of doctor
Date - Year
(2002-2021)
DATE details (e.g. 10/2, April, Summer, August-Nov., Unknown etc.)
Cerebrovascular Disease and Opinion
Date of last exam: [lastexamdate]
Date of last medical health update: [lastmhudate]
Venous Disease
Since you last provided medical information ([lastmedinfodate]) have you had . . .
Deep vein thrombosis - DVT (blood clots in legs or No
arms) Yes
Maybe Unknown
Pulmonary embolus - PE (blood clot in lungs) No Yes
Maybe Unknown
Since you last provided medical information ([lastmedinfodate]) . . .
Do you get discomfort in either leg on walking? No Yes
Unknown
If "Yes"
Does this discomfort ever begin when you are No
standing still or sitting? Yes
Unknown
When walking at an ordinary pace on level ground,
how many city blocks until symptoms develop? (where (1 = 1 block or less, 99 = Unknown) 10 blocks = 1 mile. Code as No if more than 98
blocks required to develop symptoms)
Claudication Symptoms
Discomfort in calf while walking
left
No Yes Unknown
Discomfort in calf while walking
right
Discomfort in lower leg (not calf) while walking - left
Discomfort in lower leg (not calf) while walking - right
If discomfort in either left or right not calf "Yes" Write in site of discomfort
Occurs with first steps (code worse leg) No Yes
Unknown
Do you get the discomfort when you walk up a hill or No
hurry? Yes
Unknown
Does the discomfort ever disappear while you are No
still walking? Yes
Unknown
What do you do if you get discomfort when you are Stop
walking? Slow down
Continue at same pace Unknown
Time for discomfort to be relieved by stopping
(minutes) (000 = No relief with stopping, 999 = Unknown)
Number of days/month of lower limb discomfort
(1 = 1 day/month or less, 99 = Unknown)
Since your last exam have you been told by a doctor No
you have intermittent claudication or peripheral Yes
artery disease? Unknown
If "Yes"
Have medical encounter details been entered on M01? No
Yes
If "No"
Name of doctor
Location of doctor
Date of visit - year
(2002-2021)
DATE details (e.g. 10/2, April, Summer, August-Nov., Unknown etc.)
Since your last exam have you been told by a doctor No
you have spinal stenosis? Yes
Unknown
Intermittent claudication No
Yes Maybe Unknown
Venous and Peripheral Arterial Disease and Intermittent Claudication Opinion
Name: [lastname], [firstname]DOB: [dob]Age: [age] Sex: [sex] Date of last exam: [lastexamdate]
Date of last medical health update: [lastmhudate]
Since you last provided medical information ([lastmedinfodate]) did you have any of the following cardiovascular procedures?
(if procedure was repeated, code only first and provide narrative)
Heart valvular surgery No
Yes Maybe Unknown
If "Yes" or "Maybe"
Year done
(2002 - 2021, 9999 = Unknown)
Exercise tolerance test No
Yes Maybe Unknown
If "Yes" or "Maybe"
Year done
(2002 - 2021, 9999 = Unknown)
Coronary arteriogram No
Yes Maybe Unknown
If "Yes" or "Maybe"
Year done
(2002 - 2021, 9999 = Unknown)
Coronary artery angioplasty or stent No Yes
Maybe Unknown
If "Yes" or "Maybe"
Year done
(2002 - 2021, 9999 = Unknown)
Coronary bypass surgery No
Yes Maybe Unknown
If "Yes" or "Maybe"
Year done
(2002 - 2021, 9999 = Unknown)
Permanent pacemaker insertion No
Yes Maybe Unknown
If "Yes" or "Maybe"
Year done
(2002 - 2021, 9999 = Unknown)
Carotid artery surgery or stent No
Yes Maybe Unknown
If "Yes" or "Maybe"
Year done
(2002 - 2021, 9999 = Unknown)
Thoracic aorta surgery No
Yes Maybe Unknown
If "Yes" or "Maybe"
Year done
(2002 - 2021, 9999 = Unknown)
Abdominal aorta surgery No
Yes Maybe Unknown
If "Yes" or "Maybe"
Year done
(2002 - 2021, 9999 = Unknown)
Femoral or lower extremity surgery No Yes
Maybe Unknown
If "Yes" or "Maybe"
Year done
(2002 - 2021, 9999 = Unknown)
Lower extremity amputation No
Yes Maybe Unknown
If "Yes" or "Maybe"
Year done
(2002 - 2021, 9999 = Unknown)
Other cardiovascular procedure (specify below) No Yes
Maybe Unknown
If "Yes" or "Maybe"
Year done
(2002 - 2021, 9999 = Unknown)
Specify other cardiovascular procedure
Write in other procedures, year done, location if more than one.
CVD Procedures
Name: [lastname], [firstname]DOB: [dob]Age: [age] Sex: [sex Date of last exam: [lastexamdate]
Date of last medical health update: [lastmhudate]
Systolic (to nearest 2 mm Hg)
Diastolic (to nearest 2 mm Hg)
BP cuff size Pedi
Regular adult Large adult Thigh Unknown
Protocol modification No
Yes Unknown
If "Yes"
Comments for Protocol modification
Blood Pressure 2nd MD Reading
Name: [lastname], [firstname]DOB: [dob]Age: [age] Sex: [sex] Date of last exam: [lastexamdate]
Date of last medical health update: [lastmhudate]
Since your last provided medical information No
([lastmedinfodate]) have you had a cancer or tumor? Yes Maybe Unknown
If "Yes" or "Maybe"
Cancer or tumor - #1 Esophagus
Stomach Colon Hand Rectum Pancreas Larynx
Trachea?Bronchus/Lung Leukemia
Skin Breast
Cervix/Uteru Ovary Prostate Bladder Kidney
Brain Lymphoma Other
Cancer or tumor site for "Other" - #1 ([cancersite1])
Diagnosis - #1 ([cancersite1]) Cancer
Maybe cancer Benign
Have medical encounter details been entered on M01 - No
#1 ([cancersite1]) Yes
If "No"
Year first diagnosed - #1 ([cancersite1])
DATE details for diagnose - #1 ([cancersite1]) (e.g. 10/2, April, Summer, August-Nov., Unknown etc.)
Name of MD for diagnose - #1 ([cancersite1])
Location of MD for diagnose - #1 ([cancersite1])
Was a diagnostic biopsy done? - #1 ([cancersite1]) No Yes
If "Yes"
Year of biopsy - #1 ([cancersite1])
DATE details for biopsy - #1 ([cancersite1])(e.g. 10/2, April, Summer, August-Nov., Unknown etc)
Name of MD for biopsy - #1 ([cancersite1])
Location of MD for biopsy - #1 ([cancersite1])
Have you had another cancer or tumor? No Yes
Maybe Unknown
If "Yes" or "Maybe"
Site of cancer or tumor - #2 Esophagus
Stomach Colon Hand Rectum Pancreas Larynx
Trachea?Bronchus/Lung Leukemia
Skin Breast
Cervix/Uteru Ovary Prostate Bladder Kidney
Brain Lymphoma Other
Cancer or tumor site for "Other" - #2 ([cancersite2])
Diagnosis - #2 ([cancersite2]) Cancer
Maybe cancer Benign
Have medical encounter details been entered on M02 - No
#2 ([cancersite2]) Yes
If "No"
Year first diagnosed - #2 ([cancersite2])
DATE details for diagnose - #2 ([cancersite2]) (e.g. 10/2, April, Summer, August-Nov., Unknown etc.)
Name of MD for diagnose - #2 ([cancersite2])
Location of MD for diagnose - #2 ([cancersite2])
Was a diagnostic biopsy done? - #2 ([cancersite2]) No Yes
If "Yes"
Year of biopsy - #2 ([cancersite2])
DATE details for biopsy - #2 ([cancersite2])(e.g. 10/2, April, Summer, August-Nov., Unknown etc)
Name of MD for biopsy - #2 ([cancersite2])
Location of MD for biopsy - #2 ([cancersite2])
Have you had another cancer or tumor? No Yes
Maybe Unknown
If "Yes" or "Maybe"
Site of cancer or tumor - #3 Esophagus
Stomach Colon Hand Rectum Pancreas Larynx
Trachea?Bronchus/Lung Leukemia
Skin Breast
Cervix/Uteru Ovary Prostate Bladder Kidney
Brain Lymphoma Other
Cancer or tumor site for "Other" - #3 ([cancersite3])
Diagnosis - #3 ([cancersite3]) Cancer
Maybe cancer Benign
Have medical encounter details been entered on M01 - No
#3 ([cancersite3]) Yes
If "No"
Year first diagnosed - #3 ([cancersite3])
DATE details for diagnose - #3 ([cancersite3]) (e.g. 10/2, April, Summer, August-Nov., Unknown etc.)
Name of MD for diagnose - #3 ([cancersite3])
Location of MD for diagnose - #3 ([cancersite3])
Was a diagnostic biopsy done? - #3 ([cancersite3]) No Yes
If "Yes"
Year of biopsy - #3 ([cancersite3])
DATE details for biopsy - #3 ([cancersite3])(e.g. 10/2, April, Summer, August-Nov., Unknown etc)
Name of MD for biopsy - #3 ([cancersite3])
Location of MD for biopsy - #3 ([cancersite3])
Have you had another cancer or tumor? No Yes
Maybe Unknown
If "Yes" or "Maybe"
Other
Cancer or tumor site for "Other" - #4 ([cancersite4])
Diagnosis - #4 ([cancersite4]) Cancer
Maybe cancer Benign
Have medical encounter details been entered on M01 - No
#4 ([cancersite4]) Yes
If "No"
Year first diagnosed - #4 ([cancersite4])
DATE details for diagnose - #4 ([cancersite4]) (e.g. 10/2, April, Summer, August-Nov., Unknown etc.)
Name of MD for diagnose - #4 ([cancersite4])
Location of MD for diagnose - #4 ([cancersite4])
Was a diagnostic biopsy done? - #4 ([cancersite4]) No Yes
If "Yes"
Year of biopsy - #4 ([cancersite4])
DATE details for biopsy - #4 ([cancersite4])(e.g. 10/2, April, Summer, August-Nov., Unknown etc)
Name of MD for biopsy - #4 ([cancersite4])
Location of MD for biopsy - #4 ([cancersite4])
Have you had another cancer or tumor? No Yes
Maybe Unknown
If "Yes" or "Maybe"
Other
Cancer or tumor site for "Other" - #5 ([cancersite5])
Diagnosis - #5 ([cancersite5]) Cancer
Maybe cancer Benign
Have medical encounter details been entered on M01 - No
#5 ([cancersite5]) Yes
If "No"
Year first diagnosed - #5 ([cancersite5])
DATE details for diagnose - #5 ([cancersite5]) (e.g. 10/2, April, Summer, August-Nov., Unknown etc.)
Name of MD for diagnose - #5 ([cancersite5])
Location of MD for diagnose - #5 ([cancersite5])
Was a diagnostic biopsy done? - #5 ([cancersite5]) No Yes
If "Yes"
Year of biopsy - #5 ([cancersite5])
DATE details for biopsy - #5 ([cancersite5])(e.g. 10/2, April, Summer, August-Nov., Unknown etc)
Name of MD for biopsy - #5 ([cancersite5])
Location of MD for biopsy - #5 ([cancersite5])
Cancer
Name: [lastname], [firstname]DOB: [dob]Age: [age] Sex: [sex] Date of last exam: [lastexamdate]
Date of last medical health update: [lastmhudate]
OFFSITE ONLY
MD ID#
MD Name
Rhythm Normal sinus (including s. tach, s. brady, s.
arrhy, 1 degree AV block)
2nd degress AV block, Mobitz I (Wenckebach) 2nd degree AV block, Mobitz II
3rd degree AV block / AV dissociation Atrial fibrillation / atrial flutter
Nodal Paced
Other or combination of above (list)
If "Other or combination of above (list)" Specify combination
IV block No
Yes
Fully paced or unknown
If "Yes"
Pattern Left
Right Indeterminate Unknown
IV block complete or incomplete Incomplete (QRS interval < .12 sec) Complete (QRS interval >= .12 sec) Unknown
Hemiblock No
Left ant. Left post.
Fully paced or unknown
Page 2 of 3
WPW syndrome No
Yes Maybe
Fully paced or unknown
Atrial premature beats No
Atr.
Atr. aber. Unknown
Ventricular premature beats No
Simple Multifoc. Pairs Run
R on T Unknown
If "Simple", "Multifoc.", "Pairs', "Run" or "R on T"
Number of ventricular premature beats in 10 seconds (see 10 second rhythm strip)
Anterior No
Yes Maybe
Fully paced or unknown
Inferior No
Yes Maybe
Fully paced or unknown
True posterior No
Yes Maybe
Fully paced or unknown
Nonspecific S-T segment abnormality No
S-T depression S-T flattening Other
Fully paced or unknown
Nonspecific T-wave abnormality No
T inversion T flattening Other
Fully paced or unknown
Left Right Both
Atrial fib. or unknown
RVH (If complete RBBB or LBBB present, code RVH = None
Unknown) Yes
Maybe
Fully paced or unknown
LVH (If complete LBBB present, code LVH = Unknown) None
LVH with strain
LVH with mild S-T segment abn. LVH by voltage only
Fully paced or unknown
ECG
Name: [lastname], [firstname]DOB: [dob]Age: [age] Sex: [sex] Date of last exam: [lastexamdate]
Date of last medical health update: [lastmhudate]
Have you ever been told you have . . .
Aortic valve disease Mitral valve disease
No Yes Maybe Unknown
Dementia/ TIA Parkinson's's Disease Adult seizure disorder Migraine
Other neurological disease
No Yes Maybe Unknown
Specify other neurological disease
Comments
Thyroid disease Diabetes Mellitus
Other endocrine disorders
No Yes Maybe Unknown
Specify other endocrine disorders
Renal disease
No Yes Maybe Unknown
Specify renal disease
Prostate disease Gynecological problems
No Yes Maybe Male/Female Unknown
Specify gynecological problems
Emphysema Pneumonia Asthma
Other pulmonary disease
No Yes Maybe Unknown
Specify other pulmonary disease
Gout
Degenerative joint disease Rheumatoid arthritis
Other muscular or connective tissue disease
No Yes Maybe Unknown
Specify other muscular or connective tissue disease
Gallbladder disease GERD/ ulcer disease Liver disease
Other GI disease
No Yes Maybe Unknown
Specify other GI disease
Hematologic disorder Bleeding disorder
No Yes Maybe Unknown
Infectious disease
No Yes Maybe Unknown
Specify infectious disease
Depression Anxiety
Other mental health
No Yes Maybe Unknown
Specify other mental health
Eye ENT
Skin Other
No Yes Maybe Unknown
Specify other
Clinical Diagnostic Impression
Name: [lastname], [firstname]DOB: [dob]Age: [age] Sex: [sex] Date of last exam: [lastexamdate]
Date of last medical health update: [lastmhudate]
This form is not completed for exams performed OFFSITE. Choose Save and go to Next Form to continue. No second opinions are required for this participant. Choose Save and go to Next Form to continue.
Check here to skip this form Yes
Reason why skipped
Second examiner ID number
Provide initiators, qualities, radiation, severity, timing, presence after procedures done 2nd opinion for congestive heart failure No
Yes Maybe Unknown
2nd opinion for cardiac syncope No
Yes Maybe Unknown
2nd opinion for angina pectoris No
Yes Maybe Unknown
2nd opinion for coronary insufficiency No Yes
Maybe Unknown
2nd opinion for myocardial infarct No Yes
Maybe Unknown
Comments about heart disease
Page 2 of 2
Provide initiators, qualities, radiation, severity, timing, presence after procedures done 2nd opinion for intermittent claudication No
Yes Maybe Unknown
Comments about peripheral artery disease
Provide initiators, qualities, severity, timing, presence after procedures done 2nd opinion for stroke No
Yes Maybe Unknown
2nd opinion for TIA No
Yes Maybe Unknown
Comments about possible cerebrovascular disease
Second Examiner Opinions
Name: [lastname], [firstname]DOB: [dob]Age: [age] Sex: [sex] Date of last exam: [lastexamdate]
Date of last medical health update: [lastmhudate]
Further Medical Evaluation
Was further medical evaluation recommended for this No
participant? Yes
Unknown
Blood pressure No
Yes
Result - Systolic (mmHg)
Result - Diastolic (mmHg)
Phone call if SBP >= 200 or DBP >= 110 Expedite if SBP >= 180 or DBP >= 100 Elevated if SBP >= 140 or DBP >= 90
ECG abnormality No
Yes
Specify abnormality
Clinic physician identified medical problem No Yes
Specify medical problem
Other No
Yes
Specify other
No Yes
Page 2 of 2
Face-to-face in clinic Phone call
Result letter Other
Phone call
Result letter mailed
Result letter FAX'd (inform staff if FAX needed)
No Yes
Other
Date referral made
ID number of person completing referral
Notes documenting conversation with participant or participant's personal physician
For Omni participants only: Which language was English
primarily used in conversing with the participant? Spanish Mixed Unknown
Referral Tracking
Gen 3, NOS, Omni 2 Cohort Exam 3
Page 1 of 2
FHS_IDTYPE_ID
Name: [lastname], [firstname]DOB: [dob]Age: [age] Sex: [sex] Date of last exam: [lastexamdate]
Date of last medical health update: [lastmhudate]
What is your current marital status?
Single or never married
Married or living as married/living with partner Separated
Divorced Widowed
Prefer not to answer
What is the HIGHEST degree or level of school you have completed? (if currently enrolled, mark the highest grade completed, degree received)
Grades 1-8
Grades 9-11
Completed high school (12th grade) or GED Some college but no degree
Technical school certificate
Associate degree (Junior college AA, AS) Bachelor's degree (BA, AB, BS)
Graduate or professional (master's, doctorate, MD etc.) Prefer not to answer
Please choose which of the following best describes your current employment status?
Homemaker, not working outside the home Employed (or self-employed) full time Employed (or self-employed) part time Employed, but on leave for health reasons Employed, but temporarily away from my job Unemployed or laid off
Retired from usual occupation and not working Retired from usual occupation but working for pay Retired from usual occupation but volunteering Pefer not to answer
Unemployed due to disability Full-time student
What is your current occupation?
Using the occupation coding sheet choose the code that best describes your occupation
High degree Medium degree Training required Entry level Other
Page 2 of 2
Please select which income group that best represents your combined family income for the past 12 months.
Under $20,000
$20,000 - $34,999
$35,000 - $54,999
$55,000 - $74,999
$75,000 - $100.000
Over $100,000 Prefer not to answer
How many people are supported by this income?
Additional comments for General Information (Sociodemographic)
Name: [lastname], [firstname]DOB: [dob]Age: [age] Sex: [sex] Date of last exam: [lastexamdate]
Date of last medical health update: [lastmhudate]
Health Insurance
Do you currently have health insurance? No Yes
Prefer not to answer Unknown
If "Yes"
HMO or other private insurance such as Blue Cross, No
Aetna, Harvard-Pilgrim, etc. Yes
Prefer not to answer Unknown
If "Yes"
Blue Cross Blue Shield Harvard-Pilgrim
Tufts Aetna
United Health Care Other
No Yes Unknown
Specify other health insurance
Medicare No
Yes
Prefer not to answer Unknown
Medicaid No
Yes
Prefer not to answer Unknown
Military or Veteran's Administration sponsored No Yes
Prefer not to answer Unknown
Other No
Yes
Prefer not to answer Unknown
Page 2 of 2
Do you have prescription drug coverage? No Yes
Prefer not to answer Unknown
If "Yes" (Check one, Joanne will find the most common prescription drug plans in MA)
Do you take any medications? No
Yes Unknown
If "Yes"
The questions below refer to medication recommended to you by your doctor or health care provider.
Did you ever forget to take your medicine?
No Yes Unknown
Are you careless at times about taking your medicine?
When you feel better do you stop taking your medicine?
Sometimes if you feel worse when you take the medicine, do you stop taking it?
How often do you forget to take your medicine? Never
More than once per week Once per week
More than once per month Once per month
Less than once per month
Name: [lastname], [firstname]DOB: [dob]Age: [age] Sex: [sex] Date of last exam: [lastexamdate]
Date of last medical health update: [lastmhudate]
This questionnaire asks for your views about your health. This information will help you keep track of how you feel and how well you are able to do your usual activities.
Please answer every question by marking one box. If you are unsure about how to answer a question, please give the best answer you can.
In general, would you say your health is: Poor Fair Good
Very Good Excellent
The following questions are about activities you might do during a typical day. Does your health now limit you in these activities? If so, how much?
Moderate activities, such as moving a table, No, not limited at all
pushing a vacuum cleaner, bowling, or playing golf Yes, limited a little Yes, limited a lot
Climbing several flights of stairs No, not limited at all Yes, limited a little Yes, limited a lot
During the past 4 weeks, have you had any of the following problems with your work or other regular daily activities as a result of your physical health?
Accomplished less than you would like Yes No
Were limited in the kind of work or other Yes
activities No
During the past 4 weeks, have you had any of the following problems with your work or other regular daily activities as a result of any emotional problems (such as feeling depressed or anxious)?
Accomplished less than you would like Yes No
Didn't do work or other activities as carefully as Yes
usual No
Name: [lastname], [firstname]DOB: [dob]Age: [age] Sex: [sex] Date of last exam: [lastexamdate]
Date of last medical health update: [lastmhudate]
how much did pain interfere with your normal work (including both work outside the home and housework)?
Not at all (=0) A little Bit (=1) Moderately (=2) Quite a Bit (=3) Extremely (=4)
These questions are about how you feel and how things have been with you during the past 4 weeks. For each question, please give the one answer that comes closest to the way you have been feeling.
Have you felt calm and peaceful?
All of the time (=5)
Most of the time (=4)
A good bit of the time (=3)
Some of the time (=2)
A little of the time (=1)
None of the time (=0)
Did you have a lot of energy?
Have you felt downhearted and blue?
During the past 4 weeks, how much of the time has All of the time your physical health or emotional problems interfered Most of the time with your social activities (like visiting friends, Some of the time
relatives, etc.)? A little of the time
None of the time
Name: [lastname], [firstname]DOB: [dob]Age: [age] Sex: [sex] Date of last exam: [lastexamdate]
Date of last medical health update: [lastmhudate]
These questions are being asked because in rare situations some people or families have clinical bleeding problems or abnormalities. Since we are conducting blood cell counts, measurements of blood RNA and biomarkers, and tests of blood platelet reactivity, it is helpful to know about any individual or family clinical bleeding history since this can help in interpretation and analysis of results.
Does your FAMILY have a history of bleeding problems No or complications? (EXAMPLES: frequent nosebleeds, Yes prolonged or excessive bleeding or bruising after
cuts/trauma, gum bleeding, excess bleeding after dental or other medical or surgical procedures, extreme bleeding with your period)
Have YOU ever experienced frequent (>=1week) No
nosebleeds in your lifetime? Yes
Had nosebleeds lasting longer than 5 minutes or which No required medical attention? Yes
Do YOU experience frequent or heavy bruising No
disproportionate to the size of trauma? Yes
Do YOU ever experience prolonged bleeding (>5minutes) No with minor cuts, or with bites to lip, cheek or Yes tongue?
Have YOU experienced prolonged bleeding at the No
dentist that delayed a procedure, or after leaving a Yes dentist's office?
Have YOU experienced bleeding that a No surgeon/physician termed abnormal, caused a delay in Yes discharge, or required supportive treatment (for
example: re-suturing, re-admission, transfusion, iron therapy)?
Skin bleeding/red spots (petechiae)
No Yes
Spontaneous Gum bleeding Vomiting blood (hematemesis) Black, tarry stools (melena)
Page 2 of 2
Blood stools (hematochezia)
Excess bleeding w/your period (menorrhagia)
Excess bleeding w/delivery requiring medical intervention (post-partum hemorrhage)
Gen 3, NOS, Omni 2 Cohort Exam 3
Page 1 of 3
FHS_IDTYPE_ID
Name: [lastname], [firstname]DOB: [dob]Age: [age] Sex: [sex] Date of last exam: [lastexamdate]
Date of last medical health update: [lastmhudate]
Technician Number
Check here to skip this form Yes
Reason why skipped
What state do you reside in? (If reside outside the AL = Alabama USA, code ZZZ, if plans to wear accelerometer while AK = Alaska visiting USA code state of visit) AZ = Arizona
AR = Arkansas CA = California CO = Colorado
CT = Connecticut DE = Delaware
FL = Florida GA = Georgia HI = Hawaii ID = Idaho
IL = Illinois IN = Indiana IA = Iowa
KS = Kansas KY = Kentucky LA = Louisiana ME = Maine
MD = Maryland
MA = Massachusetts MI = Michigan
MN = Minnesota MS = Mississippi MO = Missouri MT = Montana NE = Nebraska NV = Nevada
NH = New Hampshire NJ = New Jersey
NM = New Mexico NY = New York
NC = North Carolina ND = North Dakota OH = Ohio
OK = Oklahoma OR = Oregon
PA = Pennsylvania RI = Rhode Island SC = South Carolina SD = South Dakota TN = Tennessee
TX = Texas UT = Utah
VT = Vermont VA = Virginia
WA = Washington WV = West Virginia WI = Wisconsin
WY = Wyoming
ZZ = Outside United States
Weight (to nearest pound)
(400 = 400 or more, 888 = Refused, 999 = Not done or unknown)
Protocol modification - weight No
Yes
If "Yes"
Comments protocol modification - weight
Height (inches, to next lower 1/4 inch)
(88.88 = Refused, 99.99 = Not done or unknown)
Protocol modification - height No
Yes
If "Yes"
Comments protocol modification - height
Waist Girth at umbilicus (inches, to next lower 1/4
inch) (88.88 = Refused, 99.99 = Not done or unknown)
Protocol modification - waist girth No Yes
If "Yes"
Comments protocol modification - waist girth
Hip Girth (inches, to next lower 1/4 inch)
(88.88 = Refused, 99.99 = Not done or unknown)
Protocol modification - hip girth No
Yes
If "Yes"
Comments protocol modification - hip girth
Basic Information and Anthropometry Comments
Date of last exam: [lastexamdate]
Date of last medical health update: [lastmhudate]
Technician Number
Check here to skip this form Yes
Reason why skipped
The questions below ask about your feelings. For each statement, please say how often you felt that way DURING THE PAST WEEK
I was bothered by things that don't usually bother Rarely or none of the time (less than 1 day) me. Some or a little of the time (1-2 days)
Occasionally or a moderate amount of the time (3-4 days)
Most or all of the time (5-7 days)
I did not feel like eating; my appetite was poor. Rarely or none of the time (less than 1 day)
Some or a little of the time (1-2 days)
Occasionally or a moderate amount of the time (3-4 days)
Most or all of the time (5-7 days)
I felt that I could not shake off the blues even with Rarely or none of the time (less than 1 day) the help of my family or friends. Some or a little of the time (1-2 days)
Occasionally or a moderate amount of the time (3-4 days)
Most or all of the time (5-7 days)
I felt that I was just as good as other people. Rarely or none of the time (less than 1 day) Some or a little of the time (1-2 days)
Occasionally or a moderate amount of the time (3-4 days)
Most or all of the time (5-7 days)
I had trouble keeping my mind on what I was doing. Rarely or none of the time (less than 1 day)
Some or a little of the time (1-2 days)
Occasionally or a moderate amount of the time (3-4 days)
Most or all of the time (5-7 days)
Page 2 of 3
I felt depressed. Rarely or none of the time (less than 1 day) Some or a little of the time (1-2 days)
Occasionally or a moderate amount of the time (3-4 days)
Most or all of the time (5-7 days)
I felt everything I did was an effort. Rarely or none of the time (less than 1 day) Some or a little of the time (1-2 days)
Occasionally or a moderate amount of the time (3-4 days)
Most or all of the time (5-7 days)
I felt hopeful about the future. Rarely or none of the time (less than 1 day) Some or a little of the time (1-2 days)
Occasionally or a moderate amount of the time (3-4 days)
Most or all of the time (5-7 days)
I thought my life had been a failure. Rarely or none of the time (less than 1 day) Some or a little of the time (1-2 days)
Occasionally or a moderate amount of the time (3-4 days)
Most or all of the time (5-7 days)
I felt fearful. Rarely or none of the time (less than 1 day)
Some or a little of the time (1-2 days)
Occasionally or a moderate amount of the time (3-4 days)
Most or all of the time (5-7 days)
My sleep was restless. Rarely or none of the time (less than 1 day) Some or a little of the time (1-2 days)
Occasionally or a moderate amount of the time (3-4 days)
Most or all of the time (5-7 days)
I was happy. Rarely or none of the time (less than 1 day) Some or a little of the time (1-2 days)
Occasionally or a moderate amount of the time (3-4 days)
Most or all of the time (5-7 days)
I talked less than usual. Rarely or none of the time (less than 1 day) Some or a little of the time (1-2 days)
Occasionally or a moderate amount of the time (3-4 days)
Most or all of the time (5-7 days)
I felt lonely. Rarely or none of the time (less than 1 day)
Some or a little of the time (1-2 days)
Occasionally or a moderate amount of the time (3-4 days)
Most or all of the time (5-7 days)
People were unfriendly. Rarely or none of the time (less than 1 day) Some or a little of the time (1-2 days)
Occasionally or a moderate amount of the time (3-4 days)
Most or all of the time (5-7 days)
I enjoyed life. Rarely or none of the time (less than 1 day) Some or a little of the time (1-2 days)
Occasionally or a moderate amount of the time (3-4 days)
Most or all of the time (5-7 days)
I felt sad. Rarely or none of the time (less than 1 day)
Some or a little of the time (1-2 days)
Occasionally or a moderate amount of the time (3-4 days)
Most or all of the time (5-7 days)
I felt that people disliked me. Rarely or none of the time (less than 1 day) Some or a little of the time (1-2 days)
Occasionally or a moderate amount of the time (3-4 days)
Most or all of the time (5-7 days)
I could not get "going". Rarely or none of the time (less than 1 day) Some or a little of the time (1-2 days)
Occasionally or a moderate amount of the time (3-4 days)
Most or all of the time (5-7 days)
Score:
Are you able to do heavy work around the house, like No
shoveling snow or washing windows, walls, or floors Yes
without help? Unknown
Are you able to walk half a mile without help? No
(About 4-6 blocks) Yes
Unknown
Are you able to walk up and down one flight of stairs No
without help? Yes
Unknown
Additional comments for CESD and Rosow-Breslau Questions
Physical Activity Index (PAI) [firstname]DOB: [dob]Age: [age] Sex: [sex] Date of last exam: [lastexamdate] Date of last medical health update: [lastmhudate] |
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Name: [lastname], |
Technician Number |
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Check here to skip this form |
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Yes |
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Reason why skipped |
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Rest and Activity for a Typical Day over the past year. (A typical day = most days of the week) (Activities must equal 24 hours) |
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Sleep Number of hours that you typically sleep? |
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Sedentary Number of hours typically sitting? |
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Slight Activity Number of hours with activities such |
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as standing, walking? |
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Moderate Activity Number of hours with activities |
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such as housework (vacuum, dust, yard chores, climbing stairs, light sports such as bowling, golf)? |
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Heavy Activity Number of hours with activities such as heavy household work, heavy yard work such as stacking or chopping wood, exercise such as intensive sports--jogging, swimming etc.?
Total number of hours (should be the total of above
items) (Must add up to 24)
Additional comments for Physical Activity Index
Name: [lastname], [firstname]DOB: [dob]Age: [age] Sex: [sex] Date of last exam: [lastexamdate]
Date of last medical health update: [lastmhudate]
Technician Number
Check here to skip this form Yes
Reason why skipped
Now I'll ask you about your Physical Activities. Only include the time spent actually doing the activity. For example, sitting by the pool does not count as time swimming; sitting in a chair lift does not count for skiing.
First I'll ask about vigorous activities. Vigorous activities increase your heart rate, or make you sweat doing them, or make your breathe hard, or raise your body temperature. If you do an activity but not vigorously, please include it later when I ask you about other non-strenuous activities.
For all estimates, round up to nearest whole number.
In the past 12 months for at least one hour total time in any month did you do the following activities? For example, you may have done three 20 minute sessions in the month.
Jog or run? No
Yes Unknown
If "Yes"
How many months did you do this activity?
(99 = Unknown)
How many times per month did you do this activity?
(99 = Unknown)
How long did you do this activity on average each
time? (# of minutes) (999 = Unknown)
Do vigorous racket sports? No
Yes Unknown
If "Yes"
How many months did you do this activity?
(99 = Unknown)
How many times per month did you do this activity?
(99 = Unknown)
How long did you do this activity on average each
time? (# of minutes) (999 = Unknown)
Bicycle faster than 10 miles/hour or exercise hard on No
an exercise bicycle? or other machine such as... Yes Unknown
if "Yes"
Page 2 of 2
How many months did you do this activity?
(99 = Unknown)
How many times per month did you do this activity?
(99 = Unknown)
How long did you do this activity on average each
time? (# of minutes) (999 = Unknown)
Swim? No
Yes Unknown
if "Yes"
How many months did you do this activity?
(99 = Unknown)
How many times per month did you do this activity?
(99 = Unknown)
How long did you do this activity on average each
time? (# of minutes) (999 = Unknown)
Physical Activity Questionnaire - Part 1
Gen 3, NOS, Omni 2 Cohort Exam 3
Page 1 of 2
FHS_IDTYPE_ID
Name: [lastname], [firstname]DOB: [dob]Age: [age] Sex: [sex] Date of last exam: [lastexamdate]
Date of last medical health update: [lastmhudate]
Technician Number
Check here to skip this form Yes
Reason why skipped
In the past 12 months for at least one hour total time in any month did you...
Do a vigorous exercise class or vigorous dancing? No Yes
Unknown
if "Yes"
How many months did you do this activity?
(99 = Unknown)
How many times per month did you do this activity?
(99 = Unknown)
How long did you do this activity on average each
time? (# of minutes) (999 = Unknown)
Do any vigorous job activities such as lifting, No
carrying, or digging? Yes
Unknown
if "Yes"
How many months did you do this activity?
(99 = Unknown)
How many times per month did you do this activity?
(99 = Unknown)
How long did you do this activity on average each
time? (# of minutes) (999 = Unknown)
Do any home activities such as snow shoveling, moving No heavy objects, or weight lifting (including weight Yes
training)? Unknown
if "Yes"
How many months did you do this activity?
(99 = Unknown)
How many times per month did you do this activity?
(99 = Unknown)
How long did you do this activity on average each
time? (# of minutes) (999 = Unknown)
Page 2 of 2
Do other strenuous sports such as basketball, No
football, skating, skiing, etc.? Yes
Unknown
If "Yes"
How many months did you do this activity?
(99 = Unknown)
How many times per month did you do this activity?
(99 = Unknown)
How long did you do this activity on average each
time? (# of minutes) (999 = Unknown)
Now, I'd like to ask you about more leisurely activities.
In the past 12 months for at least one hour total time in any month did you... Do non-strenuous sports such as softball, shooting No
baskets, volleyball, ping pong, or leisurely jogging, Yes swimming or biking, which we haven't included above? Unknown
If "Yes"
How many months did you do this activity?
(99 = Unknown)
How many times per month did you do this activity?
(99 = Unknown)
How long did you do this activity on average each
time? (# of minutes) (999 = Unknown)
Physical Activity Questionnaire - Part 2
Gen 3, NOS, Omni 2 Cohort Exam 3
Page 1 of 2
FHS_IDTYPE_ID
Name: [lastname], [firstname]DOB: [dob]Age: [age] Sex: [sex] Date of last exam: [lastexamdate]
Date of last medical health update: [lastmhudate]
Technician Number
Check here to skip this form Yes
Reason why skipped
In the past 12 months for at least one hour total time in any month did you...
Take walks or hikes or walk to work? No Yes
Unknown
if "Yes"
How many months did you do this activity?
(99 = Unknown)
How many times per month did you do this activity?
How long did you do this activity on average each time? (# of minutes)
Bowl or play golf? No
Yes Unknown
If "Yes"
How many months did you do this activity?
(99 = Unknown)
How many times per month did you do this activity?
(99 = Unknown)
How long did you do this activity on average each
time? (# of minutes) (999 = Unknown)
Do home exercise or calisthenics? No Yes
Unknown
If "Yes"
How many months did you do this activity?
(99 = Unknown)
How many times per month did you do this activity?
(99 = Unknown)
How long did you do this activity on average each
time? (# of minutes) (999 = Unknown)
Page 2 of 2
Do home maintenance or gardening, including No
carpentry, painting, raking, mowing, etc.? Yes Unknown
if "Yes"
How many months did you do this activity?
(99 = Unknown)
How many times per month did you do this activity?
(99 = Unknown)
How long did you do this activity on average each
time? (# of minutes) (999 = Unknown)
Do non-strenuous weight training including free No
weights or machines such as Nautilus? Yes Unknown
If "Yes"
How many months did you do this activity?
(99 = Unknown)
How many times per month did you do this activity?
(99 = Unknown)
How long did you do this activity on average each
time? (# of minutes) (999 = Unknown)
Physical Activity Questionnaire - Part 3
Gen 3, NOS, Omni 2 Cohort Exam 3
Page 1 of 2
FHS_IDTYPE_ID
Name: [lastname], [firstname]DOB: [dob]Age: [age] Sex: [sex] Date of last exam: [lastexamdate]
Date of last medical health update: [lastmhudate]
Technician Number
Check here to skip this form Yes
Reason why skipped
Now I'm going to ask you some questions about your physical activity during the past year at WORK ONLY.
Do you work? No
Yes Unknown
if "Yes"
How many hours per week do you work? (number of hours)
(999 = Unknown) Please answer for the work you do most of the year if you are a seasonal worker.
At work do you SIT
At work do you STAND At work do you WALK
Never(0 hrs) Seldom Sometimes Often Always Do notrecall
My next question is about your leisure time.
In the past week, about how many hours per day did None or < 1 hour you sit and watch TV or videos? 1 hour
hours
hours
hours
hours or more Unknown
In the past week, about how many hours per day did None or < 1 hour you use a computer or play computer games or play 1 hour
video games? 2 hours
hours
hours
hours or more Unknown
Page 2 of 2
Physical Activity Questionnaire - Part 4
Name: [lastname], [firstname]DOB: [dob]Age: [age] Sex: [sex] Date of last exam: [lastexamdate]
Date of last medical health update: [lastmhudate]
Technician Number
Check here to skip this form Yes
Reason why skipped
Since your last exam...
Have you had asthma? No
Yes Unknown
If "Yes"
Do you still have it? No
Yes Unknown
Was it diagnosed by a doctor or other health care No
professional? Yes
Unknown
If it started since your last exam, at what age did
it start? (Age in years) If it started before last (88 = N/A, 99 = Unknown) exam enter 88 = N/A
If you no longer have it, at what age did it stop?
(Age in years) (88 = Still have it, 99 = Unknown)
Have you received medical treatment for this in the No
past 12 months? Yes
Unknown
Have you had any of the following conditions diagnosed by a doctor or other health care professional? Chronic Bronchitis No
Yes Unknown
Emphysema No
Yes Unknown
COPD (Chronic Obstructive Pulmonary Disease) No Yes
Unknown
Page 2 of 2
Sleep Apnea No
Yes Unknown
Pulmonary Fibrosis No
Yes Unknown
Respiratory Disease Questionnaire
Name: [lastname], [firstname]DOB: [dob]Age: [age] Sex: [sex] Date of last exam: [lastexamdate]
Date of last medical health update: [lastmhudate]
Technician Number
Check here to skip this form Yes
Reason why skipped
If more than 1 fracture at one site on the same side, enter it as a separate fracture.
Since you last provided medical information No
([lastmedinfodate]) have you broken any bones? Yes Unknown
If "Yes"
Location of fracture - #1 Hip
Upper arm (Humerus) Forearm or wrist
Hand
Clavicle (Collar bone) Rib
Back or vertebra Pelvis
Leg Ankle Foot Other
Location of fracture - #1 ([fracture1])
Side of fracture - #1 ([fracture1]) Left Right N/A
Unknown (don't remember)
Year of fracture - #1 ([fracture1])
(9999 = Unknown)
DATE details - #1 ([fracture1])(e.g. 10/2, April, Summer, August-Nov., Unknown etc.)
Have medical encounter details been entered on M01? - No
#1 ([fracture1]) Yes
If "No"
Hosp/MD for fracture - #1 ([fracture1])
Location of Hosp/MD - #1 ([fracture1])
Have you broken any more bones? No Yes
Unknown
If "Yes"
Location of fracture - #2 Hip
Upper arm (Humerus) Forearm or wrist
Hand
Clavicle (Collar bone) Rib
Back or vertebra Pelvis
Leg Ankle Foot Other
Location of fracture - #2 ([fracture2])
Side of fracture - #2 ([fracture2]) Left Right N/A
Unknown (don't remember)
Year of fracture - #2 ([fracture2])
(9999 = Unknown)
DATE details - #2 ([fracture2])(e.g. 10/2, April, Summer, August-Nov., Unknown etc.)
Have medical encounter details been entered on M01? - No
#2 ([fracture2]) Yes
If "No"
Hosp/MD for fracture - #2 ([fracture2])
Location of Hosp/MD - #2 ([fracture2])
Have you broken any more bones? No Yes
Unknown
If "Yes"
Location of fracture - #3 Hip
Upper arm (Humerus) Forearm or wrist
Hand
Clavicle (Collar bone) Rib
Back or vertebra Pelvis
Leg Ankle Foot Other
Location of fracture - #3 ([fracture3])
Side of fracture - #3 ([fracture3]) Left Right N/A
Unknown (don't remember)
Year of fracture - #3 ([fracture3])
(9999 = Unknown)
DATE details - #3 ([fracture3])(e.g. 10/2, April, Summer, August-Nov., Unknown etc.)
Have medical encounter details been entered on M01? - No
#3 ([fracture3]) Yes
If "No"
Hosp/MD for fracture - #3 ([fracture3])
Location of Hosp/MD - #3 ([fracture3])
Have you broken any more bones? No Yes
Unknown
If "Yes"
Location of fracture - #4 Hip
Upper arm (Humerus) Forearm or wrist
Hand
Clavicle (Collar bone) Rib
Back or vertebra Pelvis
Leg Ankle Foot Other
Location of fracture - #4 ([fracture4])
Side of fracture - #4 ([fracture4]) Left Right N/A
Unknown (don't remember)
Year of fracture - #4 ([fracture4])
(9999 = Unknown)
DATE details - #4 ([fracture4])(e.g. 10/2, April, Summer, August-Nov., Unknown etc.)
Have medical encounter details been entered on M01? - No
#4 ([fracture4]) Yes
If "No"
Hosp/MD for fracture - #4 ([fracture4])
Location of Hosp/MD - #4 ([fracture4])
Have you broken any more bones? No Yes
Unknown
If "Yes"
Upper arm (Humerus) Forearm or wrist
Hand
Clavicle (Collar bone) Rib
Back or vertebra Pelvis
Leg Ankle Foot Other
Location of fracture - #5 ([fracture5])
Side of fracture - #5 ([fracture5]) Left Right N/A
Unknown (don't remember)
Year of fracture - #5 ([fracture5])
(9999 = Unknown)
DATE details - #5 ([fracture5])(e.g. 10/2, April, Summer, August-Nov., Unknown etc.)
Have medical encounter details been entered on M01? - No
#5 ([fracture5]) Yes
If "No"
Hosp/MD for fracture - #5 ([fracture5])
Location of Hosp/MD - #5 ([fracture5])
Fractures
Name: [lastname], [firstname]DOB: [dob]Age: [age] Sex: [sex] Date of last exam: [lastexamdate]
Date of last medical health update: [lastmhudate]
Technician Number
Check here to skip this form Yes
Reason why skipped
Right hand Measured to the nearest kilogram
Trial 1
(99 = Unknown)
Trial 2
(99 = Unknown)
Trial 3
(99 = Unknown)
Left hand Measured to the nearest kilogram
Trial 1
(99 = Unknown)
Trial 2
(99 = Unknown)
Trial 3
(99 = Unknown)
Was this test NOT completed or NOT attempted? No Yes
If "Yes"
If not attempted or completed, why not? Physical limitation Refused
Other Unknown
Other: Write in
Hand Grip Test
Name: [lastname], [firstname]DOB: [dob]Age: [age] Sex: [sex] Date of last exam: [lastexamdate]
Date of last medical health update: [lastmhudate]
Tonometry Worksheet Questions
Have you had any caffeinated drinks in the last 6 No
hours? Yes
Unknown
If "Yes"
How many cups?
(99 = Unknown)
Have you eaten anything else including a fat freee No
cereal bar this morning? Yes
Unknown
Have you smoked cigarettes in the last 6 hours? No Yes
Unknown
If "Yes"
How many hours since your last cigarette? - hour
portion (99 = Unknown)
How many minutes since your last cigarette? - minute portion (99 = Unknown)
Tonometry Sonographer ID
Date of Tonometry scan?
Was Tonometry done? No, test was not attempted or done
Yes, test was done, even if all 4 pulses could not be acquired and recorded
If "No"
Subject refusal No
Yes
Subject discomfort No
Yes
Page 2 of 2
Time constraint No
Yes
Equipment problem No
Yes
If "Yes"
Specify equipment problem
Other No
Yes
If "Yes" Specify other
Tonometry Worksheet
Date of last exam: [lastexamdate]
Date of last medical health update: [lastmhudate]
Technician Number
Check here to skip this form Yes
Reason why skipped
Removed and shredded bar code bracelet No Yes
Procedure sheet reviewed No
Yes Unknown
Referral sheet reviewed No
Yes Unknown
Dietary questionnaire provided (if not completed in No
clinic) Yes
Unknown
Left clinic with accelerometer No
Yes Unknown
Left clinic w/ belongings No
Yes Unknown
Explanation of microbiome; agreed to participate No Yes
Unknown
Feedback No feedback
Positive feedback Negative feedback Other
Unknown
Comments for Exit Interview
Page 2 of 2
(not requiring further medical evaluation)
Technician Number
Was there an adverse event in clinic that does not No
require further medical evaluation? Yes Unknown
Comments
Technician who reviewed that all REDCap form questions were completed
Additional comments for Exit Interview and Adverse Events
File Type | application/vnd.openxmlformats-officedocument.wordprocessingml.document |
File Modified | 0000-00-00 |
File Created | 2021-01-23 |