Case Report Form TWELVE MONTH FOLLOW UP ASSESSMENT

Transcription

1 Case Report Form TWELVE MONTH FOLLOW UP ASSESSMENT Page 1 of 25

2 1. Twelve Month Follow Up Patient identification number Date of twelve month follow up GP Practice (Site) Number Researcher Initials Signature of Assessor Clinical Measures: Blood Pressure Systolic blood pressure Date recorded: mmhg Diastolic blood pressure Date recorded: mmhg Clinical Measures: Anthropometric Measures Weight. kilograms Date recorded Body Mass Index. weight in kgs/(height in metres) 2 Waist circumference. centimetres Date recorded Page 2 of 25

3 Section 3: Clinical Measures: Blood Tests Total Cholesterol Date recorded:. mmol/litre HDL Cholesterol Date recorded:. mmol/litre LDL Cholesterol. mmol/litre Date recorded: Total Cholesterol/HDL ratio. mmol/litre Date recorded: Triglycerides. mmol/litre Date recorded: Blood Glucose HBA 1C (value) Date recorded: mmol/mol or HBA 1C (percentage). % Date recorded: Fasted blood glucose Mmol/mol Date recorded : Random blood glucose Date recorded: mmol/l. Page 3 of 25

4 Section Lifestyle Questionnaires: Alcohol Use Disorders Identification Test (AUDIT) This is one unit of alcohol and each of these is more than one unit Alcohol Use Disorders Identification Test: AUDIT C Questions How often do you have a drink containing alcohol? How many units of alcohol do you drink on a typical day when you are drinking? How often have you had 6 or more units if female, or 8 or more if male, on a single occasion in the last year? Scoring system Never Monthly or less 2-4 times per month 2-3 times per week 4+ times per week Never Less than monthly Monthly Weekly Daily or almost daily Your score Scoring: A total of 5+ indicates increasing or higher risk drinking. An overall total score of 5 or above is AUDIT-C positive. SCORE Page 4 of 25

5 Score from AUDIT- C (other side) SCORE Remaining AUDIT questions (To be completed if AUDIT-C score is 5 or above) Questions How often during the last year have you found that you were not able to stop drinking once you had started? How often during the last year have you failed to do what was normally expected from you because of your drinking? How often during the last year have you needed an alcoholic drink in the morning to get yourself going after a heavy drinking session? How often during the last year have you had a feeling of guilt or remorse after drinking? How often during the last year have you been unable to remember what happened the night before because you had been drinking? Have you or somebody else been injured as a result of your drinking? Has a relative or friend, doctor or other health worker been concerned about your drinking or suggested that you cut down? Scoring system Never Never Never Never Never No No Less than monthly Less than monthly Less than monthly Less than monthly Less than monthly Monthly Monthly Monthly Monthly Monthly Yes, but not in the last year Yes, but not in the last year Weekly Weekly Weekly Weekly Weekly Daily or almost daily Daily or almost daily Daily or almost daily Daily or almost daily Daily or almost daily Yes, during the last year Yes, during the last year Your score Scoring: 0 7 Lower risk, 8 15 Increasing risk, Higher risk, 20+ Possible dependence TOTAL TOTAL Score equals Page 5 of 25

6 AUDIT C Score (above) + Score of remaining questions 4.2 Lifestyle Questionnaires: Smoking What is your current smoking status? Non smoker Ex-smoker Light smoker (9 or less cigarettes a day) Moderate smoker (between cigarettes a day) Heavy smoker (20 or more cigarettes a day) If you are a light, moderate or heavy smoker; how many cigarettes do you smoke a day? Page 6 of 25

7 4.3 Lifestyle Questionnaires: DINE and Healthy Eating DINE: Dietary Instrument for Nutrition Education 1. About how many pieces or slices per day do you eat of the following types of bread, rolls, or chapatis? (Choose one answer on each line) Breads & Rolls None Less than 1 a day 1 to 2 a day 3 to 4 a day 5 or more a day White bread or rolls Bread Brown or granary bread or rolls Wholemeal bread or rolls About how many servings per week do you eat of the following types of breakfast cereal or porridge? (Choose one answer on each line) Breakfast cereals None Less than 1 a week 1 to 2 a week 3 to 5 a week 6 or more a week Sugared type: Frosties, Coco Pops, Ricicles, Sugar Puffs Rice or Corn type: Corn Flakes, Rice Krispies, Special K Porridge or Ready Brek Wheat type: Shredded Wheat, Start, Weetabix, Fruit n Fibre, Puffed Wheat Muesli type: Alpen, Jordans Bran type: All-Bran, Bran Flakes, Country Bran Cereal 3. About how many servings per week do you eat of the following foods? (Choose one answer on each line) Vegetable foods None Less than 1 a week 1 to 2 a week 3 to 5 a week 6 to 7 a week 8 to 11 a week 12 or more a week Pasta or rice Potatoes Peas Beans (baked, tinned, Page 7 of 25

8 or dried) or lentils Other vegetables (any type) Vegetabl es Fruit (fresh, frozen, or canned) Less than 30 = Low Fibre Intake Total Fibre Rating 30 to 40 = Medium Fibre Intake More than 40 = High Fibre Intake 4. About how many servings per week do you eat of the following foods? (Choose one answer on each line) None Less than 1 a week 1 to 2 a week 3 to 5 a week 6 or more a week Cheese (any except cottage) Beefburgers or sausages Beef, pork, or lamb (for vegetarians: nuts) Bacon, meat pie, processed meat Chicken or turkey Fish (NOT fried fish) ANY fried food: fried fish, chips, cooked breakfast, samosas Score Cakes, pies, puddings, pastries Biscuits, chocolate, or crisps About how much of the following types of milk do you yourself use per day, for example in cereal, tea, or coffee? (Choose one answer on each line) Milk None Less than a quarter pint About a quarter pint About half a pint 1 pint or more Full cream (blue top) or Milk Channel Islands (gold top) Semi-skimmed (green top) Page 8 of 25

9 Skimmed (red top) About how many rounded teaspoons per day do you usually use of the following types of spreads, for example on bread, sandwiches, toast, potatoes, or vegetables? (Choose one answer on each line) Spreads None Regular margarine or butter or Reduced fat spread such as sunflower or olive spread, Flora, Vitalite, Clover, Olivio, Stork, Utterly Butterly 7 or more Low fat spread such as Flora Light, Flora Pro-activ, Light spread Spread Less than 30 = Low Fat Intake Total Fat Rating 30 to 40 = Medium Fat Intake More than 40 = High Fat Intake Page 9 of 25

10 7. What type of fat do you usually use for the following purposes? (Choose one answer on each line) Butter, lard, or dripping Solid cooking fat Half-fat butter Hard margarine Soft margarine Reduced fat spread Vegetable oil or Low fat spread No fat used On bread and vegetables For frying For baking or cooking Unsaturated Fat Rating Less than 6 = Low Unsaturated Fat Total 6 to 9 = Medium Unsaturated Fat Additional diet questions How many pieces of fruit, of any sort, do you eat on a typical day? (eg an apple or banana, a small bowl of strawberries, three tablespoons of tinned fruit, at least one glass of fresh fruit juice) How many portions of vegetables, excluding potatoes, do you eat on a typical day? (e.g. four heaped teaspoons of green vegetables such as spinach, three heaped spoonfuls of fresh, tinned or frozen vegetables (such as carrots), one medium tomato, three heaped teaspoons of beans or chickpeas.) Page 10 of 25

11 Section Medical Records: Risk Scores Has a 10-Year QRISK 2 Score been recorded in the last 12 months? YES NO If yes, 10-Year QRISK 2 Score recorded in last 12 months. % Date the 10-Year QRISK 2 Score was recorded in the last 12 months Has a 10-Year Framingham Score been recorded in the last 12 months? YES NO If yes, 10-Year Framingham Score recorded in last 12 months. % Date the 10-Year Framingham Score recorded in the last 12 months 5.2 Medical Records: Alcohol History Alcohol history Has there been a recorded history of heavy drinking or alcohol problems in the last 12 months? YES NO If yes, date history of heavy drinking or alcohol problems recorded Number of units of alcohol consumed per week Page 11 of 25

12 Date number of units of alcohol consumed per week recorded Alcohol intake/hazardous or harmful drinking Number of times alcohol intake/hazardous or harmful drinking has been checked by a doctor in the past 12 months Number of times alcohol intake/hazardous or harmful drinking has been checked by a nurse in the past 12 months Number of times alcohol intake/hazardous or harmful drinking has been checked by a healthcare assistant in the past 12 months 5.3 Medical Records: Physical Health Conditions Diagnosed physical health conditions Diagnosis of Type 1 diabetes? YES NO Diagnosis of Type 2 diabetes? YES NO Receiving treatment for YES NO hypertension? Angina or heart attack in a 1 st YES NO Not known degree relative under the age of 60? Chronic kidney disease? YES NO Atrial fibrillation? YES NO Page 12 of 25

13 Rheumatoid arthritis? YES NO Left ventricular hypertrophy? YES NO Other diagnosed major active long term conditions in the following systems: Respiratory, gastroenterology, neurology, chronic infections, endocrinology and skin in the last 12 months Date of diagnosis (dd/mm/yyyy) Page 13 of 25

14 5.4 Medical Records: Hospital Based Service Receipt: Overnight Inpatient Stays Overnight inpatient stays in the last 12 months Inpatient Service Type Dates of admissions in the last 12 months Total number of nights in hospital Reason for Admission Psychiatric intensive care ward Acute psychiatric ward Psychiatric rehabilitation ward General medical elective/planned inpatient admission General medical nonelective/unplanned inpatient admission General medical intensive care/high dependency unit Page 14 of 25

15 5.5 Medical Records: Hospital Based Service Receipt: Outpatient Appointments Outpatient appointments attended in the last 12 months Outpatient Service Type Dates of contacts in the last 12 months Reason for attendance Psychiatric outpatient appointment Day patient procedure/test General medical outpatient appointment Page 15 of 25

16 5.6 Medical Records: Hospital Based Service Receipt: Accident and Emergency (A&E) Attendances A&E service attended in the last 12 months Accident and Emergency attendance Dates of contacts in the last 12 months Reason for attendance And admitted to hospital Not admitted to hospital 5.7 Medical Records: Community Based Service Receipt: General Practice General practice services attended in the last 12 months GP Practice Service Type Dates of contacts (where available) Date of first contact with service. Date discharged from service in the last 6months (if service used during last 16 months) (services used during last 6 months) General practitioner Practice Nurse Healthcare Assistant Other practice staff (please specify) Page 16 of 25

17 5.8 Medical Records: Community Based Service Receipt: Other Community Based Services Other community based services attended in the last 12 months For the following services please fill in dates of contacts if known, otherwise the first and last dates that the patient engaged with the service for services that the patient has been in contact with in the last 12 months. Other Community Based Service Type Dates of contacts (where available) Date of first contact with service Date discharged from service (in the last 12 months) (if services used during last 12 months) (if services used during last 12 months) IAPT or other CBT services Community psychiatrist (excluding outpatient visits) Other Community Based Service Type Dates of contacts (where available) Date of first contact with service Date discharged from service (in the last 12months) (if services used during last 12months) (if services used during last 12months) Psychologist Community psychiatric nurse CPA key worker Case Manager Community mental health Page 17 of 25

18 team Learning disability service Other community nurse (eg district nurse, health visitor) Other services used (please specify) 5.9 Medical Records: Health Checks and Health Action Plans Number of times physical health checks carried out Blood pressure No times checked by Doctor in the past 12 months [ ] No times checked by Nurse in the past 12 months [ ] No times checked by healthcare assistant in the past 12 months [ ] Blood cholesterol No times checked by Doctor in the past 12 months [ ] No times checked by Nurse in the past 12 months [ ] No times checked by healthcare assistant in the past 12 months [ ] Blood sugar and/or HBA1c No times checked by Doctor in the past 12 months [ ] Page 18 of 25

19 No times checked by Nurse in the past 12 months [ ] No times checked by healthcare assistant in the past 12 months [ ] Weight and BMI No times checked by Doctor in the past 12 months [ ] No times checked by Nurse in the past 12 months [ ] No times checked by healthcare assistant in the past 12 months [ ] Smoking status No times checked by Doctor in the past 12 months [ ] No times checked by Nurse in the past 12 months [ ] No times checked by healthcare assistant in the past 12 months [ ] Page 19 of 25

20 Health action plan In the past 12 months has a health action plan for any problematic areas been developed with the patient? (Problematic areas arising from the NHS health check) YES NO If yes, please complete the following (for problem areas arising from the health check): Problem area addressed: Cholesterol YES NO Problem area addressed: Blood pressure YES NO Problem area addressed: Pre-diabetes YES NO Problem area addressed: Diabetes YES NO Problem area addressed: Smoking YES NO Problem area addressed: Weight YES NO Problem area addressed: Alcohol YES NO Problem area addressed: Other YES NO If other, please specify In the past 12 months has the patient been referred to any services for problematic areas resulting from their health check? YES NO Page 20 of 25

21 If yes, Service patient referred to as a result of their health check (Tick all that apply) NHS diabetes management services NHS stop smoking services NHS weight management services NHS alcohol services Other If Other, please specify Page 21 of 25

22 5.10 Medical Records: Prescribed Medication Complete for all medications received in the last 12 months. If the dose changes, record this again in a separate row. If you run out of space record this in the other medications row. Drug name Dose Units of dose (e.g. mg) Frequency (e.g. three times daily) Date first prescribed (DD/MM/YYYY) Duration of prescription Reason for prescription Has the medication been discontinued? Please state Yes or No If yes, please give reason/s for stopping Antipsychotics Antidepressants Mood stabilisers Page 22 of 25

23 Statins Antihypertensives Metformin Other diabetic medications Page 23 of 25

24 Stop smoking medications (e.g Varenicline or Bupoprion) Other medications Page 24 of 25

25 5.11 Medical records : appointment DNA s How many scheduled appointments with a GP, practice nurse, healthcare assistant or other practice staff were there in the last 12 months? How many of these scheduled appointments did the participant NOT attend (DNA)? Has the patient been identified by the GP practice as a frequent non-attender? YES NO Research Nurse Blinding Do you think that this patient Received the PRIMROSE service (intervention group) Received treatment as usual (control group) Page 25 of 25