1. Since your last Jackson Heart Study exam in (mm/dd /yyyy), have you been told by a physician that you had a stroke?...yes 1.
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- Norah Shaw
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1 Stroke Symptoms Form ID NUMBER: CONTACT YEAR: 0 6 FORM FORM CODE: CODE: SSF SSF VERSION VERSION B 07/29/2005 A 08/09/2000 LAST NAME: INITIALS: INSTRUCTIONS: This form should be completed during the participant s visit. ID Number, Contact Year, and Name must be entered above. Whenever numerical responses are required, enter the number so that the last digit appears in the rightmost box. Enter leading zeroes where necessary to fill all boxes. If a number is entered incorrectly, mark through the incorrect entry with an "X". Code the correct entry clearly above the incorrect entry. For "multiple choice" and "yes/no" type questions, circle the letter corresponding to the most appropriate response. If a letter is circled incorrectly, mark through it with an "X" and circle the correct response. A. STROKE HISTORY 1. Since your last Jackson Heart Study exam in (mm/dd /yyyy), have you been told by a physician that you had a stroke?...yes 1 Go to Item 3 2. When did this stroke occur? / m m y y y y B. SUDDEN LOSS OR CHANGE OF SPEECH 3. In the past 5 years, since your last Jackson Heart Study exams, have you had any sudden loss or changes in speech lasting 24 hours or longer? Yes 1 Go to Item 7 SSF/Version B 07/29/2005 Page 1 of 24
2 4. Did the episode come on suddenly?...yes 1 5. Do any of the following describe your change in speech? Yes No Don t Know Refused Missing 5a. Slurred speech like you were drunk? Could talk but the wrong words came 5b. out? Know what you wanted to say, but the 5c. words would not come out? d. Could not think of the right words? e. [IF MORE THAN ONE OF ITEMS A-D INDICATED, ASK WHICH OF THESE MOST CLOSELY DESCRIBES THE PROBLEMS? ]... Slurred speech 1 Wrong words came out 2 Words would not come out 3 Could not think of the right 4 6. While you were having your episode of change in speech, did any of the following occur? [INCLUDE ALL THAT APPLY] 6a. Numbness or tingling?.. Yes 1 Go to Item 6c SSF/Version B 07/29/2005 Page 2 of 24
3 6b. Did you have difficulty on:... The right side only 1 The left side only 2 Both sides 3 6c. Paralysis or weakness?. Yes 1 Go to Item 6e 6d. Did you have difficulty on:...the right side only 1 The left side only 2 Both sides 3 6e. Lightheadedness, dizziness, or loss of balance?. Yes 1 SSF/Version B 07/29/2005 Page 3 of 24
4 6f. Blackouts or fainting?.. Yes 1 6g. Seizures or convulsions?. Yes 1 6h. Headache? Yes 1 6i. Visual disturbances?. Yes 1 Go to Item 7 SSF/Version B 07/29/2005 Page 4 of 24
5 6j. Did you have: [READ ALL CHOICES UNTIL A POSITIVE RESPONSE IS GIVEN] Double vision 01 Vision loss in right eye only 02 Vision loss in left eye only 03 Total loss of vision in both eyes 04 Trouble in both eyes seeing to the right 05 Trouble in both eyes seeing to the left 06 Trouble in both eyes seeing to both sides or straight ahead C. SUDDEN LOSS OF VISION 7. In the past 5 years, since your last Jackson Heart Study exam, have you had any sudden loss of vision, or blurring, lasting 24 hours or longer?... Yes 1 Go to Item 11a Don't know 7 8. Did the episode come on suddenly? Yes 1 SSF/Version B 07/29/2005 Page 5 of 24
6 9a. During the episode, which of the following parts of your vision were affected?... Only the right eye 1 Only the left eye 2 Go to Item 10a Both eyes 3 9b. Did you have:.. Trouble seeing to the right, but not the left 1 [READ ALL CHOICES UNTIL A POSITIVE RESPONSE IS GIVEN] Trouble seeing to the left, but not the right 2 Trouble seeing both sides or straight ahead While you were having your loss of vision, did any of the following occur? [INCLUDE ALL THAT APPLY] 10a. Speech disturbance?. Yes Y No N SSF/Version B 07/29/2005 Page 6 of 24
7 10b. Numbness or tingling?. Yes 1 Go to Item 10d 10c. Did you have difficulty on:... The right side only 1 The left side only 2 Both sides 3 10d. Paralysis or weakness?. Yes 1 Go to Item 10f 10e. Did you have difficulty on:... The right side only 1 The left side only 2 Both sides 3 SSF/Version B 07/29/2005 Page 7 of 24
8 10f. Lightheadedness, dizziness, or loss of balance?.. Yes 1 10g. Blackouts or fainting?.. Yes 1 10h. Seizures or convulsions?...yes 1 10i. Headache? Yes 1 SSF/Version B 07/29/2005 Page 8 of 24
9 10j. Flashing lights?.. Yes 1 D. DOUBLE VISION 11a. In the past 5 years, since your last Jackson Heart Study visit, have you had a sudden spell of double vision, which lasted 24 hours or longer?... Yes 1 Go to Item 14 Don't know 7 11b. If you closed one eye, did the double vision go away?...yes 1 Go to Item 14 Don't know Did the episode come on suddenly?. Yes 1 SSF/Version B 07/29/2005 Page 9 of 24
10 13. While you were having your double vision did any of the following occur? [INCLUDE ALL THAT APPLY] 13a. Speech disturbance? Yes 1 13b. Numbness or tingling?.. Yes 1 Go to Item 13d 13c. Did you have difficulty on:... The right side only 1 The left side only 2 Both sides 3 13d. Paralysis or weakness? Yes 1 Go to Item SSF/Version B 07/29/2005 Page 10 of 24
11 13e. Did you have difficulty on... The right side only 1 The left side only 2 Both sides 3 13f. Lightheadedness, dizziness, or loss of balance? Yes 1 13g. Blackouts or fainting?. Yes 1 13h. Seizures or convulsions? Yes 1 SSF/Version B 07/29/2005 Page 11 of 24
12 13i. Headache?.. Yes 1 E. SUDDEN NUMBNESS OR TINGLING 14. In the past 5 years, since your last Jackson Heart Study exam, have you ever had sudden numbness, tingling, or loss of feeling on one side of your body, including your face, arm, or leg which lasted 24 hours or longer?... Yes 1 Go to Item 20 Don't know Did the feeling of numbness or tingling occur only when you kept your arms or legs in a certain position?...yes 1 Go to Item 20 Don't know Did the episode come on suddenly?. Yes 1 SSF/Version B 07/29/2005 Page 12 of 24
13 17. During the episode of sudden numbness or tingling, which part or parts of your body were affected? Yes No Don't Know Refused Missing 17a. Left arm or hand? b. Left leg or foot? c. Left side of face? d. Right arm or hand? e. Right leg or foot? f. Right side of face? g. Other? During this episode, did the abnormal sensation start in one part of your body and spread to another, or did it stay in the same place?... Started in one part and spread to another 1 Stayed in one part 2 Don't know While you were having your episode of numbness, tingling or loss of sensation, did any of the following occur? [INCLUDE ALL THAT APPLY] 19a. Speech disturbance?...yes 1 SSF/Version B 07/29/2005 Page 13 of 24
14 19b. Paralysis or weakness?...yes 1 Go to Item 19d 19c. Did you have difficulty on:...the right side only 1 The left side only 2 Both sides 3 19d. Lightheadedness, dizziness, or loss of balance?. Yes 1 19e. Blackouts or fainting?.. Yes 1 SSF/Version B 07/29/2005 Page 14 of 24
15 19f. Seizures or convulsions?. Yes 1 19g. Headache? Yes 1 19h. Pain in the numb or tingling arm, leg or face?.. Yes 1 19i. Visual disturbances?. Yes 1 Go to Item 20 SSF/Version B 07/29/2005 Page 15 of 24
16 19j. Did you have: [READ ALL CHOICES UNTIL A POSITIVE RESPONSE IS GIVEN] Double vision 01 Vision loss in right eye only 02 Vision loss in left eye only 03 Total loss of vision in both eyes 04 Trouble in both eyes seeing to the right 05 Trouble in both eyes seeing to the left 06 Trouble in both eyes seeing to both sides or straight ahead F. SUDDEN PARALYSIS OR WEAKNESS 20. In the past 5 years, since your last Jackson Heart Study exam, have you had any sudden episode of paralysis or weakness on one side of your body, including your face, arm, or leg which lasted at least 24 hours?... Yes 1 Go to Item Did the episode come on suddenly? Yes 1 SSF/Version B 07/29/2005 Page 16 of 24
17 22. During this episode, which part or parts of your body were affected? Yes No Don't Know Refused Missing 22a. Left arm or hand? b. Left leg or foot? c. Left side of face? d. Right arm or hand? e. Right leg or foot? f. Right side of face? g. Other? During this episode, did the paralysis or weakness start in one part of your body and spread to another, or did it stay in the same place? Started in one part and spread to another 1 Stayed in one part 2 Don't know While you were having your episode of paralysis or weakness, did any of the following occur? [INCLUDE ALL THAT APPLY] 24a. Speech disturbances?... Yes 1 SSF/Version B 07/29/2005 Page 17 of 24
18 24b. Numbness or tingling?... Yes 1 Go to Item 24d 24c. Did you have difficulty on: The right side only 1 The left side only 2 Both sides 3 24d. Lightheadedness, dizziness, or loss of balance? Yes 1 24e. Blackouts or fainting?. Yes 1 SSF/Version B 07/29/2005 Page 18 of 24
19 24f. Seizures or convulsions? Yes 1 24g. Headache?.. Yes 1 24h. Pain in the weak arm, leg or face?.. Yes 1 24i. Visual disturbances? Yes 1 Go to Item 25 SSF/Version B 07/29/2005 Page 19 of 24
20 24j. Did you have: [READ ALL CHOICES UNTIL A POSITIVE RESPONSE IS GIVEN] Double vision 01 Vision loss in right eye only 02 Vision loss in left eye only 03 Total loss of vision in both eyes 04 Trouble in both eyes seeing to the right 05 Trouble in both eyes seeing to the left 06 Trouble in both eyes seeing to both sides or straight ahead G. SUDDEN SPELLS OF DIZZINESS OR LOSS OF BALANCE 25. In the past 5 years, since your last Jackson Heart Study exam, have you had any sudden spells of dizziness, loss of balance, or sensation of spinning which lasted 24 hours or longer?.. Yes 1 Go to Item 29 Don't know 7 SSF/Version B 07/29/2005 Page 20 of 24
21 26. Did the dizziness, loss of balance or spinning sensation occur only when changing the position of your head or body? Yes 1 Go to Item 29 Don't know While you were having your episode of dizziness, loss of balance or spinning sensation, did any of the following occur? [INCLUDE ALL THAT APPLY] 27a. Speech disturbances?. Yes 1 27b. Paralysis or weakness? Yes 1 Go to Item 27d 27c. Did you have difficulty on: The right side only 1 The left side only 2 Both sides 3 SSF/Version B 07/29/2005 Page 21 of 24
22 27d. Numbness or tingling?.. Yes 1 Go to Item 27f 27e. Did you have difficulty on: The right side only 1 The left side only 2 Both sides 3 27f. Blackouts or fainting?. Yes 1 27g. Seizures or convulsions? Yes 1 SSF/Version B 07/29/2005 Page 22 of 24
23 27h. Headache?.. Yes 1 27i. Visual disturbances? Yes 1 Go to Item 28 27j. Did you have: [READ ALL CHOICES UNTIL A POSITIVE RESPONSE IS GIVEN] Double vision 01 Vision loss in right eye only 02 Vision loss in left eye only 03 Total loss of vision in both eyes 04 Trouble in both eyes seeing to the right 05 Trouble in both eyes seeing to the left 06 Trouble in both eyes seeing to both sides or straight ahead 07 7 SSF/Version B 07/29/2005 Page 23 of 24
24 Did the episode of dizziness, loss of balance, or spinning sensation come on suddenly? Yes 1 H. ADMINISTRATIVE INFORMATION 29. Date of data collection:. / / m m d d y y y y 30. Method of data collection: Computer 1 Paper form Data Collected:... In clinic 1 Off site Code number of person completing this interview:.. SSF/Version B 07/29/2005 Page 24 of 24
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