BIOBANQUE- AVAILABLE VARIABLES
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1 BIOBANQUE- AVAILABLE VARIABLES DEM DEM-11 DEM-12 DEM-13 DEM-14 DEM-21 DEM-22 DEM-31 DEM-32 DEM-33 DEM-41 DEM-42 DEM-43 DEM-44 DEM-50 DEM-51 DEM-52 DEM-53 DEM-54 DEM-61 DEM-62 CVHX CVHX-11 CVHX-12 CVHX-13 Demographics - ALL Date of screening/recruitment Age at Recruitment Gender Male/Female Race/Ethnicity Éducation Number of Years of Schooling - Highest Degree Obtained Living situation House type - Type of Geographical Area - With whom does the person live - ACTUAL Working Status - Type of Work - Work Schedule - Annual Family Income - Present working status a general reflection of your past - Past working status - Past Type of Work - Past Work Schedule - Past Annual Family Income - Family Ancestry French Canadian descent - Patientʼs parents and grandparents Origins Patientʼs cardiovascular Medical History - ALL Previous Myocardial Infarction Previous PCI (Percutaneous coronary intervention) Angina
2 CVHX-14 CVHX-15 CVHX-16 CVHX-17 CVHX-18 CVHX-19 CVHX-20 CVHX-21 CVHX-30 CVHX-40 CVHX-50 FATHX Stroke/ TIA Congestive Heart failure Peripheral Vascular Disease Hypertension Diabetes Dyslipidemia Valvular disease Disease of the aorta Cardiovascular surgeries Other Cardiovascular Diseases Other Family Incidence of Cardiovascular Disease Father Cardiovascular Medical History - ALL FATHX-10 - High Blood Pressure FATHX-11 - High Blood Cholesterol FATHX-12 - Diabetes FATHX-13 - Heart Attack before Age 55 FATHX-14 - Heart Bypass Surgery before Age 55 FATHX-15 - Stroke before Age 65 FATHX-16 - Coronary Angioplasty before Age 55 FATHX-17 - Died of Heart Disease before Age 65 FATHX-18 - Smoking FATHX-19 - History of obesity MOTHX Mother Cardiovascular Medical History - ALL MOTHX-20 - High Blood Pressure MOTHX-21 - High Blood Cholesterol MOTHX-22 - Diabetes
3 MOTHX-23 - Heart Attack before Age 55 MOTHX-24 - Heart Bypass Surgery before Age 55 MOTHX-25 - Stroke before Age 65 MOTHX-26 - Coronary Angioplasty before Age 55 MOTHX-27 - Died of Heart Disease before Age 65 MOTHX-28 - Smoking MOTHX-29 - History of Obesity FAMHX ARR ARR-11 ARR-12 ARR-13 ARR-14 ARR-15 ARR-16 ARR-17 ARR-18 ARR-19 ARR-20 ARR-21 ARR-22 ARR-30 ARR-40 ALL ALL-11 ALL-12 Family Cardiovascular Medical History Arrhythmia - ALL History of Palpitations History of Fainting History of Cardiac Arrest History of Arrhythmia Atrial Fibrillation Arrhythmia Supraventricular Tachycardia Arrhythmia Atrial Flutter Arrhythmia Ventricular Tachycardia / Fibrillation Arrhythmia Sick Sinus Syndrome Arrhythmia AV Block (Atrioventricular) Arrhythmia History of Other Arrhythmia History of Arrythmia Treatment Family History of Sudden Death or Cardiac Arrest Family History of Atrial Fibrillation Allergies - ALL Celiac Disease (Gluten allergy) Drug/ Medication Allergies
4 ALL-13 ALL-14 ALL-15 ALL-16 ALL-17 ALL-18 ALL-19 ALL-20 ALL-21 MEDHX Dust mites Food Allergies Hay Fever/ Pollen & Mold Insect Stings and Bites Jewellery Allergies (Nickel Allergy) Lactose Intolerance Latex Pet Allergies Other Allergies Non Cardiovascular Medical History - ALL MEDHX-01 Dermatological MEDHX-02 Eyes, Ears, Nose and Throat MEDHX-03 Pulmonary/ Respiratory MEDHX-04 Gastro-intestinal/ hepatic MEDHX-05 Neurological MEDHX-06 Musculoskeletal MEDHX-07 Urinary MEDHX-08 Endocrinal (thyroid) MEDHX-09 Psychiatric MEDHX-10 Blood disease MEDHX-11 Immunological diseases MEDHX-12 Other EXAMS CAN OBGYN Exams and tests - ALL Cancer and tumors - ALL Medical history female Ob/ Gyn History - ALL OBGYN-11 Menstruation has stopped for one year or more
5 OBGYN-12 Hysterectomy OBGYN-13 Ovaries Removed OBGYN-14 Number of Live Births OBGYN-15 Number of Misscarriages OBGYN-16 Uterine Fibroma OBGYN-17 Breast Disease OBGYN-18 Hormone Replacement Therapy MEDS NAT NAT-10 NAT-11 NAT-12 NAT-13 NAT-14 NAT-15 NAT-16 NAT-17 Current medication - ALL Natural/ Homeopathic products - ALL Product List Vitamine A Vitamine C Vitamine E Folic Acid Multivitamins Glucosamine Homeopathic Products NAT-18 Omega 3 NAT-19 VS VS-11 VS-12 VS-13 VS-14 VS-15 VS-16 Other Vital Signs - ALL Weight Height Waist Girth Hip Girth Brachial Blood Pressure Heart Rate
6 VS-17 PHYS NUT BEV CIGT CIGR PIPE SMOKE ALC DRUGS PS PS-1 PS-2 HAND Sphygmocor Data Physical activities Nutrition Beverages Cigarette Cigar Pipe Secondary smoke Use of alcohol Medication Without Prescription Psychosocial Psychosocial - Depression Psychosocial - Aggressivity Preferred Hand
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HD CLINIC MEDICAL HISTORY FORM Welcome to the HDSA Center of Excellence HD Clinic. Please take a few moments to answer the questions below as best as you can. If you need assistance, a caregiver/companion