The Muscatine Study Heart Health Survey
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- Ronald Franklin
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1 The Muscatine Study Heart Health Survey PARTICIPANT ID LABEL (include study ID, name, DOB, gender) Today s Date: - - (MM-DD-YYYY) Thank you for agreeing to participate in the International Childhood Cardiovascular Cohort (i3c) Consortium CV Outcomes Study. This survey is designed to update us about your health history. It should take no more than 20 minutes to complete. The information we are requesting is important in order for us to accomplish the aims of the i3c CV Outcomes Study, and we appreciate your willingness to take the time to respond to this survey. Once we receive your completed survey, we may need to call you to clarify your responses, especially if you have ever been hospitalized or had medical tests for cardiovascular conditions. If questions come up as you complete this form, please phone [Name], one of the study staff members, in the Muscatine Study Clinic at [Phone] 1. In general, how would you rate your health? Excellent Very Good Good Fair Poor 2. How long has it been since you last visited a doctor or medical facility for your own medical care? Within the past year (anytime less than 12 months ago) 1 to 2 years ago More than 2 but less than 5 years ago More than 5 but less than 10 years ago More than 10 years ago Don t know / Not sure Version: 05 Jan 2016 Form 1: Heart Health Survey 1
2 Version: 05 Jan 2016 Form 1: Heart Health Survey 2 International Childhood Cardiovascular Cohort (i3c) Consortium CV Outcomes Study The next few questions will ask about your heart health, and health conditions related to heart health. 3. Has a doctor or other health professional ever told you that you have or had any of the following? C1 C2 Ever Had Condition? A heart attack, also called a myocardial infarction (MI)? Chest pain due to heart trouble, also called angina pectoris? C3 Enlarged heart, or congestive heart failure (CHF)? Peripheral vascular disease (PVD), or decreased C4 blood circulation causing leg pain? C5 A stroke? A transient ischemic attack (TIA) or temporary C6 stroke, or temporary stroke symptoms (e.g., blurred vision, dizziness, fainting, numbness)? C7 A blocked carotid artery (in your neck)? Abdominal aortic aneurysm or a weakness in the C8 wall of the major artery in your lower chest or stomach? If Yes or Not Sure, were you hospitalized or seen by a doctor in any medical facility for the condition? Yes (complete Form Yes (complete Form Yes (complete Form Yes (complete Form Yes (complete Form Yes (complete Form Yes (complete Form Yes (complete Form
3 4. Have you ever had any of the following diagnostic tests or procedures for heart or blood vessel disease in a hospital or clinic? Version: 05 Jan 2016 Form 1: Heart Health Survey 3 International Childhood Cardiovascular Cohort (i3c) Consortium CV Outcomes Study T1 T2 T3 T4 T5 T6 Diagnostic Test or Procedure Have you ever had this test or procedure? Coronary angiogram or heart catheterization to look at the arteries (complete Form in your heart from the inside? (complete Form A coronary angioplasty, balloon angioplasty, or stent to relieve a blockage in the arteries to your heart? (complete Form (complete Form Open heart surgery, or coronary artery bypass graft surgery (CABG)? (complete Form (complete Form An angioplasty or balloon or stent to relieve a blockage in the arteries to either of your legs? (complete Form (complete Form Carotid endarterectomy surgery or a balloon or stent to relieve a blockage in the artery in your neck? (complete Form (complete Form Surgery or balloon or stent on any other artery to relieve a blockage? (complete Form (complete Form
4 What type(s) of diabetes do/did you have? (check all that apply): At what age were you first diagnosed with diabetes? years old Version: 05 Jan 2016 Form 1: Heart Health Survey 4 International Childhood Cardiovascular Cohort (i3c) Consortium CV Outcomes Study 5. Are you currently taking any of the following heart medications? Medication Type Are you currently taking this medication? a) Anti-coagulants or blood thinners? Specify Name(s) of Medication(s) If taking medication, reason(s) for taking the medication(s) b) Medication (such as nitroglycerin) for chest pain or angina? 6. Has a doctor or other health professional ever told you that you have any of the following health conditions? Health Condition Have you ever had this health condition? Are you currently taking any medication(s) to treat this health condition? If taking medication, specify medication(s) a) High blood pressure or hypertension? Yes b) Atrial fibrillation (A-fib)? Yes c) Diabetes, any type? Yes Type 1 Gestational (during pregnancy) Type 2 t sure what type d) Cancer (except skin cancer)? What type(s) of cancer (specify)?
5 We also would like to know about any other serious illness you have had in the past. Do not include bone fractures, minor accidents, minor surgeries or pregnancies and births. 7. In childhood (before age 18), did you ever have any other serious diseases or illnesses diagnosed by a physician, which you have not already mentioned? Yes 7a. If the answer is Yes, what was the diagnosis? Name of Diagnosis Year diagnosed, treated or hospitalized (YYYY) City and state where diagnosed, treated or hospitalized 8. After becoming an adult (age 18 or older), have you had any other serious diseases or illnesses diagnosed by a physician, which you have not already mentioned? Yes 8a. If the answer is Yes, what was the diagnosis? Name of Diagnosis Year diagnosed, treated or hospitalized (YYYY) City and state where diagnosed, treated or hospitalized Version: 05 Jan 2016 Form 1: Heart Health Survey 5
6 Now, we will be asking a few questions about your own smoking, as well as smoke you may have been exposed to as a child. 9. When you were a child, did anyone regularly smoke inside the house where you lived when you were: 9a. Less than 10 years old? Yes 9b years old? Yes 9c years old? Yes 10. Have you ever smoked? Never (go to question 13) Current Smoker Ex-Smoker 11. Provide your ages at starting/stopping, as best you can: 11a. First smoked any tobacco Years old Don t Know 11b. Began smoking regularly Years old, or N/A Don t Know (daily, or on most days) 11c. Last smoked regularly Years old, or N/A Don t Know 11d. Quit smoking entirely Years old, or N/A Don t Know 12. How many cigarettes a day did you smoke, now and in the past? Note: 1 pack=20 cigarettes. If you did not smoke during a given age range, enter 0. Enter 1 if you smoked 1 or fewer cigarettes a day. 12a. Now typical number of cigarettes a day 12b. In your 40s typical number of cigarettes a day 12c. In your 20s typical number of cigarettes a day Finally, we would like to ask few questions about your measurements and certain demographics. 13. How much do you weigh? (Please indicate units by checking a box for either pounds or kilograms) pounds kg Don t Know 14. How tall are you? (Please answer in EITHER feet/inches OR centimeters, NOT both) feet, inches OR cm Don t Know Version: 05 Jan 2016 Form 1: Heart Health Survey 6
7 15. What is your race? (Check all that apply) African American / Black American Indian / Alaska Native Asian Native Hawaiian / Pacific Islander White / Caucasian Other (specify: ) 16. What is your ethnicity? (Check one) Hispanic or Latino n-hispanic or Latino 17. What is your current marital status? (Check one) Single, Never Married Married, Living as Married, Civil Union Separated Divorced Widowed Other (specify: ) 18. What is your highest level of education? (Check one) Less than High school High school graduate/ged Some college or 2-year Associate s degree College (4-year) graduate Some post-college education Completed postgraduate degree For study use only: Interviewer ID: Data entry ID: Data entry date: - - (MM-DD-YYYY) Version: 05 Jan 2016 Form 1: Heart Health Survey 7
Date: / / Hello, my name is [interviewer name], and I'm calling to speak with [participant name]. Is [participant name] available?
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Date: / / Hello, my name is [interviewer name], and I'm calling to speak with [participant name]. Is [participant name] available?
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Multi-Ethnic Study of Atherosclerosis Follow-up Phone Call 17 Participant Id#: Acrostic: General Health Date: / / Day INTRODUCTION Hello, my name is [interviewer name], and I'm calling to speak with [participant
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Welcome to Medina Family Chiropractic and Acupuncture! Please fill out this form and return it to the front desk. Let us know if you have any questions! Personal information Date: First name: Middle name:
ID# Name. Today s Date DIABETES HISTORY. Michigan Diabetes Research and Training Center DH The University of Michigan - 1 -
ID# Name Today s Date DIABETES HISTORY Michigan Diabetes Research and Training Center DH2.0 1998 The University of Michigan - 1 - First, we would like to ask you about the health care you have received
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WHAT IS ATHEROSCLEROSIS?
ATHEROSCLEROSIS WHAT IS ATHEROSCLEROSIS? Atherosclerosis is a narrowing of the arteries that can significantly reduce the blood supply to vital organs such as the heart, brain and intestines. In atherosclerosis,
PRACTICE NAME NEW PATIENT MEDICAL HISTORY FORM. Chief Complaint. History of Present Illness
PRACTICE NAME NEW PATIENT MEDICAL HISTORY FORM Height: Weight: Race: African American Asian Caucasian Native American/Alaskan Pacific Islander Other Unknown Decline to Answer Ethnicity: Hispanic Non-Hispanic
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Strokes , The Patient Education Institute, Inc. hp Last reviewed: 11/11/2017 1
Strokes Introduction A stroke or a brain attack is a very serious condition that can result in death and significant disability. This disease is ranked as the third leading cause of death in the United
Patient Information First Name: Last Name: Middle Initial: Date of Birth: Sex: Male Female
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Patient Interview Form
Page 1 of 5 Orange Coast Memorial Office: 18111 Brookhurst Ave. Suite 5200, Fountain Valley, CA 92708 * Tel: (714) 962-7705 * Fax: (714) 861-4552 www.unitedgi.com Patient Interview Form Patient Information
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Dr. Doug Scherr Date of Birth: Date: CHIEF COMPLAINT What is the main reason for your visit today? ALLERGIES Are you allergic to any of the following? Please check YES or NO for each. Check here if you
New Patient Intake Form
New Patient Intake Form Please complete information below Name: DOB Age Male Female Referring Physician FAX Address Phone _ Primary Care Physician FAX Address Phone Is this a work related problem? If yes,
NEW PATIENT VISIT QUESTIONNAIRE
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