4 Stroke

OMB #0925-0493 Exp: 10/31/07

Multi-Ethnic Study of Atherosclerosis

Participant ID: 8000028

(For MESA Field
Center use only)

Sequence Num:

Physician Questionnaire:
Stroke/TIA

12

Public reporting burden for this collection of information is estimated to average 10 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- 0493 . Do not
return the completed form to this address.

Participant Name: _______________________________________

Date-of-Birth: _____/_____/_____

Please complete only this page if you are not
familiar with this participant's medical history.

Please fill in the appropriate bubbles and write responses in the blanks provided.
1.

Are you familiar with the participant's medical
history?
Yes

Are you aware of another physician who could provide
information regarding this participant?

No

Yes

No
Please sign and date the form at the
bottom of page 3 and return form.

Please continue to
Question 2 on page 2

11/09/2004

Please fill in the physician's name and address, sign and
date the form at the bottom of page 3 and return form.

0361600062
page 1 of 3

Physician Questionnaire: Stroke/TIA (Page 2)
2.

When did you last see the patient?

/

5.

Right carotid

Day

Left carotid
Vertebral/Basilar
Unknown

Year

3. In your opinion, has the patient ever had a
cerebrovascular event such as a stroke, TIA or
amaurosis fugax?
Yes

12

The symptoms were in the distribution of which vessel?

/

Month

8000028

No

6.

Unsure

Which (if any) of the following diagnostic tests did the
patient have?
Yes
No Unknown
CT of the head

If "No," skip to the end of the form,
sign and date at the bottom of
page 3 and return form..

MRI of the brain
Carotid ultrasound
Electrocardiogram

4.

Echocardiogram

When was the most recent event of this type?

Hypercoagulation work-up

/

/

Month
4a.

Day

Other
If other,
Please
specify:

Year

This most recent event was a(n):
Subarachnoid hemorrhage

7.

Intraparenchymal hemorrhage
Brain infarction
TIA

Severe headache

Stroke, uncertain type

Diminished level of
conciousness
Loss of conciousness

Not a stroke or TIA
If not a stroke or TIA, what was the diagnosis?

4b.

Language deficit/aphasia
Hemineglect
Dysarthria
Visual field deficit

The certainty of the diagnosis is:
Definite

Weakness or drift
Hemiplegia
Ataxia
Sensory deficit

Probable
Possible
4c.

Was the patient hospitalized?
Yes

No

Asymmetry of reflexes
Babinski
Abnormal gait
Other

If "No," skip to
Question 5.

Name of Hospital:

If other,
please
specify:

City/State:

11/09/2004

Which (if any) of the following symptoms or physical
findings were present in the most recent event?
Yes
No
Unknown

1164600064
page 2 of 3

Physician Questionnaire: Stroke/TIA (Page 3)

8. Did any neurological findings persist longer than
24 hours from onset?
Yes

10.

8000028

12

When was the first event of this type?

/

No
Month

/
Day

Year

Please specify:

10a.

This first event was a(n):
Subarachnoid hemorrhage
Intraparenchymal hemorrhage
Brain infarction

9. Which (if any) of the following medications were
prescribed as therapy?
Yes

No

TIA
Stroke, uncertain type

Unknown

Aspirin

Not a stroke or TIA

Dipyridamole

If not a stroke or TIA, what was the diagnosis?

Anti-coagulants
Ticlopidine or
Clopidogrel

10b.
is:

The certainty of the diagnosis
Definite

Extended Release
Dipyridamole

Probable
Possible

Other
If other,
please
specify:

10c.

Was the patient hospitalized?
Yes

If there has been more than one event of this type,
please continue to Question 10.
If not, please skip to the end of the form, sign and
date, and return the form to the MESA clinic.

No
If "No," skip to Question 5.

Name of hospital:
City/State:

Thank you very much for your contribution to MESA. Please sign and date this
questionnaire and return it to us in the self-addressed, stamped envelope. If you
do not have the envelope, the address is:

Form completed by:
For MESA Field Center Use Only:

/
11/09/2004

Date:
Reviewer ID:

Data Entry ID:

/
9949600063
page 3 of 3