3 F80 Physical Measurements

WHI

Form 80 - Physical Measurements

Ver. 3 (Draft)
OMB # 0925-0414

Public reporting 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 information 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 is 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 (0925-0414). Do not return the completed form to this address.

-

1. Date of Exam:

-

2. Performed By:

Exp: XX/XXXX

- Affix label hereClinical Center/ID: __ __ __ __ - ___ ___ ___ - __
First Name ________________________M.I.______
Last Name ________________________________

(M/D/Y)

____________________________

3. Contact Type:

4 Home Visit
8 Other
4. Visit Type:

X Non-routine

4
x 2 = _______/min

5. Resting pulse in 30 sec.:

6. Blood pressure:

6.1.

/

Systolic/Diastolic

6.2.

/

Systolic/Diastolic

Cuff used: ___S

___Reg

Side:

___R

___L

___L ___Th

Anthropometric Measures
7. Height:

.

cm

8. Weight:

.

kg

9. Waist circumference:
(to nearest 0.5 cm)

.

cm

10. Hip circumference:
(to nearest 0.5 cm)

.

cm

BMI ___________

K ________ V ________
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WHI

Form 80 - Physical Measurements

Ver. 3 (Draft)
OMB # 0925-0414

Exp: XX/XXXX

Spanish translation not required; interviewer administered form
Instructions to WHI staff under development.

K ________ V ________
R:\DOCUMENT\EXTENSION TO 2015\FORMS\F80V3.DOC

11/10/09

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