7 survey

The Jackson Heart Study: Annual Follow-up with Third Party Respondents (NHLBI)

Attach 18 - Heart Failure Survey (HFS) Form

The Jackson Heart Study: Annual Follow-up with Third Party Respondents

OMB: 0925-0491

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FORM CODE:HFS
VERSION A: 12/12/2007

JHS Heart Failure Survey

OMB# 0925-0491

EXPIRATION DATE XX/XXXX



ID NUMBER: _________________________________________




CONTACT YEAR NUMBER: ______________________________________ SEQUENCE NUMBER _________________




PATIENT NAME: Ms./Mr. _________________________________________________ PATIENT DATE OF BIRTH ____________ Last Name First Name MM/DD/YYYY







1

(If response is NO, skip to question 3)

. Has this patient ever had heart failure or cardiomyopathy of any type?
Yes Unsure No


  1. If this patient has or ever had heart failure or cardiomyopathy:

    1. Is this patient’s condition characterized as predominantly:
      Systolic dysfunction Diastolic dysfunction Mixed Not determined

    2. Estimate LVEF (worst): __________%
      (b.1) If LVEF is not specifically available, estimate LV function:
      Normal Decreased mildly Decreased moderately Decreased severely

    3. Estimate date of onset or diagnosis: _____/___________ (Month/year)


  1. Has this patient ever had (check all that apply):
    Atrial fibrillation on an ECG? Pulmonary rales on a physical examination
    Angina pectoris? Rhonchi on a physical examination?
    Previous MI? Other coronary heart disease?
    None of the above

  2. Was she/he prescribed treatment specifically for heart failure during the past year?
    Yes No Not known

  3. W

    ACE inhibitors Anticoagulants Diuretics

    Alpha blockers Aspirin / Antiplatelets Hydralazine

    Aldosterone blocker Beta blockers Lipid-lowering agents
    Amiodarone / Antiarrhythmics Calcium channel blockers Nitrates

    Angiotensin II receptor blocker Digitalis Other antihypertensives

    Hydralazine/Nitrate combination (BiDil)


    as this patient prescribed any of the following during the past year? (check all that apply)







  4. H as the patient undergone any procedures related to HF? (Check all that apply)
    □ ICD implantation □ Re-synchronization therapy □ Other


    Form Completed By: Date:


    (Signature or stamp) (MM/DD/YY)

HFS 11/02/2007 Page 1

File Typeapplication/msword
File TitleARIC ANTHROPOMETRY FORM
AuthorSusan Blackwell
Last Modified Bypandeym
File Modified2009-12-15
File Created2009-11-02

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