Form 1 survey

OMB# 0925-0491

Expiration Date XX/XXXX

Physician Questionnaire Form

FORM CODE: PHQ

ID NUMBER: CONTACT YEAR: VERSION C: 05/22/2007

LAST NAME: INITIALS:

Public reporting burden for this collection of information is estimated to average 15 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: AFU (0925-0491). Do not return the completed form to this address.

Decedent’s Name: Age:

Date of Birth:

month day year

Date of Death:

month day year

Event ID: Sequence Number:

Physician’s name: ______________________________________________________________________________

Please complete the following and return in the enclosed envelope.

A. Medical History

1. Are you familiar with the decedent’s medical history?

Yes

If No, Skip to Item 5 on Page 3

No

2. When did you last see the decedent?

month year

3. Did the decedent have a history of any of the following?

Yes No Uncertain

a. Angina pectoris or coronary insufficiency……

b. Valvular disease or cardiomyopathy…………

c. Coronary bypass surgery………………………

d. Coronary angioplasty………………………

e. Hypertension…………………………………

f. Myocardial infarction…………………………

If MI yes, date of most recent event:

month year

h. Other chronic ischemic heart disease………

i. S troke (CVA)……………………………………

j. If yes, date of most recent event:

month year

Yes No Uncertain

k. Any non-cardiac condition that might

have contributed to this death……………….

If yes, specify:

Yes No Uncertain

l. Diabetes…………………………………………

m. Cigarette smoking……………………………

4. Was the decedent taking any of the following medications within four weeks prior to death?

Yes No Uncertain

a. Nitrates……………………………………………

b. Calcium channel blockers………………………

c. Digitalis……………………………………………

d. Beta-blockers………….…………………………

d.1. Aspirin……………………..……………………

d.2. ACE or Angiotensin II inhibitors…………….

e. Other cardiovascular drugs……………….……

If yes, specify:

B. Details of Death

5. Are you familiar with the events surrounding the decedent’s death?

Yes No

6. Did you witness the death?

Yes No

7. Was there any pain in the chest, left arm, shoulder or jaw within 72 hours of death?

Yes No Uncertain

b. Did the pain include the chest?

Yes No Uncertain

c. Did you think this pain was of a cardiac origin?

Yes No Uncertain

If No, specify what you think was the cause:

8. Did the decedent take (or was he/she given) nitrates at the time of the acute episode?

Yes No Uncertain

9. Was coronary reperfusion (intravenous or intracoronary streptokinase or TPA, angioplasty, etc.)

attempted during the acute episode?

Yes No Uncertain

10. Was CPR and/or cardioversion performed within 24 hours of death?

Yes No Uncertain

11. Please give time between onset of acute symptoms to death. ( We are defining death as the

point where spontaneous breathing ceased and the patient never recovered)

More than 3 days (A) At least 1 hour, (F) but less than 4 hours

2-3 days (B) Less than 1 hour (G)

1 day (C) Death instantaneous, (H) no symptoms

At least 12 hours, but less than 24 hours (D) Unknown (I)

At least 4 hours, but less than 12 hours (E)

12. Would you classify the decedent’s cause of death as due to CHD?

Yes No Uncertain

13. If no, what do you believe to be the cause of death?

Yes No Uncertain

13a. Pulmonary embolism…………

13b. Acute pulmonary edema……

13c. Stroke…………………………

13d. Pneumonia…………………..

13e. Congestive Heart Failure ….

13f. Other…………………………

13g. Specify:

C. Signature

14. Form completed by:

Signature

1 5. Date:

month day year

Thank you very much for your help. Please return this questionnaire in the enclosed self-addressed envelope.

Office use only: 23. Self (A) Interview(B) ER. records(C)

PHQA 05//06/2003 5 of 6