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pdfOMB #0925-0493 Exp: XX/XXXX
Multi-Ethnic Study of Atherosclerosis
Participant ID: 8000028
Sequence Num:
02
(For MESA Field
Center use only)
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.
Physician Questionnaire:
Cardiac/PVD
Participant Name: _______________________________________
Date-of-Birth: _____/_____/_____
Please complete only this page if participant has not had any
condition listed in Question 2 below, OR if you are not familiar
with 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?
Yes
No
No
Please sign and date the form at the
bottom of page 4 and return form.
Please fill in the physician's name and address, sign and
date the form at the bottom of page 4 and return form.
Please complete
Question 2 below.
2. In your opinion, has the participant had any of
the conditions below? (Please check any that apply.)
MI
Please complete section A on page 2.
Angina
Please complete section B on page 2.
CHF
Please complete section C on page 2.
PAD/AA*
Please complete section D on page 2.
None
If participant has had any of the conditions
listed, we would appreciate copies of pertinent
office notes, including physical exams, reports
of stress tests, caths and EKGs.
Please sign and date at the bottom
of page 4 and return form.
* Peripheral Arterial Disease/Aortic Aneurysm.
11/09/2004
9224072657
page 1 of 4
Physician Questionnaire: Cardiac/PVD (Page 2)
A. Myocardial Infarction
Has the participant ever been diagnosed with congestive
heart failure or congestive cardiomyopathy?
Yes
If "Yes," when was the most recent event of this type?
Day
/
Year
Month
Was the participant hospitalized?
Yes
No
Unknown
If "Yes," when was the most recent episode of this type?
/
Month
02
C. CHF
Has the participant ever been diagnosed with a
myocardial infarction?
Yes
No
Unknown
/
8000028
No
Unknown
/
Day
Year
Was the participant hospitalized?
Yes
If "Yes," where was the participant hospitalized?
Name of Hospital:
No
Unknown
If "Yes," where was the participant hospitalized?
City, State:
Name of Hospital:
City, State:
The certainty of the diagnosis is:
Definite
Probable
The certainty of the diagnosis is:
Definite
Go to next relevant section or, if none, skip to Question 3.
B. Angina
Probable
Go to next relevant section or, if none, skip to Question 3.
Has the participant ever been diagnosed with angina
pectoris or coronary insufficiency?
Yes
No
D. PAD
Unknown
If "Yes," did s/he have chest pain or equivalent, or was
the diagnosis only the result of diagnostic tests?
Has the participant ever been diagnosed with claudication,
peripheral artery disease, or abdominal aortic aneurysm?
Pain or pain equivalent
No pain; diagnostic testing only
If pain (or pain equivalent), when was the most recent
episode of this type?
/
Month
No
Unknown
If "Yes," when was the most recent episode of this type?
/
Month
/
Day
Yes
/
Day
Year
Was the participant hospitalized?
Year
Yes
No
Unknown
Was the participant hospitalized for angina/coronary
insufficiency?
Yes
No
Unknown
If "Yes," where was the participant hospitalized?
If "Yes," where was the participant hospitalized?
Name of Hospital:
Name of Hospital:
City, State:
City, State:
The certainty of the diagnosis is:
Definite
Probable
The certainty of the diagnosis is:
Definite
Probable
Go to next relevant section or, if none, skip to Question 3.
11/09/2004
page 2 of 4
Go to next relevant section or, if none, skip to Question 3.
0487072659
Physician Questionnaire: Cardiac/PVD (Page 3)
8000028
02
3. Please complete the following sections for the most recent event.
If participant has been diagnosed with MI, Angina or CHF, please complete all sections on pages 3 and 4.
If participant has been diagnosed with PAD only, complete only relevant items in sections a and b.
Section a.
Section b.
Which (if any) of the following diagnostic tests did the
participant have? (Please attach copy of report.)
Which (if any) of the following procedures were done?
Yes
Electrocardiogram
No
When were they performed?
Unknown
Trial of Nitroglycerin
Date:
Excercise Tolerance Test
---With Thallium?
/
Date:
Yes
No
Yes
Unknown
/
Day
Leg angioplasty or other
leg revascularization
11/09/2004
Year
/
Year
No
Yes
/
Month
Unknown
/
Intravenous or Intracoronary
Thrombolytic Therapy
(TPA, Streptokinase)
Date:
No
Day
Month
Unknown
Year
/
Date:
No
/
Day
Month
Pertinent Results:
Year
Yes
CABG (Coronary Artery
Bypass Graft)
Other
If Other, please
specify:
Day
Month
Chest X-Ray
Unknown
/
Month
Date:
Echocardiogram
No
/
Angioplasty or
Stent Placement
Cardiac Enzymes
Angiography
Yes
Cardiac Catheterization
Unknown
/
Day
Year
5397072654
page 3 of 4
Physician Questionnaire: Cardiac/PVD (Page 4)
8000028
Section c.
Section d.
Which (if any) of the following medications were
prescribed as a therapy?
Were any of the following present?
Yes
Yes
No Unknown
No Unknown
Chest pain
Nitroglycerin
Beta-Blockers
Jugular Venous Distention
Calcium Channel Blockers
Cartoid Bruit
Aspirin
Basilar Rales or Crackles Only
Diuretics
02
Rales or Crackles Above Bases
Ace Inhibitors
Wheezing
Digitalis
S-3 Gallop
Oxygen
Cardiac Murmur
Other Vasodilators
Hepatojugular Reflex
Other
Hepatomegaly
If other, please
specify:
Peripheral/Ankle Edema
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 with
copies of pertinent office notes or tests. If you do not have the envelope, the
address is:
Notes:
Form completed by:
For MESA Field Center Use Only:
/
11/09/2004
Date:
Reviewer ID:
Data Entry ID:
/
9083072650
page 4 of 4
OMB #0925-0493 Exp: XX/XXXX
Multi-Ethnic Study of Atherosclerosis
Participant ID: 8000028
02
Hospital Code:
Sequence Num:
Physician Questionnaire:
Cardiovascular Death
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- . Do not return the completed form to this
address.
Please complete the following questions to the best of your ability by filling in the appropriate bubbles or writing the answer in
the blank provided. Please return completed forms in the self addressed stamped envelope provided. Thank you for your
contribution to MESA.
Details of Death
1. Are you familiar with the events surrounding the
decendent's death?
Yes
2.
Circumstances Surrounding Death
4. What do you believe to be the underlying cause of
death?
Acute Myocardial Infarction
No
Other Ischemic Heart Disease
Did you witness the death?
Yes
Cerebrovascular Disease
No
Other Cardiovascular Disease
If you answered "Yes" to both or either of Questions
1 and 2, please skip to Question 4.
3. If you answered "No" to both Questions, are you
aware of another physician who could provide
information regarding the death?
Yes
No
If "No," please sign and date the form
at the bottom of page 2.
Non-Cardio/Cerebrovascular
(Please specify)
5. Please specify the time between the onset of the
acute episode of symptoms and death. (We are defining
death as the point where spontaneous breathing ceased
and the patient never recovered.) Please check the
appropriate time period.
If "Yes," please provide the physician's name and address,
then sign and date the form at the bottom of page 2.
Less than 5 minutes
5 minutes to 1 hour
1 hour to 24 hours
Name of physician:
More than 24 hours
Address:
Unknown
6. Was there an acute episode of pain in the chest, left
arm or jaw during the last 72 hours prior to death?
Yes
No
Unknown
7. Was there an acute episode of shortness of breath
during the 72 hours prior to death?
Yes
No
Unknown
8. Did the decendent take or was s/he given nitrates
or nitroglycerin at the time of the acute episode?
Yes
No
Unknown
3658295187
11/09/2004
page 1 of 2
Phys. Quest.: Cardiovascular Death (Page 2)
8000028
Medical History
Transient Ischemic Attack (TIA)
9. Are you familiar with the decendent's medical
history?
Yes
Yes
If you answered "No," please skip
to the bottom of the page
10. Did the decendent have a medical history of any
of the following conditions or medications prior to the
acute event which led to death?
Myocardial Infarction (MI)
Yes
No
/
Year
No
Unknown
If "Yes," date of first diagnosis:
Year
Intermittent Claudication or Other Peripheral
Vascular Disease (PVD)
Yes
No
Unknown
No
Unknown
Coronary Bypass Surgery
Yes
No
Unknown
Coronary Angioplasty
Yes
No
Unknown
11. If you saw the participant within one month of death,
please fill out the following for the most recent visit:
/
Day
Year
Date of Visit:
/
Congestive Heart Failure (CHF) or Congestive
Cardiomyopathy
Yes
Day
Yes
Angina Pectoris, Coronary Insufficiency or Other
Chronic Ischemic Heart Disease
/
Month
/
Lower Extremity Bypass, Angioplasty or Amputation
Secondary to PVD
/
Day
Month
Unknown
/
Unknown
If "Yes," date of most recent MI:
Yes
No
If "Yes," date of first diagnosis:
No
Month
02
No
Month
Unknown
/
Day
Year
Chief Complaint:
Stroke (CVA)
Yes
No
Unknown
If "Yes," date of most recent CVA:
/
Month
/
Primary Diagnosis:
Changes in Medical Management:
Day
Year
Continued next column
Form completed by:
For MESA Field Center Use Only:
/
Date:
Reviewer ID:
Data Entry ID:
/
7459295180
11/09/2004
page 2 of 2
OMB #0925-0493 Exp: XX/XXXX
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?
/
/
Month
4a.
Hypercoagulation work-up
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:
Extended Release
Dipyridamole
The certainty of the diagnosis
Definite
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
MESA MANUAL OF OPERATIONS
E.2.2
Sample Letters for MESA Events
Appendix E, Page
HOSPCOV (Cover letter to hospital to obtain medical records)
[date]
[hospital name]
[hospital street address]
[hospital city, state zip]
Dear Correspondence Clerk:
I am writing on behalf of the Multi-Ethnic Study of Atherosclerosis (MESA), an
epidemiologic project of the [institution], along with five other centers in the United
States.
[participant] (date of birth [date of birth]), a participant in our study, was a patient at
[hospital name] during [year]. Enclosed you will find a release of medical information
signed by [next of kin name]. We are needing medical records involving that
hospitalization including ER report, History and Physical, Discharge ICD-9 codes,
Discharge Summary, Progress Notes, ECGs and Enzyme reports, and all other test and
procedure results.
If you have any questions, please feel free to call NAME, our local Surveillance
Supervisor, at PHONE NUMBER.
This information will be used for statistical purposes only, and will remain strictly
confidential. Thank you very much in advance for your help in this important study.
Sincerely,
NAME
Principal Investigator
Enclosure: Release Form
3
MESA MANUAL OF OPERATIONS
E.2.4
Sample Letters for MESA Events
Appendix E, Page
5
PHYSCOV (Cover letter to physician/clinic to obtain medical
records)
[date]
[doctor’s office or clinic name]
[doctor’s office or clinic street address]
[doctor’s office or clinic city, state zip]
Dear Correspondence Clerk:
I am writing on behalf of the Multi-Ethnic Study of Atherosclerosis (MESA), an
epidemiologic project of the [institution], along with five other centers in the United
States.
[participant] (date of birth [date of birth]), a participant in our study and your patient,
reported being under your care during [year]. Enclosed you will find a release of
medical information signed by [next of kin name]. We are needing medical records
involving diagnoses and procedures including History and Physical, Discharge ICD-9
codes, Discharge Summary, Progress Notes, ECGs and Enzyme reports, and all other test
and procedure results.
If you have any questions, please feel free to call NAME, our local Surveillance
Supervisor, at PHONE NUMBER.
This information will be used for statistical purposes only, and will remain strictly
confidential. Thank you very much in advance for your help in this important study.
Sincerely,
NAME
Principal Investigator
Enclosure: Release Form
MESA MANUAL OF OPERATIONS
E.2.7
Sample Letters for MESA Events
Appendix E, Page
MECOV (Cover letter to medical examiner (ME) to obtain
ME/coroner reports)
[date]
[medical examiner name]
[street address]
[city, state zip]
Dear [medical examiner name]:
I am writing on behalf of the Multi-Ethnic Study of Atherosclerosis (MESA), an
epidemiologic project of the [institution] along with five other centers in the United
States.
We are needing information on [participant], who died on [date of death], and whose
death was listed as a Medical Examiner case. MESA requests a copy of the Medical
Examiner’s report. A consent form signed by his/her next of kin is enclosed.
This information will be used for statistical purposes only, and will remain strictly
confidential. If you have any questions, please feel free to call NAME, our local
Surveillance Supervisor, at PHONE NUMBER. Thank you very much in advance for
your kind assistance and consideration of this request.
Sincerely,
NAME
Principal Investigator
Enclosure: Release Form
8
MESA MANUAL OF OPERATIONS
E.2.8
Sample Letters for MESA Events
Appendix E, Page
9
PQCERT (PQ cover letter to physician signing death certificate)
[date]
[physician name]
[street address]
[city, state zip]
Dear [physician name]:
I am writing on behalf of the Multi-Ethnic Study of Atherosclerosis (MESA), an
epidemiologic project of the [institution] along with five other centers in the United
States.
We are needing information on [participant], who died on [date of death], and whose
death certificate you signed on [date]. The information is needed to supplement the
death certificate in assigning a cause of death. Could you or your nurse take a few
moments to provide from your records the answers to the questions on the enclosed
form?
This information will be used for statistical purposes only, and will remain strictly
confidential. Of course, your participation is entirely voluntary, and, if you choose to not
complete and return this form, it will in no way affect any relationship you may have
with this institution. If you have any questions, please feel free to call me collect, at
PHONE NUMBER, or our local Surveillance Supervisor, NAME, at PHONE
NUMBER. Thank you very much in advance for your kind assistance and consideration
of this request.
Sincerely,
NAME
Principal Investigator
Enclosure: Physician Questionnaire
MESA MANUAL OF OPERATIONS
E.2.9
Sample Letters for MESA Events
Appendix E, Page
10
PQATND (PQ cover letter to attending physician of decedent)
[date]
[physician name]
[street address]
[city, state zip]
Dear [physician name]:
I am writing on behalf of the Multi-Ethnic Study of Atherosclerosis (MESA), an
epidemiologic project of the [institution] along with five other centers in the United
States.
We are needing information on [participant], who died on [date of death], and who,
according to the family, was your patient. The information is needed to supplement the
death certificate in assigning a cause of death. Could you or your nurse take a few
moments to provide from your records the answers to the questions on the enclosed?
This information will be used for statistical purposes only, and will remain strictly
confidential. Of course, your participation is entirely voluntary, and, if you choose to not
complete and return this form, it will in no way affect any relationship you may have
with this institution. If you have any questions, please feel free to call me collect, at
PHONE NUMBER, or our local Surveillance Supervisor, NAME, at PHONE
NUMBER. Thank you very much in advance for your kind assistance and consideration
of this request.
Sincerely,
NAME
Principal Investigator
Enclosure: Physician Questionnaire
MESA MANUAL OF OPERATIONS
Sample Letters for MESA Events
Appendix E, Page
11
E.2.10 PQCLIN (PQ cover letter to medical clinic of decedent)
[date]
[doctor’s office or clinic name]
[doctor’s office or clinic street address]
[doctor’s office or clinic city, state zip]
Dear [physician name]:
I am writing on behalf of the Multi-Ethnic Study of Atherosclerosis (MESA), an
epidemiologic project of the [institution] along with five other centers in the United
States.
We are needing information on [participant], who died on [date of death], and who,
according to the family, was a patient at [doctor’s office or clinic name]. The
information is needed to supplement the death certificate in assigning a cause of death.
Could you or your nurse take a few moments to provide from your records the answers to
the questions on the enclosed form?
This information will be used for statistical purposes only, and will remain strictly
confidential. Of course, your participation is entirely voluntary, and, if you choose to not
complete and return this form, it will in no way affect any relationship you may have
with this institution. If you have any questions, please feel free to call me collect, at
PHONE NUMBER, or our local Surveillance Supervisor, NAME, at PHONE
NUMBER. Thank you very much in advance for your kind assistance and consideration
of this request.
Sincerely,
NAME
Principal Investigator
Enclosure: Physician Questionnaire
| File Type | application/pdf |
| File Modified | 2010-10-15 |
| File Created | 2010-05-17 |