1 survey

OMB #: 0925–0216

Expiration Date: xx/xxxx

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Exam 9 Procedures Sheet 0=No, 1=Yes, 8=Offsite visit
|__|			Type of Exam		1=Complete exam, 2=Split exam(exam completed in 2 visits), 3=short exam (incomplete exam)
|__|			Informed Consent Signed		0=No, 1=Yes, 2=Consent by substituted judgment
|__|			Urine Specimen
|__|			Blood Draw
|__|			Mini-Mental Status Exam
|__|			Anthropometry
|__|			Sociodemographic Questions
|__|			SF-12 Health Survey
|__|			CES-D Scale
|__|			Exercise Questionnaire
|__|			ECG
|__|		Observed performance (Fast walk, hand grip, chair stands)
|__|			Tonometry
|__|			Ankle-brachial blood pressure by Doppler. (Participants > 40 years)
|__|			Spirometry				0=Not Done, 1=Done, 2=Test attempted but not finished, 8=Offsite
	|__|__|			Reason Spirometry not done		1=Major Surgery, 2=Heart Attack 3=Stroke, 4=Aneurysm, 5=BP>210/110, 6=Refused, 7=Test Aborted by tech, 8=Other, 10=equipment problems
|__|			Post albuterol Spirometry (sub-sample)				0=Not Done, 1=Done, 2=Test attempted but not finished, 8=Offsite
	|__|__|			Reason post bronchodilator test not done		1=Major Surgery, 2=Heart Attack 3=Stroke, 4=Aneurysm, 5=BP>210/110, 6=Refused, 7=Test Aborted by tech, 8=Other, 10=equipment problems, 11=didn’t qualify for test
|__|			Diffusion Capacity				0=Not Done, 1=Done, 2=Test attempted but not finished, 8=Offsite
	|__|__|			Reason Diffusion not done		1=Major Surgery, 2=Heart Attack 3=Stroke, 4=Aneurysm, 5=BP>210/110, 6=Refused, 7=Test Aborted by tech, 8=Other, 10=equipment problems

TECH02 CL

For Participants Who Wish to Complete Their Exam on a Second Visit (Split Exam)

|__|__|*|__|__|*|__|__|__|__|

Second Exam Date (If participant returns to finish their clinic exam on a date other than the original exam date, then fill in the date they return here. Otherwise leave entire page completely blank)

Keyers: if Second Exam Date is not filled and page is blank’ then leave the page all blank.

Fill in with 1=yes if procedure was done on the Second Exam Date and 0=no if procedure was not done on the Second Exam Date. Note that informed consent from first visit will cover the second visit.

Exam 9 Procedures Sheet 0=No, 1=Yes, 8=Offsite visit
|__|			Type of Exam		1=Complete exam, 2=Split exam(exam completed in 2 visits), 3=short exam (incomplete exam)
|__|			Informed Consent Signed		0=No, 1=Yes, 2=Consent by substituted judgment
|__|			Urine Specimen
|__|			Blood Draw
|__|			Mini-Mental Status Exam
|__|			Anthropometry
|__|			Sociodemographic Questions
|__|			SF-12 Health Survey
|__|			CES-D Scale
|__|			Exercise Questionnaire
|__|			ECG
|__|		Observed performance (Fast walk, hand grip, chair stands)
|__|			Tonometry
|__|			Ankle-brachial blood pressure by Doppler. (Participants > 40 years)
|__|			Spirometry				0=Not Done, 1=Done, 2=Test attempted but not finished, 8=Offsite
	|__|__|			Reason Spirometry not done		1=Major Surgery, 2=Heart Attack 3=Stroke, 4=Aneurysm, 5=BP>210/110, 6=Refused, 7=Test Aborted by tech, 8=Other, 10=equipment problems
|__|			Post albuterol Spirometry (sub-sample)				0=Not Done, 1=Done, 2=Test attempted but not finished, 8=Offsite
	|__|__|			Reason post bronchodilator test not done		1=Major Surgery, 2=Heart Attack 3=Stroke, 4=Aneurysm, 5=BP>210/110, 6=Refused, 7=Test Aborted by tech, 8=Other, 10=equipment problems, 11=didn’t qualify for test
|__|			Diffusion Capacity				0=Not Done, 1=Done, 2=Test attempted but not finished, 8=Offsite
	|__|__|			Reason Diffusion not done		1=Major Surgery, 2=Heart Attack 3=Stroke, 4=Aneurysm, 5=BP>210/110, 6=Refused, 7=Test Aborted by tech, 8=Other, 10=equipment problems

TECH0? CL

Numerical Data/Anthropometry

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|__|__|__|		Technician Number.(for basic information)

Basic Information
|__|	Sex of Participant 1=Male, 2=Female
|__|	Site of Exam (0=Heart Study, 1=Nursing home, 2=Residence, 3=Other).
|__|__|	Age of Participant (number of years)
|__|__|	What state do you reside in? (If reside outside the USA, code ZZ, if plans to ware accelerometer while visiting USA code state of visit) Code: AL, AK, AS, etc.

Anthropometry
Check Protocol Modification ONLY if there was one and document it in Comment section 88*88=Refused, 99*99=Not done or Unk
|__|__|__|	Weight (to nearest pound) (400=400 or more. 888=refused, 999=Unk.)
		Protocol modification.
|__|	In the past year, have you lost more than 10 pounds? 0=No, 1= Yes, unintentionally, NOT due to dieting or exercise 2= Yes, intentionally, due to dieting or exercise
|__|__|*|__|__|	Height (inches, to next lower 1/4 inch)
		Protocol modification.
|__|__|__|	Technician Number.(for anthropometry)
|__|__|*|__|__|	Neck Circumference (inches, to next lower1/4 inch)
		Protocol modification.
|__|__|*|__|__|	Waist Girth at umbilicus (inches, to next lower 1/4 inch).
		Protocol modification.
|__|__|*|__|__|	Hip Girth (inches, to next lower 1/4 inch)
		Protocol modification
|__|__|*|__|__|	Thigh Girth (inches, to next lower 1/4 inch)
		Protocol modification.

Comments for ALL Protocol Modification (specify measurement)

__________________________________________________________________________________________

____________________________________________________________________________________________________________

TECH01

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Exit Interview
|__|__|__|		Technician Number
|__|	Procedure sheet reviewed		0=No 1=Yes 9=Unk.
|__|	Referral sheet reviewed
|__|	Dietary questionnaire provided (if not completed in clinic)
|__|	Left clinic with accelerometer
|__|	Left clinic w/ belongings
|__|	Feedback 0=No feedback, 1=Positive feedback, 2=Negative feedback, 3=Other, 9=Unk.
	Comments_________________________________________________________________ __________________________________________________________________________ __________________________________________________________________________

|__|__|__|	Technician Number
|__|	Was there an adverse event in clinic that does not require further medical evaluation? (0=No, 1=Yes, 9=Unk.) Comments:______________________________________________________________ ________________________________________________________________________
OFFSITE only if yes fill 	|__|__|__|	Technician number (OFFSITE visit only)
	|__|	Was a FHS physician contacted during the examination due to adverse exam finding? (0=No, 1=Yes, (=Unk.) Comments:___________________________________________________ _____________________________________________________________

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Technician who reviewed TECH portion of exam

Your exam today was for research purposes only and is not designed to make a medical diagnosis. The exam cannot identify all serious heart and health issues. It is important that you continue regular follow-up with your physician or health care provider.

TECH0? CL

Socio-demographic Questionnaire.

(Tech-administered)

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Technician Number

Socio-demographics
|__|	Where do you live? (0=Private residence, 1=Nursing home, 2=Other institution, such as: assisted living, retirement community, 9=Unk.)
|__|	Does anyone live with you? (0=No, 1=Yes, 9=Unk.) Code Nursing Home Residents as NO
If Yes, fill  If 0 or 9, skip to next table	|__| Spouse	0=No 1=Yes, less than 3 months per year 2=Yes, more than 3 months per year 9=Unk.
	|__| Significant Other
	|__| Children
	|__| Friends
	|__| Relatives

Use of Nursing and Community Services
|__|	Have you been admitted to a nursing home (or skilled facility) in the past year)	0=No 1=Yes 9=Unk.
|__|	In the past year, have you been visited by a nursing service, or used home, community, or outpatient programs?

TECH03 CL.

Nagi Questions.

(Tech-administered)

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Technician Number

Nagi Questions
For each thing tell me whether you have: (0) No Difficulty (1) A Little Difficulty (2) Some Difficulty (3) A Lot Of Difficulty (4) Unable To Do (5) Don't Do On MD Orders (6) Unable to Assess Difficulty Because not Done as Part of Daily Activities (9) Unk.
|__|	Pulling or pushing large objects like a living room chair
|__|	Either stooping, crouching, or kneeling
|__|	Reaching or extending arms below shoulder level
|__|	Reaching or extending arms above shoulder level
|__|	Either writing, or handling, or fingering small objects
|__|	Standing in one place for long periods, say 15 minutes
|__|	Sitting for long periods, say 1 hour
|__|	Lifting or carrying weights under 10 pounds (like a bag of potatoes)
|__|	Lifting or carrying weights over 10 pounds (like a very heavy bag of groceries)

TECH04 CL

Rosow-Breslau Scales and Katz Activities of Daily Living

(Tech-administered)

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Technician Number

Rosow-Breslau Questions
|__|	Are you able to do heavy work around the house, like shoveling snow or washing windows, walls, or floors without help?	0=No 1=Yes 9=Unk.
|__|	Are you able to walk half a mile without help? (About 4-6 blocks)
|__|	Are you able to walk up and down one flight of stairs without help?

During the Course of a Normal Day, can you do the following activities independently or do you need human assistance or the use of a device. 0=No help needed, independent, 1=Uses device, independent, 2=Human assistance needed, minimally dependent, 3=Dependent, 4=Do not do during a normal day, 9=Unk.
|__|	Dressing (undressing and redressing) Devices such as: velcro, elastic laces
|__|	Bathing (including getting in and out of tub or shower) Devices such as: bath chair, long handled sponge, hand held shower, safety bars
|__|	Eating Devices such as: rocking knife, spork, long straw, plate guard.
|__|	Transferring( getting in and out of a chair) Devices such as: sliding board, grab bars, special seat
|__|	Toileting Activities (using bathroom facilities and handle clothing) Devices such as: special toilet seat, commode

TECH04 CL

CES-D Scale

Tech-administered

	Check here if whole page is blank.		Reason why_______________________________________
|__|__|__|		Technician Number

The questions below ask about your feelings. For each statement, please say how often you felt that way during the past week.

	Circle best answer for each question
DURING THE PAST WEEK	Rarely or none of the time (less than 1 day)	Some or a little of the time (1-2 days)	Occasionally or moderate amount of time (3-4 days)	Most or all of the time (5-7 days)
*I was bothered by things that usually don’t bother me.	0	1	2	3
I did not feel like eating; my appetite was poor.	0	1	2	3
I felt that I could not shake off the blues, even with help from my family and friends.	0	1	2	3
I felt that I was just as good as other people.	0	1	2	3
I had trouble keeping my mind on what I was doing.	0	1	2	3
*I felt depressed.	0	1	2	3
I felt that everything I did was an effort.	0	1	2	3
I felt hopeful about the future.	0	1	2	3
I thought my life had been a failure.	0	1	2	3
I felt fearful.	0	1	2	3
*My sleep was restless.	0	1	2	3
I was happy.	0	1	2	3
I talked less than usual.	0	1	2	3
I felt lonely.	0	1	2	3
People were unfriendly.	0	1	2	3
I enjoyed life.	0	1	2	3
I had crying spells.	0	1	2	3
I felt sad.	0	1	2	3
I felt that people disliked me	0	1	2	3
I could not “get going”	0	1	2	3

* Indicates that the technician should preface the statement with “During the past week”

TECH13

Physical Activity Questionnaire--Framingham Heart Study

Tech-administered

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Technician Number

Rest and Activity for a Typical Day (Activities must equal 24 hours)	Number of hours
Sleep - Number of hours that you typically sleep?	_______
Sedentary - Number of hours typically sitting?	_______
Slight Activity - Number of hours with activities such as standing, walking?	_______
Moderate Activity - Number of hours with activities such as housework (vacuum, dust, yard chores, climbing stairs; light sports such as bowling, golf)?	_______
Heavy Activity - Number of hours with activities such as heavy household work, heavy yard work such as stacking or chopping wood, exercise such as intensive sports--jogging, swimming etc.?	_______
Total number of hours (should be the total of above items)	24

||	What is your normal walking pace outdoors?
	0 = Unable to walk (code 0 mean unable to walk outdoors or unable to walk at all) 1 = Easy, casual, slow (less than 2 miles per hour) 2 = Normal, average (2 to 2.9 miles per hour) 3 = Brisk pace (3 to 3.9 miles per hour) 4 = Very brisk pace (4 to 4.9 miles per hour) 9 = Unk.
||	How many flights of stairs (not steps) do you climb daily? (10 stairs per flight)
	0 = No flights 1 = 1-2 flights 2 = 3-4 flights 3 = 5-9 flights 4 = 10-14 flights 5 = >15 flights 9 = Unk.

ECH05 CL

Physical Activity Questionnaire--Framingham Heart Study

Tech-administered

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Reason why___________________________________

I am going to read a list of activities. Please tell me which activities you have done in the past year.

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Technician Number

hhghDuring past year	During past year did you do? 0=No, 1=Yes, 8=Refused, 9=Unk.		In а typical 2 week period of time, how often do you (name of activity)	Average time/session			Number months/year 0-12
				hours	minutes
|__|		Walking for exercise	|__|__|	|__|__|		|__|__|	|__|__|
|__|		Calisthenics/general exercise	|__|__|	|__|__|		|__|__|	|__|__|
|__|		Moderate strenuous household chores	|__|__|	|__|__|		|__|__|	|__|__|
|__|		Mowing the lawn	|__|__|	|__|__|		|__|__|	|__|__|
|__|		Gardening	|__|__|	|__|__|		|__|__|	|__|__|
|__|		Hiking	|__|__|	|__|__|		|__|__|	|__|__|
|__|		Jogging	|__|__|	|__|__|		|__|__|	|__|__|
|__|		Biking	|__|__|	|__|__|		|__|__|	|__|__|
|__|		Exercise cycle, ski or stair machine	|__|__|	|__|__|		|__|__|	|__|__|
|__|		Dancing	|__|__|	|__|__|		|__|__|	|__|__|
|__|		Aerobics	|__|__|	|__|__|		|__|__|	|__|__|
|__|		Golf	|__|__|	|__|__|		|__|__|	|__|__|
|__|		Swimming	|__|__|	|__|__|		|__|__|	|__|__|
|__|		Weight training (free weights, machines)	|__|__|	|__|__|		|__|__|	|__|__|
|__|		Other, write in______________ ___________________________	|__|__|	|__|__|		|__|__|	|__|__|
|__|		Other, write in______________ ___________________________	|__|__|	|__|__|		|__|__|	|__|__|

TECH06 CL

Fractures

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Reason why___________________________________

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Technician Number

Fractures
|__|	Since Your Last Clinic Visit Have You Broken Any Bones? (0=No, 1=Yes, 2=Maybe, 9=Unk.)
If Yes, fill 	|__|__|	Location of fracture:
	|__|__|	Location of second fracture (if more than one):
	|__|__|	Location of third fracture (if more than two):
		Code for Location (code Unk. as 99)
		1= Clavicle (collar bone)
		2=Upper arm (humerus) or elbow
		3=Forearm or wrist
		4=Hand
		5=Back (If disc disease only, code as no)
		6=Pelvis
		7=Hip
		8=Leg
		9=Foot
		10=Other, specify___________________________________

TECH08 CL

Cognitive Function--Part I

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Reason why___________________________________

I’m going to start by asking questions that require concentration and memory. Some questions are more difficult that others and some will be asked more than one time.

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Technician Number

SCORE CORRECT No Try=6 Unk.=9	Write all responses on exam form (score 1 point for each correct response)
0 1 2 3 6 9	What Is the Date Today? (Month, day, year, correct score=3)
0 1 6 9	What Is the Season?
0 1 6 9	What Day of the Week Is it?
0 1 2 3 6 9	What Town, County and State Are We in?
0 1 6 9	What Is the Name of this Place? (any appropriate answer all right, for instance my home, street address, heart study..max score=1)
0 1 6 9	What Floor of the Building Are We on?
0 1 2 3 6 9	I am going to name 3 objects. After I have said them I want you to repeat them back to me. Remember what they are because I will ask you to name them again in a few minutes: Apple, Table, Penny
|__|__|__|__|__|	Now I am going to spell a word forward and I want you to spell it backwards. The word is world. W-O-R-L-D. Please Spell it in Reverse Order. (Letters Are Entered and Scored Later)
	Score as	66666=Not administered for reason unrelated to cognitive status 00000=Administered, but couldn’t do 99999=Unk.
0 1 2 3 6 9	What are the 3 objects I asked you to remember a few moments ago?

TECH09 CL

Cognitive Function --Part II

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SCORE CORRECT No Try=6 Unk.=9	Write all responses on exam form.
0 1 6 9	What Is this Called? (Watch)
0 1 6 9	What Is this Called? (Pencil)
0 1 6 9	Please Repeat the Following: "No Ifs, Ands, or Buts." (Perfect=1)
0 1 6 9	Please Read the Following & Do What it Says (performed=1, code 6 if low vision)
0 1 6 9	Please Write a Sentence (code 6 if low vision)
0 1 6 9	Please Copy this Drawing (code 6 if low vision)
0 1 2 3 6 9	Take this piece of paper in your right hand, fold it in half with both hands, and put in your lap (score 1 for each correctly performed act, code 6 if low vision)

No Yes Maybe Unk (coding for below)	Factor Potentially Affecting Mental Status Testing
0 1 2 9	Illiterate or low education
0 1 2 9	Not fluent in English
0 1 2 9	Poor eyesight
0 1 2 9	Poor hearing
0 1 2 9	Depression / possible depression
0 1 2 9	Other, write in ___________________________________________________

TECH10 CL

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Sentence and Design Handout for Participant

PLEASE WRITE A SENTENCE

_________________________________________________________________________________

_________________________________________________________________________________

_________________________________________________________________________________

PLEASE COPY THIS DESIGN

Observed performance. Part 1

Technician Administered

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|__|__|__|

Technician Number

HAND GRIP TEST Measured to the nearest kilogram
Right hand
Trial 1 99=Unk.	|__|__|
Trial 2 99=Unk.	|__|__|
Trial 3 99=Unk.	|__|__|
Left hand
Trial 1 99=Unk.	|__|__|
Trial 2 99=Unk.	|__|__|
Trial 3 99=Unk.	|__|__|

	Check if this test not completed or not attempted.
	|__|	If not attempted or completed, why not? 1=Physical limitation, 2=Refused, 3=Other ____________________write in, 9=Unk.

Comments: _______________________________________________________________________________

_________________________________________________________________________________________

_________________________________________________________________________________________

_________________________________________________________________________________________

TECH11 CL

Observed performance. Part 2

Technician Administered

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Reason why_______________________________________

Measured Walks
Walking aid used: 0=No aid, 1=Cane, 2=Walker, 3=Wheelchair, 4=Other, 9=Unk.			|__|
First Walk
Walk time (in seconds, 99.99=Unk.)			|__|__|*|__|__|
Laser walk time (in seconds, 99.99=Unk.)			|__|__|*|__|__|
	Check if this test not completed or not attempted.
	|__|	If not attempted or completed, why not? (1=Physical limitation, 2=Refused, 3=Other ________________________write in, 9=Unk.)
Second Walk
Walk time (in seconds, 99.99=Unk.)			|__|__|*|__|__|
Laser walk time (in seconds, 99.99=Unk.)			|__|__|*|__|__|
	Check if this test not completed or not attempted.
	|__|	If not attempted or completed, why not? (1=Physical limitation, 2=Refused, 3=Other _______________________write in, 9=Unk.)
Quick Walk
Walk time (in seconds, 99.99=Unk.)			|__|__|*|__|__|
Laser walk time (in seconds, 99.99=Unk.)			|__|__|*|__|__|
	Check if this test not completed or not attempted.
	|__|	If not attempted or completed, why not? (1=Physical limitation, 2=Refused, 3=Other ____________________write in, 9=Unk.)

TECH12 CL

Ankle Brachial Blood Pressure Measurements. Participants >40 years

SYSTOLIC BLOOD PRESSURES BY DOPPLER (to be taken in the following order with participant supine after 5 minutes of rest)

	Page blank and Participant <40			Page blank and Participant ≥40; fill	Reason why___________________________________
|__|__|__|		Technician Number for Doppler Ankle Brachial Blood Pressure.
|__|		Cuff size, arm				0= pediatric, 1= regular adult 2= large adult, 3= thigh
|__|		Cuff size, ankle

|__|__|__|	Right arm	300=>300 mmHg 888= Not Done 999= Unk.
|__|__|__|	Right ankle
|__|__|__|	Left ankle
|__|__|__|	Left arm

REPEAT SYSTOLIC BLOOD PRESSURE MEASUREMENTS (reverse order)

|__|__|__|	Left arm	300=>300 mmHg 888= Not Done 999= Unk.
|__|__|__|	Left ankle
|__|__|__|	Right ankle
|__|__|__|	Right arm

THIRD SYSTOLIC BLOOD PRESSURE MEASUREMENT (order as in repeat SBP). To be obtained if initial and repeat SBP at any site differ by more than 10 mmHg. For site that differs.

|__|__|__|	Right arm	300=>300 mmHg 888= Not Done 999= Unk.
|__|__|__|	Right ankle
|__|__|__|	Left ankle
|__|__|__|	Left arm

|__|	Right Ankle blood pressure site	0= posterior tibial (ankle) 1= dorsalis pedis (foot)
|__|	Left Ankle blood pressure site

EXCLUSIONS:

Enter exclusion ONLY if there is an 888 above.
Right	Left
|__|	|__|	Lower Extremity Exclusions 1= venous stasis ulceration, 2= amputation, 3= other___________________
|__|	|__|	Upper Extremity Exclusions 1=Mastectomy, 3= Other________________________________
	Check if Protocol modification, write in_________________________________________
Comments	__________________________________________________________________________ __________________________________________________________________________

TECH04

Respiratory Disease Questionnaire, Part 1

Technician Administered.

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Reason why___________________________________

Respiratory Diagnoses
|__|__|__|		Technician Number
|__|	Have you ever had asthma? (0=No, 1=Yes, 9=Unk.)
If yes, fill 	|__|		Do you still have it?
	|__|		Was it diagnosed by a doctor or other health care professional?
	|__|__|		At what age did it start? (Age in years 88=N/A, 99=Unk.
	|__|__|		If you no longer have it, at what age did it stop? (Age in years) 88=still have it, 99=Unk.
	|__|		Have you received medical treatment for this in the past 12 months?
|__|	Have you ever had hay fever (allergy involving the nose and/or eyes)? (0=No, 1=Yes, 9=Unk.)
If yes, fill 	|__|		Do you still have it? (0=No, 1=Yes, 9=Unk.)
Have you ever had any of the following conditions diagnosed by a doctor or other health care professional? (0=No, 1=Yes, 9=Unk.)
||	Chronic Bronchitis
|__|	Emphysema
|__|	COPD (Chronic obstructive pulmonary disease)
|__|	Sleep Apnea
|__|	Pulmonary Fibrosis

Inhaler Use (0=No, 1=Yes)
|__|	Do you take inhalers or bronchodilators?
If yes, fill 	|__|	Do you take any of the inhaled medications?- albuterol, ProAir, Proventil, Ventolin, pirbuterol, Maxair, levalbuterol, Xopenex, metaproterenol, Alupent, or ipratropium, Atrovent, Combivent
	If yes, fill 	|__|__|	How many hours ago did you last use the medication, either by inhaler or nebulizer? if last used >48 hrs ago code 88, 99= Unk.	Time in hours 1-48
	|__|	Do you take any of the following inhaled medications? salmeterol, Serevent, Advair, formoterol, Foradil, Symbicort, arformoterol, Brovana, tiotropium, or Spiriva,
	If yes, fill 	|__|__|	How many hours ago did you last use the medication, either by inhaler or nebulizer? if last used >48 hrs ago code 88, 99=Unk.	Time in hours 1-48

TECH14 CL

Respiratory Disease Questionnaire, Part 2.

Technician Administered.

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Reason why_______________________________________

Acute Respiratory Illnesses Since Last Exam
Since your last exam or medical history update
|__|	Have you been hospitalized because of breathing trouble or wheezing? (0=No, 1=Yes, 9=Unk.)
If yes, fill 	|__|__|	How many times has this occurred?
	|__|	Were any of these hospitalizations due to a lung or bronchial problem, for example COPD, asthma, bronchitis, emphysema, or pneumonia? (0=No, 1=Yes, 9=Unk.)
|__|	Have you required an emergency room visit or an unscheduled visit to a doctor’s office or clinic because of breathing trouble or wheezing? (0=No, 1=Yes, 9=Unk.)
If yes, fill 	|__|__|	How many times has this occurred?
	|__|	Were any of these emergency room or unscheduled visits due to a lung or bronchial problem, for example COPD, asthma, bronchitis, emphysema, or pneumonia? (0=No, 1=Yes, 9=Unk.)
|__|	Have you had pneumonia (including bronchopneumonia)? (0=No, 1=Yes, 9=Unk.)
If yes, fill 	|__|__|	How many times have you had pneumonia?

The following questions are about problems which occur when you DO NOT have a cold or the flu. Please list problems that occurred IN THE PAST 12 MONTH only
|__|	Have you had a problem with sneezing or a runny or blocked nose when you DID NOT have a cold or the flu? (0=No, 1=Yes, 9=Unk.)
If yes, fill 	|__|	Has this nose problem been accompanied by itchy-watery eyes? (0=No, 1=Yes, 9=Unk.)
		In which of the months did this nose problem occur? (0=No, 1=Yes) Fill in ALL months.
		|__| January	|__| July
		|__| February	|__| August
		|__| March	|__| September
		|__| April	|__| October
		|__| May	|__| November
		|__| June	|__| December

TECH15 CL

Proxy form



Check here if whole page is blank.

Reason why_______________________________________

|__| if yes, fill 	Proxy used to complete this exam (0=No, 1=Yes, 1 proxy, 2=Yes, more than 1 proxy, 9=Unk)
	Proxy Name ___________________________________________________________
	|__|	Relationship (1=1st Degree Relative(spouse, child), 2=Other Relative, 3=Friend, 4=Health Care Professional, 5=Other, 9=Unk.
	|__|__|*|__|__|	How long have you known the participant? (Years, months; 99.99=Unk) example: 3m=00*03
	|__|	Are you currently living in the same household with the participant? (0=No, 1=Yes, 9=Unk)
	|__|	How often did you talk with the participant during the prior 11 months? (1=Almost every day, 2=Several times a week, 3=Once a week, 4=1 to 3 times per month, 5=Less than once a month, 9=Unk.)
	Proxy Name ___________________________________________________________
	|__|	Relationship (1=1st Degree Relative(spouse, child), 2=Other Relative, 3=Friend, 4=Health Care Professional, 5=Other, 9=Unk.
	|__|__|*|__|__|	How long have you known the participant? (Years, months; 99.99=Unk) example: 3 m=00*03
	|__|	Are you currently living in the same household with the participant? (0=No, 1=Yes, 9=Unk)
	|__|	How often did you talk with the participant during the prior 11 months? (1=Almost every day, 2=Several times a week, 3=Once a week, 4=1 to 3 times per month, 5=Less than once a month, 9=Unk.)

TECH016 CL

Sociodemographic questions. Part I

Self-administered. Offsite - tech-administered.

What is your current marital status? (check ONE)
 1	single/never married
 2	married/living as married/living with partner
 3	separated
 4	divorced
 5	widowed
 9	prefer not to answer
Please choose which of the following best describes your current employment status? (check ONE)
 0	homemaker, not working outside the home
 1	employed (or self-employed) full time
 2	employed (or self-employed) part time
 3	employed, but on leave for health reasons
 4	employed, but temporarily away from my job
 5	unemployed or laid off
 6	retired from my usual occupation and not working
 7	retired from my usual occupation but working for pay
 8	retired from my usual occupation but volunteering
 9	prefer not to answer
10	unemployed due to disability
11	full-time student

	What is your current occupation? Write in _______________________________________________________________________
|__|__|	Using the occupation coding sheet choose the code that best describes your occupation.

 YES	 NO	Do you have some form of health insurance?
 YES	 NO	Do you have prescription drug coverage?

TECH17 CL

SF-12 Health Survey (Standard)

Self-administered

This questionnaire asks for your views about your health. This information will help you keep track of how you feel and how well you are able to do your usual activities.

Please answer every question by marking one box. If you are unsure about how to answer a question, please give the best answer you can.

1. In general, would you say your health is:
	Excellent	Very good	Good	Fair			Poor
							
The following questions are about activities you might do during a typical day. Does your health now limit you in these activities? If so, how much?
			Yes, limited a lot	Yes, limited a little		No, not limited at all
2. Moderate activities, such as moving a table, pushing a vacuum cleaner, bowling, or playing golf							
3. Climbing several flights of stairs							
During the past 4 weeks, have you had any of the following problems with your work or other regular daily activities as a result of your physical health?
					Yes	No
4. Accomplished less than you would like						
5. Were limited in the kind of work or other activities						
During the past 4 weeks, have you had any of the following problems with your work or other regular daily activities as a result of any emotional problems (such as feeling depressed or anxious)?
					Yes		No
6. Accomplished less than you would like							
7. Didn’t do work or other activities as carefully as usual							

TECH19 CL

SF-12â Health Survey (Standard)

Self-administered

. During the past 4 weeks, how much did pain interfere with your normal work (including both work outside the home and housework)?
	Not at all	A little bit	Moderately	Quite a bit	Extremely
					

These questions are about how you feel and how things have been with you during the past 4 weeks. For each question, please give the one answer that comes closest to the way you have been feeling.

How much of the time during the past 4 weeks…

	All of the time	Most of the time	A good bit of the time	Some of the time	A little of the time	None of the time
9. Have you felt calm and peaceful?						
10. Did you have a lot of energy?						
11. Have you felt downhearted and blue?						

12. During the past 4 weeks, how much of the time has your physical health or emotional problems interfered with your social activities (like visiting friends, relatives, etc.)?
		All of the time	Most of the time	Some of the time	A little of the time	None of the time
						

TECH20 CL

Sleep Questionnaire. Part 1

Self-administered

Considering only your “feeling best” rhythm, at what time would you get up if you were entirely free to plan your day? (Place a cross at the appropriate point along the scale.)

2AM 3 4 5 6 7 8 9 10 11 Noon

Considering only your “feeling best” rhythm, at what time would you go to bed if you were entirely free to plan your evening? (Place a cross at the appropriate point along the scale.)

3PM 4 5 6 7 8 9 10 11 Midnight 1 2 3AM

What is the chance that you would doze off or fall asleep (not just “feel tired”) in each of the following situations? (Circle one response for each situation. If you are never or rarely in the situation, please give your best guess for that situation)
	None	Slight	Moderate	High
Sitting and reading	0	1	2	3
Watching TV.	0	1	2	3
Sitting inactive in a public place (such as theater or a meeting)	0	1	2	3
Riding as a passenger in a car for an hour without a break.	0	1	2	3
Lying down to rest in the afternoon when circumstances permit.	0	1	2	3
Sitting and talking to someone	0	1	2	3
Sitting quietly after a lunch without alcohol.	0	1	2	3
In a car, while stopped in traffic for a few minutes.	0	1	2	3

TECH?? CL

Sleep Questionnaire. Part 2

Self-administered

During the past month...
when have you usually gone to bed at night?	|__|__|:|__|__| |__| |__| hours : min AM PM
how long has it usually taken you to fall asleep each night?	|__|__|:|__|__| hours : min
when have you usually gotten up in the morning?	|__|__|:|__|__| |__| |__| hours : min AM PM
how much actual sleep did you get at night?	|__|__|:|__|__| hours : min

When you experience the following situations, how likely is it for you to have difficulty sleeping? Circle an answer even if you have not experienced these situations recently.
	Not likely	Somewhat likely	Moderately likely	Very likely
Before an important meeting the next day	0	1	2	3
After a stressful experience during the day	0	1	2	3
After a stressful experience in the evening	0	1	2	3
After getting bad news during the day	0	1	2	3
After watching a frightening movie or TV show	0	1	2	3
After having a bad day at work	0	1	2	3
After an argument	0	1	2	3
Before having to speak in public	0	1	2	3
Before going on vacation the next day	0	1	2	3

|__|	On average over the past year, how often do you snore?	0= Never 1= Less than 1 night per week 2= 1-2 nights per week 3= 3-5 nights per week 4= 6-7 nights per week 9= Don’t know
|__|	On average over the past year, how often do you have times when you stop breathing while you are asleep?

TECH21 CL

Sleep Questionnaire. Part 3

Self-administered

One hears about “morning” and “evening” types of people. Which ONE of these types do you consider yourself to be? Please check ONE box below
	Definitely a “morning” type
	Rather more a “morning” than an “evening” type
	Neither a “morning” nor an “evening” type
	Rather more an “evening” than a “morning” type
	Definitely an “evening” type

Have you ever been told by a doctor or other health professional that you have any of the following?
(Circle one response for each item)		No	Yes	Don’t know
Sleep apnea or obstructive sleep apnea.		0	1	9
if yes, fill	Do you wear a mask (“CPAP”) or other device at night to treat sleep apnea?	0	1	9
Insomnia.		0	1	9
Restless legs.		0	1	9

TECH?? CL

Date of exam

_____/_____/_____

Framingham Heart Study

Offspring EXAM 9

Summary Sheet to Personal Physician

Blood Pressure	First Reading	Second Reading
Systolic
Diastolic

ECG Diagnosis ____________________________________________________________________________

_________________________________________________________________________________________

The following tests are done on a routine basis: Blood Glucose, Blood Lipids, Pulmonary Function Test (results enclosed). Echocardiogram findings will be forwarded at a later date only if abnormal.

Summary of Findings_______________________________________________________________________

	1. No history or physical exam findings to suggest cardiovascular disease. (check box if applicable)

__________________________________________________________________________________________

__________________________________________________________________________________________

__________________________________________________________________________________________

__________________________________________________________________________________________

__________________________________________________________________________________________

__________________________________________________________________________________________

__________________________________________________________________________________________

_______________________________

Examining Physician

The Heart Study Clinic examination is not comprehensive and does not take the place of a routine physical examination.

Referral Tracking



Check here if whole page is blank.

Reason why_____________________________________

|| if yes fill below	Was further medical evaluation recommended for this participant? 0=No, 1=Yes, 9=Unk.
RESULT Reason for further evaluation: (Check ALL that apply).
		Blood Pressure result ______/_______ mmHg result ______/_______ mmHg	SBP or DBP Phone call > 200 or >110 Expedite > 180 or >100 Elevated > 140 or >90
		Abnormal laboratory result______________________
		Write in abnormality
		ECG abnormality _____________________________________________________
		Clinic Physician identified medical problem_________________________________
		Other ________________________________________________________________

Method used to inform participant of need for further medical evaluation (Check ALL that apply)
	Face-to-face in clinic
	Phone call
	Result letter
	Other

Method used to inform participant’s personal physician of need for further medical evaluation (check ALL that apply)
	Phone call
	Result letter mailed
	Result letter FAX’d (inform staff if Fax needed)
	Other

Date referral made: _____/____/________

ID number of person completing the referral: __________

Notes documenting conversation with participant or participant’s personal physician:_________________

_____________________________________________________________________________________

TECH31 CL

Medical History—Hospitalizations, ER Visits, MD Visits

OFFSPRING EXAM 9

DATE ____________

DATE of last exam «Lexam»

DATE of last medical history update «Lupdate»

Health Care
Since your last exam or medical history update
|__|__|__|	1st Examiner ID _________________________ 1st Examiner Name
|__|	1st Examiner Prefix (0=MD, 1=Tech. for OFFSITE visit)
|__|	Hospitalizations (not just E.R.) (0=No; 1=yes, hospitalization, 2=yes, more than 1 hospitalization, 9=Unk.)
|__|	E.R. Visits (0=No; 1=Yes, 1 visit, 2=Yes, more than 1 visit, 9=Unk.)
|__|	Day Surgery (0=No, 1=Yes, 9=Unk.)
|__|	Major illness with visit to doctor (0=No, 1=Yes, 1 visit; 2=Yes, more than 1 visit; 9=Unk)
|__|	Check up by doctor or other health care provider? (0=No, 1=Yes, 9=Unk.)
|__|	Have you had a fever or infection in past two weeks? (0=No, 1=Yes, 9=Unk.)
|__|__| |__|__| |__|__|__|__| MM DD YYYY	Date of this FHS exam (Today's date ‑ See above)

Note: if FHS needs outside hospital record, please obtain details: mo/yr, hospital site.

Medical Encounter	Month/Year (of last visit)	Name & Address of Hospital or Office	Doctor

MD01 CL

Medical History—Medications

|__|	Do you take aspirin regularly? ( 0=No, 1=Yes, 9=Unk)
If yes, fill	|__|__|	Number of aspirins taken regularly (99=Unk.)
	|__|	Frequency per ( 1=Day, 2=Week 3=Month, 4=Year, 9=Unk)
	|__|__|__|	Usual dose (write in mgs, 999=Unk..)	Examples: 081=baby,160=half dose, 250= like in Excedrin , 325=usual dose, 500=extra strength

Since your last exam (0=No, 1=Yes, 9=Unk)
|__|	Have you been told by doctor you have high blood pressure or hypertension?
|__|	Have you taken medication for high blood pressure or hypertension?
|__|	Have you been told by doctor you have high blood cholesterol or high triglycerides?
|__|	Have you taken medication for high blood cholesterol or high triglycerides?
|__|	Have you been told by doctor you have high blood sugar or diabetes?
|__|	Have you taken medication for high blood sugar or diabetes?
|__|	Have you taken medication for cardiovascular disease? (for example angina/chest pain, heart failure, atrial fibrillation/heart rhythm abnormality, stroke, leg pain when walking, peripheral artery disease)

MD02 CL

Medical History – Prescription and Non-Prescription Medications

Copy the name of medicine, the strength including units, and the total number of doses per day/week/month/year. Include vitamins and minerals.

|__|

Medication bag with medications brought to exam? (0=No 1=Yes)

**List medications taken regularly in past month/ongoing medications** Code ASPIRIN ONLY on screen MD02.

Medication Name (Print first 20 letters)

Strength (include mg, IU, etc)

Route 1= Oral, 2=topical, 3=injection, 4=inhaled, 5=drops,6=other

Number per (circle one)

PRN 0=no, 1=yes,9=Unk.

Check if OTC med

#

day/week/month/year 1 / 2 / 3 / 4

100

mg

1

1

D W M Y

0

EXAMPLE:

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Continue on the next page 

MD03 CL

Medical History – Prescription and Non-Prescription Medications

Medication Name (Print first 20 letters)

Strength (include mg, IU, etc)

Route 1= Oral, 2=topical, 3=injection, 4=inhaled, 5=drops,6=other

Number per (circle one)

. PRN 0=no, 1=yes, 9-Unk

Check if OTC med.

#

day/week/month/year 1 / 2 / 3 / 4

100

mg

1

1

D W M Y

0

EXAMPLE:

S

A

M

P

L

E

D

R

U

G

N

A

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E

D W M Y

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D W M Y



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MD04 CL

Medical History–Female Reproductive History. Part 1.

	Check here if Male Participant (and skip to Smoking Questions page 46/MD07)

	Check here if definitely menopausal (and skip to Female History Part 3 page 45) to be preloaded from previous exam

|__|	Since your last exam have you taken or used birth control pills, shots, or hormone implants for birth control or medical indications (not post menopausal hormone replacement)? (0=no, 1=yes, now, 2=yes, not now, 9=Unk.)
|__| If yes, fill	Have you been pregnant since last exam? (0=no, 1=yes, 9=Unk.)
	|__|__|	Number of pregnancies?	fill in number
	|__|__|	Number of live births?
	|__|	During any of these pregnancies, were you told you had high blood pressure or hypertension?	0=No 1=Yes 9=Unk
	|__|	During any of these pregnancies, were you told you had eclampsia, pre-eclampsia (toxemia)
	|__|	During any of these pregnancies, were you told you had high blood sugar or diabetes?

MD05 CL

Medical History–Female Reproductive History. Part 2

below: content is the same but the wording was changed

What is the best way to describe your periods? Check the BEST answer – only one.
	Not stopped
	Periods stopped due to pregnancy, breast feeding, or hormonal contraceptive (for example: depo-provera, progestin releasing IUD, extended release birth control pill)
	Periods stopped due to low body weight, heavy exercise, or due to medication or health condition such as thyroid disease, pituitary tumor, hormone imbalance, stress,
	Write in cause		______________________________________________________
	Periods stopped for less than 1 year (perimenopausal)
	|__|__|	Number of months since last period 99=Unk.
	Periods stopped for 1 year or more
	Periods stopped, but now have periods induced by hormones.
	|__|__|	Number months stopped before hormones started. 99=Unk.

|__|__|*|__|__|*|__|__|__|__|		When was the first day of your last menstrual period? 99/99/9999=Unk. 88/88/8888= periods stopped for more than 1 year or using postmenopausal hormones If periods stopped due to pregnancy, breast feeding, hormonal contraception or health condition code date of last menstrual period
|__|__|	Age when periods stopped (00=not stopped, 99=Unk.) If periods now induced by hormones, code age when periods naturally stopped. If periods stopped due to pregnancy, breast feeding, or hormonal contraception code as “0=not stopped”
|__|	Was your menopause natural or the result of surgery, chemotherapy, or radiation? (0=still menstruating, 1=natural, 2=surgical, 3=chemo/radiation, 4=other, 9=Unk.) If periods stopped due to pregnancy, breast feeding, or hormonal contraception code as “0=still menstruating”

MD06 CL

Medical History–Female Reproductive History. Part 3

Surgery History
|__|	Since your last exam have you had a hysterectomy (uterus/womb removed)? (0=no, 1=yes, 9=Unk.)
If yes, fill	|__|__|			Age at hysterectomy? 99=Unk.
	|__|__|*|__|__|__|__|			Date of surgery (mo/yr) 99/9999=Unk.
|__|	Since last exam have you had an operation to remove one or both of your ovaries? (0=no, 1=yes, 9=Unk.)
If yes, fill	|__|__|	Age when ovaries removed? If more than one surgery, use age at last surgery 99=Unk.
	Number of ovaries removed? (check one)
						
	1=one ovary		2=two ovaries		3= unknown. number of ovaries	4= part of an ovary

|__|	Have you since your last exam taken hormone replacement therapy (estrogen/progesterone) or a selective estrogen receptor modulator (such as evista or raloxifene)? (0=no, 1=yes, now, 2=yes, not now, 9=Unk.)

Comments_________________________________________________________________________________

__________________________________________________________________________________________

__________________________________________________________________________________________

__________________________________________________________________________________________

__________________________________________________________________________________________

MD06 CL

Medical History--Smoking

Cigarettes
|__| If yes, fill	Since your last exam have you smoked cigarettes regularly? (0=no, 1=yes, 9=Unk.)
	||	Have you smoked cigarettes regularly in the last year? (No means less than 1 cigarette a day for 1 year.) (0=no, 1=yes, 9=Unk.)
	||	Do you now smoke cigarettes (as of 1 month ago)? (0=no, 1=yes, 9=Unk.)
	|__|__|	How many cigarettes do you smoke per day now? (99=Unk.)
	Questions below refer to “since your last exam”
	|__|__|	During the time you were smoking, on avarage how many cigarettes per day did you smoke (99=Unk)
	|__|__|	If you have stopped smoking cigarettes completely, how old were you when you stopped? (Age stopped, 00=not stopped, 99=Unk.)
	|__|	When you were smoking, did you ever stop smoking for >6 months? (0=no, 1=yes, 9=Unk.)
	If yes, fill	|__|__|	For how many years in total did you stop smoking cigarettes (1=6 months – 1 year, 99=Unk.)

Pipes or Cigars
|__|	Since your last exam, have you regularly smoked a pipe or cigar?		0=No 1=Yes 9=Unk.
If yes, fill	|__|	Do you smoke a pipe or cigar now

Comments:_______________________________________________________________________________

_________________________________________________________________________________________

_________________________________________________________________________________________

MD07 CL

Medical History –Alcohol Consumption.

Now I will ask you questions regarding your alcohol use.

Do you drink any of the following beverages at least once a month? (0=no, 1=yes, 9=Unk.)
|__|	Beer
|__|	Wine
|__|	Liquor/spirits
If yes, what is your average number of servings in a typical week or month over past year? (999=Unknown) Code alcohol intake as EITHER weekly OR monthly as appropriate.
Beverage		Per week	Per month
Beer (12oz bottle, glass, can)		|__|__|__|	|__|__|__|
Wine (red or white, 4oz glass)		|__|__|__|	|__|__|__|
Liquor/spirits (1oz cocktail/highball)		|__|__|__|	|__|__|__|

|__|__|__|

At what age did you stop drinking alcohol? (0= not stopped, 888=Never drinker 999=Unk.)

|__|	Over the past year, on average on how many days per week did you drink an alcoholic beverage of any type? (0=no drinks, 1=1or less, 9=Unk.)
|__|__|	Over the past year, on a typical day when you drink, how many drinks do you have? (0=no drinks, 1=1or less, 99=Unk.)
|__|__|	What was the maximum number of drinks you had in 24 hr. period during the past month? (0=no drinks, 1=1or less, 99=Unk.)
|__|	Since last exam has there been a time when you drank 5 or more alcoholic drinks of any kind almost daily? (0=no, 1=yes, 9=Unk.)

	Check if over past year participant drinks less than one alcoholic drink of any type per month.

Comments:_______________________________________________________________________________

_________________________________________________________________________________________

_________________________________________________________________________________________

MD08 CL

Medical History—Respiratory Symptoms. Part I

Cough (0=No, 1=Yes, 9=Unk.)
|__|	Do you usually have a cough? (Exclude clearing of the throat)
|__|	Do you usually have a cough at all on getting up or first thing in the morning?
If YES to either question above answer the following:
	|__|	Do you cough like this on most days for three consecutive months or more during the past year?
	|__|__|	How many years have you had this cough? (# of years.)	1=1 year or less 99=Unk

Phlegm (0=No, 1=Yes, 9=Unk.)
|__|	Do you usually bring up phlegm from your chest?
|__|	Do you usually bring up phlegm at all on getting up or first thing in the morning?
If YES to either question above answer the following:
	|__|	Do you bring up phlegm from your chest on most days for three consecutive months or more during the year?
	|__|__|	How many years have you had trouble with phlegm? (# of years)	1=1 year or less 99=Unk

Wheeze (0=No, 1=Yes, 9=Unk.)
In the past 12 months…
|__|	Have you had wheezing or whistling in your chest at any time?
if yes, fill all	|__|	How often have you had this wheezing or whistling? 0=Not at all 1=MOST days or nights 2=A few days or nights a WEEK 3=A few days or nights a MONTH 4=A few days or nights a YEAR 9=Unk.
	|__|	Have you had this wheezing or whistling in the chest when you had a cold?
	|__|	Have you had this wheezing or whistling in the chest apart from colds?
	|__|	Have you had an attack of wheezing or whistling in the chest that had made you feel short of breath?

MD09 CL

Medical History—Respiratory Symptoms. Part II

Nocturnal chest symptoms (0=No, 1=Yes, 9=Unk.)
In the past 12 months…
|__|	Have you been awakened by shortness of breath?
|__|	Have you been awakened by a wheezing/whistling in your chest?
|__|	Have you been awakened by coughing?
if yes, fill all	|__|	How often have you been awakened by coughing? 0=Not at all 1=MOST days or nights 2=A few days or nights a WEEK 3=A few days or nights a MONTH 4=A few days or nights a YEAR 9=Unk.

Shortness of breath (0=No, 1=Yes, 9=Unk.)
Since your last exam…
|__|	Are you troubled by shortness of breath when hurrying on level ground or walking up a slight hill?
if yes, fill all	|__|		Do you have to walk slower than people of your age on level ground because of shortness of breath?
	|__|		Do you have to stop for breath when walking at your own pace on level ground?
	|__|		Do you have to stop for breath after walking 100 yards (or after a few minutes) on level ground?
|__|		Do you/have you needed to sleep on two or more pillows to help you breathe (Orthopnea)?
|__|		Have you since last exam had swelling in both your ankles (ankle edema)?
|__|		Have you been told by your doctor you had heart failure or congestive heart failure?
if yes, fill l		Name of doctor ______________________________________________________
		Date of visit |__|__|*|__|__|*|__|__|__|__| 99/99/9999=Unk.
|__|		Have you been hospitalized for heart failure? (Provide details on MD01-Health Care page 47)

CHF First Examiner Opinion
|__|	First examiner believes CHF	0=No,1=Yes 2=Maybe, 9=Unk.

Comments________________________________________________________________________________

__________________________________________________________________________________________

__________________________________________________________________________________________

MD10 CL

Physical Exam—Blood Pressure

Physician Blood Pressure First reading
Systolic	BP cuff size
|__|__|__| to nearest 2 mm Hg	|__| 0=pedi,1=reg.adult, 2=large adult, 3= thigh, 9=Unk.
Diastolic	Protocol modification
|__|__|__| to nearest 2 mm Hg	|__| 0=No, 1=Yes, 9=Unk.

Comments for Protocol modification________________________________________________________

_______________________________________________________________________________________

_______________________________________________________________________________________

_______________________________________________________________________________________

MD11 CL

Medical History—Chest pain

|__|	Since your last exam have you experienced any chest discomfort? (please provide narrative comments in addition to completing the appropriate boxes)					0=No, 1=Yes, 2=Maybe, 9=Unk.
if yes, fill and below	|__|	Chest discomfort with exertion or excitement
	|__|	Chest discomfort when quiet or resting
	Chest Discomfort Characteristics
	|__|__|*|__|__|__|__|		Date of onset (mo/yr)		99/9999=Unk.
	|__|__|__|		Usual duration (minutes)		1=1 min or less, 900=15 hrs or more, 999=Unk.
	|__|__|__|		Longest duration (minutes)		1=1 min or less, 900=15 hrs or more, 999=Unk.
	|__|		Location		0=No, 1=Central sternum and upper chest, 2=L Up Quadrant, 3=L Lower ribcage, 4=R Chest, 5=Other, 6=Combination, 9=Unk.
	|__|		Radiation		0=No, 1=Left shoulder or L arm, 2=Neck, 3=R shoulder or arm, 4=Back, 5=Abdomen, 6=Other, 7=Combination, 9=Unk.
	|__|__|__|		Number of episodes of chest pain in past month		999=Unk.
	|__|__|__|		Number of episodes of chest pain in past year.		999=Unk.
	|__|		Type		1=Pressure, heavy, vise, 2=Sharp, 3=Dull, 4=Other, 9=Unk.
	|__|			Relief by Nitroglycerin in <15 minutes		0=No,
	|__|			Relief by Rest in <15 minutes		1=Yes,
	|__|			Relief Spontaneously in <15 minutes		8=Not tried
	|__|			Relief by Other cause in <15 minutes		9=Unk.

|__|	Since your last exam have you been told by a doctor you had a heart attack or myocardial infarction?	0=No, 1=Yes, 2=Maybe, 9=Unk.
if yes, fill l	Name of doctor ______________________________________________________
	Date of visit |__|__|*|__|__|*|__|__|__|__| 99/99/9999=Unk.

CHD First Examiner Opinions
|__|	Angina pectoris		0=No, 1=Yes, 2=Maybe, 9=Unk.
if yes,fill	|__|	Angina pectoris since revascularization procedure
|__|	Coronary insufficiency
|__|	Myocardial infarct

Comments_________________________________________________________________________________

__________________________________________________________________________________________

__________________________________________________________________________________________

MD12 CL

Medical History—Atrial Fibrillation/Syncope

Since your last exam or medical history update….
|__|	Have you been told you have/had atrial fibrillation?	0=No, 1=Yes, 2=Maybe, 9=Unk.

if yes,fill

|__|__|*|__|__|*|__|__|__|__|

Date of first episode

99/99/9999=Unk

|__|

ER/hospitalized or saw M.D.

0=No, 1=Hosp/ER, 2=Saw M.D., 9=Unk.

if yes, fill

____________________________________

Name of the Hospital (write Unk. if unknown)

____________________________________

Name of M.D. (write Unk. if unknown)

|__|

Do you have a family history of a heart rhythm problem called atrial fibrillation?

0=No, 1=Yes, 9=Unk

if yes,fill

Mother

Father

Siblings

Children

0=No, 1=Yes, 9=Unk

|__|

|__|

|__|

|__|

|__|

Have you fainted or lost consciousness? (If event immediately preceded by head injury or accident code 0=No)

0=No, 1=Yes, 2=Maybe, 9=Unk.

if yes, fill all

|__|__|__|

Number of episodes in the past two years

999=Unk.

|__|__|*|__|__|__|__|

Date of first episode (mo/yr)

99/9999=Unk.

|__|__|__|

Usual duration of loss of consciousness (minutes)

999=Unk.,1=1 min or less

|__|

Did you have any injury caused by the event?

0=No, 1=Yes, 2=Maybe, 9=Unk.

|__|

ER/hospitalized or saw M.D.

0=No, 1=Hosp/ER, 2=Saw M.D., 9=Unk.

if yes, fill

____________________________________

Name of the Hospital (write Unk. if unknown)

____________________________________

Name of M.D. (write Unk. if unknown)

|__|

Have you had a head injury with loss of consciousness?

0=No, 1=Yes, 2=Maybe, 9=Unk.

if yes, fill

|__|__| * |__|__| * |__|__|__|__|

Date of serious head injury with loss of consciousness

99/99/9999=Unk.

|__|

Have you had a seizure?

0=No, 1=Yes, 2=Maybe, 9=Unk.

if yes,fill

|__|__| * |__|__| * |__|__|__|__|

Date of most recent seizure

99/99/9999=Unk.

|__|

Are you being treated for a seizure disorder?

0=No, 1=Yes, 2=Maybe, 9=Unk.

Syncope First Examiner Opinion
|__|	Syncope (0=No, 1=Yes, 2=Maybe, 3=Presyncope, 9=Unk.) needs second opinion
if yes, fill	|__|	Cardiac syncope	0=No, 1=Yes, 2=Maybe, 9=Unk.
	|__|	Vasovagal syncope
	|__|	Other-Specify: _____________________

Comments:________________________________________________________________________________

_______________________________________________________________MD13 CL

Medical History—Cerebrovascular, Neurological and Venous Diseases

Since your last exam or medical history update have you had…
|__|	Sudden muscular weakness			0=No, 1=Yes, 2=Maybe, 9=Unk.
|__|	Sudden speech difficulty
|__|	Sudden visual defect
|__|	Sudden double vision
|__|	Sudden loss of vision in one eye
|__| if yes, fill 	Sudden numbness, tingling
	|__|	Numbness and tingling is positional
|__|	Head CT scan OTHER THAN FOR THE FHS			0=No,1=Yes, 2= Maybe,9=Unk.
if yes, fill 	|__|__| * |__|__| * |__|__|__|__|		Date	99/99/9999=Unk.
	___________________________		Place
|__|	Head MRI scan OTHER THAN FOR THE FHS			0=No,1=Yes, 2= Maybe,9=Unk.
if yes, fill 	|__|__| * |__|__| * |__|__|__|__|		Date	99/99/9999=Unk.
	___________________________		Place
|__|	Seen by neurologist (write in who and when below.) _________________________________________________			0=No, 1=Yes, 2=Maybe, 9=Unk.
|__|	Have you been told by a doctor you had a stroke or TIA (transient ischemic attack, mini-stroke)?
|__|	Have you been told by a doctor you have Parkinson Disease?
|__|	Have you been told by a doctor you have memory problems, dementia or Alzheimer’s disease?
|__	Do you feel or do other people think that you have memory problems that prevent you from doing things you’ve done in the past?
|__|	Do you feel like your memory is becoming worse?

Cerebrovascular Disease First Examiner Opinion
|__|	TIA or stroke took place		0=No, 1=Yes,2=Maybe, 9=Unk.
if yes or maybe fill 	|__|__|*|__|__|__|__|	Date (mo/yr, 99/9999=Unk.) Observed by_____________________________________________
	|__|__|*|__|__|*|__|__|	Duration (use format days/hours/mins, 99/99/99=Unk.)
	|__|	Hospitalized or saw M.D. (0=No, 1=Hosp.,2=Saw M.D, 9=Unk) Name__________________________________________________ Address_________________________________________________

Comments_________________________________________________________________________________

___________________________________________________________________________________________

MD14 CL

Medical History--Venous and Peripheral Arterial Disease

Venous Disease
Since your last exam or medical history update have you had…
|__|	Deep Vein Thrombosis - DVT (blood clots in legs or arms)	0=No,1=Yes, 2=Maybe, 9=Unk.
|__|	Pulmonary Embolus – PE (blood clot in lungs)

Peripheral Arterial Disease
Since your last exam have you had…
|__|	Do you get discomfort in either leg on walking? (0=No, 1=Yes, 9=Unk.)
if yes, fill 	|__|	Does this discomfort ever begin when you are standing still or sitting? (0=no, 1=yes, 9=Unk.)
	|__|__|	When walking at an ordinary pace on level ground, how many city blocks until symptoms develop (1=1 block or less, 99=Unk.) where 10 blocks=1 mile, code as no if more than 98 blocks required to develop symptoms
	Left		Right	Claudication symptoms	0=No, 1=Yes, 9=Unk.
	|__|		|__|	Discomfort in calf while walking
	|__|		|__|	Discomfort in lower extremity (not calf) while walking Write in site of discomfort_____________________________________
	|__|			Occurs with first steps (code worse leg)
	|__|			Do you get the discomfort when you walk up hill or hurry?
	|__|			Does the discomfort ever disappear while you are still walking?
	|__|			What do you do if you get discomfort when you are walking? (1=stop, 2=slow down, 3=continue at same pace, 9=Ukn.)
	|__|__|__|			Time for discomfort to be relieved by stopping (minutes) (000=No relief with stopping, 999=Unk.)
	|__|__|			Number of days/month of lower limb discomfort (1=1 day/month or less, 99=Unk.)
|__|	Since your last exam have you been told by a doctor you have intermittent claudication or peripheral artery disease? (0=No, 1=Yes, 9=Unk).
if yes, fill 	Name of doctor ______________________________________________________
	Date of visit |__|__|*|__|__|*|__|__|__|__| 99/99/9999=Unk.
|__|	Since your last exam have you been told by a doctor you have spinal stenosis? (0=No, 1=Yes, 9=Unk).

Intermittent Claudication First Examiner Opinion
|__|	Intermittent Claudication	0=No, 1=Yes, 2=Maybe, 9=Unk.

Comments _________________________________________________________________________________________

________________________________________________________________________________________

MD15 CL

Medical History-- CVD Procedures

Since your last exam or medical history update did you have any of the following cardiovascular procedures?
0=No, 1=Yes 2=Maybe, 9=Unk.	Cardiovascular Procedures (if procedure was repeated code only first and provide narrative)
|__|	Heart Valvular Surgery
if yes fill	|__|__|__|__| Year done (9999=Unk)
|__|	Exercise Tolerance Test
if yes fill	|__|__|__|__| Year done (9999=Unk)
|__|	Coronary arteriogram
if yes fill 	|__|__|__|__| Year done (9999=Unk)
|__|	Coronary artery angioplasty or stent
if yes fill	|__|__|__|__| Year done (9999=Unk)
|__|	Coronary bypass surgery
if yes fill	|__|__|__|__| Year done (9999=Unk)
|__|	Permanent pacemaker insertion
if yes fill 	|__|__|__|__| Year done (9999=Unk)
|__|	AICD
if yes fill 	|__|__|__|__| Year done (9999=Unk)
|__|	Carotid artery surgery or stent
if yes fill 	|__|__|__|__| Year done (9999=Unk)
|__|	Thoracic aorta surgery
if yes fill 	|__|__|__|__| Year done (9999=Unk)
|__|	Abdominal aorta surgery
if yes fill 	|__|__|__|__| Year done (9999=Unk)
|__|	Femoral or lower extremity surgery
if yes fill 	|__|__|__|__| Year done (9999=Unk)
|__|	Lower extremity amputation
if yes fill 	|__|__|__|__| Year done (9999=Unk)
|__|	Other Cardiovascular Procedure (write in below)
if yes fill 	|__|__|__|__| Year done (9999=Unk) Description______________________________________

Write in other procedures, year done, and location if more than one.

Comments:____________________________________________________________________________

______________________________________________________________________________________

MD16 CL

Physical Exam—Blood Pressure

Physician Blood Pressure Second reading
Systolic	BP cuff size
|__|__|__| to nearest 2 mm Hg	|__| 0=pedi,1=reg.adult, 2=large adult, 3= thigh, 9=Unk.
Diastolic	Protocol modification
|__|__|__| to nearest 2 mm Hg	|__| 0=No, 1=Yes, 9=Unk.

Comments for Protocol modification__________________________________________________________

__________________________________________________________________________________________

__________________________________________________________________________________________

__________________________________________________________________________________________

__________________________________________________________________________________________

__________________________________________________________________________________________

MD??

Cancer Site or Type

|__|	Since your last exam or medical history update have you had a cancer or a tumor? (0=No and skip to next page MD21; If 1=Yes, 2=Maybe, 9=Unk. please continue)

Check ALL that apply	Site of Cancer or Tumor	Year First Diagnosed	Cancer	Maybe cancer	Benign	Name Diagnosing M.D.	City/State of M.D.
			Check ONE
			1	2	3
	Esophagus				
	Stomach				
	Colon				
	Rectum				
	Pancreas				
	Larynx				
	Trachea/Bronchus/Lung				
	Leukemia				
	Skin				
	Breast				
	Cervix/Uterus				
	Ovary				
	Prostate				
	Bladder				
	Kidney				
	Brain				
	Lymphoma				
	Other/Unk. ______________				

Comment (If participant has more details concerning tissue diagnosis, other hospitalization, procedures, and treatments)

__________________________________________________________________________________________

__________________________________________________________________________________________

__________________________________________________________________________________________

MD17

Physical Exam—Respiratory, Heart, Abdomen

OFFSITE VISIT – leave page BLANK

Respiratory
|__|	Wheezing on auscultation	0=No, 1=Yes, 2=Maybe, 9=Unk.
|__|	Rales
|__|	Abnormal breath sounds

Heart
|__|	S3 Gallop	0=No, 1=Yes, 2=Maybe, 9=Unk.
|__|	S4 Gallop
|__|	Systolic Click
|__|	Neck vein distention at 90 degrees (sitting upright)

|__| if yes, fill below	Systolic murmur(s)				0=No, 1=Yes, 2=Maybe, 9=Unk.
Murmur Location	Grade 0=No sound 1 to 6 for grade of sound heard 9=Unk.		Type 0=None 1=Ejection 2=Regurgitant 3=Other 9=Unk.	Radiation 0=None 1=Axilla 2=Neck 3=Back 4=Rt. chest 9=Unk.	Origin 0=None, indet. 1=Mitral 2=Aortic 3=Tricuspid 4=Pulm 9=Ukn.
Apex	|__|		|__|	|__|
Left Sternum	|__|		|__|	|__|
Base	|__|		|__|	|__|
|__| if yes, fill 	Diastolic murmur(s)				0=No, 1=Yes, 2=Maybe, 9=Unk.
	|__|	Valve of origin for diastolic murmur(s) (1=Mitral, 2=Aortic, 3=Both, 4=Other, 8=N/A, 9=Unk)

Abdominal Abnormalities
|__|	Liver enlarged	0=No, 1=Yes, 2=Maybe, 9=Unk.
|__|	Surgical scar
|__|	Abdominal aneurysm
|__|	Abdominal bruit

Comments ________________________________________________________________________________

__________________________________________________________________________________________

__________________________________________________________________________________________

MD18 CL

Physical Exam--Peripheral Vessels—Veins and Arterial pulses

OFFSITE VISIT – leave page BLANK

Left	Right		Lower Extremity Abnormalities
|__|	|__|		Stem varicose veins (Do not code reticular or spider varicosities) (0=No abnormality 1=Yes 9=Unk.)
|__|	|__|		Ankle edema (0=No, 1=Yes, 2=Maybe, 8=absent due to amputation 9=Unk.)
|__|		|__|	Amputation level (0=No, 1=Toes only, 2=Foot, 3=below Knee, 4=above Knee, 5= Other, write in______________, 9=Unk.)

Artery	Pulse		Bruit
	(0=Normal, 1=Abnormal, 9=Unk.)		(0=Normal, 1=Abnormal, 9=Unk.)
	Left	Right	Left	Right
Femoral	||	||	||	||
Popliteal			|__|	|__|
Post Tibial	|__|	|__|
Dorsalis Pedis	|__|	|__|

Comments__________________________________________________________________________________

___________________________________________________________________________________________

___________________________________________________________________________________________

MD19

Physical Exam--Neurological Exam

OFFSITE VISIT – leave page BLANK

Neurological Exam
Left	Right
|__|	|__|	Carotid Bruit	0=No, 1=Yes, 2=Maybe, 9=Unk.
|__|		Speech disturbance
|__|		Disturbance in gait
|__|		Other neurological abnormalities on exam Specify___________________________________

Comments ________________________________________________________________________________

__________________________________________________________________________________________________

__________________________________________________________________________________________________

__________________________________________________________________________________________________

MD20 CL

Electrocardiograph--Part I

OFFSITE ONLY
|__|__|__|	MD Id#	______________________	MD Name

Rates and Intervals
||||	Ventricular rate per minute (999=Unk.)
|__|__|__|	P-R Interval (milliseconds) (999=Fully Paced, Atrial Fib, or Unk.)
|__|__|__|	QRS interval (milliseconds) (999=Fully Paced, Unk.)
|__|__|__|	Q‑T interval (milliseconds) (999=Fully Paced, Unk.)
|__|__|__|__|	QRS angle (put plus or minus as needed) (e.g. ‑045 for minus 45 degrees, +090 for plus 90, 9999=Fully paced or Unk.)

Rhythm--predominant
|__|	0 or 1 = Normal sinus, (including s.tach, s.brady, s arrhy, 1 degree AV block) 3 = 2nd degree AV block, Mobitz I (Wenckebach) 4 = 2nd degree AV block, Mobitz II 5 = 3rd degree AV block / AV dissociation 6 = Atrial fibrillation / atrial flutter 7 = Nodal 8 = Paced 9 = Other or combination of above (list)

Ventricular conduction abnormalities
|__|	IV Block (0=No, 1=Yes, 9=Fully paced or Unk.)
if yes, fill 	|__|	Pattern (1=Left, 2=Right, 3=Indeterminate, 9=Unk.)
	||	Complete (QRS interval=.12 sec or greater) (0=No, 1=Yes, 9=Unk.)
	|__|	Incomplete (QRS interval = .10 or .11 sec) (0=No, 1=Yes, 9=Unk.)
||	Hemiblock (0=No, 1=Left Ant, 2=Left Post, 9=Fully paced or Unk.)
|__|	WPW Syndrome (0=No, 1=Yes, 2=Maybe, 9=Fully paced or Unk.)

Arrhythmias
|__|	Atrial premature beats (0=No, 1=Atr, 2=Atr Aber, 9=Unk.)
||	Ventricular premature beats (0=No, 1=Simple, 2=Multifoc, 3=Pairs, 4=Run, 5=R on T, 9=Unk)
|__|__|	Number of ventricular premature beats in 10 seconds (see 10 second rhythm strip)

MD21 CL

Electrocardiograph‑Part II

Myocardial Infarction Location
||	Anterior	0=No, 1=Yes, 2=Maybe, 9=Fully paced or Unk.
||	Inferior
||	True Posterior

Left Ventricular Hypertrophy Criteria
||	R > 20mm in any limb lead	0=No, 1=Yes, 9=Fully paced, Complete LBBB or Unk
||	R > 11mm in AVL
||	R in lead I plus S in lead III  25mm
Measured Voltage
*|||	R AVL in mm (at 1 mv = 10 mm standard) Be sure to code these voltages
*|||	S V3 in mm (at 1 mv = 10 mm standard) Be sure to code these voltages
R in V5 or V6-----S in V1 or V2
||	R 25mm	0=No, 1=Yes, 9=Fully paced, Complete LBBB or Unk
||	S 25mm
||	R or S  30mm
||	R + S  35mm
||	Intrinsicoid deflection .05 sec
||	S-T depression (strain pattern)

Hypertrophy, enlargement, and other ECG Diagnoses
||	Nonspecific S‑T segment abnormality (0=No, 1=S-T depression, 2=S-T flattening, 3=Other, 9=Fully paced or Unk.)
||	Nonspecific T‑wave abnormality (0=No, 1=T inversion, 2=T flattening, 3=Other, 9=Fully paced or Unk.)
||	U‑wave present (0=No, 1=Yes, 2=Maybe, 9=Paced or Unk.)
||	Atrial enlargement (0=None, 1=Left, 2=Right, 3=Both, 9=Atrial fib. or Unk.)
||	RVH (0=No, 1=Yes, 2=Maybe, 9=Fully paced or Unk.; If complete RBBB OR LBBB present, RVH=9)
||	LVH (0=No, 1=LVH with strain, 2=LVH with mild S‑T Segment Abn, 3=LVH by voltage only, 9=Fully paced or Unk., If complete LBBB present, LVH=9)

Comments_________________________________________________________________________________

__________________________________________________________________________________________

__________________________________________________________________________________________

MD22……..CL

Clinical Diagnostic Impression--Part I

Heart Diagnoses
|__|	Rheumatic Heart Disease	0=No, 1=Yes, 2=Maybe, 9=Unk.
|__|	Aortic Valve Disease
|__|	Mitral Valve Disease
|__|	Arrhythmia
|__|	Other Heart Disease (includes congenital)
	(Specify)_____________________________________________

Peripheral Vascular Disease
|__|	Other Peripheral Vascular Disease	0=No, 1=Yes, 2=Maybe, 9=Unk.
|__|	Other Vascular Diagnosis
	(Specify)_____________________________________________

Neurological Disease
|__|	Stroke/ TIA	0=No, 1=Yes, 2=Maybe, 9=Unk.
|__|	Dementia
|__|	Parkinson's Disease
|__|	Adult Seizure Disorder
|__|	Migraine
|__|	Other Neurological Disease
	(Specify)_____________________________________________

Comments _________________________________________________________________________________

__________________________________________________________________________________________

__________________________________________________________________________________________

__________________________________________________________________________________________

MD23 CL

Clinical Diagnostic Impression--Part II. Non Cardiovascular Diagnoses

Endocrine
|__|	Thyroid Disease	0=No, 1=Yes, 2=Maybe, 9=Unk.
|__|	Diabetes Mellitus
|__|	Other endocrine disorders, specify_________________________________
GU/GYN
|__|	Renal disease, specify_____________________________________________	0=No, 1=Yes, 2=Maybe, 8=male/female 9=Unk.
|__|	Prostate disease
|__|	Gynecologic problems, specify_____________________________________
Pulmonary
|__|	Emphysema	0=No, 1=Yes, 2=Maybe, 9=Unk.
|__|	Pneumonia
|__|	Asthma
|__|	Other pulmonary disease, specify__________________________________
Rheumatologic Disorders
|__|	Gout	0=No, 1=Yes, 2=Maybe, 9=Unk.
|__|	Degenerative joint disease
|__|	Rheumatoid arthritis
|__|	Other musculoskeletal or connective tissue disease, specify_______________
GI
|__|	Gallbladder disease	0=No, 1=Yes, 2=Maybe, 9=Unk.
|__|	GERD/ulcer disease
|__|	Liver disease
|__|	Other GI disease, specify__________________________________________
Blood
|__|	Hematologic disorder	0=No, 1=Yes, 2=Maybe, 9=Unk
|__|	Bleeding disorder
Infectious Disease
|__|	Infectious Disease	0=No, 1=Yes, 2=Maybe, 9=Unk
if yes 	specify_________________________________________________________
Mental Health
|__|	Depression	0=No, 1=Yes, 2=Maybe, 9=Unk.
|__|	Anxiety
|__|	Psychosis
|__|	Other Mental health, specify_______________________________________
Other
|__|	Eye	0=No, 1=Yes, 2=Maybe, 9=Unk.
|__|	ENT
|__|	Skin
|__|	Other, specify___________________________________________________

Comments ________________________________________________________________________________________

_________________________________________________________________________________________

MD24

Second Examiner Opinions

OFFSITE VISIT – leave page BLANK

|__|__|__|

2nd Examiner ID number

______________________

2nd Examiner Last Name

Coronary Heart Disease (Provide initiators, qualities, radiation, severity, timing, presence after procedures done)
Item requireS 2nd opinion Check ALL that apply.	2nd opinion
	|__|	Congestive Heart Failure	0=No, 1=Yes, 2=Maybe, 9=Unk.
	|__|	Cardiac Syncope
	|__|	Angina Pectoris
	|__|	Coronary Insufficiency
	|__|	Myocardial Infarct

Comments about heart disease ________________________________________________________________

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Intermittent Claudication (Provide initiators, qualities, radiation, severity, timing, presence after procedures done)
Item requires 2nd opinion Check ALL that apply.	2nd opinion
	|__|	Intermittent Claudication	0=No, 1=Yes, 2=Maybe, 9=Unk.

Comments about peripheral artery disease _____________________________________________________

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Cerebrovascular Disease (Provide initiators, qualities, severity, timing, presence after procedures done)
Item requires 2nd opinion Check ALL that apply.	2nd opinion
	|__|	Stroke	0=No, 1=Yes, 2=Maybe, 9=Unk.
	|__|	TIA

Comments about possible cerebrovascular disease_________________________________________________

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MD25 CL

Any Additional Comments for Second Examiner Opinions.

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08-18-10 OMB NO=0925-0216 03-08-2010