2 survey

OMB #: 0925-0216

Expiration Date: xx/xxxx

Public reporting burden for this collection of information is estimated to average 90 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 (0925-0216). Do not return the completed form to this address.

Numerical Data (Anthropometry)

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Technician Number.

Basic Information Check Protocol Modification ONLY if there was one and document it in Comment section
|__|	Marital Status (1=Single, 2=Married, 3=Widowed, 4=Divorced, 5=Separated)
|__|	Site of Exam (0=Heart Study, 1=Nursing home, 2=Residence, 3=Other, 9=Unk.)
|__|__|__|	Weight (to nearest pound, 999=Unk.)
	|__|	Protocol modification for weight (check if Yes)
if not FHS protocol fill	|__|	Method used to obtain weight, if not FHS protocol or field visit with portable scale (1=recorded in NH chart, 2=Other write in _________________________________________)
	|__|__|*|__|__|*|__|__|__|__|	Date weight obtained (99/99/9999=Unk.) if not Exam date
|__|__|*|__|__|	Height (inches, to next lower 1/4 inch, 99/99=Unk.) 88/88=field visit
	|__|	Protocol modification for height. (check if Yes)

Comments on all protocol modifications: ________________________________________________________________________________________

________________________________________________________________________________________

________________________________________________________________________________________

__________________________________________________________________________________________________________

TECH01

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

EXAM 31 Procedures Sheet
|__|	ECG
|__|	Physician Medical History (Tech. Medical History, off-site)
|__|	Observed Physical Performance	0=No
|__|	CES-D
|__|	MMSE	1=Yes
|__|	Berkman Social Network
|__|	Physical function: Katz, Rosow-Breslau, Nagi, IADL
|__|	Leisure Time Cognitive and Physical Activities	9=Unk.
|__|	Height 8=not done due to offsite visit
|__|	Weight
|__|	Socio-demographic, Nursing (Community) Services Use

Adverse Events
|__|__|__|	Technician ID#
|__|	Was there an adverse event in clinic/offsite exam that does not require further medical evaluation? (0=No, 1=Yes, 9=Unk.) Comments:____________________________________________________________
|__|	Was a FHS physician contacted during the offsite examination due to medical concern? (0=No, 1=Yes, 9=Unk.) (offsite exam only) Comments:____________________________________________________________

Exit Interview
|__|__|__|		Technician ID
	|__|		Procedure Sheet Review	0=No 1=Yes
	|__|		Referral Sheet Review
	|__|		Left Clinic with all belongings 8=n/a, offsite
	|__|		Feedback 0=No feedback, 1=Positive feedback, 2=Negative feedback, 3=Other
			Comments_____________________________________________________ ______________________________________________________________ ______________________________________________________________

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.

TECH02

Observed performance. Part 1 Technician Administered

|__|	Check here if whole page is blank.		Reason why___________________________________
|__|__|__|		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.

PHYSICAL FUNCTION TEST 10 seconds stand
Side by Side
Was this test completed? Held for 10 seconds (0=No, 1=Yes, 8=N/A, 9=Unk.)	|__|
Number of seconds held if less than 10 99.99=Unk.	|__|__|*|__|__|
If not attempted or completed, why not? 1=Physical limitation 3=Other ____________________write in 2=Refused 9=Unk.	|__|
Semi-Tandem
Was this test completed? Held for 10 seconds (0=No, 1=Yes, 8=N/A, 9=Unk.)	|__|
Number of seconds held if less than 10 99.99=Unk.	|__|__|*|__|__|
If not attempted or completed, why not? 1=Physical limitation 3=Other ____________________write in 2=Refused 9=Unk.	|__|
Tandem
Was this test completed? Held for 10 seconds (0=No, 1=Yes, 8=N/A, 9=Unk.)	|__|
Number of seconds held if less than 10 99.99=Unk.	|__|__|*|__|__|
If not attempted or completed, why not? 1=Physical limitation 3=Other ____________________write in 2=Refused 9=Unk.	|__|

TECH03

Observed performance. Part 2 Technician Administered

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Reason why___________________________________

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Technician Number

Repeated Chair Stands
Time to complete five stands in seconds (99.99=Unk.)			|__|__|*|__|__|
If less than five stands, enter the number (9=Unk.)			|__|
IF OFFSITE visit, Chair height (in inches, 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.

Measured Walks
Course in meters. OFFSITE ONLY (check one)			|__| |__| 3m 4m
Walking aid used: (0=No aid, 1=Cane, 2=Walker, 3=Other, 9=Unk.)			|__|
First Walk
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.)			|__|__|*|__|__|
|__|	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.)			|__|__|*|__|__|
|__|	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.)

TECH04

Mini-Mental State Exam

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Reason why___________________________________

Read Script: I’m going to ask some questions that require concentration and memory. Some questions are more difficult than 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, nursing 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. Write in Letters, ____________________ (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?

TECH05

Mini-Mental State Exam

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Reason why___________________________________

SCORE CORRECT No Try=6, Unk.=9	Write all responses on exam form. (score 1 point for each correct answer)
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)

0=No, 1=Yes, 2=Maybe, 9=Unk	Factor Potentially Affecting Mental State Testing
0 1 2 9	Illiterate or low education
0 1 2 9	Poor eyesight
0 1 2 9	Poor hearing
0 1 2 9	Depression / possible depression
0 1 2 9	Other

TECH06

Socio-demographics

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Reason why___________________________________

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Technician Number for Socio-demographics

Socio-demographics
|__|	Where do you live? (0=Private residence, 1=Nursing home, 2=Other institution, such as: assisted living or retirement community, 9=Unk.)
|__|	Does anyone live with you? (0=No, 1=Yes, 9=Unk.) Code Nursing Home Residents as NO to these questions
If Yes  If 0 or 9, skip down	|__| Spouse	0=No 1=Yes, less than 3 months per year 2=Yes, at least 3 months per year 9=Unk.
	|__| Children
	|__| Other Relatives
|__|	Are you Currently working at a paying job or doing unpaid volunteer or community work? (0=No,1=Yes.)
|__|__|__|	During the past 6 months (180 days) how many days were you so sick that you were unable to carry out your usual activities? (999=Unk.)

** Proxy may NOT be used to help complete this section **
|__|	In general, how is your health now: (1=Excellent, 2=Good, 3=Fair, 4=Poor, 9=Unkn)
|__|	Compare your health to most people your own age: (1=Better, 2=About the same, 3=Worse than most people your own age, 9=Unk.)
|__|	As I get older, things are: (1= Better than I thought they’d be, 2=About the same that I thought they’d be, 3= Worse, 9=Unk.

TECH07

Instrumental Activities of Daily Living (Lawton IADL)

(Not administered to nursing home residents)

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Reason why___________________________________

Instructions: Use the prompt cards when asking these questions .If code=2 –write in definition of “some help”

|__|__|	1. Can you use the phone:
	01	completely unable to use the phone
	02	with some help
	03	without help (operates phone on own initiative, looks up, dials number, etc.)
|__|__|	2. Can you get to places out of walking distance:
	01	completely unable to travel unless special arrangements are made (taxi or car with human assistance)
	02	with some help (when assisted or accompanied by another)
	03	without help (travels independently: drives car, public transportation or use of taxi)
|__|__|	3. Can you go shopping for groceries :
	01	completely unable to do any shopping
	02	with some help (needs to be accompanied on any shopping trip)
	03	without help
	88	resides in assisted living facility, does not do
|__|__|	4. Can you prepare your own meals:
	01	completely unable to prepare meals (needs meals prepared and served)
	02	with some help (heat and serve prepared meals)
	03	without help (plans, prepares, serves meals)
	88	resides in assisted living facility, does not do
|__|__|	5. Can you do your own housework :
	01	completely unable to do any housework
	02	with some help
	03	without help (performs light daily tasks – dishwashing, bed making, etc).
	88	resides in assisted living facility, does not do
|__|__|	6. Can you do your own handyman work:
	01	completely unable to do any handyman work
	02	with some help
	03	without help
	88	resides in assisted living facility, does not do
|__|__|	7. Can you do your own laundry:
	01	completely unable to use the laundry
	02	with some help (such as using laundry service)
	03	without help (does personal laundry completely)
	88	resides in assisted living facility, does not do
|__|__|	8. A. Do you take medicines or use any medications:
		01	Yes Go to question 8B
		02	No Go to question 8C
|__|__|	8. B. Do you take your own medicines:
		01	completely unable to take own medicine
		02	with some help (if someone prepares it or reminds you)
		03	without help (in the right doses at the right time)
|__|__|	8. C. If you had to take medicine, could you do it:
		01	completely unable to take own medicine
		02	with some help (if someone prepares it or reminds you)
		03	without help (in the right doses at the right time)
|__|__|	9. Can you manage your own money:
	01	completely unable to manage own money
	02	with some help (manages day-to-day purchases, needs help with banking, major purchases)
	03	without help

TECH08

Self-Reported Physical Function.

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Reason why___________________________________

Note: If the participant is unable to answer the Nagi & Rosow-Breslau questions, Proxy may answer these questions.

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Technician Number for Rosow-Breslau and Nagi Quest.

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 or Institutional 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)

	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, unable to do 1=Yes, able 2=Does not do 9=Unk.
	|__|	Are you able to walk half a mile without help? (About 4-6 blocks)
	if NO then 	|__|	Are you able to walk a quarter of a mile without help? (About 2-3 blocks)
	|__|	Are you able to walk up and down stairs to the second floor without any help?
	if NO then 	|__|	Are you able to climb up 10 steps without help?
	|__|	Do you drive now? (0=No, 1=Yes, 9=Unk)
if NO then 		|__|	Reason for not driving now (1=Health, 2=Other non‑health reason, 3=never licensed, 9=Unk.)

TECH09

Self-Reported Physical Function.

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Reason why___________________________________

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Technician Number for Physical Function

Katz: Activities of Daily Living
During the Course of a Normal Day, can you do the following activities independently or do you need help from another person or use special equipment or 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.
|__|	Bladder Continence (ask if person has "accidents"; code=5 if use special products) Devices such as: external catheter, drainage bags, ileal appliance, protective devices.
|__|	Bowel Continence (ask if person has "accidents") (code=5 if use special products) Devices such as: suppositories, bedpan, regular enemas, colostomy.
|__|	Walking on Level Surface about 50 Yards Devices such as: cane, crutches, or walker.
|__|	Walking up and down One Flight Stairs Devices such as: handrail, cane.

TECH10

Activities Questions.

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Reason why___________________________________

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Technician Number for Activities Questions

Use of Nursing and Community Services
|__|	Have you been admitted to a nursing home (or skilled facility) since your last exam or medical history update? (0=No, 1=Yes, 9=Unk.)
|__|	Since your last exam, have you been visited by a nursing service, or used home, community, or outpatient programs? (0=No, 1=Yes, 9=Unk.)
if yes, check all services	|__|	Home health aides
	|__|	Homemaker visits
	|__|	Visiting Nurses
	|__|	Other (write in)_______________________________________________

|__|	Are you in bed or a chair for most or all of the day (on the average)? Note: this is a lifestyle question, not related to poor health. (0=No, 1=Yes, 9=Unk.)
|__| if yes then 	Do you need a special aid (wheelchair, cane, walker) to get around? (0=No, 1=Yes, 9=Unk.) If yes, which of the following equipment do you use?
	|__|	Cane or walking stick	0=No 1=Yes, always 2=Yes, sometimes 9=Unk.
	|__|	Wheelchair
	|__|	Walker
	|__|	Other (Write in )_____________________________

TECH11

Falls and Fractures

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Technician Number for Falls and Fractures

|__| if yes, fill 	Since your last exam have you accidentally fallen and hit the floor or ground? (code as no if during sports activity) (0=No, 1=Yes, 2=Maybe, 9=Unk)
	|__|__|		How many times did you fall in the past year? (99=Unk.)
|__| If 1 or 2, fill 	Since your last exam or medical history update have you broken any bones? (0=No, 1=Yes, 2=Maybe, 9=Unk.)
	|__|__|	Location of 1st fracture
	|__|__|	Location of 2nd fracture
	|__|__|	Location of 3rd fracture
		Location Fracture Code
		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)____________________________

TECH12

Berkman Social Network Questionnaire. Tech-administered

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Reason why___________________________________

The next questions ask about your social support. Please tell me the response that most closely describes your current situation.

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Technician Number for Berkman Questionnaire.

For each question please circle one answer
Coding scheme	None	1 or 2	3 to 5	6 to 9	10 or more	Unk.
1. How many close friends do you have, people that you feel at ease with, can talk to about private matters?	0	1	2	3	4	9
2. How many of these close friends do you see at least once a month?	0	1	2	3	4	9
3. How many relatives do you have, people, that you feel at ease with, can talk to about private matters?	0	1	2	3	4	9
4. How many of these relatives do you see at least once a month?	0	1	2	3	4	9

5. Do you participate in any groups such as a senior center, social or work group, religious connected group, self-help group, or charity, public service or community group?
Circle one answer
No	Yes	Unk.
0	1	9

6. About how often do you go to religious meetings or services?
Circle one answer
Never or almost never	Once or twice a year	Every few months	Once or twice a month	Once a week		More than once a week	Unk.
0	1	2	3	4		5	9

TECH13

Berkman Social Network Questionnaire

Tech- Administered

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Reason why___________________________________

|__|	7. Do you have health insurance other than Medicare or Medicaid? (0=No, 1=Yes, 9=Ukn.)

For each question please circle one answer
Coding Scheme	None of the time	A little of the time	Some of the time	Most of the time	All of the time	Unk.
8. Is there someone available to you whom you can count on to listen to you when you need to talk?	0	1	2	3	4	9
9. Is there someone available to give you good advice about a problem?	0	1	2	3	4	9
10. Is there someone available to you who shows you love and affection?	0	1	2	3	4	9
11. Can you count on anyone to provide you with emotional support (talking over problems or helping you make a difficult decision)?	0	1	2	3	4	9
12. Do you have as much contact as you would like with someone you feel close to, someone in whom you can trust and confide?	0	1	2	3	4	9

TECH14

Leisure Time Cognitive and Physical Activities

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Technician Number for Leisure time activities.

During the past year, how often have you participated in the following leisure time activities?

Questions to be answered Circle best answer for each question	Never	Daily (7 days per week)	Several days per week (2-6 days per week)	Once weekly (1 day per week)	Monthly (once a month)	Occasionally (< once a month)	Unk.
1. Reading books/newspapers	0	1	2	3	4	5	9
2. Writing for pleasure	0	1	2	3	4	5	9
3. Doing crossword puzzles	0	1	2	3	4	5	9
4. Playing board games or cards	0	1	2	3	4	5	9
5. Participating in organized group discussions	0	1	2	3	4	5	9
6. Group exercises	0	1	2	3	4	5	9
7. Housework	0	1	2	3	4	5	9
8. Playing musical instruments	0	1	2	3	4	5	9

TECH15

CES-D Scale

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Reason why___________________________________

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Technician Number for CES-D Scale

The next questions ask about your feelings. For each of the following statements, please say if 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

TECH16

Proxy form

|__| 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.)

TECH17

Mini-Mental State Exam

Sentence and Design Handout for Participant

PLEASE WRITE A SENTENCE

_________________________________________________________________________________

_________________________________________________________________________________

_________________________________________________________________________________

PLEASE COPY THIS DESIGN

Date of exam

_____/_____/_____

Framingham Heart Study

Cohort Exam 31

Summary Sheet to Personal Physician

Blood Pressure	First Reading	Second Reading
Systolic
Diastolic

ECG Diagnosis ______________________________________________________________________

___________________________________________________________________________________

Summary of Findings__________________________________________________________________

____________________________________________________________________________________

____________________________________________________________________________________

____________________________________________________________________________________

____________________________________________________________________________________

____________________________________________________________________________________

____________________________________________________________________________________

____________________________________________________________________________________

____________________________________________________________________________________

____________________________________________________________________________________

__________________________

Examining Physician

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

Referral Tracking

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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	SBP or DBP Phone call > 200 or >110 Expedite > 180 or >100 Elevated > 140 or >90
		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:_________________

_____________________________________________________________________________________

REF1

Medical History—Hospitalizations, ER Visits, MD Visits

Cohort Exam31

DATE ______________

DATE of last exam «Lastexamdate»

DATE of last health update «Evdate»

Health Care
Since your last exam or health update
|__|__|__|	1st Examiner ID _________________________ 1st Examiner Name
|__|	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.)
|__|__| |__|__| |__|__|__|__| MM DD YYYY	Date of this FHS exam (Today's date ‑ See above)

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

MD01

Medical History—Medications

Hypertension
|__|	Since your last exam have you taken medication for the treatment of hypertension? (high blood pressure) (0=No, 1=Yes, now, 2=Yes, not now, 9=Unk)

Aspirin use
|__| If yes, fill 	Take aspirin regularly? (0=No, 1=Yes, 9=Unk)
	|__|__|	Number of aspirins taken regularly (99=Unk.)
	|__|	Aspirin frequency- number taken regularly (0=Never, 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

MD02

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 or med bottles/packs used by examiner to complete form? (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

Fill in Number per or PRN

Number per (circle one)

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

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

100

mg

1

D W M Y

0

EXAMPLE:

S

A

M

P

L

E

D

R

U

G

N

A

M

E

D W M Y

D W M Y

D W M Y

D W M Y

D W M Y

D W M Y

D W M Y

D W M Y

D W M Y

D W M Y

D W M Y

Continue on the next page 

MD03

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

Fill in Number per or PRN

Number per (circle one)

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

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

100

mg

1

D W M Y

0

EXAMPLE:

S

A

M

P

L

E

D

R

U

G

N

A

M

E

D W M Y

D W M Y

D W M Y

D W M Y

D W M Y

D W M Y

D W M Y

D W M Y

D W M Y

D W M Y

D W M Y

D W M Y

D W M Y

D W M Y

D W M Y

MD04

Medical History–Blood Pressure, Smoking

Blood Pressure (first reading)
Systolic	BP cuff size
|__|__|__| to nearest 2 mm Hg 999=Unk.	|__| 0=pediatric,1=regular adult, 2=large adult, 3= thigh, 9=Unk.
Diastolic	Protocol modification
|__|__|__| to nearest 2 mm Hg 999=Unk.	|__| 0=No, 1=Yes, 9=Unk. write in _____________________

Smoking
|__| if yes fill 	Have you smoked cigarettes regularly since your last exam?		0=No, 1=Yes, now, 2=Yes, not now, 9=Unk.
	|__|__|	How many cigarettes do/did you smoke a day? (01=one or less, 99=Unk.)

MD05

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
What is your average number of servings in a typical week or month since your last exam? (999=Unk.) 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)		||||	||||

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

MD06

Medical History—Respiratory Symptoms. Part 1

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?

MD07

Medical History—Respiratory Symptoms. Part 2

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.)
|__|	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 		Name of doctor ______________________________________________________
		Date of visit |__|__|*|__|__|*|__|__|__|__| 99/99/9999=Unk.
|__|		Have you been hospitalized for heart failure?
if yes, fill 		Name of hospital ______________________________________________________
		Date of visit |__|__|*|__|__|*|__|__|__|__| 99/99/9999=Unk.

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

Comments________________________________________________________________________________

__________________________________________________________________________________________

MD08

Medical History—Heart

|__|	Any chest discomfort since last exam or medical history update? (0=No, 1=Yes, 2=Maybe, 9=Unk.) (please provide narrative comments in addition to checking the appropriate boxes)
if yes, filland below	|__|	Chest discomfort with exertion or excitement (0=No, 1=Yes, 2=Maybe, 9=Unk.)
	|__|	Chest discomfort when quiet or resting
	Chest Discomfort Characteristics (must have checked box at top of table)
	|__|__|*|__|__|__|__|		Date of onset	mo/yr, 99/9999=Unk.
	|__|__|__|		Usual duration (min)	1=1 min or less, 900=15 hrs or more, 999=Unk.
	|__|__|__|		Longest duration (min)	1=1 min or less, 900=15 hrs or more, 999=Unk.
	|__|		Location	0=No, 1=Central sternum and upper chest, 2=L up per 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.
	|__|__|__|		Frequency (number in past month)	999=Unk.
	|__|__|__|		Frequency (number in past year)	999=Unk.
	|__|		Type	1=Pressure, heavy, vise, 2=Sharp, 3=Dull, 4=Other, 9=Unk
	|__|		Relief by Nitroglycerine in <15 minutes		0=No 1=Yes, 8=Not tried 9=Unk.
	|__|		Relief by Rest in <15 minutes
	|__|		Relief Spontaneously in <15 minutes
	|__|		Relief by Other cause in <15 minutes

MD09

Medical History—Heart (Continued)

|__|	Have you since your last exam been told by doctor you have/had a heart attack or myocardial infarction? (0=No, 1=Yes, 2=Maybe, 9=Unknown)

if yes, fill 	Name of doctor ______________________________________________________
	Date of visit |__|__|*|__|__|*|__|__|__|__| 99*99*9999=Unk.
|__|	Have you been hospitalized for heart attack?
if yes, fill 	Name of hospital ______________________________________________________
	Date of visit |__|__|*|__|__|*|__|__|__|__| 99*99*9999=Unk.

CHD First Opinions
|__|	Angina pectoris in interim		0=No, 1=Yes, 2=Maybe, 9=Unk.
	|__|	Angina pectoris since revascularization procedure
|__|	Coronary insufficiency in interim
|__|	Myocardial infarct in interim

Comments_____________________________________________________________________________

______________________________________________________________________________________

______________________________________________________________________________________

______________________________________________________________________________________

MD10

Medical History—Atrial Fibrillation/Syncope

|__|	Have you been told you have/had a heart rhythm problem called 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.)
		Hospitalized at:___________________________________________
		M.D. seen: _______________________________________________

|__|	Have you fainted or lost consciousness since your last exam? (If due to stroke skip to screen 11) If event immediately preceded by head injury, or accident code 0=No				Code: 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.)
	|__|		Did you have any injury caused by the event? (0=No, 1=Yes, 2=Maybe, 9=Unk.)
	if yes, fill 	|__|		ER/hospitalized or saw M.D. (0=No, 1=ER/Hosp., 2=Saw M.D., 9=Unk.) Hospitalized at: _______________________________________ M.D. seen: ___________________________________________

Syncope First Opinions
|__|	Syncope (0=No, 1=Yes, 2=Maybe, 3=Presyncope, 9=Unk.)
	|__|	Cardiac syncope	0=No, 1=Yes, 2=Maybe, 9=Unk.
	|__|	Vasovagal syncope
	|__|	Other-Specify: ______________________
|__|	Seizure Disorder (0=No, 1=Yes, 2=Maybe,, 9=Unk.)

Comments ______________________________________________________________________________

_______________________________________________________________________________________

_______________________________________________________________________________________

_______________________________________________________________________________________

_______________________________________________________________________________________

MD11

Medical History—Cerebrovascular Disease

Cerebrovascular Episodes in Interim
|__|		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
|__|		Sudden numbness, tingling
if yes, fill 		|__|	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?

Comments:________________________________________________________________________________

__________________________________________________________________________________________

__________________________________________________________________________________________

MD12

Medical History—Cerebrovascular Disease Continued

Details for "Serious" Cerebrovascular Event in Interim
|__| if yes or maybe fill all 	Examiner's opinion that TIA or stroke took place in interim (0=No, 1=Yes, 2=Maybe, 9=Unk.)
	|__|__|*|__|__|__|__|	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______________________________

Neurology First Opinions
|__|	Stroke in Interim	0=No, 1=Yes, 2=Maybe, 9=Unk.
|__|	TIA
|__|	Dementia
|__|	Parkinson Disease
|__|	Other, Specify: __________________

Comments________________________________________________________________________________

__________________________________________________________________________________________

__________________________________________________________________________________________

__________________________________________________________________________________________

MD13

Medical History--Peripheral Arterial Disease

Peripheral Arterial Disease
|__|	Are you able to walk 50 feet without help? (0=Able to walk 50 feet without help, 1=Needs help, 2=Can’t walk, 9=Unknown)
|__|	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)
	|__|		After walking a while.
	|__|		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? Check one below
	|__| 1=stop		|__| 2=slow down	|__| 3=continue at same pace		|__| 9=Unk.
	|__|__|__|		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.)

MD14

Medical History--Peripheral Arterial Disease Continued

|__|	Since your last exam have you been told you have intermittent claudication or peripheral artery disease? (0=No, 1=Yes, 2=Maybe, 9=Unk.)
if yes, fill 	Name of doctor ______________________________________________________
	Date of visit |__|__|*|__|__|*|__|__|__|__|
|__|	Have you been hospitalized for intermittent claudication or peripheral artery disease? (0=No, 1=Yes, 2=Maybe, 9=Unk.)
if yes, fill 	Name of hospital ______________________________________________________
	Date of visit |__|__|*|__|__|*|__|__|__|__|

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

Comments________________________________________________________________________________

_________________________________________________________________________________________

_________________________________________________________________________________________

MD15

Venous Disease and Second Blood Pressure

Venous Disease
|__|	Since your last exam have you had a Deep Vein Thrombosis (blood clots in legs or arms)	0=No, 1=Yes, 9=Unk.
|__|	Since your last exam have you had a Pulmonary Embolus (blood clots in lungs)

Blood Pressure (second reading)
Systolic	BP cuff size
|__|__|__| to nearest 2 mm Hg 999=Unk.	|__| 0=pediatric,1=regular adult, 2=large adult, 3= thigh, 9=Unk.
Diastolic	Protocol modification
|__|__|__| to nearest 2 mm Hg 999=Unk.	|__| 0=No, 1=Yes, 9=Unk. write in _____________________

Comments on Protocol modification

_________________________________________________________________________________________

_________________________________________________________________________________________

_________________________________________________________________________________________

MD16

Medical History-- CVD Procedures

Since your last exam or health 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)
|__|	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______________________________________

Comments:___________________________________________________________________________

_____________________________________________________________________________________

_____________________________________________________________________________________

MD17

Cancer Site or Type

|__|	Since your last exam or health update have you had a cancer or a tumor? (0=No and skip to MD19 (next screen); 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 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)

__________________________________________________________________________________________

__________________________________________________________________________________________

__________________________________________________________________________________________

MD18

Electrocardiograph--Part I

|__|__|__|	Examiner ID Number _________________________________ Examiner Last Name
|__| if Yes, fill out rest of form	ECG done (0=No, 1=Yes)
	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, 99=Unk.)

MD19

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  25mm in lead III
	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 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 and Diagnosis______________________________________________________________________________________

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MD20

Clinical Diagnostic Impression.

Non Cardiovascular Diagnoses First Examiner Opinions
|__|	Diabetes Mellitus	0=No, 1=Yes, 2=Maybe, 9=Unk.
|__|	Prostate disease
|__|	Renal disease (specify)___________________
|__|	Emphysema
|__|	Chronic bronchitis
|__|	Pneumonia
|__|	Asthma
|__|	Other pulmonary disease
|__|	Gout
|__|	Degenerative joint disease
|__|	Rheumatoid arthritis
|__|	Gallbladder disease
|__|	Other non C-V diagnosis (for cancer, see special screen)

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MD21

Continue from MD21

Comments CDI Other Diagnoses______________________________________________________________________________

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MD22

Version wv1

01-11-2010 GM

03-08-2010 OMB No=0925-0216 04/30/2011