15 survey

OMB#: 0925-0216

Expiration Date: xx/xxxx

Public reporting burden for this collection of information is estimated to average 10 minutes per response, including the time for reviewing instructions, searching existing data sources, gathering and maintaining the data needed, and completing and reviewing the collection of information. An agency may not conduct or sponsor, and a person is not required to respond to, a collection of information unless it displays a currently valid OMB control number. Send comments regarding this burden estimate or any other aspect of this collection of information, including suggestions for reducing this burden, to: NIH, Project Clearance Branch, 6705 Rockledge Drive, MSC 7974, Bethesda, MD 20892-7974, ATTN: PRA (0925-0216). Do not return the completed form to this address.

Physician’s Name	Participant’s Name:
Physician's Mailing Address	Exam Date:
	DOB:
	ID:

________________________________________________________________________

The Heart Study evaluation focuses on cardiovascular disease and is NOT a comprehensive exam. Our research exam does NOT take the place of regular check-ups with a complete physical examination. The following tests are done on a routine basis: Lipids, Glucose, Pulmonary Function, Ankle-brachial BP. Abnormal findings for non-invasive C-V tests will be forwarded separately.

BLOOD PRESSURE:	FIRST READING	SECOND READING
Systolic Blood Pressure
Diastolic Blood Pressure
ECG DIAGNOSIS:
SUMMARY OF SIGNIFICANT HISTORY AND PHYSICAL EXAM:
1. No history or physical exam findings to suggest cardiovascular disease.

OMB No = 0925-0216 3/9/2010 ------------------------------------

HEART STUDY PHYSICIAN