Attach #fram3

OMB#: 0925-0216

Expiration Date: xx/xxxx

«FName» «MName» «LName»«Suffix»

«Str1»                                                                   

«Str2»

«City», «State»  «Zip»

ID#: «ID»

Dear «Prefix» «LName»,

We would like to update the health information that we have on file for you at the Framingham Heart Study.   As a participant in the Heart Study, it is important that we have information regarding diagnoses for any significant heart disease, vascular disease, stroke or cancer since we last examined you.

Please complete the enclosed medical history update form.  Also, please sign and date the consent form.  This procedure will give us permission to obtain the necessary information from the physicians and hospitals where you may have received care. Please inform us if there is any name, address or telephone number change.

If you have questions, please don’t hesitate to call Mary Ann Crossen at 1-508-935-3430 or 1-800-854-7582, extension 430.

Thank you for your help. 

                                                              Sincerely,

                                                                                               

                                   

                                                                                 

Daniel Levy

                                                                                                Director

                                                                                                Framingham Heart Study

                                   

                                                                                   

I hereby authorize _________________________________________________

                              _________________________________________________

                              _________________________________________________

to release to the Framingham Heart Study

                          73 Mt. Wayte Avenue

                          Framingham, MA 01702

The following protected health information my medical record.

Patient Name:             «FName» «MName» «LName»                     Date of Birth:              «DOB»

Address:                      «Str1»

                                    «Str2»

                                    «City», «State» «Zip»

Disclose the following information for dates from «Evdate» to present.

Face Sheet	CT Scan (Head)
Discharge Summary	MRI/MRA (Head/Neck)
ER Report	Lab Reports – Cardiac Enzymes
Admission Notes	Consults (Cardiac & Neuro)
Progress Notes	Cardiac Catheterization
Operative Report	Exercise Tolerance Test
Pathology Report	Nursing Home Notes
Chest X-Ray	Notes near time of death
EKGs (All)	Other _______________________
Echocardiogram	____________________________

The purpose for this disclosure is research.

The information disclosed under this authorization will not be redisclosed to anyone but the researchers conducting this study, except as required by law.

I understand I may revoke this authorization at any time by requesting such of the above referenced physician/hospital in writing. If I do it will not have any effect on actions that the hospital/physician took before it received the revocation.         

This authorization expires at the end of the research study.

Date: _______________________                Signed: _____________________________

For Office Use Only

TYPE   |___|___|	1=TELEPHONE     2=MAILER     3=ONSITE BONE STUDY     4=ONSITE EBCT     88=OTHER
INTERVIEWER   |___|___|___|		DATA ENTRY   |___|___|___|1     |___|___|___|2

ID                                                                                «ID» 

DATE OF LAST EXAM OR UPDATE                   «Evdate»

NAME                                                                        «FName» «MName» «LName»

ADDRESS and PHONE (if changed             _______________________________________________

since last exam/update)                                                                                  

                                                             _______________________________________________

SOCIAL SECURITY NUMBER |___|___|___| - |___|___| - |___|___|___|___|

DATE COMPLETED |___|___| - |___|___| - |___|___|

1.         a. First, please tell us who is completing this form:

                          Framingham Heart Study (FHS) participant whose name is above (Go to question 3)                                            Spouse

• Family member other than spouse

            (Relationship) ______________________________                                    

Go to1.b.

                           Friend             

                          Health care provider for FHS participant                   

                          Other __________________________

                                                                                                    

If other than participant, please answer the following questions.

                                   

b. Name ________________________________________

            c. How long have you known the participant?

                        |___|___| years    |___|___| months     

            d. Are you currently living in the same household with the participant? 

 yes              no

e. How often did you talk with the participant during the prior 11 months?  Check one.    

                                       Almost every day

• Several times a week

• Once a week

• 1 to 3 times per month

• Less than once a month

• Unknown / N/A

2.         Have you noticed that he/she has had any memory problems or change in personality?       

 yes              no

            Specifically:    ______________________________________________________

            If response to #2 “yes”:

            Has there been a diagnosis of dementia or Alzheimer’s Disease made by a doctor?

 yes              no

to whom should we send a consent form to be signed so that we can obtain medical records?

            name:    ___________________________________________________

            address: ___________________________________________________

            relationship:  _______________________________________________

           

Please go on to the next page

3.         Since the date of the last Framingham Heart Study exam or update on the first page of the Medical History Update form, have you seen a doctor or been hospitalized?

 yes              no              If yes, did you have any of the following problems?

            a.         Heart Problems, such as:

                        Yes      No       (Mark yes or no for each question)

                               Chest pain, angina or angina pectoris

                               Heart attack or myocardial infarction or MI

                               Heart failure or congestive heart failure or CHF

                 Atrial fibrillation or atrial flutter    

                               Heart catheterization or cardiac catheterization

                               Heart bypass operation or coronary bypass surgery or CABG

                               Procedure to unblock narrowed blood vessels to your heart

muscles (PTCA, coronary angioplasty, or coronary stent)

       Other heart problem (pacemaker, valve problem, aorta surgery,                                                                    ventricular tachycardia, other rhythm problem)

                                                Specify _________________________________________________

             b.        Circulatory Problems, such as:

Yes      No       (Mark yes or no for each question)

       Stroke, TIA (transient ischemic attack), sudden paralysis, vision

loss, inability to speak

                               Procedure to unblock narrowed blood vessels in your neck

                                                (carotid endarterectomy, carotid angioplasty).

       Poor blood circulation or blocked or narrowed blood vessels to the legs or                                                  feet, (claudication, peripheral arterial disease, gangrene)

       Amputation of part of a leg or toes, because of poor circulation or                                                               gangrene.

                               Blood clot or embolism in leg or lung.

                               Other circulatory problem.

                                                Specify __________________________________________________

Since the date of the last Framingham Heart Study exam or update on the  first page of the Medical History Update form, have you seen a doctor or been hospitalized for the following:

c.         Other Neurological Problems

Yes      No       (Mark yes or no for each question)

       Memory problems

       Other neurological problems such as Parkinson’s, multiple sclerosis,

                                                seizures, head injury. Specify problem________________________

                      Have you had an MRI scan of your brain other than for the Framingham

                                                Heart Study?

                                                Name of MRI Facility ____________________________________

                                                Date of MRI      |___|___| - |___|___| - |___|___|

                                                Reason for MRI:_________________________________________

            d.         Other Problems

Yes      No       (Mark yes or no for each question)

               Diabetes    If yes, please list medications you take for diabetes

                                                ______________________________________________________

       Cancer   Specify type ____________________________________

                                                Physician ______________________________________________

                                                Place where biopsy performed______________________________

                                                ______________________________________________________

                                                ______________________________________________________

       Fracture, broken bone (Specify including hip, back, arm, leg, pelvis,

                        collarbone, foot, toe and others)_____________________________      

       Other   Specify problem __________________________________

Please go on to the next page

4.         Since the date of your last Framingham Heart Study exam or update on the first page of the  Medical History Update form, have you been admitted to a HOSPITAL or gone to an EMERGENCY ROOM or seen a PHYSICIAN for other than a routine examination?

 yes (if yes, please give details)      no (go to question 5 on the next page)

Date |___|___| - |___|___| - |___|___|

Type* _______________________________________________________   _____

Reason** _______________________________________________________   _____

Hospital Name _____________________________ Doctor’s Name _____________________________

Address __________________________________  Address __________________________________

_________________________________________  __________________________________________

Date |___|___| - |___|___| - |___|___|

Type* _______________________________________________________   _____

Reason** _______________________________________________________   _____

Hospital Name _____________________________ Doctor’s Name _____________________________

Address __________________________________  Address __________________________________

_________________________________________  __________________________________________

Date |___|___| - |___|___| - |___|___|

Type* _______________________________________________________   _____

Reason** _______________________________________________________   _____

Hospital Name _____________________________ Doctor’s Name _____________________________

Address __________________________________  Address __________________________________

_________________________________________  __________________________________________

* Type                                                     ** Reason

1. Overnight admission                       1.  Heart problems

2. Emergency room visit                    2.  Stroke or transient ischemic attack (TIA), sudden paralysis, vision loss, inability

3. Day Surgery/Procedure                       to speak

4. M.D. visit                                          3.  Broken, crushed or fractured bones

                                                                4.  Cancer or malignant tumor

                                                                5.  Circulation problem, or blood clots

                                                                6.  Other reasons (Please specify)

Nursing Home/Rehabilitation Admissions.            

5.         Have you stayed overnight as a patient in a nursing home, rehabilitation center or transitional care unit (TCU) since the date of your last Framingham Heart Study exam or update on the top of  the first page of the Medical History Update form?

                yes                    no              (if no, go to Question 8.)

6.         Please list the name and location of the nursing home or rehabilitation center and the date

            you were admitted.

            Nursing home/Rehab Center name: __________________________________________

            Street address: ___________________________________________________________

            City/State/Zip Code _______________________________________________________

            Date you entered the nursing home/rehabilitation center |___|___| - |___|___| - |___|___|

7.         Were you an overnight patient in a nursing home, rehabilitation center or transitional care unit (TCU) at any other time since your last exam?

                yes                    no 

            Nursing home/Rehab Center name: __________________________________________

            Street address: ___________________________________________________________

            City/State/Zip Code _______________________________________________________

            Date you entered the nursing home/rehabilitation |___|___| - |___|___| - |___|___|

Marital Status.

8.         What is your current marital status?  Please check one

             married      widowed      divorced      separated          

 single, never married           living with partner

Health Status.   (Questions 9 and 10 to be filled out only by the participant.)    

9.         In general, how is your health now?

             Excellent

 Fair

             Poor

 Good        

             Don’t know

10.       Compare your health to most people your own age.  Would you say your health is?

             Better

 Worse than most people

             About the same

 Don’t know

Primary Care Physician

11.       Please list the name and address of your primary care physician.

            Name _____________________________________________

            Address ____________________________________________

            ___________________________________________________

you might be sent a consent form to sign so that we may obtain your medical records.