ACAM2000® Myopericarditis Registry

7253320103

ACAM2000 ® Myopericarditis Registry
Follow-up
For office use only

Subject ID

MARKING INSTRUCTIONS
• Use BLACK or BLUE ink.
• Shade circles like this:
• Mistakes must be crossed out with an "X".
• Print in CAPITAL LETTERS and avoid contact with the edge of the box. EXAMPLE:

A B C D E F G H

I

J K L M N O P Q R S T U V W X Y Z

• Answer every question to the best of your ability.
• It will take approximately 30 minutes to complete the questionnaire.

DoD RCS # DD-HA(SA)2424 (expires12/31/2013)
Protocol # NHRC.2009.0015

1. What is your current mailing address?
Address Line 1:
Address Line 2
(optional):
City (or FPO/APO):
State/Province/Region
(or AA/AE/AP):

ZIP/Postal Code:

Country:

2. Phone number:

To update your contact information, please contact us by email at
[email protected] or by phone at 619-553-9255.
3. What is today's date?
M

M

D

6. What is your current military status?

D

/

Y

Y

Y

Regular Active Duty

Y

/

Active Reserve/Guard
Reserve/Guard (not active)

4. What is your date of birth?
M

M

D

/

D

1

Separated
Y

Y

Y

Y

/

7. What is your Rank/Grade? (For example: E-01, W-05,
O-10, etc.)

5. What is your current weight?

pounds

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9. What is the highest level of education that you have
completed? (Choose the single best answer)

8. What is your current marital status?
(Choose the single best answer)
Single, never married

Less than high school completion/diploma

Separated (no longer living as a married couple)

High school degree/GED/or equivalent

Married (not separated)

Some college, no degree

Divorced

Associate's degree

Widowed

Bachelor's degree
Master's, doctorate, or professional degree

10. Have you received any vaccinations since the time covered in your last survey?
No

Yes
If you marked "NO," to question 10 skip to question 12.
If you marked "YES" please proceed to question 11.

11. Please list all the vaccinations you have received since the time covered in your last survey.
M M

Y

Y

M M

Y Y

Y

a.

/

d.

/

b.

/

e.

/

c.

/

f.

/

Y

Y Y

12. Since the time covered in your last survey:
a. Have you had a biological grandmother(s), mother, or sister(s) under the age
of 65 develop heart disease?

No

Yes

Unsure

b. Have you had a biological grandfather(s), father, or brother(s) under the age
of 55 develop heart disease?

No

Yes

Unsure

c. Have you had a first degree relative (for example, mother, father, sister, or
brother) under the age of 50 develop a heart condition?

No

Yes

Unsure

d. Has someone in your family been diagnosed with Myocarditis or Pericarditis?

No

Yes

Unsure

13. Since the time covered in your last survey, have you been diagnosed with any medical
conditions and/or have you received treatment for any medical conditions? (please consider
cardiac and non-cardiac conditions)
If YES, please specify:

Page 2

No

Yes

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7956320103

14. Since the time covered in your last survey, have you had any of the following symptoms?
a. Weakness (not related to exercise)

No

Yes

b. Fever

No

Yes

c. Gastrointestinal symptoms

No

Yes

d. Shortness of breath

No

Yes

e. Chest pain

No

Yes

If you have NOT experienced chest pain since completing your last survey, please skip to question 17 on page 4.
If you marked "YES" to question 14e, please proceed to question 15.

15. The following questions relate to the chest pain you have experienced since completing your last survey.
Does the pain...
a. Increase when you lie on your back?

No

Yes e. Worsen when leaning forward while sitting?

b. Decrease when you lie on your back?

No

Yes

c. Improve when lying on one side?

No

Yes

d. Worsen when lying on one side?

No

Yes

No

Yes

f. Feel tender when you touch it?

No

Yes

g. Other? (if YES, please describe)

No

Yes

describe other chest pain

16. The following questions ask how much your heart condition affected your life during the past 4 weeks. After each
question, select 0, 1, 2, 3, 4, or 5 to show how much your life was affected. If a question does not apply to you,
mark the 0 after that question.
Did your heart condition prevent you from living as
you wanted during the PAST 4 WEEKS by:

No

Very
Little

a. Causing swelling in your ankles or legs?

0

1

2

3

4

5

b. Making you sit or lie down to rest during
the day?

0

1

2

3

4

5

c. Making your walking about or climbing
stairs difficult?

0

1

2

3

4

5

d. Making your working around the house or
yard difficult?

0

1

2

3

4

5

e. Making your going places away from
home difficult?

0

1

2

3

4

5

0

1

2

3

4

5

f.

Making your sleeping well at night
difficult?

Page 3

Very
Much

Moderately

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Question 16 continued...
Did your heart condition prevent you from living as
you wanted during the PAST 4 WEEKS by:

No

Very
Little

Very
Much

Moderately

g. Making your relating to or doing things
with your friends or family difficult?

0

1

2

3

4

5

h. Making your working to earn a living
difficult?

0

1

2

3

4

5

i.

Making your recreational pastimes, sports
or hobbies difficult?

0

1

2

3

4

5

j.

Making your sexual activities difficult?

0

1

2

3

4

5

k. Making you eat less of the foods you like?

0

1

2

3

4

5

l.

0

1

2

3

4

5

m. Making you tired, fatigued, or low on
energy?

0

1

2

3

4

5

n. Making you stay in a hospital?

0

1

2

3

4

5

o. Costing you money for medical care?

0

1

2

3

4

5

p. Giving you side effects from treatments?

0

1

2

3

4

5

q. Making you feel you are a burden to your
family or friends?

0

1

2

3

4

5

0

1

2

3

4

5

0

1

2

3

4

5

0

1

2

3

4

5

0

1

2

3

4

5

r.

Making you short of breath?

Making you feel a loss of self-control in
your life?

s. Making you worry?
t.

Making it difficult for you to concentrate or
remember things?

u. Making you feel depressed?

17. Have you taken over the counter or prescription non-steroidal anti-inflammatory drugs (NSAIDs) in the past six
months? NSAIDs include aspirin, ibuprofen, and naproxen, which are frequently used to relieve fever, pain, and/or
inflammation. There are several generic and name brand versions of NSAIDs, such as Motrin®, Advil®, Aleve®, and
Relafen®.
No

Yes

If you marked "NO," to question 17, please skip to question 19.
If you marked "YES" , please proceed to question 18.

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0607320109

18. Please list all of the NSAIDs (over the counter and/or prescription) that you have taken in the past six months.
Frequency
Type/name of NSAID

Dose
(in mg)

More than
once a day

Daily

4-6 times
a week

2-3 times
a week

Weekly

Rarely

a.
b.
c.
d.

19. Have you ever been diagnosed with an autoimmune disorder (e.g. Graves' disease, rheumatoid arthritis, systemic
lupus erythematosus, etc.)?
No

M M

Y

Y

Y Y

/

Yes, if yes, please specify:

20. Are you currently taking any prescription medications?
No

Yes

If you marked "NO," to question 20, please skip to question 22.
If you marked "YES", please proceed to question 21.

21. Please list all of the prescription medications you are currently taking.

Drug Name

Dose

Frequency

Indication

a.
b.
c.
d.
e.

22. In general, would you say your health is: (Please select only one)
Excellent

Very good

Good

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Fair

Poor

Protocol # NHRC.2009.0015

8077320108

23. Over the past month, how many hours of sleep did you get in an average
24-hour period?

hours

24. About how many times each week do you floss your teeth?
None

Once a week

2-3 times/week

4-7 times/week

> 7 times/week

25. Other than conventional medicine, what other health treatments have you used in the last 6 months?
a. Mind-body medicine: (e.g. biofeeback, hypnosis,spirtual healing)

No

Yes

b. Biological based practices: (e.g. herbal therapy, highdose/megavitamin therapy, homeopathy)

No

Yes

c. Manipulative and body-based practices: (e.g. acupressure, chiropractic care, massage)

No

Yes

d. Energy medicine: (e.g. acupuncture, energy healing, magnet therapy)

No

Yes

26. Excluding energy drinks, on an average day, how many 8-12 oz beverages containing caffeine do you drink (e.g.
coffee, tea, soda)?
None

1-2 per day

3-5 per day

6-10 per day

11 or more per day

27. On an average day, how many servings of energy drinks do you drink (e.g. Monster, ROCKSTAR, Red Bull, SoBe
Adrenalin Rush, etc.)? NOTE: One can may exceed one serving. For example, one Monster is equal to two servings.
None

1-2 per day

3-5 per day

6-10 per day

11 or more per day

28. About how many times each week do you eat from a fast food restaurant (like hamburgers, tacos, or pizza)?
None

Once a week

2-3 times/week

4-7 times/week

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8-14 times/week

15 or more times/week

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7991320102

29. About how many days a week do you eat what is described as a heart healthy diet? (e.g. > 5 servings of fruit and
vegetables a day, low fat protein sources, whole grains, limit unhealthy oils)?
None

Once a week

2-3 days/week

4-6 days/week

7 days/week

30. In a typical week, how much time do you spend participating in...
(Please mark both your typical "days per week" and "minutes per day" doing these activities)
None

a. STRENGTH TRAINING or work that strengthens your
muscles? (e.g. lifting/pushing/pulling weights)
Days per week
b. VIGOROUS exercise or work that causes heavy
sweating or large increases in breathing or heart
rate? (e.g. running, active sports, marching, biking)
c. MODERATE or LIGHT exercise or work that causes
light sweating or slight increases in breathing or
heart rate? (e.g. walking, cleaning, slow jogging)

Minutes per day

Cannot physically do
None

Days per week

Minutes per day

Cannot physically do
None

Days per week

Minutes per day

Cannot physically do

31. Choose the single best description of your USUAL daily activities.
You sit during the day and do not walk much.
You stand or walk a lot during the day, but do not carry or lift things often.
You lift or carry light loads, or climb stairs or hills often.
You do heavy work or carry heavy loads often.

32. On a typical day, how much time do you spend sitting and watching TV or videos or using a computer?

Hours per day

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These next few questions are about drinking alcoholic beverages. Alcoholic beverages include liquor such as
whiskey, gin, beer, wine, wine coolers, etc. For the purpose of this questionnaire:
One drink = one 12-ounce beer, one 4-ounce glass of wine, or one 1.5-ounce shot of liquor

33. In the past 6 months, how often did you have a drink containing alcohol?
Never

Monthly or less

2-4 times a month

2-3 times a week

4 or more times a week

If you marked "Never," skip to question 36.

34. In the past 6 months, on those days that you drank alcoholic beverages,
on average, how many drinks did you have?

drinks

35. In the past 6 months, how often did you have 5 or more alcoholic beverages on one occasion?
Never

Monthly or less

2-4 times a month

5-10 times a month

11 or more times a month

36. In the past 6 months, have you used any of the following tobacco products?

a. Cigarettes

No

Yes

b. Cigars

No

Yes

c. Pipes

No

Yes

d. Smokeless tobacco (chew, dip, snuff)

No

Yes

If you marked a "YES," go to question 37.
Page
If you marked
all8"NO," skip to question 38.

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1657320105

37. When smoking, how many packs per day did you or do you smoke?
Less than half a pack per day
Half to 1 pack per day
1 to 2 packs per day
More than 2 packs per day

38. Have you ever tried to quit smoking?
Yes, and succeeded
Yes, but not successfully
No

39. The following questions ask how often you felt or behaved a certain way.
In the past MONTH, how often have you...
Almost
Never
Never
a. been upset because of something that happened
unexpectedly?
b. felt that you were unable to control the important
things in your life?
c. felt nervous and/or stressed?
d. dealt successfully with irritating life hassles?
e. felt that you were effectively coping with important
changes that were occurring in your life?
f.

felt confident about your ability to handle your
personal problems?

g. felt that things were going your way?
h. found that you could not cope with all the things that
you had to do?
i.

been able to control irritations in your life?

j.

felt you were on top of things?

k. been angered because of things that happened that
were outside of your control?
l.

found yourself thinking about things that you have to
accomplish?

m. been able to control the way you spend your time?
n. felt difficulties were piling up so high that you could
not overcome them?

Page 9

Sometimes

Fairly
Often

Very
Often

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0823320109

Because of your frequent military moves, please provide contact information
for someone who will always know your whereabouts.
Alternative point of contact:
Last Name:

First Name:

Middle Initial:

Relationship:
Address Line 1:
Address Line 2
(optional):
City (or FPO/APO):
State/Province/Region
(or AA/AE/AP):

ZIP/Postal Code:

Country:

Phone number:
Email address:

Thank you for taking the time to complete this survey. If you have any
questions or concerns regarding this survey, please contact us at:
[email protected]

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