Minnesota Clinic Visit

Attachment 5f. (MN7.3) Clinic Visit Form

Reading level 0.9 for questions

Study ID FORM APPROVED

OMB No. 0923-XXXX

Expiration Date: MM/DD/ YYYY

Clinic Visit Form

Body Measurements
Height _____ feet _____ inches or ________ cm □ Refused	Weight _______ pounds or _______ kg □ Refused	Waist Circumference _______ inches or _______ cm □ Refused	Blood Pressure _______/_______ or _____ systolic _____ diastolic □ Refused
ASK: Have you lost weight in the past 12 months? Yes, How many pounds did you lose? ______ lbs No DK Refused		ASK: Have you gained weight in the past 12 months? Yes, How many pounds did you gain? ______ lbs No DK Refused

Notes:

Venipuncture Assessment

□ No draw due to assessment

Reason Unable:

□ Medical condition, doctor’s advice – cannot reschedule

□ Temporary condition – able to reschedule

□ Unwilling/Refused

Notes:

Public reporting burden of this collection of information is estimated to average 1 minute 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 CDC/ATSDR Information Collection Review Office, 1600 Clifton Road NE, MS D-74, Atlanta, Georgia 30333; ATTN: PRA (0923-XXXX).

Blood Sample
Collected	Not Collected
□ ___/2 - 10 ml red top tubes □ ___/2 - 7 ml red top tubes □ 4 ml purple top tube (EDTA) □ ___/2 - 2 ml (EDTA) tubes	□ Draw attempted / less than 27 ml obtained □ Unwilling/Refused

Blood collection - Staff initials: __________________

Notes:

Lab Sample ID:

Urine Sample
□ Urine collected Time: _________	□ Not able	□ Unwilling/Refused

Notes:

Date: __________

Study Staff: _____

Appendix 7.3. page 1