National Ambulatory Medical Care Survey 2013 Look Back M

NOTICE-Public reporting burden of 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 CDC/.ATSDR Information Collection Review Office, 1600 Clifton Road, MS D-74, Atlanta, GA 30333, ATTN: PRA (0920-0234).

Attachment C

NAMCS-73(LB)
(4-13-2012)

SAMPLE
NATIONAL AMBULATORY MEDICAL CARE SURVEY
2012 LOOKBACK MODULE
2013
Form Approved: OMB No. 0920-0234; Expiration date 2/28/2013

Assurance of Confidentiality – All information which would permit identification of an individual, a practice, or an establishment will be held
confidential; will be used for statistical purposes only by NCHS staff, contractors, and agents only when required and with necessary controls; and will
not be disclosed or released to other persons without the consent of the individual or establishment in accordance with section 308(d) of the Public
Heath Service Act (42 USC 242m) and the Confidential Information Protection and Statistical Efficiency Act (PL-107-347).

LOOKBACK MODULE
Collect the following data for each prior visit in the previous 12 months.
Collect up to 10 prior visits, starting with the oldest. (Exclude telephone calls, emails and faxes).
VISITS
Month

Day

Year

Does the patient now have —
Mark (X) all that apply.
1
NONE
Cerebrovascular disease/
2
History of stroke or transient
ischemic attack (TIA)
Congestive heart failure (CHF)
3
Diabetes
4
Hypertension
5
Hyperlipidemia
6
Ischemic heart disease
7

2 0 1
Was the patient pregnant at the time of visit?
Yes

1

No

2

Smoke cigarettes?
Not current

2

Current

3

Unknown

OR

cm

Blood tests – Mark (X) all that apply.
2

Lipids/Cholesterol

1

3

HbA1c (Glycohemoglobin)

2

4

Fasting blood glucose (FBG)

3

5

Creatinine
Potassium

4

Sodium
AST/ALT

6

5

Basic metabolic panel
Comprehensive metabolic panel (CMP)

Assessment and
plan – Blood pressure
1
2
3
4
5

Controlled
Elevated or uncontrolled
Medication being titrated
Ambulatory/home blood
pressure monitoring normal
Patient nonadherence

Assessment and
plan – Cholesterol
1
2
3
4

Controlled
Elevated or uncontrolled
Medication being titrated
Patient nonadherence

Is patient allergic to any medications?
2
3

Yes
No or no known allergies
Unknown

D

1

Enter medication(s) patient is allergic to (Up to 8)

(30)

1

Yes

2

No

3

kg

Unknown

Unknown

/

gm

Assessment and plan –
Mark (X) all that apply.
1
2
3

NONE
Blood pressure assessment and plan
Cholesterol assessment and plan
Blood glucose assessment and plan
Referral

4
5

Assessment and
plan – Blood glucose
1
2
3
4

Assessment and plan – Referral
Mark (X) all that apply.

Controlled
Elevated or uncontrolled
Medication being titrated
Patient nonadherence

1
2
3
4
5

Nurse management
Nutritionist
Smoking-cessation program
Weight loss program
Other physician, including
primary care provider

Has the patient had any adverse reactions to any
medications e.g., bleeding from aspirin?
Yes
1
2
No or no known adverse reactions
3
Unknown
Enter medication(s) patient had adverse reactions(s) to (Up to 8)

Enter drugs that were ordered, supplied, administered or continued
during this visit. Include Rx and OTC drugs, immunizations, allergy shots,
oxygen, anesthetics, chemotherapy, and dietary supplements (Up to 30).

(1)

3

Does the patient have a family history of premature
coronary heart disease (CHD), coronary artery
disease (CAD), or ischemic heart disease (IHD), in a
mother, daughter, or sister less than age 55?

OR

NONE
Diet/Nutrition-Reduce fat/cholesterol
Diet/Nutrition-Reduce salt/sodium
Weight or caloric reduction
Exercise
Smoking cessation

R

9

oz

Health education/Counseling –
Mark (X) all that apply.

NONE

10

No

Blood pressure
Systolic
Diastolic
lb

1

8

2

T

in

ft

7

Yes

Weight

Height

6

1

AF

1

Does the patient have a family history of premature
coronary heart disease (CHD), coronary artery
disease (CAD), or ischemic heart disease (IHD), in a
father, son, or brother less than age 55?

New

Continued

Same
dose

Dose
increased

Dose
decreased

1

2

1

2

3

1

2

1

2

3

1

2

1

2

3

1

2

1

2

3

1

2

1

2

3

1

2

1

2

3

1

2

1

2

3

1

2

1

2

3

1

2

1

2

3

1

2

1

2

3

TEST RESULTS

Was blood for the following laboratory tests drawn on the day of the sampled visit or during the 15 months prior
to the visit?
Collect up to 15 results for each type of test, starting with the oldest.
Type of Test

Test
Results

Total Cholesterol

mg/dL

1
2

Yes
None found

Date of test
(mm/dd/yyyy)

/
/
/
/
/
/
/

mg/dL

mg/dL

mg/dL

High density lipoprotein (HDL)
1
2

Yes
None found

mg/dL

mg/dL

/
/
/
/
/
/
/

mg/dL

mg/dL

mg/dL

2

mg/dL

Yes
None found

mg/dL

mg/dL

3

mg/dL

Triglycerides (TGS)
1

Yes
None found

mg/dL

mg/dL

D

2

/
/
/
/
/

/
/
/
/
/

/
/
/
/
/

/
/
/
/
/

mg/dL

4

mg/dL

mg/dL

HbA1c (Glycohemoglobin)

%

Yes
None found

%

1
2

%

%

Fasting blood glucose (FBG)
1
2

Yes
None found

mg/dL

mg/dL

/
/
/
/
/

/
/
/
/
/

mg/dL

mg/dL

NAMCS-73(LB) (4-13-2012)

Add #7 Serum creatinine

mg/dL

mg/dL

mg/dL

mg/dL

mg/dL

mg/dL

mg/dL

mg/dL
mg/dL

mg/dL

mg/dL

mg/dL

%

%

/
/
/
/
/

/
/
/
/
/

%

%
mg/dL

mg/dL

/
/
/
/
/

/
/
/
/
/

/
/
/
/
/

/
/
/
/
/

mg/dL

mg/dL

mg/dL

mg/dL

mg/dL

mg/dL
mg/dL

mg/dL

/ /
/ /
/ /
/ /
/ /
/ /
/ /

mg/dL

mg/dL

mg/dL

mg/dL

/
/
/
/
/

/
/
/
/
/

/
/
/
/
/

/
/
/
/
/

/
/
/
/
/

/
/
/
/
/

/
/
/
/
/

/
/
/
/
/

mg/dL

mg/dL

mg/dL
mg/dL

mg/dL

mg/dL

/
/
/
/
/

/
/
/
/
/

mg/dL

mg/dL

%

%

%

/
/
/
/
/

/
/
/
/
/

mg/dL

/ /
/ /
/ /

Date of test
(mm/dd/yyyy)

mg/dL

%

mg/dL

6

mg/dL

mg/dL

%

5

mg/dL

/
/
/
/
/
/
/

mg/dL

R

mg/dL

mg/dL

/
/
/
/
/
/
/

AF

1

mg/dL

Test
Results
mg/dL

mg/dL

2

Low density lipoprotein (LDL)

Date of test
(mm/dd/yyyy)

mg/dL

mg/dL

1

Test
Results

T

Item
no.

%

%
mg/dL

mg/dL

mg/dL

/ /
/ /
/ /

mg/dL

mg/dL

/ /
/ /
/ /