Form 1 Heart Failure

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 (0925-0281). Do not return the completed form to this address.

OMB#: 0925-0281
Exp. //

HEART FAILURE SURVEY
ID
NUMBER:

FORM CODE:

P

H

DATE: 05/02/2011
Version 1.0

F

ADMINISTRATIVE INFORMATION
0a. Completion Date:

Month

/

Day

/

0b. Staff ID:

Year

0c. Consent Form Status:
Consent form mailed to participant…………..
Consent form received from participant……..
Note: Sections I and II will not appear on the data entry screen.
Section I: Instructions to Physicians:
Dear < Dr

>,

Your patient, <
Ms/Mr.
> who is a long time participant in the ARIC Study, has
indicated to ARIC study personnel that < s/he > has been diagnosed with heart failure. We have your
patient’s authorization to ask you to provide this information for our study records. We appreciate your
response to the following questions and request that you return this form in the enclosed envelope at your
earliest convenience (ideally within 2 weeks).
Thank you.
Sincerely,
<
Field center medical director

>

Date <

Date letter is sent >

Section II: Patient Confidential Information:
Patient Name: _______________________________
Patient Date of Birth: __________________________
Section III: Data Reported by Physician:
0. Name of medical doctor to whom inquiry sent:

1. Has this patient ever had heart failure or cardiomyopathy of any type?
Yes ................
No .................

 GO TO QUESTION 3

2. If the patient has or ever had heart failure or cardiomyopathy:
a. Is this patient’s condition characterized as predominantly:
Systolic dysfunction ..............
Diastolic dysfunction .............
Mixed ...................................
Not Determined ....................
b. Estimated LVEF (worst):
%
b.1. If LVEF is not specifically available, estimate LV function:
Normal ..................................
Decreased mildly ..................
Decreased moderately ..........
Decreased severely ..............
c. Estimated date of onset or diagnosis (month/year):

/

3. Has this patient ever had (check all that apply):
Atrial fibrillation on an ECG?....................................
Angina pectoris?......................................................
Pulmonary rales on a physical examination? ...........
Previous MI? ...........................................................
Rhonchi on a physical examination? .......................
Other coronary heart disease? ................................
None of the above? .................................................
4. Was s/he prescribed treatment specifically for heart failure during the past year?
Yes ................
No .................
5. Was this patient prescribed any of the following during the past year (check all that apply):
ACE inhibitors ..................................
Aldosterone blocker ..........................
Alpha blockers ..................................
Amiodarone / Antiarrhythmics...........
Angiotensisn II receptor blockers ......
Anticoagulants ..................................
Aspirin / Antiplatelets ........................
Beta blockers ...................................
Calcium channel blockers .................
Digitalis ............................................
Diuretics ...........................................
Hydralazine ......................................
Lipid-lowering agents........................
Nitrates .............................................
Other antihypertensives....................
6. Form completed by:
MD ................
Other .............

7. Date:

Month

/

Day

/

Year