Questionnaire for Patients who Suffered Cardiac Arrest b

Form Approved

OMB No. 0920-XXXX

Exp. Date XX/XX/2016

Questionnaire for patients who suffered from cardiac arrest but survived

We had a few questions about when you had the event (pass out) on

__ __/__ __/__ __ __ __ (mm/dd/yyyy).

What do you remember about that day?

________________________________________________________________________

________________________________________________________________________

________________________________________________________________________

________________________________________________________________________

________________________________________________________________________

Did you have any unusual symptoms before you started dialysis that day (for example: shortness of breath, faint, anxious, itching, rash…)? Yes/No

If Yes, what were they and when did they occur?

________________________________________________________________________

________________________________________________________________________

________________________________________________________________________

________________________________________________________________________

Did you have any unusual symptoms during the time you had dialysis that day but before you passed out?

If so, what were they and when did they occur?

________________________________________________________________________

________________________________________________________________________

________________________________________________________________________

________________________________________________________________________

Have you had any recent changes in your medications?

If yes, what were changed and when?

________________________________________________________________________

________________________________________________________________________

________________________________________________________________________

________________________________________________________________________

Have you been eating differently? If yes, described any new foods on the day of event or the day before event

________________________________________________________________________

________________________________________________________________________

________________________________________________________________________

________________________________________________________________________

Do you have any changes in activities?

If yes, what were changed and when?

________________________________________________________________________

________________________________________________________________________

________________________________________________________________________

________________________________________________________________________

What medications did you take that morning?

________________________________________________________________________

________________________________________________________________________

________________________________________________________________________

________________________________________________________________________

Did you receive any different medications during your dialysis session that day?

If yes, list them

________________________________________________________________________

________________________________________________________________________

________________________________________________________________________

________________________________________________________________________

Did you have any recent medical problems or hospitalizations prior to the event?

If yes, please describe

________________________________________________________________________

________________________________________________________________________

________________________________________________________________________

________________________________________________________________________

Did you notice anything unusual happen during your dialysis session?

Ask the following:

-Any access problems?

-Did they take more fluid off or more quickly?

-Did you notice any new staff or new service persons on that day?

-Did you notice any staff that provided care to you on that day that were different than your regular staff?

-What happened after the event?

-What did the doctors say at the hospital?

-What medications were changed at the hospital?

-What tests did you have done at the hospital?

-What symptoms have you had since the event?

________________________________________________________________________

________________________________________________________________________

________________________________________________________________________

________________________________________________________________________

Public reporting burden of this collection of information is estimated to average 30 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 Reports Clearance Officer; 1600 Clifton Road NE, MS D-74 Atlanta, Georgia 30333; ATTN: PRA (0920-XXXX)