A7b Exam Scheduling Form

OMB #: 0925–0216
Expiration Date: xx/xxxx

Public reporting burden for this collection of information is estimated to average
35 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 (09250216). Do not return the completed form to this address.

OMB #: 0925–0216
Expiration Date: xx/xxxx

+

Dear Mr. Banks:
We thank you for participating in the Framingham Heart Study. Your clinic appointment is scheduled
for Friday October 5, 2012 at9:00 A.M.
The Framingham Heart Study’s new address is 73 Mt. Wayte Avenue, in the Perini Building. The
Framingham Heart Study offices are located in the wing at the Franklin Street side of the Building.
There is reserved parking for participants behind the Franklin Street wing. Please see the
enclosed map. The building is handicap accessible.
You should bring slippers. We will provide you with a robe but you may bring your own robe which
will be worn over ours. In order to perform certain tests, we ask that you NOT eat after 8:00 P.M. the
previous evening. You may have water, decaffeinated black coffee or tea (no creamer, milk or
sugar) that evening and again in the morning before your appointment. A urine sample will be
collected when you arrive. If you cannot fast for medical reasons and have questions please call
Maureen Valentino, Project Coordinator at the number below.

PLEASE TAKE ANY PRESCRIPTION MEDICATIONS AS YOU NORMALLY WOULD.
Using the enclosed MEDICATION BAG, please bring all prescription and nonprescription
medications you currently take or have taken in the past month in their original containers. They
will be returned to you before you leave.
ON THE BACK OF THIS SHEET, please list information regarding hospitalizations and major
illnesses you have experienced in the past. PLEASE BRING THIS LETTER WITH YOU TO
YOUR APPOINTMENT. If you need help completing this form, Clinic staff can assist you at the
time of your appointment.
If you have any questions, please call Maureen Valentino, Project Coordinator at
(508) 935-3417 locally and for long distance at (800) 536-4143.
Thank you once again for helping in our battle against heart disease!
Sincerely yours,

Daniel Levy, MD
Director
Framingham Heart Study
OVER →
OMB No= 0925-0216

OMB #: 0925–0216
Expiration Date: xx/xxxx

Doctor(s)/Health Care Provider you want your report sent to:
Name

Address

Telephone

_________________________

_______________________________________________________

_________________________

_______________________________________________________

_________________________

_______________________________________________________

Hospitalizations, Emergency Room Visits, or Day Surgeries since (DATE)

Date

Reason

Hospital Name & Address

Doctor’s Name

_____ _______________ ________________________ _____________________
_____ _______________ ________________________ _____________________
_____ _______________ ________________________ _____________________
_____ _______________ ________________________ _____________________
Doctor Office Visits:

Date

Reason

Doctor’s Name

______ _______________________________

_________________________________________

______ _______________________________

_________________________________________

______ _______________________________

_________________________________________

______ _______________________________

_________________________________________

______ _______________________________

_________________________________________

OSMB No= 0925-0216

OMB #: 0925–0216
Expiration Date: xx/xxxx

DIRECTIONS
South of Framingham
Merge onto I-95 N.
Take the I-495 N exit- exit number 6B- towards
WORCESTER. Merge onto I-495 N. Take the I-90 exit- exit number 22- towards
MASS. PIKE/BOSTON/ALBANY N.Y. Keep RIGHT at the fork in the ramp.
Merge onto I-90 E (Portions toll). Follow directions from Mass Pike Eastbound.
Mass Pike Eastbound, Exit 12 or Route 9 Eastbound
Route 9 East to the “Edgell Rd, Main St, Framingham” exit. Turn right at the end
of ramp to Main Street/Union Ave. Take the 2nd right onto Franklin Street (at the
light). Follow Franklin St for ½ mile (through the lights). Take a left into the
Heart Study (Perini) parking lot. Go to the far left of the parking lot, behind the
building to the Heart Study parking spaces.
North of Framingham
Merge onto I-95 S. Stay straight to go onto I-295 S. Take I-95 S (Portions toll).
Take the I-90/MASS. PIKE exit - exit number 25. Keep RIGHT at the fork in the
ramp. Merge onto I-90 W (Portions toll). Follow directions from Mass Pike
Westbound.
Mass Pike Westbound, Exit 13
After tollbooth, bear right towards Framingham, Route 30 West. Proceed on
Route 30 straight until the end. Turn right onto Route 9 West. Follow Route 9
West to the “30 West, Framingham, Southboro” exit. At the end of the ramp (at
the traffic light, not before!) go left onto Main Street. Go through 1 quick traffic
light and take the 2nd right onto Franklin Street (at the light). Follow Franklin St
for ½ mile (through the the traffic lights). Take a left into the Heart Study (Perini)
parking lot. Go to the far left of the parking lot, behind the building to the Heart
Study parking spaces.
Route 9 Westbound
Follow Route 9 West to the “30 West, Framingham, Southboro” exit. At the end
of the ramp (at the traffic light, not before!) go left onto Main Street. Go right onto
Franklin Street (at the light). Follow Franklin St for ½ mile (through the lights).
Take a left into the Heart Study (Perini) parking lot. Go to the far left of the
parking lot, behind the building to the Heart Study parking spaces.
[LL REV. 050111]
PLEASE SEE MAP ON THE BACK →

OMB #: 0925–0216
Expiration Date: xx/xxxx

SOUTHBORO

BOSTON

NATICK

HOLLISTON

OMB #: 0925–0216
Expiration Date: xx/xxxx

Instructions for Completing the Food
Frequency Questionnaire

THANK YOU for participating in this research study. An important part of this
study is the Food Frequency Questionnaire, designed to measure your dietary pattern
over the past year. Remember, the information we get from the study is only as good as
the information you give us. Accuracy is essential!

When completing the questionnaire we are asking that you:
1)

Please use a No. 2 pencil, and make sure the
circles are completely darkened.

2)

Please do not leave any questions blank. If the section does not apply to you,
please fill in the “never” section.

3)

Please do not separate, staple or rip the booklet.

4)

Please do not leave any stray marks. Make sure all erasures are complete.