Download:
pdf |
pdfOMB #: 0925–0216
Expiration Date: xx/xxxx
Public reporting burden for this collection of information is estimated to average 60 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 (0925-0216). Do not return
the completed form to this address.
OMB #: 0925-0216OMB #: 0925–0216
Expiration Date: xx/xxxx
E xpir a t ion Da t e: xx/xxxx
Offspr in g E xa m 9, Om n i1 E xa m 4
«IDType»-«ID»
«LNa m e», «F Na m e»
1
ID: «Idtype» - «Id»
Numerical Data/Anthropometry
Check here if whole page is blank.
Reason why___________________________________
Technician Number (for basic information)
|__|__|__|
Basic Information
«Sex»
Sex of Participant
|_0_|
Site of Exam (0=Heart Study, 1=Nursing home, 2=Residence, 3=Other)
1=Male, 2=Female
|__|__|
Age of Participant (number of years)
|__|__|
What state do you reside in? (If reside outside the USA, code ZZ, if plans to wear
accelerometer while visiting USA code state of visit)
Code: AL, AK, AS, etc.
Anthropometry
Check Protocol Modification ONLY if there was one and document it in Comment section
88*88=Refused, 99*99=Not done or Unk.
|__|__|*|__|__|
Height (inches, to next lower 1/4 inch)
Protocol modification
Weight (to nearest pound)
|__|__|__|
(400=400 or more 888=refused, 999=Unk.)
Protocol modification
In the past year, have you lost more than 10 pounds?
0=No, 1= Yes, unintentionally, NOT due to dieting or exercise
2= Yes, intentionally, due to dieting or exercise
|__|
Technician Number (for anthropometry)
|__|__|__|
|__|__|*|__|__|
Neck Circumference (inches, to next lower1/4 inch)
|__|__|*|__|__|
Waist Girth at umbilicus (inches, to next lower 1/4 inch).
|__|__|*|__|__|
Protocol modification
Hip Girth (inches, to next lower 1/4 inch)
|__|__|*|__|__|
Protocol modification
Protocol modification
Thigh Girth (inches, to next lower 1/4 inch)
Protocol modification
Comments for ALL Protocol Modification (specify measurement)
__________________________________________________________________________________________
____________________________________________________________________________________________________________
Ver sion 5
GM
06-06-2011
OMB #: 0925-0216 OMB #: 0925–0216
Expiration Date: xx/xxxx
E xpir a t ion Da t e: xx/xxxx
Offspr in g E xa m 9, Om n i1 E xa m 4
«IDType»-«ID»
«LNa m e», «F Na m e»
TECH01
Ver sion 5
GM
06-06-2011
2
OMB #: 0925-0216OMB #: 0925–0216
Expiration Date: xx/xxxx
E xpir a t ion Da t e: xx/xxxx
Offspr in g E xa m 9, Om n i1 E xa m 4
«IDType»-«ID»
Check here if whole page is blank.
«LNa m e», «F Na m e»
3
Reason why___________________________________
Procedures Sheet
0=No, 1=Yes, 8=Offsite visit
|__|
Type of Exam
1=Complete exam, 2=Split exam(exam completed in 2
visits), 3=short exam (incomplete exam), 8=offsite
|__|
Informed Consent Signed
0=No, 1=Yes, 2= offspring waiver of consent, LAR, or
next-of-kin
|__|
Urine Specimen
|__|
Blood Draw
|__|
Mini-Mental Status Exam
|__|
Anthropometry
|__|
Sociodemographic Questions (self administered)
|__|
SF-12 Health Survey
|__|
CES-D Scale
|__|
NAGI, Rosow-Breslau, Katz
|__|
Exercise Questionnaire
|__|
ECG
P Wave Signal Averaged ECG
|__|
|__|
If not performed why: 1=AF, 2=Pacemaker, 3=Pat. ran out of time, 4=Pat. couldn’t lie flat,
5=equipment malfunction, 6=other
|__|
Observed performance (Timed walk, hand grip, chair stands)
|__|
Tonometry
|__|
Ankle-brachial blood pressure by Doppler. (Participants > 40 years)
|__|
Spirometry
0=Not Done, 1=Done, 2=Attempted, not
finished, 3= Attempted, tech aborted ,4=Other
|__|
1=Medical exclusion, 2=Refused,
3=equipment problems 4=Other
Post Albuterol Spirometry
|__|
|__|
|__|
Ver sion 5
Reason Spirometry not done
GM
Reason Post Alb. Spir. not
done
0=Not Done, 1=Done, 2=Attempted, not
finished, 3= Attempted, tech aborted ,4=Other
1=Medical exclusion, 2=Refused,
3=equipment problems 4=Other 5=Do not qualify
Diffusion Capacity
0=Not Done, 1=Done, 2=Attempted, not
finished, 3= Attempted, tech aborted ,4=Other
|__|
1=Medical exclusion, 2=Refused,
3=equipment problems 4=Other
06-06-2011
Reason Diffusion not done
OMB #: 0925-0216 OMB #: 0925–0216
Expiration Date: xx/xxxx
E xpir a t ion Da t e: xx/xxxx
Offspr in g E xa m 9, Om n i1 E xa m 4
|__|
«IDType»-«ID»
«LNa m e», «F Na m e»
Accelerometer
TECH02
Ver sion 5
GM
06-06-2011
4
OMB #: 0925–0216
OMB #: 0925-0216
Expiration Date: xx/xxxx
E xpir a t ion Da t e: xx/xxxx
Offspr in g E xa m 9, Om n i1 E xa m 4
«IDType»-«ID»
«LNa m e», «F Na m e»
5
For Participants Who Wish to Complete Their Exam on a Second Visit (Split Exam)
Second Exam Date (If participant returns to finish their clinic exam on a date
|__|__|*|__|__|*|__|__|__|__| other than the original exam date, then fill in the date they return here. Otherwise
leave entire page completely blank)
Keyers: if Second Exam Date is not filled and page is blank’ then leave the page all blank.
Fill in with 1=yes if procedure was done on the Second Exam Date and 0=no if procedure was not done on the
Second Exam Date. Note that informed consent from first visit will cover the second visit.
Procedures Sheet
0=No, 1=Yes, 8=Offsite visit
1=Complete exam, 2=Split exam(exam completed in 2
visits), 3=short exam (incomplete exam), 8=offsite
|__|
Type of Exam
|__|
Urine Specimen
|__|
Blood Draw
|__|
Mini-Mental Status Exam
|__|
Anthropometry
|__|
Sociodemographic Questions (self administered)
|__|
SF-12 Health Survey
|__|
CES-D Scale
|__|
NAGI, Rosow-Breslau, Katz
|__|
Exercise Questionnaire
|__|
ECG
|__|
P Wave Signal Averaged ECG
|__|
If not performed why: 1=AF, 2=Pacemaker, 3=Pat. ran out of time, 4=Pat. couldn’t lie flat,
5=equipment malfunction, 6=other
|__|
Observed performance (Timed walk, hand grip, chair stands)
|__|
Tonometry
|__|
Ankle-brachial blood pressure by Doppler. (Participants > 40 years)
|__|
Spirometry
0=Not Done, 1=Done, 2=Attempted, not finished,
3= Attempted, tech aborted ,4=Other
|__|
1=Medical exclusion, 2=Refused,
3=equipment problems 4=Other
Post Albuterol Spirometry
|__|
|__|
|__|
|__|
Ver sion 5
Reason Spirometry not done
Reason Post Alb. Spir. not
done
1=Medical exclusion, 2=Refused,
problems 4=Other 5=Do not qualify
3=equipment
Diffusion Capacity
0=Not Done, 1=Done, 2=Attempted, not finished,
3= Attempted, tech aborted ,4=Other
|__|
1=Medical exclusion, 2=Refused,
3=equipment problems 4=Other
Reason Diffusion not done
Accelerometer
GM
0=Not Done, 1=Done, 2=Attempted, not finished,
3= Attempted, tech aborted ,4=Other
06-06-2011
OMB #: 0925-0216 OMB #: 0925–0216
Expiration Date: xx/xxxx
E xpir a t ion Da t e: xx/xxxx
Offspr in g E xa m 9, Om n i1 E xa m 4
«IDType»-«ID»
«LNa m e», «F Na m e»
TECH03
Ver sion 5
GM
06-06-2011
6
OMB #: 0925–0216
OMB #: 0925-0216
Expiration Date: xx/xxxx
E xpir a t ion Da t e: xx/xxxx
Offspr in g E xa m 9, Om n i1 E xa m 4
Ver sion 5
GM
06-06-2011
«IDType»-«ID»
«LNa m e», «F Na m e»
7
OMB #: 0925–0216
OMB #: 0925-0216
Expiration Date: xx/xxxx
E xpir a t ion Da t e: xx/xxxx
Offspr in g E xa m 9, Om n i1 E xa m 4
«IDType»-«ID»
Check here if whole page is blank.
«LNa m e», «F Na m e»
8
Reason why___________________________________
Exit Interview
|__|__|__|
|__|
Technician Number
Procedure sheet reviewed
0=No
1=Yes
8=Offsite
9=Unk.
|__|
Referral sheet reviewed
|__|
Left clinic w/ belongings
|__|
Dietary questionnaire provided 1=Brought to exam completed or filled out in clinic,
2=Given in clinic to complete at home and send back, 3=Other, 8=Offsite, 9=Unk.
|__|
Left clinic with accelerometer
8=Offsite, 9=Unk.
|__|
Feedback 0=No feedback, 1=Positive feedback, 2=Negative feedback, 3=Other, 9=Unk.
0=No, refused, 1=Yes, 2=it will be mailed to them,
Comments_________________________________________________________________
__________________________________________________________________________
__________________________________________________________________________
CLINIC visit only
|__|__|__|
Technician Number
Was there an adverse event in clinic that does not require further medical evaluation?
(0=No, 1=Yes, 9=Unk.)
Comments:______________________________________________________________
________________________________________________________________________
|__|
OFFSITE visit only
|__|__|__|
Technician Number
Was a FHS physician contacted during the examination due to adverse exam finding?
(0=No, 1=Yes, 9=Unk.)
Comments:______________________________________________________________
_________________________________________________________________________
|__|
|__|__|__|
Technician who reviewed TECH portion of exam
Your exam today was for research purposes only and is not designed to make a medical
diagnosis. The exam cannot identify all serious heart and health issues. It is important
that you continue regular follow-up with your physician or health care provider.
Ver sion 5
GM
06-06-2011
OMB #: 0925–0216
OMB #: 0925-0216
Expiration Date: xx/xxxx
E xpir a t ion Da t e: xx/xxxx
Offspr in g E xa m 9, Om n i1 E xa m 4
«IDType»-«ID»
«LNa m e», «F Na m e»
TECH04
Ver sion 5
GM
06-06-2011
9
OMB #: 0925-0216
OMB #: 0925–0216
Expiration Date: xx/xxxx
E xpir a t ion Da t e: xx/xxxx
Offspr in g E xa m 9, Om n i1 E xa m 4
Ver sion 5
GM
06-06-2011
«IDType»-«ID»
«LNa m e», «F Na m e»
10
OMB #: 0925-0216
OMB #: 0925–0216
Expiration Date: xx/xxxx
E xpir a t ion Da t e: xx/xxxx
Offspr in g E xa m 9, Om n i1 E xa m 4
«IDType»-«ID»
«LNa m e», «F Na m e»
11
MMSE-Cognitive Function-Part I
Check here if whole page is blank.
Reason why___________________________________
I’m going to start by asking questions that require concentration and memory. Some questions are
more difficult than others and some will be asked more than one time.
|__|__|__|
Technician Number
Write all responses on exam form
0=incorrect, 1-3=score 1 point for each correct response,
6=item administered, Participant doesn’t answer, 9=Unk.
SCORE
0 1 2 3 6
9
What Is the Date Today? (Month, day, year, correct score=3)
0 1
6
9
What Is the Season?
0 1
6
9
What Day of the Week Is it?
0 1 2 3 6
9
What Town, County and State Are We in? (Town, county, state, correct score=3)
What Is the Name of this Place?
0 1
6 9
(any appropriate answer all right, for instance my home, street address, heart study..max
score=1)
0 1
6
9
What Floor of the Building Are We on?
9
I am going to name 3 objects. After I have said them I want you to repeat them
back to me. Are you ready? Apple, Table, Penny. Could you repeat the
three items for me
Remember what they are because I will ask you to name them again in a few
minutes.
0 1 2 3
6
Now I am going to spell a word forward and I want you to spell it backwards.
The word is world. W-O-R-L-D.
Please Spell it in Reverse Order.
|__|__|__|__|__|
(Letters Are Entered and Scored Later)
Score as
0 1 2 3
6
9
66666=Not administered for reason unrelated to cognitive status
00000=Administered, but couldn’t do
99999=Unk.
What are the 3 objects I asked you to remember a few moments ago?
TECH05
Ver sion 5
GM
06-06-2011
OMB #: 0925-0216
OMB #: 0925–0216
Expiration Date: xx/xxxx
E xpir a t ion Da t e: xx/xxxx
Offspr in g E xa m 9, Om n i1 E xa m 4
«IDType»-«ID»
«LNa m e», «F Na m e»
12
MMSE-Cognitive Function -Part II
Check here if whole page is blank.
Reason why___________________________________
Write all responses on exam form
0=incorrect, 1-3=score 1 point for each correct response,
6=item administered, Participant doesn’t answer, 9=Unk.
SCORE
0 1
6
9
What Is this Called? (Watch)
0 1
6
9
What Is this Called? (Pencil)
0 1
6
9
Please Repeat the Following: "No Ifs, Ands, or Buts." (Perfect=1)
0 1
6
9
Please Read the Following & Do What it Says (performed=1, code 6 if low vision)
0 1
6
9
Please Write a Sentence (code 6 if low vision)
0 1
6
9
Please Copy this Drawing (code 6 if low vision)
0 1 2 3 6
9
Take this piece of paper in your right hand, fold it in half with both hands,
and put in your lap (score 1 for each correctly performed act, code 6 if low vision)
No Yes Maybe Unk.
Factor Potentially Affecting Mental Status Testing
(coding for below)
0
1
2
9
Not fluent in English
0
1
2
9
Poor eyesight
0
1
2
9
Poor hearing
0
1
2
9
Other, write in ___________________________________________________
TECH06
Ver sion 5
GM
06-06-2011
OMB #: 0925-0216
OMB #: 0925–0216
Expiration Date: xx/xxxx
E xpir a t ion Da t e: xx/xxxx
Offspr in g E xa m 9, Om n i1 E xa m 4
«IDType»-«ID»
«LNa m e», «F Na m e»
13
Sentence and Design Handout for Participant
PLEASE WRITE A SENTENCE
_________________________________________________________________________________
_________________________________________________________________________________
_________________________________________________________________________________
PLEASE COPY THIS DESIGN
Ver sion 5
GM
06-06-2011
OMB #: 0925–0216
Expiration Date: xx/xxxx
OMB #: 0925-0216
E xpir a t ion Da t e: xx/xxxx
Offspr in g E xa m 9, Om n i1 E xa m 4
Ver sion 5
GM
06-06-2011
«IDType»-«ID»
«LNa m e», «F Na m e»
14
OMB #: 0925-0216 OMB #: 0925–0216
Expiration Date: xx/xxxx
E xpir a t ion Da t e: xx/xxxx
Offspr in g E xa m 9, Om n i1 E xa m 4
«IDType»-«ID»
«LNa m e», «F Na m e»
15
Socio-demographic Questionnaire
(Tech-administered)
Check here if whole page is blank.
|__|__|__|
Reason why___________________________________
Technician Number
Socio-demographics
Where do you live? (0=Private residence, 1=Nursing home, 2=Other, setting (no longer
able to live independently) such as assisted living, 9=Unk.)
Does anyone live with you?
(0=No, 1=Yes, 9=Unk.)
Code Nursing Home Residents as NO
|__|
|__|
If Yes, fill
If 0 or 9,
skip to next
table
|__|
Spouse
|__|
Significant Other
|__|
Children
|__|
Friends
|__|
Relatives
0=No
1=Yes, more than 3 months per year
2=Yes, less than 3 months per year
9=Unk.
Use of Nursing and Community Services
|__|
Have you been admitted to a nursing home (or skilled facility) in the past
year?
|__|
In the past year, have you been visited by a nursing service, or used home,
community, or adult day care programs? (examples: home health aide,
visiting nurses, etc)
TECH07
Ver sion 5
GM
06-06-2011
0=No
1=Yes
9=Unk.
OMB #: 0925–0216
OMB #: 0925-0216
Expiration Date: xx/xxxx
E xpir a t ion Da t e: xx/xxxx
Offspr in g E xa m 9, Om n i1 E xa m 4
«IDType»-«ID»
«LNa m e», «F Na m e»
16
Nagi Questions
(Tech-administered)
Check here if whole page is blank.
|__|__|__|
Reason why___________________________________
Technician Number
Nagi Questions
For each activity tell me whether you have:
(0) No Difficulty
(1) A Little Difficulty
(2) Some Difficulty
(3) A Lot Of Difficulty
(4) Unable To Do
(5) Don't Do On Physician or Health Care Provider Orders
(6) Don’t Know
(9) Unk.
|__|
Pulling or pushing large objects like a living room chair
|__|
Either stooping, crouching, or kneeling
|__|
Reaching or extending arms below shoulder level
|__|
Reaching or extending arms above shoulder level
|__|
Either writing, or handling, or fingering small objects
|__|
Standing in one place for long periods, say 15 minutes
|__|
Sitting for long periods, say 1 hour
|__|
Lifting or carrying weights under 10 pounds (like a bag of potatoes)
|__|
Lifting or carrying weights over 10 pounds (like a very heavy bag of groceries)
TECH08
Ver sion 5
GM
06-06-2011
OMB #: 0925-0216 OMB #: 0925–0216
Expiration Date: xx/xxxx
E xpir a t ion Da t e: xx/xxxx
Offspr in g E xa m 9, Om n i1 E xa m 4
«IDType»-«ID»
«LNa m e», «F Na m e»
17
Rosow-Breslau Scale and Katz Activities of Daily Living
(Tech-administered)
Check here if whole page is blank.
|__|__|__|
Reason why___________________________________
Technician Number
Rosow-Breslau Questions
Are you able to do heavy work around the house, like shoveling snow or
washing windows, walls, or floors without help?
|__|
|__|
Are you able to walk half a mile without help? (About 4-6 blocks)
|__|
Are you able to walk up and down one flight of stairs without help?
0=No
1=Yes
9=Unk.
Katz ADLs
During the Course of a Normal Day, can you do the following activities independently or do
you need help from another person or use special equipment or a device?
0=No help needed, independent,
1=Uses device, independent,
2=Human assistance needed, minimally dependent,
3=Dependent,
4=Does not do during a normal day,
9=Unk.
|__|
Dressing (undressing and redressing)
Devices such as: velcro, elastic laces
|__|
Bathing (including getting in and out of tub or shower)
Devices such as: bath chair, long handled sponge, hand held shower, safety bars
|__|
Eating
Devices such as: rocking knife, spork, long straw, plate guard.
|__|
Transferring(getting in and out of a chair)
Devices such as: sliding board, grab bars, special seat
|__|
Toileting Activities (using bathroom facilities and handle clothing)
Devices such as: special toilet seat, commode
TECH09
Ver sion 5
GM
06-06-2011
OMB #: 0925–0216
OMB #: 0925-0216
Expiration Date: xx/xxxx
E xpir a t ion Da t e: xx/xxxx
Offspr in g E xa m 9, Om n i1 E xa m 4
«IDType»-«ID»
«LNa m e», «F Na m e»
18
Fractures
Check here if whole page is blank.
|__|__|__|
Reason why___________________________________
Technician Number
Fractures
|__|
Since Your Last Clinic Visit Have You Broken Any Bones?
(0=No, 1=Yes, 2=Maybe, 9=Unk.)
If Yes, fill
|__|__|
Location of fracture:
|__|__|
Location of second fracture (if more than one):
|__|__|
Location of third fracture (if more than two):
Code for Location (code Unk. as 99)
1= Clavicle (collar bone)
2=Upper arm (humerus) or elbow
3=Forearm or wrist
4=Hand
5=Back (If disc disease only, code as no)
6=Pelvis
7=Hip
8=Leg
9=Foot
10=Other, specify___________________________________
TECH10
Ver sion 5
GM
06-06-2011
OMB #: 0925-0216 OMB #: 0925–0216
Expiration Date: xx/xxxx
E xpir a t ion Da t e: xx/xxxx
Offspr in g E xa m 9, Om n i1 E xa m 4
«IDType»-«ID»
«LNa m e», «F Na m e»
19
Physical Activity Questionnaire Part 1--Framingham Heart Study
Tech-administered
Check here if whole page is blank.
|__|__|__|
Reason why___________________________________
Technician Number
Rest and Activity for a Typical Day over the past year
(A typical day = most days of the week)
(Activities must equal 24 hours)
Number
of hours
Sleep - Number of hours that you typically sleep?
_______
Sedentary - Number of hours typically sitting? Such as reading, watching TV,
using the computer, doing handcrafts
_______
Slight Activity - Number of hours with activities such as standing, walking?
_______
Moderate Activity - Number of hours with activities such as housework
(vacuum, dust, yard chores, climbing stairs; light sports such as bowling, golf)?
_______
Heavy Activity - Number of hours with activities such as heavy household work,
heavy yard work such as stacking or chopping wood, exercise such as intensive
sports--jogging, swimming etc.?
_______
Total number of hours
(should be the total of above items)
24
Over the past 7 days, how often did you participate in SITTING ACTIVITIES such as
reading, watching TV, using the computer, or doing handcrafts?
||
0 = Never
1 = Seldom/1-2 days
2 = Sometimes/3-4 days
3 = Often/5-7 days
8 = refused
9 = Don’t know/Unknown
||
Over the past 7 days, how many hours per day did you engage in these sitting activities?
1 = less than 1 hour
2 = 1 hour but less than 2 hours
3 = 2-4 hours
4 = more than 4 hours
8 = refused
9 = Don’t know/Unknown
TECH11
Ver sion 5
GM
06-06-2011
OMB #: 0925–0216
OMB #: 0925-0216
Expiration Date: xx/xxxx
E xpir a t ion Da t e: xx/xxxx
Offspr in g E xa m 9, Om n i1 E xa m 4
Ver sion 5
GM
06-06-2011
«IDType»-«ID»
«LNa m e», «F Na m e»
20
OMB #: 0925–0216
OMB #: 0925-0216
Expiration Date: xx/xxxx
E xpir a t ion Da t e: xx/xxxx
Offspr in g E xa m 9, Om n i1 E xa m 4
«IDType»-«ID»
«LNa m e», «F Na m e»
21
Physical Activity Questionnaire Part 2--Framingham Heart Study
Tech-administered
Check here if whole page is blank.
|__|__|__|
Reason why___________________________________
Technician Number
I am going to read a list of activities. Please tell me which activities you have done in the past year.
During the past year did you (do)?
In а typical 2 week
hhghDuring past year
0=No, 1=Yes, 8=Refused,
period of time, how often
9=Unk.
do you (name of activity)
|__|
|__|
|__|
|__|
|__|
Walk (walking to work, walking the
dog, walking in the mall)
Calisthenics/general exercise
(yoga, pilates)
Exercise cycle, ski or stair machine
(treadmill, elliptical, stair master,
etc.)
Exercises to increase muscle
strength or endurance -Weight
training (free weights, machines)
Moderate/strenuous household
chores (vacuuming, scrubbing
floors, washing windows, carrying
wood)
Average time/session
Number
months/year
hours
minutes
|__|__|
|__|__|
|__|__|
|__|__|
|__|__|
|__|__|
|__|__|
|__|__|
|__|__|
|__|__|
|__|__|
|__|__|
|__|__|
|__|__|
|__|__|
|__|__|
|__|__|
|__|__|
|__|__|
|__|__|
0-12
|__|
Jog
|__|__|
|__|__|
|__|__|
|__|__|
|__|
Bike
|__|__|
|__|__|
|__|__|
|__|__|
|__|
Dance
|__|__|
|__|__|
|__|__|
|__|__|
|__|
Aerobics
|__|__|
|__|__|
|__|__|
|__|__|
|__|
Swim
|__|__|
|__|__|
|__|__|
|__|__|
|__|
Tennis
|__|__|
|__|__|
|__|__|
|__|__|
|__|
Golf (no cart)
|__|__|
|__|__|
|__|__|
|__|__|
|__|
Lawn work or yard care* (Mowing
the lawn, snow or leaf removal)
|__|__|
|__|__|
|__|__|
|__|__|
|__|
Outdoor Gardening
|__|__|
|__|__|
|__|__|
|__|__|
|__|
Hike
|__|__|
|__|__|
|__|__|
|__|__|
|__|
Light sport or recreational
activities (bowling, golf with a cart,
shuffleboard, fishing, ping-pong)
|__|__|
|__|__|
|__|__|
|__|__|
|__|
Other*, write in______________
___________________________
|__|__|
|__|__|
|__|__|
|__|__|
Ver sion 5
GM
06-06-2011
OMB #: 0925-0216 OMB #: 0925–0216
Expiration Date: xx/xxxx
E xpir a t ion Da t e: xx/xxxx
Offspr in g E xa m 9, Om n i1 E xa m 4
«IDType»-«ID»
«LNa m e», «F Na m e»
TECH12
Ver sion 5
GM
06-06-2011
22
OMB #: 0925–0216
OMB #: 0925-0216
Expiration Date: xx/xxxx
E xpir a t ion Da t e: xx/xxxx
Offspr in g E xa m 9, Om n i1 E xa m 4
«IDType»-«ID»
«LNa m e», «F Na m e»
23
CES-D Scale
Tech-administered
Check here if whole page is blank.
|__|__|__|
Reason why_______________________________________
Technician Number
The questions below ask about your feelings. For each statement, please say how often you felt that
way during the past week.
Circle best answer for each question
DURING THE PAST WEEK
*I was bothered by things that usually don’t bother me.
Rarely or
none of the
time
(less than 1 day)
Some or a Occasionally
little of the
or moderate
time
amount of time
(1-2 days)
(3-4 days)
Most or all
of the time
(5-7 days)
0
1
2
3
I did not feel like eating; my appetite was poor.
0
1
2
3
I felt that I could not shake off the blues, even with
help from my family and friends.
0
1
2
3
I felt that I was just as good as other people.
0
1
2
3
I had trouble keeping my mind on what I was doing.
0
1
2
3
*I felt depressed.
0
1
2
3
I felt that everything I did was an effort.
0
1
2
3
I felt hopeful about the future.
0
1
2
3
I thought my life had been a failure.
0
1
2
3
I felt fearful.
0
1
2
3
*My sleep was restless.
0
1
2
3
I was happy.
0
1
2
3
I talked less than usual.
0
1
2
3
I felt lonely.
0
1
2
3
People were unfriendly.
0
1
2
3
I enjoyed life.
0
1
2
3
I had crying spells.
0
1
2
3
I felt sad.
0
1
2
3
I felt that people disliked me
0
1
2
3
I could not ―get going‖
0
1
2
3
Ver sion 5
GM
06-06-2011
OMB #: 0925–0216
OMB #: 0925-0216
Expiration Date: xx/xxxx
E xpir a t ion Da t e: xx/xxxx
Offspr in g E xa m 9, Om n i1 E xa m 4
«IDType»-«ID»
«LNa m e», «F Na m e»
* Indicates that the technician should preface the statement with “During the past week”
TECH13
Ver sion 5
GM
06-06-2011
24
OMB #: 0925–0216
OMB #: 0925-0216
Expiration Date: xx/xxxx
E xpir a t ion Da t e: xx/xxxx
Offspr in g E xa m 9, Om n i1 E xa m 4
Ver sion 5
GM
06-06-2011
«IDType»-«ID»
«LNa m e», «F Na m e»
25
OMB #: 0925–0216
OMB #: 0925-0216
Expiration Date: xx/xxxx
E xpir a t ion Da t e: xx/xxxx
Offspr in g E xa m 9, Om n i1 E xa m 4
«IDType»-«ID»
«LNa m e», «F Na m e»
26
Proxy form
Check here if whole page is blank.
Reason why_______________________________________
Proxy used to complete this exam (0=No, 1=Yes, 1 proxy, 2=Yes, more than 1 proxy, 9=Unk.)
|__|
if yes,
fill
Proxy Name ___________________________________________________________
|__|
|__|__|*|__|__|
Relationship (1=1st Degree Relative(spouse, child), 2=Other Relative,
3=Friend, 4=Health Care Professional, 5=Other, 9=Unk.
How long have you known the participant?
(Years, months; 99.99=Unk.) example: 3m=00*03
|__|
Are you currently living in the same household with the participant?
(0=No, 1=Yes, 9=Unk.)
|__|
How often did you talk with the participant during the prior 11 months? (1=Almost
every day, 2=Several times a week, 3=Once a week,
4=1 to 3 times per month, 5=Less than once a month, 9=Unk.)
Proxy Name ___________________________________________________________
|__|
|__|__|*|__|__|
Relationship (1=1st Degree Relative(spouse, child), 2=Other Relative,
3=Friend, 4=Health Care Professional, 5=Other, 9=Unk.
How long have you known the participant?
(Years, months; 99.99=Unk.) example: 3 m=00*03
|__|
Are you currently living in the same household with the participant?
(0=No, 1=Yes, 9=Unk.)
|__|
How often did you talk with the participant during the prior 11 months? (1=Almost
every day, 2=Several times a week, 3=Once a week,
4=1 to 3 times per month, 5=Less than once a month, 9=Unk.)
TECH014
Ver sion 5
GM
06-06-2011
OMB #: 0925–0216
OMB #: 0925-0216
Expiration Date: xx/xxxx
E xpir a t ion Da t e: xx/xxxx
Offspr in g E xa m 9, Om n i1 E xa m 4
Ver sion 5
GM
06-06-2011
«IDType»-«ID»
«LNa m e», «F Na m e»
27
OMB #: 0925-0216 OMB #: 0925–0216
Expiration Date: xx/xxxx
E xpir a t ion Da t e: xx/xxxx
Offspr in g E xa m 9, Om n i1 E xa m 4
«IDType»-«ID»
«LNa m e», «F Na m e»
28
Observed performance Part 1
Technician Administered
Check here if whole page is blank.
|__|__|__|
Reason why_______________________________________
Technician Number
HAND GRIP TEST Measured to the nearest kilogram
Right hand
Trial 1
99=Unk.
|__|__|
Trial 2
99=Unk.
|__|__|
Trial 3
99=Unk.
|__|__|
Left hand
Trial 1
99=Unk.
|__|__|
Trial 2
99=Unk.
|__|__|
Trial 3
99=Unk.
|__|__|
Check if this test not completed or not attempted.
If not attempted or completed, why not?
1=Physical limitation, 2=Refused, 3=Other ____________________ write in, 9=Unk.
|__|
Protocol modification for Hand Grip , Chair stands and Walk testing
Check for Protocol modification
Comments: _______________________________________________________________________________
_________________________________________________________________________________________
_________________________________________________________________________________________
_________________________________________________________________________________________
TECH15
Ver sion 5
GM
06-06-2011
OMB #: 0925–0216
OMB #: 0925-0216
Expiration Date: xx/xxxx
E xpir a t ion Da t e: xx/xxxx
Offspr in g E xa m 9, Om n i1 E xa m 4
Ver sion 5
GM
06-06-2011
«IDType»-«ID»
«LNa m e», «F Na m e»
29
OMB #: 0925-0216 OMB #: 0925–0216
Expiration Date: xx/xxxx
E xpir a t ion Da t e: xx/xxxx
Offspr in g E xa m 9, Om n i1 E xa m 4
«IDType»-«ID»
«LNa m e», «F Na m e»
30
Observed performance Part 2
Technician Administered
Check here if whole page is blank.
|__|__|__|
Reason why_______________________________________
Technician Number
Repeated Chair Stands (5)
Time to complete five stands in seconds (99.99=Unk.)
|__|__|*|__|__|
If less than five stands, enter the number (9=Unk.)
|__|
IF OFFSITE visit, Chair height (in inches, 99*99=Unk.)
|__|__|*|__|__|
Check if this test not completed or not attempted.
|__|
If not attempted or completed, why not?
(1=Physical limitation, 2=Refused, 3=Other _______________________ write in, 9=Unk.)
Measured Walks
Walking aid used: 0=No aid, 1=Cane, 2=Walker, 3=Wheelchair, 4=Other, 9=Unk.
|__|
First Walk
Walk time (in seconds, 99.99=Unk.)
|__|__|*|__|__|
Laser walk time (in seconds, 99.99=Unk.)
|__|__|*|__|__|
Check if this test not completed or not attempted.
|__|
If not attempted or completed, why not?
(1=Physical limitation, 2=Refused, 3=Other ________________________write in, 9=Unk.)
Second Walk
Walk time (in seconds, 99.99=Unk.)
|__|__|*|__|__|
Laser walk time (in seconds, 99.99=Unk.)
|__|__|*|__|__|
Check if this test not completed or not attempted.
|__|
If not attempted or completed, why not?
(1=Physical limitation, 2=Refused, 3=Other _______________________ write in, 9=Unk.)
Quick Walk
Walk time (in seconds, 99.99=Unk.)
|__|__|*|__|__|
Laser walk time (in seconds, 99.99=Unk.)
|__|__|*|__|__|
Check if this test not completed or not attempted.
|__|
Ver sion 5
GM
If not attempted or completed, why not?
(1=Physical limitation, 2=Refused, 3=Other ____________________write in, 9=Unk.)
06-06-2011
OMB #: 0925-0216 OMB #: 0925–0216
Expiration Date: xx/xxxx
E xpir a t ion Da t e: xx/xxxx
Offspr in g E xa m 9, Om n i1 E xa m 4
«IDType»-«ID»
«LNa m e», «F Na m e»
TECH16
Ver sion 5
GM
06-06-2011
31
OMB #: 0925-0216 OMB #: 0925–0216
Expiration Date: xx/xxxx
E xpir a t ion Da t e: xx/xxxx
Offspr in g E xa m 9, Om n i1 E xa m 4
«IDType»-«ID»
«LNa m e», «F Na m e»
32
Ankle Brachial Blood Pressure Measurements. Participants >40 years
Check here if whole page is blank
Reason why___________________________________
. |__|__|__|
Technician Number for Doppler Ankle Brachial Blood Pressure.
|__|
Have you had any problems with blood clots in your legs?
If yes, fill
do NOT proceed with testing in the extremity with the blood clot
|__|
Are you being treated for this problem now?
Cuff size, arm
Cuff size, ankle
|__|
|__|
0=No
1=Yes
|__|__|__|
Right arm
|__|__|__|
Right ankle
|__|__|__|
Left ankle
|__|__|__|
Left arm
0= pediatric, 1= regular adult
2= large adult, 3= thigh
300=>300 mmHg
888= Not Done
999= Unk.
REPEAT SYSTOLIC BLOOD PRESSURE MEASUREMENTS (reverse order)
|__|__|__|
Left arm
|__|__|__|
Left ankle
|__|__|__|
Right ankle
|__|__|__|
Right arm
300=>300 mmHg
888= Not Done
999= Unk.
THIRD SYSTOLIC BLOOD PRESSURE MEASUREMENT (order as in repeat SBP). To be obtained if initial and repeat
SBP at any site differ by more than 10 mmHg. For site that differs.
|__|
|__|__|__|
Right arm
|__|__|__|
Right ankle
|__|__|__|
Left ankle
|__|__|__|
Left arm
Right Ankle blood pressure site
|__|
Left Ankle blood pressure site
EXCLUSIONS:
300=>300 mmHg
888= Not Done
999= Unk.
0= posterior tibial (ankle)
1= dorsalis pedis (foot), 8=Not Done
Enter exclusion ONLY if there is an 888 above
Right
Left
|__|
|__|
|__|
|__|
Ver sion 5
Lower Extremity Exclusions 1= venous stasis ulceration, or DVT
2= amputation, 3= other___________________
Upper Extremity Exclusions 1=Mastectomy,
3= Other________________________________
Check if Protocol modification, write in_________________________________________
GM
06-06-2011
OMB #: 0925-0216 OMB #: 0925–0216
Expiration Date: xx/xxxx
E xpir a t ion Da t e: xx/xxxx
Offspr in g E xa m 9, Om n i1 E xa m 4
Comments
Ver sion 5
GM
«IDType»-«ID»
«LNa m e», «F Na m e»
33
__________________________________________________________________________
__________________________________________________________________________
TECH17
06-06-2011
OMB #: 0925-0216 OMB #: 0925–0216
Expiration Date: xx/xxxx
E xpir a t ion Da t e: xx/xxxx
Offspr in g E xa m 9, Om n i1 E xa m 4
Ver sion 5
GM
06-06-2011
«IDType»-«ID»
«LNa m e», «F Na m e»
34
OMB #: 0925-0216 OMB #: 0925–0216
Expiration Date: xx/xxxx
E xpir a t ion Da t e: xx/xxxx
Offspr in g E xa m 9, Om n i1 E xa m 4
«IDType»-«ID»
«LNa m e», «F Na m e»
35
Respiratory Disease Questionnaire Part 1
Technician Administered
DATE of last exam «Lexam»
DATE of last medical history update «Lupdate»
Check here if whole page is blank.
Reason why___________________________________
|__|__|__|
Technician Number
Respiratory Diagnoses
Have you ever had asthma? (0=No, 1=Yes, 9=Unk.)
|__|
If yes,
fill
|__|
Do you still have it?
|__|
Was it diagnosed by a doctor or other health care professional?
|__|__|
At what age did it start? (Age in years 88=N/A, 99=Unk.
|__|__|
If you no longer have it, at what age did it stop? (Age in years) 88=still have it, 99=Unk.
|__|
Have you received medical treatment for this in the past 12 months?
|__|
Have you ever had hay fever (allergy involving the nose and/or eyes)? (0=No, 1=Yes, 9=Unk.)
If yes,
fill
|__|
Do you still have it? (0=No, 1=Yes, 9=Unk.)
Have you ever had any of the following conditions diagnosed by a doctor or other health care
professional? (0=No, 1=Yes, 9=Unk.)
||
Chronic Bronchitis
|__|
Emphysema
|__|
COPD (Chronic obstructive pulmonary disease)
|__|
Sleep Apnea
|__|
Pulmonary Fibrosis
Inhaler Use (0=No, 1=Yes)
|__|
If yes,
fill
Do you take inhalers or bronchodilators?
Do you take any of the inhaled medications?- albuterol, ProAir, Proventil,
|__|
Ventolin, pirbuterol, Maxair, levalbuterol, Xopenex, metaproterenol,
Alupent, or ipratropium, Atrovent, Combivent
If yes,
fill
|__|__|
How many hours ago did you last use the medication, either by inhaler
or nebulizer?
if last used >48 hrs ago code 88, 99= Unk.
Time in
hours 1-48
Do you take any of the following inhaled medications? salmeterol,
Serevent, Advair, formoterol, Foradil, Symbicort, arformoterol, Brovana,
tiotropium, or Spiriva,
|__|
If yes,
fill
Ver sion 5
GM
|__|__|
06-06-2011
How many hours ago did you last use the medication, either by inhaler
or nebulizer?
if last used >48 hrs ago code 88, 99=Unk.
Time in
hours 1-48
OMB #: 0925-0216 OMB #: 0925–0216
Expiration Date: xx/xxxx
E xpir a t ion Da t e: xx/xxxx
Offspr in g E xa m 9, Om n i1 E xa m 4
«IDType»-«ID»
«LNa m e», «F Na m e»
TECH18
Ver sion 5
GM
06-06-2011
36
OMB #: 0925-0216 OMB #: 0925–0216
Expiration Date: xx/xxxx
E xpir a t ion Da t e: xx/xxxx
Offspr in g E xa m 9, Om n i1 E xa m 4
«IDType»-«ID»
«LNa m e», «F Na m e»
37
Respiratory Disease Questionnaire Part 2
Technician Administered
Check here if whole page is blank.
Reason why_______________________________________
Acute Respiratory Illnesses Since Last Exam
Since your last exam or medical history update
Have you been hospitalized because of breathing trouble or wheezing? (0=No, 1=Yes, 9=Unk.)
|__|
If yes,
fill
|__|__|
How many times has this occurred?
Were any of these hospitalizations due to a lung or bronchial problem, for example COPD,
asthma, bronchitis, emphysema, or pneumonia?
(0=No, 1=Yes, 9=Unk.)
|__|
Have you required an emergency room visit or an unscheduled visit to a doctor’s office or clinic
because of breathing trouble or wheezing? (0=No, 1=Yes, 9=Unk.)
|__|
If yes,
fill
|__|__|
How many times has this occurred?
Were any of these emergency room or unscheduled visits due to a lung or bronchial
problem, for example COPD, asthma, bronchitis, emphysema, or pneumonia? (0=No,
1=Yes, 9=Unk.)
|__|
Have you had pneumonia (including bronchopneumonia)? (0=No, 1=Yes, 9=Unk.)
|__|
If yes,
fill
|__|__|
How many times have you had pneumonia?
The following questions are about problems which occur when you DO NOT have a cold or the flu.
Please list problems that occurred IN THE PAST 12 MONTHS only
Have you had a problem with sneezing or a runny or blocked nose when you DID NOT have a
cold or the flu? (0=No, 1=Yes, 9=Unk.)
|__|
If yes,
fill
|__|
Has this nose problem been accompanied by itchy-watery eyes? (0=No, 1=Yes, 9=Unk.)
In which of the months did this nose problem occur? (0=No, 1=Yes) Fill in ALL months.
Ver sion 5
GM
|__| January
|__| July
|__| February
|__| August
|__| March
|__| September
|__| April
|__| October
|__| May
|__| November
|__| June
|__| December
06-06-2011
OMB #: 0925-0216 OMB #: 0925–0216
Expiration Date: xx/xxxx
E xpir a t ion Da t e: xx/xxxx
Offspr in g E xa m 9, Om n i1 E xa m 4
«IDType»-«ID»
«LNa m e», «F Na m e»
TECH19
Ver sion 5
GM
06-06-2011
38
OMB #: 0925-0216 OMB #: 0925–0216
Expiration Date: xx/xxxx
E xpir a t ion Da t e: xx/xxxx
Offspr in g E xa m 9, Om n i1 E xa m 4
«IDType»-«ID»
«LNa m e», «F Na m e»
39
Sociodemographic questions.
Self-administered (Offsite - tech-administered)
|__|__|__|
Technician Number for OFFSITE visit ONLY
What is your current marital status? (check ONE)
1
single/never married
2
married/living as married/living with partner
3
separated
4
divorced
5
widowed
9
prefer not to answer
Please choose which of the following best describes your current employment status? (check ONE)
0
homemaker, not working outside the home
1
employed (or self-employed) full time
2
employed (or self-employed) part time
3
employed, but on leave for health reasons
4
employed, but temporarily away from my job
5
unemployed or laid off
6
retired from my usual occupation and not working
7
retired from my usual occupation but working for pay
8
retired from my usual occupation but volunteering
9
prefer not to answer
10
unemployed due to disability
What is your current occupation?
Write in _______________________________________________________________________
|__|__|
YES
YES
Using the occupation coding sheet choose the code that best describes your occupation.
NO
NO
Do you have some form of health insurance?
Do you have prescription drug coverage?
TECH20
Ver sion 5
GM
06-06-2011
OMB #: 0925-0216
OMB #: 0925–0216
Expiration Date: xx/xxxx
E xpir a t ion Da t e: xx/xxxx
Offspr in g E xa m 9, Om n i1 E xa m 4
«IDType»-«ID»
«LNa m e», «F Na m e»
40
Medication Questionnaire
Self-administered (Offsite - tech-administered)
Check if NO medication taken and leave the page BLANK
This questionnaire refers to medication recommended to you by your doctor or health care provider.
For the question below, please check YES or NO
YES
NO
Did you ever forget to take your medicine?
YES
NO
Are you careless at times about taking your medicine?
YES
NO
When you feel better do you stop taking your medicine?
YES
NO
Sometimes if you feel worse when you take the medicine, do you stop taking it?
How often do you forget to take your medicine? (Circle only ONE)
1.
Never
2.
More than once per week
3
Once per week
4.
More than once per month
5.
Once per month
6.
Less than once per month.
TECH21
Ver sion 5
GM
06-06-2011
OMB #: 0925–0216
OMB #: 0925-0216
Expiration Date: xx/xxxx
E xpir a t ion Da t e: xx/xxxx
Offspr in g E xa m 9, Om n i1 E xa m 4
«IDType»-«ID»
«LNa m e», «F Na m e»
41
SF-12 Health Survey (Standard)
S e lf-a d m in is te re d
This questionnaire asks for your views about your health. This information will help you keep track
of how you feel and how well you are able to do your usual activities.
Please answer every question by marking one box. If you are unsure about how to answer a
question, please give the best answer you can.
1. In general, would you say your health is:
Excellent
Very good
Good
Fair
Poor
The following questions are about activities you might do during a typical day. Does your
health now limit you in these activities? If so, how much?
Yes,
limited
a lot
Yes,
limited
a little
No, not
limited
at all
2. Moderate activities, such as moving a table, pushing a
vacuum cleaner, bowling, or playing golf
3. Climbing several flights of stairs
During the past 4 weeks, have you had any of the following problems with your work or
other regular daily activities as a result of your physical health?
Yes
No
4. Accomplished less than you would like
5. Were limited in the kind of work or other activities
During the past 4 weeks, have you had any of the following problems with your work or
other regular daily activities as a result of any emotional problems (such as feeling
depressed or anxious)?
Yes
No
6. Accomplished less than you would like
7. Didn’t do work or other activities as carefully as usual
Ver sion 5
GM
06-06-2011
OMB #: 0925–0216
OMB #: 0925-0216 Expiration Date: xx/xxxx
E xpir a t ion Da t e: xx/xxxx
Offspr in g E xa m 9, Om n i1 E xa m 4
«IDType»-«ID»
«LNa m e», «F Na m e»
TECH22
Ver sion 5
GM
06-06-2011
42
OMB #: 0925–0216
Expiration Date: xx/xxxx
OMB #: 0925-0216
E xpir a t ion Da t e: xx/xxxx
Offspr in g E xa m 9, Om n i1 E xa m 4
«IDType»-«ID»
«LNa m e», «F Na m e»
43
SF-12 Health Survey (Standard)
Self-administered
8. During the past 4 weeks, how much did pain interfere with your normal work (including both work
outside the home and housework)?
Not
at all
A little
bit
Moderately
Quite a
bit
Extremely
These questions are about how you feel and how things have been with you during the past 4
weeks. For each question, please give the one answer that comes closest to the way you have
been feeling.
How much of the time during the past 4 weeks…
All of
the time
Most of
the time
A good bit
of the time
Some of
the time
A little of
the time
None of
the time
9. Have you felt calm and
peaceful?
10. Did you have a lot of
energy?
11. Have you felt
downhearted and blue?
12. During the past 4 weeks, how much of the time has your physical health or emotional problems
interfered with your social activities (like visiting friends, relatives, etc.)?
Ver sion 5
GM
06-06-2011
All of
the time
Most of
the time
Some of
the time
A little of
the time
None of
the time
OMB #: 0925–0216
Expiration Date: xx/xxxx
OMB #: 0925-0216
E xpir a t ion Da t e: xx/xxxx
Offspr in g E xa m 9, Om n i1 E xa m 4
«IDType»-«ID»
«LNa m e», «F Na m e»
TECH23
Ver sion 5
GM
06-06-2011
44
OMB #: 0925-0216 OMB #: 0925–0216
Expiration Date: xx/xxxx
E xpir a t ion Da t e: xx/xxxx
Offspr in g E xa m 9, Om n i1 E xa m 4
«IDType»-«ID»
«LNa m e», «F Na m e»
45
Sleep Questionnaire. Part 1
Self-administered
What is the chance that you would doze off or fall asleep (not just “feel tired”) in each
of the following situations? (Circle one response for each situation. If you are never or rarely in
the situation, please give your best guess for that situation)
None
Slight
Moderate
High
Sitting and reading
0
1
2
3
Watching TV
0
1
2
3
Sitting inactive in a public place (such as theater or a
meeting)
0
1
2
3
Riding as a passenger in a car for an hour without a break
0
1
2
3
Lying down to rest in the afternoon when circumstances
permit
0
1
2
3
Sitting and talking to someone
0
1
2
3
Sitting quietly after a lunch without alcohol
0
1
2
3
In a car, while stopped in traffic for a few minutes
0
1
2
3
TECH24
Ver sion 5
GM
06-06-2011
OMB #: 0925-0216 OMB #: 0925–0216
Expiration Date: xx/xxxx
E xpir a t ion Da t e: xx/xxxx
Offspr in g E xa m 9, Om n i1 E xa m 4
«IDType»-«ID»
«LNa m e», «F Na m e»
46
Sleep Questionnaire Part 2
Self-administered
During the past month...
when have you usually gone to bed at night?
|__|__|:|__|__| |__| |__|
hours : min
AM PM
how long has it usually taken you to fall asleep each night?
|__|__|:|__|__|
hours : min
when have you usually gotten up in the morning?
|__|__|:|__|__| |__| |__|
hours : min
AM PM
how much actual sleep did you get at night?
|__|__|:|__|__|
hours : min
When you experience the following situations, how likely is it for you to have difficulty sleeping?
Circle an answer even if you have not experienced these situations recently.
Not likely
Somewhat
likely
Moderately
likely
Very likely
Before an important meeting the next day
0
1
2
3
After a stressful experience during the day
0
1
2
3
After a stressful experience in the evening
0
1
2
3
After getting bad news during the day
0
1
2
3
After watching a frightening movie or TV show
0
1
2
3
After having a bad day at work
0
1
2
3
After an argument
0
1
2
3
Before having to speak in public
0
1
2
3
Before going on vacation the next day
0
1
2
3
|__|
On average over the past year, how often do you snore?
|__|
On average over the past year, how often do you have times
when you stop breathing while you are asleep?
Ver sion 5
GM
06-06-2011
0= Never
1= Less than 1 night per week
2= 1-2 nights per week
3= 3-5 nights per week
4= 6-7 nights per week
9= Don’t know
OMB #: 0925-0216 OMB #: 0925–0216
Expiration Date: xx/xxxx
E xpir a t ion Da t e: xx/xxxx
Offspr in g E xa m 9, Om n i1 E xa m 4
«IDType»-«ID»
«LNa m e», «F Na m e»
TECH25
Ver sion 5
GM
06-06-2011
47
OMB #: 0925–0216
OMB #: 0925-0216 Expiration Date: xx/xxxx
E xpir a t ion Da t e: xx/xxxx
Offspr in g E xa m 9, Om n i1 E xa m 4
«IDType»-«ID»
«LNa m e», «F Na m e»
48
Sleep Questionnaire Part 3
Self-administered
One hears about “morning” and “evening” types of people. Which ONE of these types do you
consider yourself to be? Please check ONE box below
1
Definitely a ―morning‖ type
2
Rather more a ―morning‖ than an ―evening‖ type
3
Neither a ―morning‖ nor an ―evening‖ type
4
Rather more an ―evening‖ than a ―morning‖ type
5
Definitely an ―evening‖ type
|__|__| |__|__|
hour
min
AM
PM
Considering only your ―feeling best‖ rhythm, at what time would
you get up if you were entirely free to plan your day?
|__|__| |__|__|
hour
min
AM
PM
Considering only your ―feeling best‖ rhythm, at what time would
you go to bed if you were entirely free to plan your evening?
Have you ever been told by a doctor or other health professional that you have any of the following?
(Circle one response for each item)
No
Yes
Don’t know
0
1
9
0
1
9
Insomnia
0
1
9
Restless legs
0
1
9
Sleep apnea or obstructive sleep apnea
if yes,
fill
Do you wear a mask (―CPAP‖) or other device
at night to treat sleep apnea?
TECH26
Ver sion 5
GM
06-06-2011
OMB #: 0925–0216
OMB #: 0925-0216 Expiration Date: xx/xxxx
E xpir a t ion Da t e: xx/xxxx
Offspr in g E xa m 9, Om n i1 E xa m 4
Ver sion 5
GM
06-06-2011
«IDType»-«ID»
«LNa m e», «F Na m e»
49
OMB #: 0925–0216
OMB #: 0925-0216 Expiration Date: xx/xxxx
E xpir a t ion Da t e: xx/xxxx
Offspr in g E xa m 9, Om n i1 E xa m 4
«IDType»-«ID»
«LNa m e», «F Na m e»
50
Framingham Study Vascular Function Participant Worksheet
(circle on)e
0
1
Keyer 2:
______________________
Keyer 1: _______________________
Have you had any caffeinated drinks in the last 6 hours?
(0=No, 1=Yes, 9=Unk.)
9
if yes
fill
|__|__|
How many cups?
(99=Unk.)
0
1
9
Have you eaten anything else including a fat free cereal bar this morning?
(0=No, 1=Yes, 9=Unknown)
0
1
9
Have you smoked cigarettes in the last 6 hours? (0=No, 1=Yes, 9=Unk.)
if yes
fill
|__|__|:|__|__|
If yes, how many hours and minutes since your last cigarette?
(99:99=Unk.)
Tonometry
|__|__|/|__|__|/|__|__|__|__|
|__|__|__|
|__|__|__|-|__|__|__|
0
1
If no fill
Date of Tonometry scan?
(99/99/9999=Unk.)
Tonometry Sonographer ID
Tonometry CD number
Was Tonometry done?
0= No, test was not attempted or done
1= Yes, test was done, even if all 4 pulses could not be acquired and
recorded.
Reason why: (Check all that apply)
Subject refusal
Subject discomfort
Time constraint
Equipment problem, specify
Other, specify
___________________________________________
_____________________________________________________
Not for Data Entry.
Distances:
Ver sion 5
GM
06-06-2011
OMB #: 0925–0216
OMB #: 0925-0216 Expiration Date: xx/xxxx
E xpir a t ion Da t e: xx/xxxx
Offspr in g E xa m 9, Om n i1 E xa m 4
______Carotid(mm)
Ver sion 5
GM
06-06-2011
«IDType»-«ID»
_______Brachial(mm)
«LNa m e», «F Na m e»
_______Radial(mm)
51
_______Femoral(mm)
OMB #: 0925–0216
OMB #: 0925-0216 Expiration Date: xx/xxxx
E xpir a t ion Da t e: xx/xxxx
Offspr in g E xa m 9, Om n i1 E xa m 4
Ver sion 5
GM
06-06-2011
«IDType»-«ID»
«LNa m e», «F Na m e»
52
OMB #: 0925–0216
OMB #: 0925-0216 Expiration Date: xx/xxxx
E xpir a t ion Da t e: xx/xxxx
Offspr in g E xa m 9, Om n i1 E xa m 4
«IDType»-«ID»
«LNa m e», «F Na m e»
53
Date of exam
_____/_____/_____
Framingham Heart Study
Summary Sheet to Personal Physician
Blood
Pressure
First Reading
Second Reading
Systolic
Diastolic
ECG Diagnosis ____________________________________________________________________________
_________________________________________________________________________________________
The following tests are done on a routine basis: Blood Glucose, Blood Lipids, Pulmonary Function Test (results enclosed).
Summary of Findings_______________________________________________________________________
1. No history or physical exam findings to suggest cardiovascular disease
(check box if applicable)
__________________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
_______________________________
Examining Physician
The Heart Study Clinic examination is not comprehensive and does not take the place of a routine physical
examination.
Ver sion 5
GM
06-06-2011
OMB #: 0925–0216
OMB #: 0925-0216
Expiration Date: xx/xxxx
E xpir a t ion Da t e: xx/xxxx
Offspr in g E xa m 9, Om n i1 E xa m 4
Ver sion 5
GM
06-06-2011
«IDType»-«ID»
«LNa m e», «F Na m e»
54
OMB #: 0925–0216
OMB #: 0925-0216
Expiration Date: xx/xxxx
E xpir a t ion Da t e: xx/xxxx
Offspr in g E xa m 9, Om n i1 E xa m 4
«IDType»-«ID»
«LNa m e», «F Na m e»
55
Referral Tracking
Check here if whole page is blank.
||
if yes fill below
RESULT
Reason why_____________________________________
Was further medical evaluation recommended for this participant? 0=No, 1=Yes,
9=Unk.
Reason for further evaluation:
(Check ALL that apply).
Blood Pressure
result ______/_______
mmHg
result ______/_______
mmHg
SBP or DBP
Phone call > 200 or >110
Expedite > 180 or >100
Elevated > 140 or >90
Write in abnormality
Abnormal laboratory result______________________
ECG abnormality _____________________________________________________
Clinic Physician identified medical problem_________________________________
Other ________________________________________________________________
Method used to inform participant of need for further medical evaluation
(Check ALL that apply)
Face-to-face in clinic
Phone call
Result letter
Other
Method used to inform participant’s personal physician of need for further
medical evaluation (check ALL that apply)
Phone call
Result letter mailed
Result letter FAX’d (inform staff if Fax needed)
Other
Date referral made: _____/____/________
ID number of person completing the referral: __________
Notes documenting conversation with participant or participant’s personal physician:_________________
Ver sion 5
GM
06-06-2011
OMB #: 0925–0216
OMB #: 0925-0216
Expiration Date: xx/xxxx
E xpir a t ion Da t e: xx/xxxx
Offspr in g E xa m 9, Om n i1 E xa m 4
«IDType»-«ID»
«LNa m e», «F Na m e»
56
_____________________________________________________________________________________
TECH27
Ver sion 5
GM
06-06-2011
OMB #: 0925–0216
OMB #: 0925-0216
Expiration Date: xx/xxxx
E xpir a t ion Da t e: xx/xxxx
Offspr in g E xa m 9, Om n i1 E xa m 4
Ver sion 5
GM
06-06-2011
«IDType»-«ID»
«LNa m e», «F Na m e»
57
OMB #: 0925-0216 OMB #: 0925–0216
E xpir a t ion Da t e: xx/xxxx
Expiration Date: xx/xxxx
Offspr in g E xa m 9, Om n i1 E xa m 4
«IDType»-«ID»
«LNa m e», «F Na m e»
58
Medical History—Hospitalizations, ER Visits, MD Visits
DATE ____________
DATE of last exam «Lexam»
DATE of last medical history update «Lupdate»
Health Care
Since your last exam or medical history update
|__|__|__|
|_0_|
1st Examiner Prefix (0=MD, 1=Tech. for OFFSITE visit)
Hospitalizations (not just E.R.) (0=No; 1=yes, hospitalization, 2=yes, more than 1
|__|
hospitalization, 9=Unk.)
|__|
E.R. Visits (0=No, 1=Yes, 1 visit, 2=Yes, more than 1 visit, 9=Unk.)
|__|
Day Surgery (0=No, 1=Yes, 9=Unk.)
Major illness with visit to doctor (0=No, 1=Yes, 1 visit, 2=Yes, more than 1 visit;
|__|
9=Unk.)
|__|
Check up by doctor or other health care provider? (0=No, 1=Yes, 9=Unk.)
|__|
Have you had a fever or infection in past two weeks? (0=No, 1=Yes, 9=Unk.)
|__|__| |__|__| |__|__|__|__|
MM
DD
GM
Date of this FHS exam (Today's date - See above)
YYYY
Medical Encounter
Ver sion 5
1st Examiner ID _________________________ 1st Examiner Name
06-06-2011
Month/Year
(of last visit)
Name & Address of Hospital or
Office
Doctor
OMB #: 0925-0216 OMB #: 0925–0216
E xpir a t ion Da t e: xx/xxxx
Expiration Date: xx/xxxx
Offspr in g E xa m 9, Om n i1 E xa m 4
«IDType»-«ID»
«LNa m e», «F Na m e»
MD01
Ver sion 5
GM
06-06-2011
59
OMB #: 0925–0216
Expiration Date: xx/xxxx
OMB #: 0925-0216
E xpir a t ion Da t e: xx/xxxx
Offspr in g E xa m 9, Om n i1 E xa m 4
«IDType»-«ID»
«LNa m e», «F Na m e»
60
Medical History—Medications
|__|
Do you take aspirin regularly? ( 0=No, 1=Yes, 9=Unk.)
If yes,
fill
|__|__|
Number of aspirins taken regularly (99=Unk.)
|__|
Frequency per ( 1=Day, 2=Week 3=Month, 4=Year, 9=Unk.)
|__|__|__|
Usual dose (write in mgs, 999=Unk.)
Examples: 081=baby,160=half dose,
250= like in Excedrin, 325=usual dose,
500=extra strength
Since your last exam
(0=No, 1=Yes, 9=Unk.)
|__|
Have you been told by doctor you have high blood pressure or hypertension?
|__|
Have you taken medication for high blood pressure or hypertension?
|__|
Have you been told by doctor you have high blood cholesterol or high triglycerides?
|__|
Have you taken medication for high blood cholesterol or high triglycerides?
|__|
Have you been told by doctor you have high blood sugar or diabetes?
|__|
Have you taken medication for high blood sugar or diabetes?
|__|
Have you taken medication for cardiovascular disease? (for example angina/chest pain,
heart failure, atrial fibrillation/heart rhythm abnormality, stroke, leg pain when walking,
peripheral artery disease)
MD02
Ver sion 5
GM
06-06-2011
OMB #: 0925–0216
Expiration Date: xx/xxxx
OMB #: 0925-0216
E xpir a t ion Da t e: xx/xxxx
Offspr in g E xa m 9, Om n i1 E xa m 4
«IDType»-«ID»
«LNa m e», «F Na m e»
61
Medical History – Prescription and Non-Prescription Medications
Copy the name of medicine, the strength including units, and the total number of doses per day/week/month/year. Include vitamins and minerals.
Medication bag with medications or bottles/packs brought **List medications taken regularly in past month/ongoing medications**
Code ASPIRIN ONLY on screen MD02.
to exam?
(0=No 1=Yes)
Strength
(Print first 20 letters)
EXAMPLE:
S A M P
L
E
D R U G
(include mg, IU,
etc)
N A
M E
100
mg
Route
Number per
1= oral, 2=topical,
3=injection,
4=inhaled,
5=drops,6=nasal
88=other
#
1
1
(circle one)
day/week/month/year
1 / 2 / 3
/ 4
DWMY
Check if
OTC med
Medication Name
1=yes,9=Unk.
Check if NO medication taken
PRN 0=no,
|__|
0
DWMY
DWMY
DWMY
DWMY
DWMY
DWMY
DWMY
DWMY
DWMY
DWMY
Continue on the next page
Ver sion 5
GM
06-06-2011
OMB #: 0925–0216
Expiration Date: xx/xxxx
OMB #: 0925-0216
E xpir a t ion Da t e: xx/xxxx
Offspr in g E xa m 9, Om n i1 E xa m 4
«IDType»-«ID»
«LNa m e», «F Na m e»
62
MD03
Ver sion 5
GM
06-06-2011
OMB #: 0925–0216
Expiration Date: xx/xxxx
OMB #: 0925-0216
E xpir a t ion Da t e: xx/xxxx
Offspr in g E xa m 9, Om n i1 E xa m 4
«IDType»-«ID»
«LNa m e», «F Na m e»
63
Medical History – Prescription and Non-Prescription Medications
Ver sion 5
GM
Route
(include mg, IU, etc)
1= oral, 2=topical,
3=injection,
4=inhaled,
5=drops,6=nasal
88=other
#
1
1
S A M P
06-06-2011
L
E
D R U G
N A
M E
100
mg
Number per
(circle one)
day/week/month/year
/ 2 / 3
/ 4
0
.
1
Check if
OTC med.
Strength
(Print first 20 letters)
PRN 0=no,
1=yes, 9-Unk
EXAMPLE:
Medication Name
DWMY
DWMY
DWMY
DWMY
DWMY
DWMY
DWMY
DWMY
DWMY
DWMY
DWMY
DWMY
DWMY
DWMY
DWMY
DWMY
OMB #: 0925–0216
Expiration Date: xx/xxxx
OMB #: 0925-0216
E xpir a t ion Da t e: xx/xxxx
Offspr in g E xa m 9, Om n i1 E xa m 4
«IDType»-«ID»
«LNa m e», «F Na m e»
64
MD04
Ver sion 5
GM
06-06-2011
OMB #: 0925–0216
OMB #: 0925-0216
Expiration Date: xx/xxxx
E xpir a t ion Da t e: xx/xxxx
Offspr in g E xa m 9, Om n i1 E xa m 4
«IDType»-«ID»
«LNa m e», «F Na m e»
65
Medical History–Female Reproductive History Part 1
Check here if Male Participant (and skip to Smoking Questions page 48/MD08)
Check here if definitely menopausal (and skip to Female History Part 3 page 47)
(preloaded from previous exam)
«Meno»
|__|
|__|
If yes,
fill
Since your last exam have you taken or used birth control pills, shots, or hormone implants
for birth control or medical indications (not post menopausal hormone replacement)?
(0=no, 1=yes, now, 2=yes, not now, 9=Unk.)
Have you been pregnant since last exam?
|__|__|
(0=No, 1=Yes, 9=Unk.)
Number of pregnancies?
fill in number
|__|__|
Number of live births?
|__|
During any of these pregnancies, were you told you had high blood
pressure or hypertension?
0=No
|__|
During any of these pregnancies, were you told you had eclampsia, pre1=Yes
eclampsia (toxemia)?
|__|
During any of these pregnancies, were you told you had high blood
sugar or diabetes?
9=Unk.
MD05
Ver sion 5
GM
06-06-2011
OMB #: 0925–0216
OMB #: 0925-0216Expiration Date: xx/xxxx
E xpir a t ion Da t e: xx/xxxx
Offspr in g E xa m 9, Om n i1 E xa m 4
«IDType»-«ID»
«LNa m e», «F Na m e»
66
Medical History–Female Reproductive History Part 2
What is the best way to describe your periods? Check the BEST answer – only one
Not stopped
Periods stopped due to pregnancy, breastfeeding, or hormonal contraceptive (for example:
Periods stopped due to low body weight, heavy exercise, or due to medication or health
condition such as thyroid disease, pituitary tumor, hormone imbalance, stress,
depo-provera, progestin releasing IUD, extended release birth control pill)
Write in cause
______________________________________________________
Periods stopped for less than 1 year (perimenopausal)
|__|__|
Number of months since last period
99=Unk.
Periods stopped for 1 year or more
Periods stopped, but now have periods induced by hormones.
|__|__|
|__|__|*|__|__|*|__|__|__|__|
month
day
year
Number months stopped before hormones started.
99=Unk.
When was the first day of your last menstrual period? 99/99/9999=Unk.
88/88/8888= periods stopped for more than 1 year or using postmenopausal hormones
If periods stopped due to pregnancy, breastfeeding, hormonal contraception or health
condition code date of last menstrual period
Age when periods stopped (00=not stopped, 99=Unk.)
|__|__|
If periods now induced by hormones, code age when periods naturally stopped.
If periods stopped due to pregnancy, breastfeeding, or hormonal contraception code as 0=not
stopped
Was your menopause natural or the result of surgery, chemotherapy, or radiation?
|__|
(0=still menstruating, 1=natural, 2=surgical, 3=chemo/radiation, 4=other, 9=Unk.)
If periods stopped due to pregnancy, breast feeding, or hormonal contraception code as 0=still
menstruating
MD06
Ver sion 5
GM
06-06-2011
OMB #: 0925–0216
Expiration Date: xx/xxxx
OMB #: 0925-0216
E xpir a t ion Da t e: xx/xxxx
Offspr in g E xa m 9, Om n i1 E xa m 4
«IDType»-«ID»
«LNa m e», «F Na m e»
67
Medical History–Female Reproductive History Part 3
Surgery History
|__|
If yes,
fill
|__|
If yes,
fill
Since your last exam have you had a hysterectomy (uterus/womb removed)?
(0=No, 1=Yes, 9=Unk.)
|__|__|
Age at hysterectomy? 99=Unk.
|__|__|*|__|__|__|__|
Date of surgery (mo/yr)
99/9999=Unk.
Since last exam have you had an operation to remove one or both of your ovaries?
(0=No, 1=Yes, 9=Unk.)
Age when ovaries removed? If more than one surgery, use age at last surgery 99=Unk.
|__|__|
Number of ovaries removed? (check one)
|__|
1=one ovary
2=two ovaries
3= unknown number of ovaries
4= part of an ovary
Have you since your last exam taken hormone replacement therapy (estrogen/progesterone) or
a selective estrogen receptor modulator (such as evista or raloxifene)?
(0=No, 1=Yes, now, 2=Yes, not now, 9=Unk.)
Comments_________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
MD07
Ver sion 5
GM
06-06-2011
OMB #: 0925–0216
Expiration Date: xx/xxxx
OMB #: 0925-0216
E xpir a t ion Da t e: xx/xxxx
Offspr in g E xa m 9, Om n i1 E xa m 4
«IDType»-«ID»
«LNa m e», «F Na m e»
68
Medical History--Smoking
Cigarettes
Since your last exam have you smoked cigarettes regularly? (0=No, 1=Yes, 9=Unk.)
|__|
If yes,
fill
||
Have you smoked cigarettes regularly in the last year? (No means less than 1
cigarette a day for 1 year.)
(0=No, 1=Yes, 9=Unk.)
||
Do you now smoke cigarettes (as of 1 month ago)? (0=No, 1=Yes, 9=Unk.)
|__|__|
How many cigarettes do you smoke per day now? (99=Unk.)
Questions below refer to “since your last exam”
|__|__|
During the time you were smoking, on average how many cigarettes per day did you
smoke (99=Unk.)
|__|__|
If you have stopped smoking cigarettes completely, how old were you when you
stopped? (Age stopped, 00=Not stopped, 99=Unk.)
|__|
When you were smoking, did you ever stop smoking for >6 months? (0=No, 1=Yes,
9=Unk.)
If yes,
fill
|__|__|
For how many years in total did you stop smoking cigarettes (01=6 months
– 1 year, 99=Unk.)
Pipes or Cigars
|__|
Since your last exam, have you regularly smoked a pipe or cigar?
If yes,
fill
|__|
Do you smoke a pipe or cigar now
0=No
1=Yes
9=Unk.
Comments:_______________________________________________________________________________
_________________________________________________________________________________________
_________________________________________________________________________________________
MD08
Ver sion 5
GM
06-06-2011
OMB #: 0925–0216
Expiration Date: xx/xxxx
OMB #: 0925-0216
E xpir a t ion Da t e: xx/xxxx
Offspr in g E xa m 9, Om n i1 E xa m 4
Ver sion 5
GM
06-06-2011
«IDType»-«ID»
«LNa m e», «F Na m e»
69
OMB #: 0925–0216
OMB #: 0925-0216 Expiration Date: xx/xxxx
E xpir a t ion Da t e: xx/xxxx
Offspr in g E xa m 9, Om n i1 E xa m 4
«IDType»-«ID»
«LNa m e», «F Na m e»
70
Medical History –Alcohol Consumption
Now I will ask you questions regarding your alcohol use.
Do you drink any of the following beverages at least once a month?
(0=No, 1=Yes, 9=Unk.)
|__|
Beer
|__|
Wine
Liquor/spirits
||
If yes, what is your average number of servings in a typical week or month over past year?
(999=Unk.)
Code alcohol intake as EITHER weekly OR monthly as appropriate.
Beverage
Per week
Per month
Beer (12oz bottle, glass, can)
|__|__|__|
|__|__|__|
Wine (red or white, 4oz glass)
||||
||||
Liquor/spirits (1oz cocktail/highball)
||||
||||
|__|__|__| At what age did you stop drinking alcohol? (0= Not stopped, 888=Never drank, 999=Unk.)
Over the past year, on average on how many days per week did you drink an
|__|
alcoholic beverage of any type?
|||
|__|__|
(0=No drinks, 1=1or less, 9=Unk.)
Over the past year, on a typical day when you drink, how many drinks do you
have?
(0=No drinks, 1=1or less, 99=Unk.)
What was the maximum number of drinks you had in 24 hr. period during the
past month?
(0=No drinks, 1=1or less, 99=Unk.)
Since last exam has there been a time when you drank 5 or more alcoholic drinks
||
of any kind almost daily?
(0=No, 1=Yes, 9=Unk.)
Check if over past year participant drinks less than one alcoholic drink of any type per
month.
Comments:_______________________________________________________________________________
_________________________________________________________________________________________
_________________________________________________________________________________________
Ver sion 5
GM
06-06-2011
OMB #: 0925–0216
OMB #: 0925-0216 Expiration Date: xx/xxxx
E xpir a t ion Da t e: xx/xxxx
Offspr in g E xa m 9, Om n i1 E xa m 4
«IDType»-«ID»
«LNa m e», «F Na m e»
MD09
Ver sion 5
GM
06-06-2011
71
OMB #: 0925-0216 OMB #: 0925–0216
Expiration Date: xx/xxxx
E xpir a t ion Da t e: xx/xxxx
Offspr in g E xa m 9, Om n i1 E xa m 4
«IDType»-«ID»
«LNa m e», «F Na m e»
72
Medical History—Respiratory Symptoms Part I
Cough
(0=No, 1=Yes, 9=Unk.)
|__|
Do you usually have a cough? (Exclude clearing of the throat)
||
Do you usually have a cough at all on getting up or first thing in the
morning?
If YES to either question above answer the following:
|__|
Do you cough like this on most days for three consecutive months or
more during the past year?
|__|__|
How many years have you had this cough? (# of years)
Phlegm
1=1 year or less
99=Unk.
(0=No, 1=Yes, 9=Unk.)
|__|
Do you usually bring up phlegm from your chest?
||
Do you usually bring up phlegm at all on getting up or first thing in the
morning?
If YES to either question above answer the following:
|__|
Do you bring up phlegm from your chest on most days for three
consecutive months or more during the year?
|__|__|
How many years have you had trouble with phlegm? (# of years)
Wheeze
1=1 year or less
99=Unk.
(0=No, 1=Yes, 9=Unk.)
In the past 12 months…
|__|
if yes,
fill
all
Have you had wheezing or whistling in your chest at any time?
|__|
How often have you had this wheezing or whistling?
0=Not at all 1=MOST days or nights 2=A few days or nights a WEEK
3=A few days or nights a MONTH
4=A few days or nights a YEAR 9=Unk.
|__|
Have you had this wheezing or whistling in the chest when you had
a cold?
|__|
Have you had this wheezing or whistling in the chest apart from
colds?
|__|
Have you had an attack of wheezing or whistling in the chest that
had made you feel short of breath?
MD10
Ver sion 5
GM
06-06-2011
OMB #: 0925-0216 OMB #: 0925–0216
Expiration Date: xx/xxxx
E xpir a t ion Da t e: xx/xxxx
Offspr in g E xa m 9, Om n i1 E xa m 4
Ver sion 5
GM
06-06-2011
«IDType»-«ID»
«LNa m e», «F Na m e»
73
OMB #: 0925-0216 OMB #: 0925–0216
Expiration Date: xx/xxxx
E xpir a t ion Da t e: xx/xxxx
Offspr in g E xa m 9, Om n i1 E xa m 4
«IDType»-«ID»
«LNa m e», «F Na m e»
74
Medical History—Respiratory Symptoms Part II
Nocturnal chest symptoms
(0=No, 1=Yes, 9=Unk.)
In the past 12 months…
|__|
Have you been awakened by shortness of breath?
|__|
Have you been awakened by a wheezing/whistling in your chest?
|__|
Have you been awakened by coughing?
if yes,
fill
all
How often have you been awakened by coughing?
|__|
0=Not at all 1=MOST days or nights 2=A few days or nights a WEEK
3=A few days or nights a MONTH
4=A few days or nights a YEAR 9=Unk.
Shortness of breath
(0=No, 1=Yes, 9=Unk.)
Since your last exam…
|__|
if yes,
fill
all
Are you troubled by shortness of breath when hurrying on level ground or walking up a slight
hill?
|__|
Do you have to walk slower than people of your age on level ground because of shortness
of breath?
|__|
Do you have to stop for breath when walking at your own pace on level ground?
|__|
Do you have to stop for breath after walking 100 yards (or after a few minutes) on level
ground?
|__|
Do you/have you needed to sleep on two or more pillows to help you breathe (Orthopnea)?
|__|
Have you since last exam had swelling in both your ankles (ankle edema)?
|__|
Have you been told by your doctor you had heart failure or congestive heart failure?
if yes,
fill
Name of doctor ______________________________________________________
Date of visit |__|__|*|__|__|*|__|__|__|__|
|__|
99/99/9999=Unk.
Have you been hospitalized for heart failure? (Provide details on MD01-Health Care page 41)
CHF First Examiner Opinion
|__|
First examiner believes CHF
0=No,1=Yes
2=Maybe, 9=Unk.
Comments________________________________________________________________________________
__________________________________________________________________________________________
Ver sion 5
GM
06-06-2011
OMB #: 0925-0216 OMB #: 0925–0216
Expiration Date: xx/xxxx
E xpir a t ion Da t e: xx/xxxx
Offspr in g E xa m 9, Om n i1 E xa m 4
«IDType»-«ID»
«LNa m e», «F Na m e»
75
__________________________________________________________________________________________
MD11
Ver sion 5
GM
06-06-2011
OMB #: 0925-0216 OMB #: 0925–0216
Expiration Date: xx/xxxx
E xpir a t ion Da t e: xx/xxxx
Offspr in g E xa m 9, Om n i1 E xa m 4
«IDType»-«ID»
«LNa m e», «F Na m e»
76
Physical Exam—Blood Pressure
Physician Blood Pressure
First reading
Systolic
BP cuff size
|__|__|__|
to nearest 2 mm Hg
|__|
0=pedi,1=reg.adult, 2=large adult,
3= thigh, 9=Unk.
Diastolic
Protocol modification
|__|__|__|
to nearest 2 mm Hg
|__|
0=No, 1=Yes, 9=Unk.
Comments for Protocol modification________________________________________________________
_______________________________________________________________________________________
_______________________________________________________________________________________
_______________________________________________________________________________________
MD12
Ver sion 5
GM
06-06-2011
OMB #: 0925–0216
OMB #: 0925-0216
Expiration Date: xx/xxxx
E xpir a t ion Da t e: xx/xxxx
Offspr in g E xa m 9, Om n i1 E xa m 4
«IDType»-«ID»
«LNa m e», «F Na m e»
77
Medical History—Chest pain
Since your last exam have you experienced any chest discomfort? (please
provide narrative comments in addition to completing the appropriate boxes)
Chest discomfort with exertion or excitement
|__|
|__|
if yes,
fill
and below
|__|
Chest discomfort when quiet or resting
0=No,
1=Yes,
2=Maybe,
9=Unk.
Chest Discomfort Characteristics
|__|__|*|__|__|__|__|
Date of onset (mo/yr)
99/9999=Unk.
|__|__|__|
Usual duration (minutes)
1=1 min or less, 900=15 hrs or more, 999=Unk.
|__|__|__|
Longest duration (minutes)
1=1 min or less, 900=15 hrs or more, 999=Unk.
|__|
Location
|__|
Radiation
|__|__|__|
|__|__|__|
0=No, 1=Central sternum and upper chest,
2=L Up Quadrant, 3=L Lower ribcage, 4=R
Chest, 5=Other, 6=Combination, 9=Unk.
0=No, 1=Left shoulder or L arm, 2=Neck,
3=R shoulder or arm, 4=Back, 5=Abdomen,
6=Other, 7=Combination, 9=Unk.
Number of episodes of chest pain in
past month
Number of episodes of chest pain in
past year.
999=Unk.
999=Unk.
1=Pressure, heavy, vise, 2=Sharp, 3=Dull,
4=Other, 9=Unk.
|__|
Type
|__|
Relief by Nitroglycerin in <15 minutes
0=No,
|__|
Relief by Rest in <15 minutes
1=Yes,
|__|
Relief Spontaneously in <15 minutes
8=Not tried
|__|
Relief by Other cause in <15 minutes
9=Unk.
Since your last exam have you been told by a doctor you had a heart
attack or myocardial infarction?
|__|
0=No, 1=Yes,
2=Maybe, 9=Unk.
Name of doctor ______________________________________________________
if yes,
fill l
Date of visit |__|__|*|__|__|*|__|__|__|__|
99/99/9999=Unk.
CHD First Examiner Opinions
|__|
Angina pectoris
Angina pectoris since revascularization procedure
if yes,fill |__|
|__|
Coronary insufficiency
|__|
Myocardial infarct
0=No,
1=Yes,
2=Maybe,
8=No revasculation
9=Unk.
Comments_________________________________________________________________________________
__________________________________________________________________________________________
Ver sion 5
GM
06-06-2011
OMB #: 0925-0216 OMB #: 0925–0216
Expiration Date: xx/xxxx
E xpir a t ion Da t e: xx/xxxx
Offspr in g E xa m 9, Om n i1 E xa m 4
«IDType»-«ID»
«LNa m e», «F Na m e»
78
__________________________________________________________________________________________
MD13
Ver sion 5
GM
06-06-2011
OMB #: 0925–0216
OMB #: 0925-0216
Expiration Date: xx/xxxx
E xpir a t ion Da t e: xx/xxxx
Offspr in g E xa m 9, Om n i1 E xa m 4
«IDType»-«ID»
«LNa m e», «F Na m e»
79
Medical History—Atrial Fibrillation/Syncope
Since your last exam or medical history update…
|__|
0=No, 1=Yes, 2=Maybe, 9=Unk.
Have you been told you have/had atrial fibrillation?
if yes,fill
|__|__|*|__|__|*|__|__|__|__|
|__|
0=No, 1=Hosp/ER, 2=Saw M.D.,
9=Unk.
ER/hospitalized or saw M.D.
if yes, fill
____________________________________ Name of the Hospital (write Unk. if unknown)
____________________________________
|__|
99/99/9999=Unk.
Date of first episode
Name of M.D. (write Unk. if unknown)
Do you have a family history of a heart rhythm problem called atrial fibrillation? 0=No, 1=Yes, 9=Unk
if yes,fill
|__|
if yes,
fill all
Mother
Father
Siblings
Children
|__|
|__|
|__|
|__|
Have you fainted or lost consciousness?
(If event immediately preceded by head injury or accident code 0=No)
Number of episodes in the past two years
999=Unk.
|__|__|*|__|__|__|__|
Date of first episode (mo/yr)
99/9999=Unk.
|__|__|__|
Usual duration of loss of consciousness (minutes)
999=Unk.,1=1 min or less
|__|
Did you have any injury caused by the event?
0=No, 1=Yes, 2=Maybe, 9=Unk.
|__|
ER/hospitalized or saw M.D.
0=No, 1=Hosp/ER, 2=Saw M.D.,
9=Unk.
____________________________________ Name of the Hospital (write Unk.. if unknown)
____________________________________
if yes,
fill
|__|
if yes,fill
0=No, 1=Yes, 2=Maybe,
9=Unk..
|__|__|__|
if yes, fill
|__|
0=No, 1=Yes, 9=Unk.
Name of M.D. (write Unk. if unknown)
Have you had a head injury with loss of consciousness?
|__|__| * |__|__| * |__|__|__|__|
Date of serious head injury with loss of
consciousness
Have you had a seizure?
|__|__| * |__|__| * |__|__|__|__|
|__|
0=No, 1=Yes, 2=Maybe,
9=Unk.
99/99/9999=Unk.
0=No, 1=Yes, 2=Maybe, 9=Unk.
Date of most recent seizure
99/99/9999=Unk.
Are you being treated for a seizure
disorder?
0=No, 1=Yes, 2=Maybe, 9=Unk.
Syncope First Examiner Opinion
|__|
Syncope (0=No, 1=Yes, 2=Maybe, 3=Presyncope, 9=Unk.) needs second opinion
if yes,
fill
|__|
Cardiac syncope
|__|
Vasovagal syncope
|__|
Other-Specify: _____________________
0=No,
1=Yes,
2=Maybe,
9=Unk.
Comments:________________________________________________________________________________
Ver sion 5
GM
06-06-2011
OMB #: 0925–0216
OMB #: 0925-0216
Expiration Date: xx/xxxx
E xpir a t ion Da t e: xx/xxxx
Offspr in g E xa m 9, Om n i1 E xa m 4
«IDType»-«ID»
«LNa m e», «F Na m e»
_______________________________________________________________MD14
Ver sion 5
GM
06-06-2011
80
OMB #: 0925-0216OMB #: 0925–0216
Expiration Date: xx/xxxx
E xpir a t ion Da t e: xx/xxxx
Offspr in g E xa m 9, Om n i1 E xa m 4
«IDType»-«ID»
«LNa m e», «F Na m e»
81
Medical History—Cerebrovascular Diseases
Since your last exam or medical history update have you had…
|__|
Sudden muscular weakness
|__|
Sudden speech difficulty
|__|
Sudden visual defect
|__|
Sudden double vision
|__|
Sudden loss of vision in one eye
0=No,
1=Yes,
2=Maybe,
|__|
if yes,
fill
|__|
if yes,
fill
Sudden numbness, tingling
|__|
Numbness and tingling is positional
if yes,
fill
|__|
|__|
0=No,1=Yes,
2= Maybe,9=Unk.
Head CT scan OTHER THAN FOR THE FHS
|__|__| * |__|__| * |__|__|__|__|
___________________________
|__|
9=Unk.
Date
99/99/9999=Unk.
Place
Head MRI scan OTHER THAN FOR THE FHS
0=No,1=Yes,
2= Maybe,9=Unk.
|__|__| * |__|__| * |__|__|__|__|
Date
99/99/9999=Unk.
___________________________
Place
Seen by neurologist (write in who and when below)
_________________________________________________
Have you been told by a doctor you had a stroke or TIA
(transient ischemic attack, mini-stroke)?
0=No,
|__|
Have you been told by a doctor you have Parkinson Disease?
1=Yes,
|__|
Have you been told by a doctor you have memory problems, dementia or
Alzheimer’s disease?
Do you feel or do other people think that you have memory problems that
prevent you from doing things you’ve done in the past?
2=Maybe,
|__|
|__|
9=Unk.
Do you feel like your memory is becoming worse?
Cerebrovascular Disease First Examiner Opinion
|__|
if yes or
maybe
fill
TIA or stroke took place
0=No, 1=Yes,2=Maybe, 9=Unk.
|__|__|*|__|__|__|__|
Date (mo/yr, 99/9999=Unk.)
Observed by_____________________________________________
|__|__|*|__|__|*|__|__|
Duration (use format days/hours/mins, 99/99/99=Unk.)
|__|
Hospitalized or saw M.D. (0=No, 1=Hosp.,2=Saw M.D, 9=Unk.)
Name__________________________________________________
Address_________________________________________________
Com m en t s_________________________________________________________________________________
Ver sion 5
GM
06-06-2011
OMB #: 0925-0216 OMB #: 0925–0216
Expiration Date: xx/xxxx
E xpir a t ion Da t e: xx/xxxx
Offspr in g E xa m 9, Om n i1 E xa m 4
«IDType»-«ID»
«LNa m e», «F Na m e»
82
___________________________________________________________________________________________
MD15
Ver sion 5
GM
06-06-2011
OMB #: 0925–0216
OMB #: 0925-0216
Expiration Date: xx/xxxx
E xpir a t ion Da t e: xx/xxxx
Offspr in g E xa m 9, Om n i1 E xa m 4
«IDType»-«ID»
«LNa m e», «F Na m e»
83
Medical History--Venous and Peripheral Arterial Disease
Venous Disease
Since your last exam or medical history update have you had…
|__|
Deep Vein Thrombosis - DVT (blood clots in legs or arms)
|__|
Pulmonary Embolus – PE (blood clot in lungs)
0=No,1=Yes,
2=Maybe, 9=Unk.
Peripheral Arterial Disease
Since your last exam have you had…
Do you get discomfort in either leg on walking ? (0=No, 1=Yes, 9=Unk.)
|__|
if yes,
fill
|__|
Does this discomfort ever begin when you are standing still or sitting? (0=no, 1=yes, 9=Unk.)
When walking at an ordinary pace on level ground, how many city blocks until symptoms
|__|__| develop (1=1 block or less, 99=Unk.) where 10 blocks=1 mile, code as no if more than 98 blocks
required to develop symptoms
Left
Right
Claudication symptoms
|__|
|__|
Discomfort in calf while walking
|__|
|__|
Discomfort in lower extremity (not calf) while walking
Write in site of discomfort_____________________________________
0=No, 1=Yes, 9=Unk.
|__|
Occurs with first steps (code worse leg)
|__|
Do you get the discomfort when you walk up hill or hurry?
|__|
Does the discomfort ever disappear while you are still walking?
|__|
What do you do if you get discomfort when you are walking? (1=stop,
2=slow down, 3=continue at same pace, 9=Ukn.)
Time for discomfort to be relieved by stopping (minutes)
(000=No relief with stopping, 999=Unk.)
Number of days/month of lower limb discomfort (1=1 day/month or less,
99=Unk.)
|__|__|__|
|__|__|
Since your last exam have you been told by a doctor you have intermittent claudication or
peripheral artery disease? (0=No, 1=Yes, 9=Unk.)
|__|
if yes,
Name of doctor ______________________________________________________
fill
Date of visit |__|__|*|__|__|*|__|__|__|__|
99/99/9999=Unk.
Since your last exam have you been told by a doctor you have spinal stenosis ? (0=No, 1=Yes,
9=Unk.)
|__|
Intermittent Claudication First Examiner Opinion
|__|
Intermittent Claudication
0=No, 1=Yes, 2=Maybe, 9=Unk.
Comments
_________________________________________________________________________________________
________________________________________________________________________________________
Ver sion 5
GM
06-06-2011
OMB #: 0925–0216
OMB #: 0925-0216
Expiration Date: xx/xxxx
E xpir a t ion Da t e: xx/xxxx
Offspr in g E xa m 9, Om n i1 E xa m 4
«IDType»-«ID»
«LNa m e», «F Na m e»
MD16
Ver sion 5
GM
06-06-2011
84
OMB #: 0925-0216OMB #: 0925–0216
Expiration Date: xx/xxxx
E xpir a t ion Da t e: xx/xxxx
Offspr in g E xa m 9, Om n i1 E xa m 4
«IDType»-«ID»
«LNa m e», «F Na m e»
Medical History-- CVD Procedures
85
Since your last exam or medical history update did you have any of the
following cardiovascular procedures?
0=No, 1=Yes
Cardiovascular Procedures
2=Maybe, 9=Unk.
(if procedure was repeated code only first and provide narrative)
|__|
Heart Valvular Surgery
if yes
fill
|__|
|__|__|__|__| Year done (9999=Unk.)
Exercise Tolerance Test
if yes
fill
|__|
|__|__|__|__| Year done (9999=Unk.)
Coronary arteriogram
if yes
fill
|__|
|__|__|__|__| Year done (9999=Unk.)
Coronary artery angioplasty or stent
if yes
fill
|__|
|__|__|__|__| Year done (9999=Unk.)
Coronary bypass surgery
if yes
fill
|__|
|__|__|__|__| Year done (9999=Unk.)
Permanent pacemaker insertion
if yes
fill
|__|__|__|__| Year done (9999=Unk.)
AICD
|__|
if yes
fill
|__|
|__|__|__|__| Year done (9999=Unk.)
Carotid artery surgery or stent
if yes
fill
|__|
|__|__|__|__| Year done (9999=Unk.)
Thoracic aorta surgery
if yes
fill
|__|
|__|__|__|__| Year done (9999=Unk.)
Abdominal aorta surgery
if yes
fill
|__|
|__|__|__|__| Year done (9999=Unk.)
Femoral or lower extremity surgery
if yes
fill
|__|
|__|__|__|__| Year done (9999=Unk.)
Lower extremity amputation
if yes
fill
|__|
|__|__|__|__| Year done (9999=Unk.)
Other Cardiovascular Procedure (write in below)
if yes
fill
|__|__|__|__ | Year done (9999=Unk.) Description______________________________________
Write in other procedures, year done, and location if more than one.
Comments:____________________________________________________________________________
Ver sion 5
GM
06-06-2011
OMB #: 0925-0216 OMB #: 0925–0216
Expiration Date: xx/xxxx
E xpir a t ion Da t e: xx/xxxx
Offspr in g E xa m 9, Om n i1 E xa m 4
«IDType»-«ID»
«LNa m e», «F Na m e»
86
______________________________________________________________________________________
MD17
Ver sion 5
GM
06-06-2011
OMB #: 0925–0216
OMB #: 0925-0216
Expiration Date: xx/xxxx
E xpir a t ion Da t e: xx/xxxx
Offspr in g E xa m 9, Om n i1 E xa m 4
«IDType»-«ID»
«LNa m e», «F Na m e»
87
Physical Exam—Blood Pressure
Physician Blood Pressure
Second reading
Systolic
BP cuff size
|__|__|__|
to nearest 2 mm Hg
|__|
0=pedi,1=reg.adult, 2=large adult,
3= thigh, 9=Unk.
Diastolic
Protocol modification
|__|__|__|
to nearest 2 mm Hg
|__|
0=No, 1=Yes, 9=Unk.
Comments for Protocol modification__________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
History of Kidney Disease
|__|
if yes,
fill
Have you had a kidney stone in the past 10 years? (0=No, 1=Yes, 9=Unk.)
|__|
if yes, fill
ER/hospitalized or saw M.D.
(0=No, 1=Hosp/ER, 2=Saw M.D., 9=Unk.)
____________________________________
____________________________________
Ver sion 5
GM
06-06-2011
Name of the Hospital (write Unk.. if unknown)
Name of M.D. (write Unk. if unknown)
OMB #: 0925–0216
OMB #: 0925-0216
Expiration Date: xx/xxxx
E xpir a t ion Da t e: xx/xxxx
Offspr in g E xa m 9, Om n i1 E xa m 4
«IDType»-«ID»
«LNa m e», «F Na m e»
MD18
Ver sion 5
GM
06-06-2011
88
OMB #: 0925-0216 OMB #: 0925–0216
Expiration Date: xx/xxxx
E xpir a t ion Da t e: xx/xxxx
Offspr in g E xa m 9, Om n i1 E xa m 4
«IDType»-«ID»
«LNa m e», «F Na m e»
89
Cancer Site or Type
|__|
Check
ALL that
apply
Since your last exam or medical history update have you had a cancer or a tumor?
(0=No and skip to next page MD20; If 1=Yes, 2=Maybe, 9=Unk. please continue)
Cancer
Site of Cancer or Year First
Tumor
Diagnosed
Maybe
Benign
cancer
Check ONE
1
2
3
Esophagus
Stomach
Colon
Rectum
Pancreas
Larynx
Trachea/Bronchus/
Lung
Name Diagnosing
M.D.
Leukemia
Skin
Breast
Cervix/Uterus
Ovary
Prostate
Bladder
Kidney
Brain
Lymphoma
Other/Unk.
______________
Diagnostic biopsy done?
(0=No, 1=Yes, 9=Unk.)
|__|
if yes fill ___ - ___
-______ Date
Hosp./office name_________________________
City/State of M.D.
Location of biopsy_________________________________________
Address (city/state)_________________________________________
Comment (If participant has more details concerning tissue diagnosis, other hospitalization, procedures, and treatments)
__________________________________________________________________________________________
Ver sion 5
GM
06-06-2011
OMB #: 0925-0216 OMB #: 0925–0216
Expiration Date: xx/xxxx
E xpir a t ion Da t e: xx/xxxx
Offspr in g E xa m 9, Om n i1 E xa m 4
«IDType»-«ID»
«LNa m e», «F Na m e»
90
__________________________________________________________________________________________
MD19
Ver sion 5
GM
06-06-2011
OMB #: 0925-0216 OMB #: 0925–0216
Expiration Date: xx/xxxx
E xpir a t ion Da t e: xx/xxxx
Offspr in g E xa m 9, Om n i1 E xa m 4
«IDType»-«ID»
«LNa m e», «F Na m e»
91
Physical Exam—Respiratory, Heart, Abdomen
OFFSITE VISIT – leave page BLANK
Respiratory
|__|
Wheezing on auscultation
|__|
Rales
|__|
Abnormal breath sounds
0=No,
1=Yes,
2=Maybe,
9=Unk.
Heart
|__|
S3 Gallop
|__|
S4 Gallop
|__|
Systolic Click
|__|
Neck vein distention at 90 degrees (sitting upright)
|__|
if yes, fill below
Systolic murmur(s)
Grade
0=No sound
1 to 6 for grade of
sound heard
9=Unk.
Murmur
Location
0=No,
1=Yes,
2=Maybe,
9=Unk.
Type
0=None
1=Ejection
2=Regurgitant
3=Other
9=Unk.
Radiation
0=None
1=Axilla
2=Neck
3=Back
4=Rt. chest
9=Unk.
0=No, 1=Yes,
2=Maybe, 9=Unk.
Origin
0=None, indet.
1=Mitral
2=Aortic
3=Tricuspid
4=Pulm
9=Ukn.
Apex
|__|
|__|
|__|
|__|
Left Sternum
||
||
||
|__|
Base
|__|
|__|
|__|
|__|
|__|
Diastolic murmur(s)
if yes,
fill
||
0=No, 1=Yes, 2=Maybe,
9=Unk.
Valve of origin for diastolic murmur(s)
(1=Mitral, 2=Aortic, 3=Both, 4=Other, 8=N/A, 9=Unk)
Abdominal Abnormalities
|__|
Liver enlarged
|__|
Surgical scar
|__|
Abdominal aneurysm
|__|
Abdominal bruit
0=No,
1=Yes,
2=Maybe,
9=Unk.
Comments ________________________________________________________________________________
__________________________________________________________________________________________
Ver sion 5
GM
06-06-2011
OMB #: 0925-0216 OMB #: 0925–0216
Expiration Date: xx/xxxx
E xpir a t ion Da t e: xx/xxxx
Offspr in g E xa m 9, Om n i1 E xa m 4
«IDType»-«ID»
«LNa m e», «F Na m e»
92
__________________________________________________________________________________________
MD20
Ver sion 5
GM
06-06-2011
OMB #: 0925-0216 OMB #: 0925–0216
Expiration Date: xx/xxxx
E xpir a t ion Da t e: xx/xxxx
Offspr in g E xa m 9, Om n i1 E xa m 4
«IDType»-«ID»
«LNa m e», «F Na m e»
93
Physical Exam--Peripheral Vessels—Veins and Arterial pulses
OFFSITE VISIT – leave page BLANK
Lower Extremity Abnormalities
Left
Right
|__|
|__|
Stem varicose veins
|__|
|__|
Ankle edema
|__|
|__|
(Do not code reticular or spider varicosities)
(0=No abnormality 1=Yes
(0=No,
1=Yes,
9=Unk.)
2=Maybe,
8=absent due to amputation
9=Unk.)
Amputation level
(0=No,
1=Toes only,
2=Foot,
5= Other, write in______________,
Artery
Femoral
3=below Knee,
9=Unk.)
4=above Knee,
Pulse
Bruit
(0=Normal, 1=Abnormal, 9=Unk.)
(0=Normal, 1=Abnormal, 9=Unk.)
Left
Right
Left
Right
||
||
||
||
|__|
|__|
Popliteal
Post Tibial
||
||
Dorsalis Pedis
|__|
|__|
Comments__________________________________________________________________________________
___________________________________________________________________________________________
___________________________________________________________________________________________
MD21
Ver sion 5
GM
06-06-2011
OMB #: 0925-0216 OMB #: 0925–0216
Expiration Date: xx/xxxx
E xpir a t ion Da t e: xx/xxxx
Offspr in g E xa m 9, Om n i1 E xa m 4
Ver sion 5
GM
06-06-2011
«IDType»-«ID»
«LNa m e», «F Na m e»
94
OMB #: 0925-0216 OMB #: 0925–0216
Expiration Date: xx/xxxx
E xpir a t ion Da t e: xx/xxxx
Offspr in g E xa m 9, Om n i1 E xa m 4
«IDType»-«ID»
«LNa m e», «F Na m e»
95
Physical Exam--Neurological Exam
OFFSITE VISIT – leave page BLANK
Neurological Exam
Left
Right
|__|
|__|
Carotid Bruit
0=No,
|__|
Speech disturbance
|__|
Disturbance in gait
1=Yes,
2=Maybe,
Other neurological abnormalities on exam
9=Unk.
|__|
Specify___________________________________
Comments ________________________________________________________________________________
__________________________________________________________________________________________________
__________________________________________________________________________________________________
__________________________________________________________________________________________________
MD22
Ver sion 5
GM
06-06-2011
OMB #: 0925-0216OMB #: 0925–0216
Expiration Date: xx/xxxx
E xpir a t ion Da t e: xx/xxxx
Offspr in g E xa m 9, Om n i1 E xa m 4
«IDType»-«ID»
«LNa m e», «F Na m e»
96
Electrocardiograph--Part I
OFFSITE ONLY
|__|__|__|
______________________
MD Id#
MD Name
Rates and Intervals
||||
Ventricular rate per minute
|__|__|__|
P-R Interval (milliseconds)
|__|__|__|
QRS interval (milliseconds)
(999=Fully Paced, Unk.)
|__|__|__|
Q-T interval (milliseconds)
(999=Fully Paced, Unk.)
|__|__|__|__|
(999=Unk.)
(999=Fully Paced, Atrial Fib, or Unk.)
QRS angle (put plus or minus as needed)
(e.g. -045 for minus 45 degrees, +090 for plus 90,
9999=Fully paced or Unk.)
Rhythm-predominant
0 or 1 = Normal sinus, (including s.tach, s.brady, s arrhy, 1 degree AV block)
3 = 2nd degree AV block, Mobitz I (Wenckebach)
4 = 2nd degree AV block, Mobitz II
5 = 3rd degree AV block / AV dissociation
6 = Atrial fibrillation / atrial flutter
7 = Nodal
8 = Paced
9 = Other or combination of above (list)
|__|
Ventricular conduction abnormalities
|__|
IV Block
(0=No, 1=Yes, 9=Fully paced or Unk.)
if yes,
fill
|__|
Pattern
(1=Left, 2=Right, 3=Indeterminate, 9=Unk.)
||
Complete (QRS interval=.12 sec or greater )
(0=No, 1=Yes, 9=Unk.)
|__|
Incomplete (QRS interval = .10 or .11 sec)
(0=No, 1=Yes, 9=Unk.)
||
Hemiblock
|__|
WPW Syndrome
(0=No, 1=Left Ant, 2=Left Post, 9=Fully paced or Unk.)
(0=No, 1=Yes, 2=Maybe, 9=Fully paced or Unk.)
Arrhythmias
|__|
Atrial premature beats
||
Ventricular premature beats (0=No, 1=Simple, 2=Multifoc, 3=Pairs, 4=Run, 5=R on T, 9=Unk.)
|__|__|
Ver sion 5
GM
(0=No, 1=Atr, 2=Atr Aber, 9=Unk.)
Number of ventricular premature beats in 10 seconds (see 10 second rhythm strip)
06-06-2011
OMB #: 0925-0216 OMB #: 0925–0216
Expiration Date: xx/xxxx
E xpir a t ion Da t e: xx/xxxx
Offspr in g E xa m 9, Om n i1 E xa m 4
«IDType»-«ID»
«LNa m e», «F Na m e»
MD23
Ver sion 5
GM
06-06-2011
97
OMB #: 0925-0216 OMB #: 0925–0216
Expiration Date: xx/xxxx
E xpir a t ion Da t e: xx/xxxx
Offspr in g E xa m 9, Om n i1 E xa m 4
«IDType»-«ID»
«LNa m e», «F Na m e»
98
Electrocardiograph-Part II
Myocardial Infarction Location
||
0=No,
1=Yes,
2=Maybe,
9=Fully paced or Unk.
Anterior
Inferior
True Posterior
||
||
Left Ventricular Hypertrophy Criteria
||
R > 20mm in any limb lead
||
R > 11mm in AVL
R in lead I plus S in lead III 25mm
||
0=No,
1=Yes,
9=Fully paced, Complete
LBBB or Unk.
Measured Voltage
*|||
R AVL in mm (at 1 mv = 10 mm standard) Be sure to code these voltages
*|||
S V3 in mm (at 1 mv = 10 mm standard) Be sure to code these voltages
R in V5 or V6-----S in V1 or V2
||
R 25mm
||
S 25mm
||
R or S 30mm
||
R + S 35mm
||
Intrinsicoid deflection .05 sec
||
S-T depression (strain pattern)
0=No,
1=Yes,
9=Fully paced, Complete
LBBB or Unk.
||
Hypertrophy, enlargement, and other ECG Diagnoses
Nonspecific S-T segment abnormality (0=No, 1=S-T depression, 2=S-T flattening, 3=Other, 9=Fully
||
Nonspecific T-wave abnormality
||
U-wave present
||
Atrial enlargement
||
RVH (0=No, 1=Yes, 2=Maybe, 9=Fully paced or Unk.; If complete RBBB OR LBBB present, RVH=9)
paced or Unk.)
(0=No, 1=T inversion, 2=T flattening, 3=Other, 9=Fully paced or
Unk.)
(0=No, 1=Yes, 2=Maybe, 9=Paced or Unk.)
(0=None, 1=Left, 2=Right, 3=Both, 9=Atrial fib. or Unk.)
LVH
(0=No, 1=LVH with strain, 2=LVH with mild S-T Segment Abn, 3=LVH by voltage only,
9=Fully paced or Unk., If complete LBBB present, LVH=9)
||
Comments_________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
Ver sion 5
GM
06-06-2011
OMB #: 0925–0216
OMB #: 0925-0216
Expiration Date: xx/xxxx
E xpir a t ion Da t e: xx/xxxx
Offspr in g E xa m 9, Om n i1 E xa m 4
«IDType»-«ID»
«LNa m e», «F Na m e»
MD24
Ver sion 5
GM
06-06-2011
99
OMB #: 0925-0216 OMB #: 0925–0216
Expiration Date: xx/xxxx
E xpir a t ion Da t e: xx/xxxx
Offspr in g E xa m 9, Om n i1 E xa m 4
«IDType»-«ID»
«LNa m e», «F Na m e»
100
Clinical Diagnostic Impression--Part I
Heart Diagnoses
|__|
Rheumatic Heart Disease
|__|
Aortic Valve Disease
|__|
Mitral Valve Disease
|__|
Arrhythmia
|__|
Other Heart Disease (includes congenital)
0=No,
1=Yes,
2=Maybe,
9=Unk.
(Specify)_____________________________________________
Peripheral Vascular Disease
|__|
Other Peripheral Vascular Disease
|__|
Other Vascular Diagnosis
(Specify)_____________________________________________
0=No,
1=Yes,
2=Maybe,
9=Unk.
Neurological Disease
|__|
Stroke/ TIA
|__|
Dementia
|__|
Parkinson's Disease
1=Yes,
|__|
Adult Seizure Disorder
2=Maybe,
|__|
Migraine
|__|
Other Neurological Disease
0=No,
9=Unk.
(Specify)_____________________________________________
Comments _________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
Ver sion 5
GM
06-06-2011
OMB #: 0925–0216
OMB #: 0925-0216
Expiration Date: xx/xxxx
E xpir a t ion Da t e: xx/xxxx
Offspr in g E xa m 9, Om n i1 E xa m 4
«IDType»-«ID»
«LNa m e», «F Na m e»
MD25
Ver sion 5
GM
06-06-2011
101
OMB #: 0925-0216 OMB #: 0925–0216
E xpir a t ion Da t e: xx/xxxx
Expiration Date: xx/xxxx
Offspr in g E xa m 9, Om n i1 E xa m 4
«IDType»-«ID»
«LNa m e», «F Na m e»
102
Clinical Diagnostic Impression--Part II. Non Cardiovascular Diagnoses
Endocrine
|__|
|__|
|__|
Thyroid Disease
Diabetes Mellitus
Other endocrine disorders, specify_________________________________
0=No, 1=Yes,
2=Maybe,
9=Unk.
GU/GYN
Renal disease, specify_____________________________________________
Prostate disease
Gynecologic problems, specify_____________________________________
|__|
|__|
|__|
0=No, 1=Yes,
2=Maybe,
8=male/female
9=Unk.
Pulmonary
|__|
|__|
|__|
|__|
Emphysema
Pneumonia
Asthma
Other pulmonary disease, specify__________________________________
0=No,
1=Yes,
2=Maybe,
9=Unk.
Rheumatologic Disorders
|__|
|__|
|__|
|__|
Gout
Degenerative joint disease
Rheumatoid arthritis
Other musculoskeletal or connective tissue disease, specify_______________
0=No,
1=Yes,
2=Maybe,
9=Unk.
GI
|__|
|__|
|__|
|__|
Gallbladder disease
GERD/ulcer disease
Liver disease
Other GI disease, specify__________________________________________
0=No,
1=Yes,
2=Maybe,
9=Unk.
Blood
|__|
|__|
Hematologic disorder
Bleeding disorder
0=No, 1=Yes,
2=Maybe, 9=Unk.
Infectious Disease
|__|
Infectious Disease
if yes
specify_________________________________________________________
0=No, 1=Yes,
2=Maybe, 9=Unk.
Mental Health
|__|
|__|
|__|
|__|
Depression
Anxiety
Psychosis
Other Mental health, specify_______________________________________
0=No,
1=Yes,
2=Maybe,
9=Unk.
Other
|__|
|__|
|__|
|__|
Eye
ENT
Skin
Other, specify___________________________________________________
0=No, 1=Yes,
2=Maybe,
9=Unk.
Comments
________________________________________________________________________________________
Ver sion 5
GM
06-06-2011
OMB #: 0925-0216 OMB #: 0925–0216
E xpir a t ion Da t e: xx/xxxx
Expiration Date: xx/xxxx
Offspr in g E xa m 9, Om n i1 E xa m 4
«IDType»-«ID»
«LNa m e», «F Na m e»
103
_________________________________________________________________________________________
MD26
Ver sion 5
GM
06-06-2011
OMB #: 0925-0216 OMB #: 0925–0216
Expiration Date: xx/xxxx
E xpir a t ion Da t e: xx/xxxx
Offspr in g E xa m 9, Om n i1 E xa m 4
«IDType»-«ID»
«LNa m e», «F Na m e»
104
Second Examiner Opinions
OFFSITE VISIT – leave page BLANK
|__|__|__|
2nd Examiner ID number
______________________
2nd Examiner Last Name
Coronary Heart Disease
(Provide initiators, qualities, radiation, severity, timing, presence after procedures done)
nd
Item requires 2 opinion
nd
Check ALL that apply.
2
opinion
|__|
Congestive Heart Failure
|__|
Cardiac Syncope
|__|
Angina Pectoris
|__|
Coronary Insufficiency
|__|
Myocardial Infarct
0=No,
1=Yes,
2=Maybe,
9=Unk.
Comments about heart disease ________________________________________________________________
_________________________________________________________________________________________
_________________________________________________________________________________________
Intermittent Claudication
(Provide initiators, qualities, radiation, severity, timing, presence after procedures done)
nd
Item requires 2 opinion
nd
Check ALL that apply.
2
opinion
|__|
Intermittent Claudication
0=No, 1=Yes,
2=Maybe, 9=Unk.
Comments about peripheral artery disease _____________________________________________________
_________________________________________________________________________________________
Cerebrovascular Disease
(Provide initiators, qualities, severity, timing, presence after procedures done)
nd
Item requires 2
opinion
Check ALL that apply.
2nd opinion
|__|
Stroke
|__|
TIA
0=No, 1=Yes,
2=Maybe, 9=Unk.
Comments about possible cerebrovascular disease_________________________________________________
_________________________________________________________________________________________
Ver sion 5
GM
06-06-2011
OMB #: 0925-0216OMB #: 0925–0216
Expiration Date: xx/xxxx
E xpir a t ion Da t e: xx/xxxx
Offspr in g E xa m 9, Om n i1 E xa m 4
«IDType»-«ID»
«LNa m e», «F Na m e»
105
_________________________________________________________________________________________
MD27
Ver sion 5
GM
06-06-2011
OMB #: 0925-0216 OMB #: 0925–0216
Expiration Date: xx/xxxx
E xpir a t ion Da t e: xx/xxxx
Offspr in g E xa m 9, Om n i1 E xa m 4
«IDType»-«ID»
«LNa m e», «F Na m e»
106
Any Additional Comments for Second Examiner Opinions.
__________________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
Ver sion 5
GM
06-06-2011
OMB #: 0925-0216OMB #: 0925–0216
Expiration Date: xx/xxxx
E xpir a t ion Da t e: xx/xxxx
Offspr in g E xa m 9, Om n i1 E xa m 4
Ver sion 5
GM
06-06-2011
«IDType»-«ID»
«LNa m e», «F Na m e»
107
| File Type | application/pdf |
| Author | pandeym |
| File Modified | 2013-09-17 |
| File Created | 2013-04-11 |