Form A4 Health Status Update Form

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

Public reporting burden for this collection of information is estimated to average 15 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 #: 0925–0216
Expiration Date: xx/xxxx

Date

NAME
ADDRESS

ID#:

Dear
We would like to update the health information that we have on file for you at the
Framingham Heart Study. As a participant in the Heart Study, it is important that we
have information regarding diagnoses for any significant heart disease, vascular disease,
stroke or cancer since we last examined you.
Please complete the enclosed medical history update form. Also, please sign and date the
consent form. This procedure will give us permission to obtain the necessary information
from the physicians and hospitals where you may have received care. Please inform us if
there is any name, address or telephone number change.
If you have questions, please don’t hesitate to call Mary Ann Crossen at 1-508-935-3430
or 1-800-854-7582, extension 430.
Thank you for your help.

Sincerely,

Daniel Levy, M.D.
Director
Framingham Heart Study

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

I hereby authorize _________________________________________________
_________________________________________________
_________________________________________________
to release to the Framingham Heart Study
73 Mt. Wayte Avenue
Framingham, MA 01702
The following protected health information my medical record.

Date of Birth:
Address

Disclose the following information for dates from present.











Face Sheet
Discharge Summary
ER Report
Admission Notes
Progress Notes
Operative Report
Pathology Report
Chest X-Ray
EKGs (All)
Echocardiogram











CT Scan (Head)
MRI/MRA (Head/Neck)
Lab Reports – Cardiac Enzymes
Consults (Cardiac & Neuro)
Cardiac Catheterization
Exercise Tolerance Test
Nursing Home Notes
Notes near time of death
Other _______________________
____________________________

The purpose for this disclosure is research.
The information disclosed under this authorization will not be redisclosed to anyone but
the researchers conducting this study, except as required by law.
I understand I may revoke this authorization at any time by requesting such of the above
referenced physician/hospital in writing. If I do it will not have any effect on actions that
the hospital/physician took before it received the revocation.
This authorization expires at the end of the research study.
Date: _______________________

Signed: _____________________________

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

ID
3

FRAMINGHAM STUDY MEDICAL HISTORY UPDATE
For Office Use Only
TYPE

|___|___|

INTERVIEWER

1=TELEPHONE

|___|___|___|

2=MAILER

DATA ENTRY

3=ONSITE BONE STUDY

4=ONSITE EBCT

88=OTHER

|___|___|___|1 |___|___|___|2

ID
DATE OF LAST EXAM OR UPDATE
NAME

ADDRESS and PHONE (if changed _______________________________________________
since last exam/update)
_______________________________________________
SOCIAL SECURITY NUMBER |___|___|___| - |___|___| - |___|___|___|___|
DATE COMPLETED |___|___| - |___|___| - |___|___|
1.

a. First, please tell us who is completing this form:








Framingham Heart Study (FHS) participant whose name is above (Go to question 3)
Spouse
Family member other than spouse
(Relationship) ______________________________
Friend
Go to 1.b.

Health care provider for FHS participant
Other __________________________

If other than participant, please answer the following questions.
b. Name ________________________________________
c. How long have you known the participant?
|___|___| years

|___|___| months

d. Are you currently living in the same household with the participant?

 yes
FHS HUMAIL Version 8:8/1/08

 no
OMB No: 0925-0216

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

ID
4

FRAMINGHAM STUDY MEDICAL HISTORY UPDATE

e. How often did you talk with the participant during the prior 11 months? Check one.







2.

Almost every day
Several times a week
Once a week
1 to 3 times per month
Less than once a month
Unknown / N/A

Have you noticed that he/she has had any memory problems or change in personality?

 yes

 no

Specifically: ______________________________________________________
If response to #2 “yes”:
Has there been a diagnosis of dementia or Alzheimer’s Disease made by a doctor?

 yes

 no

TO WHOM SHOULD WE SEND A CONSENT FORM TO BE SIGNED SO THAT WE CAN OBTAIN MEDICAL RECORDS?

NAME:

___________________________________________________

ADDRESS: ___________________________________________________
RELATIONSHIP:

_______________________________________________

Please go on to the next page

FHS HUMAIL Version 8:8/1/08

OMB No: 0925-0216

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

ID
5

FRAMINGHAM STUDY MEDICAL HISTORY UPDATE
3.

Since the date of the last Framingham Heart Study exam or update on the first page of the
Medical History Update form, have you seen a doctor or been hospitalized?

 yes
a.

 no

If yes, did you have any of the following problems?

Heart Problems, such as:
Yes No
(Mark yes or no for each question)

  Chest pain, angina or angina pectoris
  Heart attack or myocardial infarction or MI
  Heart failure or congestive heart failure or CHF
 Atrial fibrillation or atrial flutter 
  Heart catheterization or cardiac catheterization
  Heart bypass operation or coronary bypass surgery or CABG
  Procedure to unblock narrowed blood vessels to your heart
muscles (PTCA, coronary angioplasty, or coronary stent)







 

b.

Circulatory Problems, such as:
Yes No
(Mark yes or no for each question)



 
 





 





 
 
 

Other heart problem (pacemaker, valve problem, aortic surgery,
ventricular tachycardia, other rhythm problem)
Specify _________________________________________________

Stroke, TIA (transient ischemic attack), sudden paralysis, vision
loss, inability to speak
Procedure to unblock narrowed blood vessels in your neck
(carotid endarterectomy, carotid angioplasty).
Poor blood circulation or blocked or narrowed blood vessels to the legs or
feet, (claudication, peripheral arterial disease, gangrene)
Amputation of part of a leg or toes, because of poor circulation or
gangrene.
Blood clot or embolism in leg or lung.
Other circulatory problem.
Specify __________________________________________________

FHS HUMAIL Version 8:8/1/08

OMB No: 0925-0216

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

ID
6

FRAMINGHAM STUDY MEDICAL HISTORY UPDATE
Since the date of the last Framingham Heart Study exam or update on the first page of the Medical
History Update form, have you seen a doctor or been hospitalized for the following:
c.




Other Neurological Problems
Yes No
(Mark yes or no for each question)

  
  
 

Memory problems
Other neurological problems such as Parkinson’s, multiple sclerosis,
seizures, head injury. Specify problem________________________
Have you had an MRI scan of your brain other than for the Framingham
Heart Study?
Name of MRI Facility ____________________________________
Date of MRI

|___|___| - |___|___| - |___|___|

Reason for MRI:_________________________________________
d.

Other Problems
Yes

No

(Mark yes or no for each question)

Diabetes

If yes, please list medications you take for diabetes

______________________________________________________

 

Cancer Specify type ____________________________________
Physician ______________________________________________
Place where biopsy performed______________________________
______________________________________________________
______________________________________________________

 

Fracture, broken bone (Specify including hip, back, arm, leg, pelvis,
collarbone, foot, toe and others)_____________________________

 

Other Specify problem __________________________________
Please go on to the next page

FHS HUMAIL Version 8:8/1/08

OMB No: 0925-0216

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

ID
7

FRAMINGHAM STUDY MEDICAL HISTORY UPDATE
4.

Since the date of your last Framingham Heart Study exam or update on the first page of the
Medical History Update form, have you been admitted to a HOSPITAL or gone to an
EMERGENCY ROOM or seen a PHYSICIAN for other than a routine examination?

 yes (if yes, please give details)  no (go to question 5 on the next page)
Date |___|___| - |___|___| - |___|___|
Type* _______________________________________________________ _____
Reason** _______________________________________________________ _____
Hospital Name _____________________________ Doctor’s Name _____________________________
Address __________________________________ Address __________________________________
_________________________________________ __________________________________________

Date |___|___| - |___|___| - |___|___|
Type* _______________________________________________________ _____
Reason** _______________________________________________________ _____
Hospital Name _____________________________ Doctor’s Name _____________________________
Address __________________________________ Address __________________________________
_________________________________________ __________________________________________

Date |___|___| - |___|___| - |___|___|
Type* _______________________________________________________ _____
Reason** _______________________________________________________ _____
Hospital Name _____________________________ Doctor’s Name _____________________________
Address __________________________________ Address __________________________________
_________________________________________ __________________________________________
* Type

** Reason

1. Overnight admission
2. Emergency room visit
3. Day Surgery/Procedure
4. M.D. visit

1. Heart problems
2. Stroke or transient ischemic attack (TIA), sudden paralysis, vision loss, inability
to speak
3. Broken, crushed or fractured bones
4. Cancer or malignant tumor
5. Circulation problem, or blood clots
6. Other reasons (Please specify)

FHS HUMAIL Version 8:8/1/08

OMB No: 0925-0216

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

ID
8

FRAMINGHAM STUDY MEDICAL HISTORY UPDATE
Nursing Home/Rehabilitation Admissions.
5.

Have you stayed overnight as a patient in a nursing home, rehabilitation center or transitional
care unit (TCU) since the date of your last Framingham Heart Study exam or update on the top
of the first page of the Medical History Update form?

 yes
6.

 no

(if no, go to Question 8.)

Please list the name and location of the nursing home or rehabilitation center and the date
you were admitted.
Nursing home/Rehab Center name: __________________________________________
Street address: ___________________________________________________________
City/State/Zip Code _______________________________________________________
Date you entered the nursing home/rehabilitation center |___|___| - |___|___| - |___|___|

7.

Were you an overnight patient in a nursing home, rehabilitation center or transitional care unit
(TCU) at any other time since your last exam?

 yes

 no

Nursing home/Rehab Center name: __________________________________________
Street address: ___________________________________________________________
City/State/Zip Code _______________________________________________________
Date you entered the nursing home/rehabilitation |___|___| - |___|___| - |___|___|

Marital Status.
8.

What is your current marital status? Please check one

 married  widowed  divorced  separated
 single, never married
 living with partner

FHS HUMAIL Version 8:8/1/08

OMB No: 0925-0216

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

ID
9

FRAMINGHAM STUDY MEDICAL HISTORY UPDATE
Health Status. (Questions 9 and 10 to be filled out only by the participant.)
9.




10.

In general, how is your health now?

 Excellent
 Fair
 Poor
 Good
 Don’t know
Compare your health to most people your own age. Would you say your health is?

 Better
 Worse than most people
 About the same
 Don’t know
Primary Care Physician
11.

Please list the name and address of your primary care physician.
Name _____________________________________________
Address ____________________________________________
___________________________________________________

YOU MIGHT BE SENT A CONSENT FORM TO SIGN SO THAT WE MAY OBTAIN YOUR MEDICAL RECORDS.

FHS HUMAIL Version 8:8/1/08

OMB No: 0925-0216