Medical Record Abstraction - Adult

Attachment 19a.

Pease Study

Medical Record Abstraction Form - Adult

Flesch-Kincaid Readability Score – 11.1

Form Approved

OMB No. 0923-XXXX

Exp. Date xx/xx/201x xx/xx/20xxExDaxx/xx/20xx

Exp. Date xx/xx/20xx

Agency for Toxic Substances and Disease Registry (ATSDR)

ATSDR estimates the average public reporting burden for this collection of information as 20 minutes per response, including the time for reviewing instructions, searching existing data/information sources, gathering and maintaining the data/information needed, and completing and reviewing the collection of information. An agency may not conduct or sponsor, and a person is not required to respond to a collection of information unless it displays a currently valid OMB Control Number. Send comments regarding this burden estimate or any other aspect of this collection of information, including suggestions for reducing this burden to CDC/ATSDR Information Collection Review Office, 1600 Clifton Road NE, MS D-74, Atlanta, Georgia 30333; ATTN: PRA (0923-xxxx).

Pease Study

Medical Record Abstraction Form - Adult

Study ID: [____________]

Participant Name: [_____________________________________]

Date of Birth: ___/___/_____

SSN: xxx-xx-xxxx

The person named above, or his or her legal representative, has authorized you to release his or her medical records to ATSDR for research purposes. Please check If you have a record that a doctor or other health care provider diagnosed or is treating any of the following medical conditions.

Please fill out the table below. Circle appropriate response and specify requested details as directed. Thank you.

Medical Condition	Record Located (Comments)	Year of Diagnosis or Treatment
High cholesterol?	Yes No
Other dyslipidemia?	Yes (Please specify diagnosis) ______________________ No
Heart disease?	Yes No
Hypertension?	Yes No
Pregnancy induced hypertension?	Yes No
Thyroid disease?	Yes (Please specify diagnosis) ______________________ No
Liver disease?	Yes (Please specify diagnosis) ______________________ No
Kidney disease?	Yes (Please specify diagnosis) _____________________ No
Diabetes?	Yes (Please specify diagnosis) _____________________ No
j. Gestational diabetes?	Yes No
Osteoarthritis?	Yes (Please specify diagnosis) ______________________ No
Osteopenia or Osteoporosis?	Yes (Please specify diagnosis) ______________________ No
Ulcerative colitis?	Yes No
Rheumatoid arthritis?	Yes No
Autoimmune disease? (i.e. Lupus, Multiple sclerosis, Emphysema, Fibromyalgia, Celiac Disease, Crohn’s Disease)	Yes (Please specify) _____________________ No
Endometriosis?	Yes No
Asthma?	Yes No
Cancer?	Yes (Please specify) ______________________ No
Other cancer?	Yes (Please specify) ______________________ No

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