Medical Record Abstraction -Adult

Human Health Effects of Drinking Water Exposures to Per- and Polyfluoroalkyl Substances (PFAS) at Pease International Tradeport, Portsmouth, NH (The Pease Study)

P_Att19a_MedRecAbstrctnForm_Adult_20180802

OMB: 0923-0061

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Attachment 19a.

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Pease Study

Medical Record Abstraction Form - Adult

Flesch-Kincaid Readability Score – 11.1

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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)

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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

  1. High cholesterol?

Yes

No


  1. Other dyslipidemia?

Yes (Please specify diagnosis) ______________________

No


  1. Heart disease?

Yes

No


  1. Hypertension?

Yes

No


  1. Pregnancy induced hypertension?

Yes

No


  1. Thyroid disease?

Yes (Please specify diagnosis) ______________________

No


  1. Liver disease?

Yes (Please specify diagnosis) ______________________

No


  1. Kidney disease?

Yes (Please specify diagnosis) _____________________

No


  1. Diabetes?

Yes (Please specify diagnosis) _____________________

No


j. Gestational diabetes?

Yes

No


  1. Osteoarthritis?

Yes (Please specify diagnosis) ______________________

No


  1. Osteopenia or Osteoporosis?

Yes (Please specify diagnosis) ______________________

No


  1. Ulcerative colitis?

Yes

No


  1. Rheumatoid arthritis?

Yes

No


  1. Autoimmune disease?

(i.e. Lupus, Multiple sclerosis, Emphysema, Fibromyalgia, Celiac Disease, Crohn’s Disease)

Yes (Please specify) _____________________

No


  1. Endometriosis?

Yes

No


  1. Asthma?

Yes

No


  1. Cancer?

Yes (Please specify) ______________________

No


  1. Other cancer?

Yes (Please specify) ______________________

No



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File Typeapplication/vnd.openxmlformats-officedocument.wordprocessingml.document
AuthorStephanie Davis
File Modified0000-00-00
File Created2022-04-08

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