2 Cardiac

OMB #0925-0493 Exp: 10/31/07

Multi-Ethnic Study of Atherosclerosis

Participant ID: 8000028

02

Hospital Code:

Sequence Num:

Physician Questionnaire:
Cardiovascular Death

Public reporting burden for this collection of information is estimated to average 10 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- . Do not return the completed form to this
address.

Please complete the following questions to the best of your ability by filling in the appropriate bubbles or writing the answer in
the blank provided. Please return completed forms in the self addressed stamped envelope provided. Thank you for your
contribution to MESA.

Details of Death
1. Are you familiar with the events surrounding the
decendent's death?
Yes
2.

Circumstances Surrounding Death
4. What do you believe to be the underlying cause of
death?
Acute Myocardial Infarction

No

Other Ischemic Heart Disease

Did you witness the death?
Yes

Cerebrovascular Disease

No

Other Cardiovascular Disease

If you answered "Yes" to both or either of Questions
1 and 2, please skip to Question 4.

3. If you answered "No" to both Questions, are you
aware of another physician who could provide
information regarding the death?
Yes

No
If "No," please sign and date the form
at the bottom of page 2.

Non-Cardio/Cerebrovascular
(Please specify)

5. Please specify the time between the onset of the
acute episode of symptoms and death. (We are defining
death as the point where spontaneous breathing ceased
and the patient never recovered.) Please check the
appropriate time period.

If "Yes," please provide the physician's name and address,
then sign and date the form at the bottom of page 2.

Less than 5 minutes
5 minutes to 1 hour
1 hour to 24 hours

Name of physician:

More than 24 hours
Address:

Unknown
6. Was there an acute episode of pain in the chest, left
arm or jaw during the last 72 hours prior to death?
Yes

No

Unknown

7. Was there an acute episode of shortness of breath
during the 72 hours prior to death?
Yes

No

Unknown

8. Did the decendent take or was s/he given nitrates
or nitroglycerin at the time of the acute episode?
Yes

No

Unknown

3658295187
11/09/2004

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Phys. Quest.: Cardiovascular Death (Page 2)

8000028
Medical History

Transient Ischemic Attack (TIA)

9. Are you familiar with the decendent's medical
history?
Yes

Yes

If you answered "No," please skip
to the bottom of the page

10. Did the decendent have a medical history of any
of the following conditions or medications prior to the
acute event which led to death?
Myocardial Infarction (MI)
Yes
No

/

Month

Day

Yes

No

Yes
Year

No

Unknown

If "Yes," date of first diagnosis:

Unknown

No

Unknown

Coronary Bypass Surgery
Yes
No

Unknown

Coronary Angioplasty
Yes
No

Unknown

11. If you saw the participant within one month of death,
please fill out the following for the most recent visit:

/
Day

Year

Date of Visit:

/

Congestive Heart Failure (CHF) or Congestive
Cardiomyopathy
Month

Yes

Year

Lower Extremity Bypass, Angioplasty or Amputation
Secondary to PVD

Angina Pectoris, Coronary Insufficiency or Other
Chronic Ischemic Heart Disease

/

/

Intermittent Claudication or Other Peripheral
Vascular Disease (PVD)

/
Day

Month

Unknown

/

Unknown

If "Yes," date of most recent MI:

Yes

No

If "Yes," date of first diagnosis:

No

Month

02

No

/
Day

Year

Unknown
Chief Complaint:

Stroke (CVA)
Yes

No

Unknown

If "Yes," date of most recent CVA:

/

Primary Diagnosis:

/
Changes in Medical Management:

Month

Day

Year
Continued next column

Form completed by:
For MESA Field Center Use Only:

/

Date:

Reviewer ID:

Data Entry ID:

/
7459295180

11/09/2004

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