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pdfOMB #0925-0493 Exp: 10/31/07
Multi-Ethnic Study of Atherosclerosis
Participant ID: 8000028
02
(For MESA Field
Center use only)
Sequence Num:
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 0925-0493. Do not return the completed form to this
address.
Physician Questionnaire:
Cardiac/PVD
Participant Name: _______________________________________
Date-of-Birth: _____/_____/_____
Please complete only this page if participant has not had any
condition listed in Question 2 below, OR if you are not familiar
with participant's medical history.
Please fill in the appropriate bubbles and write responses in the blanks provided.
1.
Are you familiar with the participant's medical
history?
Yes
Are you aware of another physician who could provide
information regarding this participant?
Yes
No
No
Please sign and date the form at the
bottom of page 4 and return form.
Please fill in the physician's name and address, sign and
date the form at the bottom of page 4 and return form.
Please complete
Question 2 below.
2. In your opinion, has the participant had any of
the conditions below? (Please check any that apply.)
MI
Please complete section A on page 2.
Angina
Please complete section B on page 2.
CHF
Please complete section C on page 2.
PAD/AA*
Please complete section D on page 2.
None
Please sign and date at the bottom
of page 4 and return form.
If participant has had any of the conditions
listed, we would appreciate copies of pertinent
office notes, including physical exams, reports
of stress tests, caths and EKGs.
* Peripheral Arterial Disease/Aortic Aneurysm.
9224072657
11/09/2004
page 1 of 4
Physician Questionnaire: Cardiac/PVD (Page 2)
A. Myocardial Infarction
8000028
02
C. CHF
Has the participant ever been diagnosed with a
myocardial infarction?
Yes
No
Unknown
Has the participant ever been diagnosed with congestive
heart failure or congestive cardiomyopathy?
Yes
No
Unknown
If "Yes," when was the most recent event of this type?
/
If "Yes," when was the most recent episode of this type?
/
Month
Day
/
Year
Month
Was the participant hospitalized?
Yes
No
Unknown
/
Day
Year
Was the participant hospitalized?
Yes
If "Yes," where was the participant hospitalized?
Name of Hospital:
No
Unknown
If "Yes," where was the participant hospitalized?
City, State:
Name of Hospital:
City, State:
The certainty of the diagnosis is:
Definite
Probable
The certainty of the diagnosis is:
Go to next relevant section or, if none, skip to Question 3.
B. Angina
Definite
Probable
Go to next relevant section or, if none, skip to Question 3.
Has the participant ever been diagnosed with angina
pectoris or coronary insufficiency?
Yes
No
D. PAD
Unknown
If "Yes," did s/he have chest pain or equivalent, or was
the diagnosis only the result of diagnostic tests?
Has the participant ever been diagnosed with claudication,
peripheral artery disease, or abdominal aortic aneurysm?
Yes
Pain or pain equivalent
No
Unknown
No pain; diagnostic testing only
If "Yes," when was the most recent episode of this type?
If pain (or pain equivalent), when was the most recent
episode of this type?
/
Month
Month
/
Day
/
/
Day
Year
Was the participant hospitalized?
Year
Yes
No
Unknown
Was the participant hospitalized for angina/coronary
insufficiency?
Yes
No
Unknown
If "Yes," where was the participant hospitalized?
If "Yes," where was the participant hospitalized?
Name of Hospital:
Name of Hospital:
City, State:
City, State:
The certainty of the diagnosis is:
Definite
Probable
The certainty of the diagnosis is:
Definite
Probable
Go to next relevant section or, if none, skip to Question 3.
11/09/2004
page 2 of 4
Go to next relevant section or, if none, skip to Question 3.
0487072659
Physician Questionnaire: Cardiac/PVD (Page 3)
8000028
02
3. Please complete the following sections for the most recent event.
If participant has been diagnosed with MI, Angina or CHF, please complete all sections on pages 3 and 4.
If participant has been diagnosed with PAD only, complete only relevant items in sections a and b.
Section a.
Section b.
Which (if any) of the following diagnostic tests did the
participant have? (Please attach copy of report.)
Which (if any) of the following procedures were done?
Yes
Electrocardiogram
No
When were they performed?
Unknown
Yes
Cardiac Catheterization
/
Trial of Nitroglycerin
Date:
No
Unknown
/
Month
Day
Year
Excercise Tolerance Test
---With Thallium?
Angioplasty or
Stent Placement
Cardiac Enzymes
Date:
Date:
Day
Yes
Day
Month
Day
Unknown
Year
No
Yes
/
Month
No
Yes
/
Leg angioplasty or other
leg revascularization
Date:
Unknown
Year
/
Date:
No
/
Intravenous or Intracoronary
Thrombolytic Therapy
(TPA, Streptokinase)
Pertinent Results:
Unknown
Year
/
Month
Other
No
/
CABG (Coronary Artery
Bypass Graft)
Chest X-Ray
If Other, please
specify:
/
Month
Echocardiogram
Angiography
Yes
Unknown
/
Day
Year
5397072654
11/09/2004
page 3 of 4
Physician Questionnaire: Cardiac/PVD (Page 4)
8000028
Section c.
Section d.
Which (if any) of the following medications were
prescribed as a therapy?
Were any of the following present?
Yes
Yes
No Unknown
02
No Unknown
Chest pain
Nitroglycerin
Beta-Blockers
Jugular Venous Distention
Calcium Channel Blockers
Cartoid Bruit
Aspirin
Basilar Rales or Crackles Only
Diuretics
Rales or Crackles Above Bases
Ace Inhibitors
Wheezing
Digitalis
S-3 Gallop
Oxygen
Cardiac Murmur
Other Vasodilators
Hepatojugular Reflex
Other
Hepatomegaly
If other, please
specify:
Peripheral/Ankle Edema
Thank you very much for your contribution to MESA. Please sign and date this
questionnaire and return it to us in the self-addressed, stamped envelope with
copies of pertinent office notes or tests. If you do not have the envelope, the
address is:
Notes:
Form completed by:
For MESA Field Center Use Only:
/
Date:
Reviewer ID:
Data Entry ID:
/
9083072650
11/09/2004
page 4 of 4
| File Type | application/pdf |
| File Modified | 2006-06-07 |
| File Created | 2004-11-09 |