3 CHS Call

OMB #0925-0334 Exp. 09/30/07

CHS Semi-Annual Surveillance Call

Public reporting burden for the collection of information is estimated to average 30 minutes including the time for reviewing instructions, gathering needed information and completing and reviewing the questionnaire. If you have comments regarding this burden, please send them to Reports Clearance Officer, PHS, 721-H Hubert H. Humphrey Building , 200 Independence Avenue S.W., Washington, D.C. 20201. Attention: PRA, and to the Office of Information and Regulatory Affairs, Office of management and Budget, Washington, D.C., 20503.

Using clinic and events records, please investigate whether participant is not currently married or recently widowed. If the participant’s marital status is known, you may fill in Question 1.

Hello, may I please speak with (participant)?

Hello, this is (interviewer name) from the Cardiovascular Health Study. Do you have a few minutes to speak on the phone now?

₁ Yes ₀ No

If by proxy, reason:

₁ Hearing

₂ Cognitive

₃ Hospitalized

₄ Other Illness

₅ Other (specify)

_________________

_________________

CHS Semi-Annual Surveillance Call

1. What is your marital status? Are you…?

₁ Married

2 Widowed

3 Divorced

4 Separated

5 Never Married

₆ Other

₈ Don’t Know

₉ Refused

I would like to ask you some questions that we also asked you 6 months ago. The reason for asking them again is to find out how you’ve been over the last six months.

2. Would you say, in general, your health is:

₁ Excellent

₂ Very Good

₃ Good

₄ Fair

₅ Poor

₈ Don’t Know

₉ Refused

3. During the past two weeks, how many days have you stayed in bed all or most of the day because of illness or injury? (Do not include days in a hospital or nursing home. If you do not remember the exact number of days, please estimate as closely as possible.)

Days ₈ Don’t Know ₉ Refused

Answer “0” if you haven’t spent any days in bed in the last two weeks.

4. Did you have a procedure in or out of the hospital to open up the arteries in your heart such as angioplasty, PTCA, coronary artery bypass graft or CABG, since we spoke with you last time?

₁ Yes ₀ No ₈ Don’t Know ₉ Refused

CHS Semi-Annual Surveillance Call

4. Have you had cardiac catheterization or coronary angiography since we spoke with you last time?

₁ Yes ₀ No ₈ Don’t Know ₉ Refused

6. Did you have a procedure in or out of the hospital to open up the arteries in either of your legs since we spoke with you last time?

₁ Yes ₀ No ₈ Don’t Know ₉ Refused

7. Has a doctor told you that you had a new myocardial infarction or heart attack since we spoke with you last time?

₁ Yes ₀ No ₈ Don’t know

1. Date of event or diagnosis: ___ ___/ ___ ___/ ___ ___ ___ ___

Month Day Year

2. Were you in the hospital at least one night for this condition since we last spoke to you?

₁ Yes ₀ No ₈ Don’t know

3. What was the admission date of each hospitalization and the name and location of the hospital.

Date ___ ___/ ___ ___/ ___ ___ ___ ___

Month Day Year

Name:____ ____________________ __________________________

Address:_________________________________________________

City_______________________ State: ____ Zip: _________________

CHS Semi-Annual Surveillance Call

8. Has a doctor told you that you had a new incident of angina pectoris or chest pain due to heart disease since we spoke with you last time?

₁ Yes ₀ No ₈ Don’t know

1. Date of event or diagnosis: ___ ___/ ___ ___/ ___ ___ ___ ___

Month Day Year

2. Were you in the hospital at least one night for this condition since we last spoke to you?

₁ Yes ₀ No ₈ Don’t Know

3. What was the admission date of each hospitalization and the name and location of the hospital?

Date ___ ___/ ___ ___/ ___ ___ ___ ___

Month Day Year

Name:_____________________ ____________________________

Address:________________________________________________

City: ___________________ State: _____ Zip: _____________

CHS Semi-Annual Surveillance Call

9. Has a doctor told you that you had a new incident of heart failure or congestive heart failure since we spoke with you last time?

₁ Yes ₀ No ₈ Don’t know

1. Date of event or diagnosis: ___ ___/ ___ ___/ ___ ___ ___ ___

Month Day Year

2. Were you in the hospital at least one night for this condition since we last spoke to you?

₁ Yes ₀ No ₈ Don’t Know

3. What was the admission date of each hospitalization and the name and location of the hospital?

Date ___ ___/ ___ ___/ ___ ___ ___ ___

Month Day Year

Name: ____________________________________________________________

Address: __________________________________________________________

City: _______________________________ State: _____ Zip: _____________

CHS Semi-Annual Surveillance Call

9. Has a doctor told you that you had a new incident of intermittent claudication or pain in your legs from a blockage of the arteries since we spoke with you last time?

₁ Yes ₀ No ₈ Don’t know

1. Date of event or diagnosis: ___ ___/ ___ ___/ ___ ___ ___ ___

Month Day Year

2. Were you in the hospital at least one night for this condition since we last spoke to you?

₁ Yes ₀ No ₈ Don’t Know

3. What was the admission date of each hospitalization and the name and location of the hospital?

Date ___ ___/ ___ ___/ ___ ___ ___ ___

Month Day Year

Name: ___________________________________________________________

Address: _________________________________________________________

City:__________________________ State:______ Zip:__________________

CHS Semi-Annual Surveillance Call

9. Has a doctor told you that you had a new stroke or cerebrovascular accident since we spoke with you last time?

₁ Yes ₀ No ₈ Don’t know

1. Date of event or diagnosis: ___ ___/ ___ ___/ ___ ___ ___ ___

Month Day Year

2. Were you in the hospital at least one night for this condition since we last spoke to you?

₁ Yes ₀ No ₈ Don’t Know

3. What was the admission date of each hospitalization and the name and location of the hospital?

Date ___ ___/ ___ ___/ ___ ___ ___ ___

Month Day Year

Name: _____________________________________________________________

Address: ____________________________________________________________

City: __________________________________ State: _____ Zip: ____________

CHS Semi-Annual Surveillance Call

9. Has a doctor told you that you had a new transient ischemic attack or TIA or mini stroke since we spoke with you last time?

₁ Yes ₀ No ₈ Don’t know

1. Date of event or diagnosis: ___ ___/ ___ ___/ ___ ___ ___ ___

Month Day Year

2. Were you in the hospital at least one night for this condition since we last spoke to you?

₁ Yes ₀ No ₈ Don’t Know

3. What was the admission date of each hospitalization and the name and location of the hospital?

Date ___ ___/ ___ ___/ ___ ___ ___ ___

Month Day Year

Name: ___________________________________________________________

Address: ________________________________________________________

City: _________________________________ State: _____ Zip: ___________

CHS Semi-Annual Surveillance Call

13. Have you stayed overnight as a patient in a hospital for any other reasons not reported in Questions 7 through 12 since we spoke with you last time?

₁ Yes ₀ No ₈ Don’t Know

Now, I would like to ask you for more information about each of your overnight stays at a hospital.

1. Reason for admission________________________________________________

Hospital Name______________________________________________________

Address ___________________________________City/State ________________

Date of hospitalization:___ ___/___ ___/___ ___ ___ ___ Length of stay _____days

Month Day Year

2. Reason for admission_________________________________________________

Hospital Name_______________________________________________________

Address________________________________City/State____________________

Date of hospitalization:___ ___/___ ___/___ ___ ___ ___ Length of stay:_____days

Month Day Year

As explained at your original clinic visit, records of these hospitalizations will be reviewed for medical information that may apply to the CHS study.

So that we may better understand any changes that may occur in your health, please remember to call us if you are admitted to a hospital for any reason.

CHS Semi-Annual Surveillance Call

14. Have you stayed overnight as a patient in a nursing home or rehabilitation center since we spoke with you last time?

₁ Yes ₀ No ₈ Don’t Know

Now, I would like to ask you for more information about each of your overnight stays at a nursing home or rehabilitation center.

1. Reason for admission__________________________________________________

Nursing home name___________________________________________________

Address______________________ City/State ______________________________

Date of admission:___ ___/___ ___/___ ___ ___ ___ Length of stay:_____days

Month Day Year

2. A re you currently staying in a nursing home or rehabilitation center?

₁ Yes ₀ No ₈ Don’t Know

So that we may better understand any changes that may occur in your health, please remember to call us if you are admitted to a nursing home or rehabilitation center for any reason.

CHS Semi-Annual Surveillance Call

14. Do you plan to be out of the area 6 months from now?

₁ Yes ₂ No ₈ Don’t Know ₉ Refused

1. Are you moving out of the area permanently or will you only be gone temporarily?

1. ₁ Permanently

1. Do you know what your new address and telephone number will be?

₁ Yes ₂ No

2. ₂ Temporarily Out of the Area (vacation, business, etc)

CHS Semi-Annual Surveillance Call

14. You previously told us the name of someone who could provide information and answer questions for you in the event that you were unable to answer for yourself. Please tell me if the information I have is still correct.

14. You previously provided us with information about friends or relatives who you are likely to keep in touch with, but who do not live with you, and who are not planning to move any time soon. Please tell me if the information I have is still correct.

Thank you very much for answering these questions. I enjoyed talking to you. Please call us if you move or if you should go to a hospital or nursing home, even if you have moved from the area. You are always welcome to call collect.

12

Limited Phone Visit Quest. Revision 1.7 10/26/06