Form 1 Form

OMB#: 0925-0216

Exp. 12/2007        

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 (0925-0216). Do not return the completed form to this address.

 

OMB#: 0925-0216

Exp. 12/2007  

Dear _________________:

Once again, we thank you for participating in the Framingham Heart Study. Your next clinic appointment is scheduled for ____________

at _______P.M.

As you probably know, we are now located at 73 Mt. Wayte Avenue, in the Perini Building. Our clinic is located in the wing on the Franklin Street side of the building. The building is handicap accessible and we have reserved parking for you behind the Franklin Street wing.

We suggest you wear comfortable clothes that are easy for you to remove. You should bring slippers and, if you wish, your own robe although we provide hospital robes.

Eat your regular meals and take medications as usual. PLEASE BRING ALL MEDICATIONS YOU TAKE, BOTH PRESCRIPTION AND NON-PRESCRIPTION, WITH YOU. On the back of this form, we would appreciate information regarding hospitalizations and/or major illnesses since your last visit or health history update. PLEASE BRING THIS LETTER WITH YOU TO THE CLINIC. If you need help completing it, our staff will be happy to assist you at the time of your appointment.

If you have any questions, please call Linda Clark, Participant Coordinator, at (508) 935-3426 or 1-(800)-248-0409. Thank you again for your participation in the Heart Study and your ongoing help in our battle against heart disease

Sincerely yours,

Daniel Levy, M.D.

Director

Framingham Heart Study

Primary Care Doctor (Name & Address): ________________________________________

_________________________________________

_________________________________________

Power of Attorney/Health Care Proxy: ____________________________________________

(If you have documentation, please bring a copy or we will make a copy for our records)

List Overnight Hospitalizations Since Your Last Exam or Update on ____________________

Date Reason Hospital Doctor’s Name

_______ _____________________ ____________________________ ___________________________

_______ _____________________ ____________________________ ___________________________

_______ _____________________ ____________________________ ___________________________

List Same Day ER Visits Since Your Last Exam or Update:

Date Reason Hospital Doctor’s Name

_______ _____________________ ____________________________ ____________________________

_______ _____________________ ____________________________ ____________________________

_______ _____________________ ____________________________ ____________________________

Most Recent Dr. Visit & Day Surgeries Since Last Exam or Update:

Date Doctor’s Name Findings (if applicable)

Physical: __________ ______________________ __________________________________

__________________________________

Day Surgery __________ _______________________ __________________________________

___________ _______________________ _____________________