2 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  

Date

Address

Dear ­­­­­­­­­­­­­­­

This letter confirms your appointment for a home visit from the Framingham Heart Study on (date) at (time) as part of the Heart Study Exam 30. Elizabeth Oberacker will visit you at that time to do the exam.

If you could help us by preparing the following beforehand, it would be greatly appreciated:

1. Please wear a top that is easily removed for your EKG. Many people prefer to wear their bathrobes.

2. Using the attached form, please list any major medical events which have occurred since your last examination on date. We would like to know approximate dates, doctors, and where you were seen.

3. Please have all your medication bottles handy, including all your prescriptions, non-prescriptions, creams, salves and/or injections.

4. If you have a legal healthcare proxy or Power of Attorney, we would like a copy of this authorization for our records, if possible.

This will help the exam run smoothly, but if you are unable to prepare beforehand we will be happy to help you during our visit. If you have any questions, please call Linda Clark at 508-935-3426 or 800-248-0409, or call Elizabeth Oberacker at 508-935-3493.

Sincerely yours,

Linda S. Clark

Patient Coordinator

OMB No=0925-0216

Date

Address

RE: participant name

This letter confirms (name)’s appointment for a visit from the Framingham Heart Study on (date), at (time) as part of the

Heart Study Exam 30. Elizabeth Oberacker will visit at that time to do the exam.

It would be most helpful if a staff member who knows the patient well and can provide a good history be available to speak with Ms. Oberacker at the time of her visit. Please let (participant name) know she is coming and have her wear a top that is easily removed for the ECG. We will need access to her nursing home chart to review medical events.

Thank you in advance for your help. If you have any questions, please call Linda Clark at 800-248-0409 or call Elizabeth Oberacker at 508-935-3493.

Sincerely yours,

Linda S. Clark

Participant Coordinator

Primary Care Doctor (Name,Address,Tel: ________________________________________

_________________________________________

_________________________________________

Power of Attorney/Health Care Proxy: ____________________________________________

(If you have documentation please have a copy available to give to the FHS for their records)

List Overnight Hospitalizations Since Your Last Exam or Update on July 11, 2007:

Date Reason Hospital Doctor’s Name

_______ _____________________ ____________________________ ___________________________

_______ _____________________ ____________________________ ___________________________

_______ _____________________ ____________________________ ___________________________

List Same Day ER Visits Since Your Last Exam or Update on July 11, 2007:

Date Reason Hospital Doctor’s Name

_______ _____________________ ____________________________ ____________________________

_______ _____________________ ____________________________ ____________________________

_______ _____________________ ____________________________ ____________________________

Most Recent Dr. Visit & Day Surgeries Since Your Last Exam or Update on July 11, 2007:

Date Doctor’s Name Findings (if applicable)

Physical: __________ ______________________ __________________________________

__________________________________

Day Surgery __________ _______________________ __________________________________

___________ _______________________ _________________________