Form 3 survey

O.M.B 0925-0281
Exp. XX/XXXX

ARIC

ANNUAL FOLLOW-UP QUESTIONNAIRE FORM

Atherosclerosis Risk in Communities
ID NUMBER:
DATE:02/07/08

CONTACT YEAR:

FORM CODE:

LAST NAME:

A

F

U

VERSION: M

INITIALS:

Public reporting burden for this collection of information is estimated to average 6-15 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 208927974, ATTN: PRA (0925-0281). Do not return the completed form to this address.
INSTRUCTIONS: This form should be completed during the interview portion of the participant's annual
follow-up. ID Number, Contact Year, and Name must be entered above. Whenever numerical responses are
required, enter the number so that the last digit appears in the rightmost box. Enter leading zeros where
necessary to fill all boxes. If a number is entered incorrectly, mark through the incorrect entry with an
"X". Code the correct entry clearly above the incorrect entry. For "multiple choice" and "yes/no" type
questions, circle the letter corresponding to the most appropriate response. If a letter is circled
incorrectly, mark through it with an "X" and circle the correct response.
ANNUAL FOLLOW-UP QUESTIONNAIRE (AFUM)

A. VITAL STATUS
1. Date of status determination: ............…….

/

/
Month

2. Final Status:
{Circle one below}

Day

Year

3. Information obtained from:
{Circle one corresponding choice below}
Phone

A

Personal Interview

B

Letter

C

Go to Item 6
Contacted and Alive

Contacted and Refused

Reported Alive

Reported Deceased

Unknown

C

Go to Item 23
Go to Item 52

F

R

D

Relative, spouse, acquaintance

D

Employer information

E

Other

F

Relative, spouse, acquaintance

G

Surveillance

H

Other (National Death Index)

I

Go to Item 23

Continue to Item 4

Go to Item 52

U

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B. DEATH INFORMATION

4. Date of death:

/

/

Month

Day

Year

5. Location of death:
a. City/ County

b. State:

After Item 5, skip to Item 23, Screen 12.

C. GENERAL HEALTH
6. "Now I will ask you some questions about your health. Over the past year, compared to other people your age, would you say that your health
has been excellent, good, fair or poor?"
Excellent ... E
Good ........ G
Fair ........ F
Poor ...... . P
If YES, go to Q9
7a. [DO NOT ASK] Has this participant previously completed version L of the AFU form? Y N
7b. [DO NOT ASK] Has participant ever reported a heart failure diagnosis in AFU without a documented HF hospitalization in the ARIC
database? (to be done for 1 year only).
Y N
If NO, skip to Q9
8. In a previous ARIC phone call in [< year >], you indicated that you had been diagnosed with heart failure or congestive heart failure. Do you
recall that you had such a diagnosis of heart failure?
Y N
U
No or Unknown skip to Q9
What is the name and address of the doctor you last saw for heart failure?
8.a. Name: _______________________________________
8.b. Address: _______________________________________________________________

/

8.c. What was the approximate date ?
M M

Y

Y

Y

Y

8.d [DO NOT ASK] Was this within 3 yrs. of today’s date ? Y N U

If you answered NO or UNKNOWN in 8.d, skip 8.e.
[Request for authorization to release medical records for selected self-reported diagnoses / physician visits]

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8.e. “The ARIC study would like to ask your physician to tell us more about your health. If you agree to do this I will send you a form that tells
your physician that you authorize the ARIC study to get this information from your doctor. Once you sign that form and mail it back to me I will
contact your physician’s office.”
May I send you this release form and an addressed envelope for you to mail it back?

Y

N

8.f. Were you hospitalized for heart failure at that time?
Y

N

U

If Yes, go to “obtain hospital information and date” Section F Q 28a and then return to Q 8g

8.g. Were you hospitalized for heart failure or congestive heart failure at another time ?
Y

N

U

If Yes, go to “obtain hospital information and date” Section F Q 28a and return to Q 10.

9. Since we last contacted you on mm/dd/yyyy, has a doctor said that you had heart failure or congestive heart failure?
Y

N

U

No or Unknown skip to Q 10.

What is the name and address of the doctor who said you had heart failure?
9.a. Name: _______________________________________
9.b Address: _______________________________________________________
9.c. What was the approximate date?

/
M

M

Y

9.d. [DO NOT ASK] Was this within 3 yrs. of today’s date]

Y

Y
Y

Y
N

U

9.e. Were you hospitalized for heart failure at that time?
Y

N

U

If Yes, go to “obtain hospital information and date” Section F Q 28a and return to
Q.10.
If you answered NO or UNKNOWN in 9d, skip 9f.
[Request for authorization to release medical records for selected self-reported diagnoses / physician visits. If this is the same doctor as listed in
Q.8. you do not need to re-read the script.]
9.f. “The ARIC study would like to ask your physician to tell us more about your health. If you agree to do this I will send you a form that tells
your physician that you authorize the ARIC study to get this information from your doctor. Once you sign that form and mail it back to me I will
contact your physician’s office.”
May I send you this release form and an addressed envelope for you to mail it back?

Y

N

10. Since we last contacted you has a doctor said that your heart is weak, or does not pump as strongly as it should, or that you had fluid on the
lungs?
Y

N

U

No or Unknown skip to Q 11a.

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What is the name and address of the doctor you saw?
10.a. Name: _______________________________________
10.b. Address: _______________________________________________________

/

10.c. What was the approximate date?
M

M

Y

Y

Y

Y

Question 10d deleted
10.e. Were you hospitalized for the weak heart muscle at that time?
Y N U
If Yes: go to obtain hospital information and date Section F Q 28a and return to
question 11a

[Request for authorization to release medical records for selected self-reported diagnoses / physician visits. If this is the same doctor as listed in
Q.8. or Q.9. you do not need to re-read the script.]
10.f. “The ARIC study would like to ask your physician to tell us more about your health. If you agree to do this I will send you a form that tells
your physician that you authorize the ARIC study to get this information from your doctor. Once you sign that form and mail it back to me I will
contact your physician’s office.”
May I send you this release form and an addressed envelope for you to mail it back?

Y

N

11.a. Since we last contacted you on mm/dd/yyyy, has a doctor said that you had a heart attack?
Y

N

U

Question 11b deleted

11.c. Since we last contacted you has a doctor said that you had angina, angina pectoris or chest pain due to heart disease?
Y

N

U

12. Since we last contacted you, has a doctor said that you had an irregular heart beat called atrial fibrillation, or atrial fibrillation on a heart scan or
electrocardiogram tracing?
Y

N

U

13.a. Do you often have swelling in your feet or ankles at the end of the day?
Y

N

U

No or Unknown skip to Q 14.

13.b. Is the swelling in your feet or ankles gone in the morning?
Y
N
U
14. Since we last contacted you has a doctor said you had high blood pressure?
Y

N

U

15. Since we last contacted you has a doctor said you have diabetes or sugar in the blood?
Y

N

U

16. Since we last contacted you has a doctor said that you had a blood clot in a leg or deep vein thrombosis?
Y

N

U

No or Unknown skip to Q 17a.

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What is the name and address of the doctor you saw? (If same physician as above, no need to records address)
16.a. Name: _______________________________________
16.b. Address: _______________________________________________________

/

16.c. What was the approximate date?
M M

Y

Y

Y

Y

16.d. Were you hospitalized for a blood clot in a leg or deep vein thrombosis at that time?
Y N U
If Yes: go to obtain hospital information and date Section F Q 28a and return to Q.17a, below.

Question 16e deleted
17.a. Has a doctor ever said that you had a blood clot in your lungs or a pulmonary embolus?
Y

N

U

No or Unknown skip to Q 18b.

17.b. Since we last contacted you were you hospitalized for a blood clot in your lungs or a pulmonary embolus at that time?
Y N U
If Yes: go to obtain hospital information and date Section F Q 28a and return to Q.18.b.below.

Question 18a deleted

18.b. Since we last contacted you has a doctor told you that you had chronic lung disease, such as bronchitis, or emphysema?
Y N U
If Yes skip to Q 20a.

19.a. Are there times when you wake up at night because of difficulty breathing?
Y N U
19.b. Do you have trouble breathing or shortness of breath when hurrying on the level?
Y N U Unable to walk
Go to Q 19 f
If No or U: Go to Q 19f.

19.c. Do you have trouble breathing or shortness of breath when walking at ordinary pace on a level surface?
Y N U
If No or U: Go to Q 19g.

19.d. Do you stop for breath when walking at your own pace?
Y N U
If No or U: Go to Q 19g.

19.e. Do you stop for breath after walking 100 yards on the level?
Y N U
If No or U: Go to Q 19g.

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19.f.

Do you have difficulty breathing when you are not walking or active?
Y N U

19.g. Do you usually have some cough or wheezing?
Y
N
U
Question 20 deleted
20.a. Since we last contacted you on mm/dd/yy has a doctor said you had asthma?
Y
20.b

N

U

Do you have pain in your legs caused by a blockage of the arteries?
Y
N
U

20.c Since we last contacted you has a doctor said that you have peripheral vascular disease or intermittent
claudication ?
Y
N
U

21.a. Since we last contacted you has a doctor said that you had cancer?
Y
N
U
Go to Item
22a

21.b. Can you tell me in what part of the body the most recently diagnosed cancer was
located?

21.c. And the date it was diagnosed?

/
Month

Year

D. STROKE/TIA
22.a. Since our last contact on (mm/dd/yyyy), have you been
told by a physician that you had a stroke, slight
stroke, transient ischemic attack, or TIA? ........... Yes
No

Y
N

If “No”, go to question 23
22.b.

Were you hospitalized for this stroke, slight stroke, transient ischemic
attack or TIA? ...........
Yes
Y
No

N

If "Yes", ensure that this event is included in the "HOSPITALIZATIONS"
section, Section F Q 28a, if appropriate.

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E. ADMISSIONS
23. Were you (Was [name])hospitalized for a heart attack since our last contact on (mm/dd/yyyy)?
Y

N

U

24. Have you stayed (Did [name]stay) overnight as a patient in a hospital for any other reason
since our last contact?
Y
N
U
If "Yes" to either 23 or 24, add to "HOSPITALIZATIONS" section F Q28a and return to Q. 25a.

25.a. Were you (Was [name]) admitted to an emergency room or a medical facility for outpatient
treatment since our last contact on(mm/dd/yyyy)?
Y

N

U

If No or Unknown: Go to Q 27a

25.b.

Was this related to a heart problem or difficulty breathing ?
Y

N

U

If No or Unknown: Go to Q27a

What is the name and address of this medical facility ?
26.a. Name: _______________________________________
26.b. Address: _______________________________________________________
26.c. What was the approximate date?

/
M

M

Y

Y

Y

Y

27.a. Since our last contact, (Did [name]stay)have you stayed overnight as a patient in a nursing
home? ....................
Yes
Y
Go to Item 40.

No

N

For DECEASED, REPORTED ALIVE, or CONTACTED BY LETTER statuses, go to Q.52

27.b. Are you currently staying in a nursing home? .......

On the paper form skip Section F and continue to Item 40.
or jump-to (CTRL-J), to Item 40.

Yes

Y

No

N

To skip in the DMS Page down to,

F. HOSPITALIZATIONS
For each time you were (he/she was) a patient in a hospital, I would like to obtain the reason you
were (he/she was) admitted, the name of the hospital, and the date. When was the first time you
were (he/she was) hospitalized since our last contact with you (him/her) on (mm/dd/yyyy of last
contact)? [Fill in, probing as necessary. Press F3 for a list of hospitals and press on
the correct one if found. Otherwise press and type in the appropriate information. Probe
for additional hospitalizations. For linkage, H indicates that the hospitalization was reported;
N indicates that the hospitalization was fully sought by Surveillance, and not found.]

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28.a. Hospitalization Reason:
_______________________________________________________________________________________

28.b. Hospital Name, City, and State:
_______________________________________________________________________________________

/

28.c. Month and Year:
M

M

28.d. Linkage Status:
(H) or (N)
Y

Y

Y

Y

29.a. Hospitalization Reason:
_______________________________________________________________________________________

29.b. Hospital Name, City, and State:
_______________________________________________________________________________________

/

29.c. Month and Year:
M

29.d. Linkage Status:
(H) or (N)

M

Y

Y

Y

Y

30.a. Hospitalization Reason:
_______________________________________________________________________________________

30.b. Hospital Name, City, and State:
_______________________________________________________________________________________

/

30.c. Month and Year:
M

M

30.d. Linkage Status:
(H) or (N)
Y

Y

Y

Y

31.a. Hospitalization Reason:
_______________________________________________________________________________________

31.b. Hospital Name, City, and State:
_______________________________________________________________________________________

31.c. Month and Year:

31.d. Linkage Status:
(H) or (N)

/
M

M

Y

Y

Y

Y

32.a. Hospitalization Reason:
_______________________________________________________________________________________

32.b. Hospital Name, City, and State:
_______________________________________________________________________________________

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32.c. Month and Year:

32.d. Linkage Status:
(H) or (N)

/
M

M

33.a. Hospitalization Reason:

Y

Y

Y

Y

______________________________________________________________

33.b. Hospital Name, City, and State:
_______________________________________________________________________________________

/

33.c. Month and Year:
M

M

33.d. Linkage Status:
(H) or (N)
Y

Y

Y

Y

34.a. Hospitalization Reason:
_______________________________________________________________________________________

34.b. Hospital Name, City, and State:
_______________________________________________________________________________________

/

34.c. Month and Year:
M

M

34.d. Linkage Status:
(H) or (N)
Y

Y

Y

Y

35.a. Hospitalization Reason:
_______________________________________________________________________________________

35.b. Hospital Name, City, and State:
_______________________________________________________________________________________

/

35.c. Month and Year:
M

M

35.d. Linkage Status:
Y

Y

Y

Y

(H) or (N)

36.a. Hospitalization Reason:
_______________________________________________________________________________________

36.b. Hospital Name, City, and State:
_______________________________________________________________________________________

/

36.c. Month and Year:
M

M

36.d. Linkage Status:
(H) or (N)
Y

Y

Y

Y

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37.a. Hospitalization Reason:
_______________________________________________________________________________________
37.b. Hospital Name, City, and State:
_______________________________________________________________________________________

/

37.c. Month and Year:
M

M

37.d. Linkage Status:
(H) or (N)
Y

Y

Y

Y

38.a. Hospitalization Reason:
_______________________________________________________________________________________

38.b. Hospital Name, City, and State:
_______________________________________________________________________________________

/

38.c. Month and Year:
M

M

39.a. Hospitalization Reason:

38.d. Linkage Status:
(H) or (N)
Y

Y

Y

Y

______________________________________________________________

39.b. Hospital Name, City, and State:
_______________________________________________________________________________________

/

39.c. Month and Year:
M

M

39.d. Linkage Status:
(H) or (N)
Y

Y

Y

Y

G. INVASIVE PROCEDURES
"The following questions ask about various types of surgery and procedures.
We are interested in both those that occurred in the hospital or as an
outpatient."

40. [DO NOT ASK]
Has participant completed a previous version 'G' or later of Annual Follow-up?
Yes
Go to Item 41b.

Y

No

N

41.a. Since we last contacted you on (mm/dd/yyyy) have you had surgery on your heart, or the
arteries of your neck or legs, excluding surgery for varicose veins?
Go to Item 42a.
Go to Item 44a

Yes

Y

No

N

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41.b. Since your last ARIC visit on (mm/dd/yyyy) have you had surgery on your heart,
or the arteries of your neck or legs, excluding surgery for varicose veins?
Yes
Go to Item 44b.

Y

No

N

42. Did you have:
a. Coronary bypass? ............. Yes

Y

No

N

b. Other heart procedure? ....... Yes

Y

No
Specify:

N

_____________________________________________________________________

c. Carotid endarterectomy? ......
Go to Item 42e.

Yes

Y

No

N

d. Site: ................ Right

e. Other arterial
revascularization?

R

Left

L

Both

B

...... Yes

Y

No

N

Specify: ___________________________________________________________________________
f. Any other type of surgery on your heart or the arteries of your neck or
legs? .................. Yes
Y
No

N

43. [DO NOT ASK]
Has participant completed a previous version 'G' or later of Annual Follow-up?

Go to Item 44b.

Yes

Y

No

N

44.a. Since we last contacted you on (mm/dd/yyyy) have you had a balloon angioplasty or stent on
the arteries of your heart, neck, or legs?
Go to Item 45a.

Yes

Y

Go to Item 46a.

No

N

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44.b. Since your last visit to the ARIC clinic on (mm/dd/yyyy) have you had a balloon
angioplasty or stent on the arteries of your heart, neck, or legs?
Yes
Go to Item 46a.

No

Y

N

45. Did you have:
a. Angioplasty or stent of the coronary arteries:
Yes

Y

No

N

b. Angioplasty or stent in the arteries of your neck:
Yes

Y

No

N

c. Angioplasty or stent of the lower extremity arteries:
Yes

Y

No

N

H. INTERVIEW
"Now I would like to ask about medication use during the past two weeks."

46. Did you take any medications during the past two weeks for:
No
Unknown
Yes
a. High blood pressure? .. Y

N

U

b. High blood
cholesterol?

…………………. Y

N

U

c. Diabetes or
high blood sugar? ………..Y

N

U

d. Heart failure?………………... Y

N

U

"Now I would like to ask about the prescription medications you currently use [optional: as
mentioned in the scheduling reminder we sent recently]. Can I ask you to bring all the
prescription medications you are taking to the telephone?

47.

[DO NOT ASK} Does the participant have medications to report?
Yes…………………………………………………………… Y
No……………………………………………………………… N
Participant
refused to provide
medication information………… R
Unknown

………………………………………………U

If the answer is NO, REFUSED, or UNKNOWN, skip to question 49

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[Once participant has all medications or prescriptions] Please read the names of all the
medications prescribed by a doctor. This includes pills, liquid medications, skin patches,
inhalers, and injections. Please do not include over the counter medications unless prescribed by
a doctor. [If asked: currently taking applies to medications taken in the past two weeks. Use the
look-up table to enter, if medication is available in table]
Medication Name
48.a. ________________________________
48.b. ________________________________
48.c. ________________________________
48.d. ________________________________
48.e. ________________________________
48.f. ________________________________
48.g. ________________________________
48.h. ________________________________
48.i. ________________________________
48.j. ________________________________
48.k. ________________________________
48.l. ________________________________
48.m. ________________________________
48.n. ________________________________
48.o. ________________________________
48.p. ________________________________
48.q. ________________________________
48.r. ________________________________
48.s. ________________________________
48.t. ________________________________
"Next I would like to ask you about your regular use of aspirin. This includes aspirin alone, or
in a combination with another drug, such as aspirin in a cold medicine. By regular use, I mean
taking aspirin at least once a week for several months."

49. Are you NOW taking aspirin, or a medicine containing aspirin, on a regular basis?
not include Tylenol or Advil. [Use look-up table]
Yes

Y

No

N

Unknown

U

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This does

I. OTHER ITEMS
"Next, I have a few miscellaneous questions."

50. Do you now smoke cigarettes?

..

Yes

Y

No

N

51. Please tell me which of the following describes your current marital status:
[READ EACH CATEGORY]
Married

.........

M

Widowed

.........

W

Divorced

........

D

Separated

.......

S

Never Married

...

N

J. ADMINISTRATIVE INFORMATION
52. Code number of person completing this form:

53.

Does participant (still) live within official
ARIC study boundaries? ..... Yes
Y
No

N

Unknown

U

54. Will your center (still) be able to get his/her records
via community surveillance? ...... Yes
Y
No

N

55. Result code:
Result Codes
01 – No Action Taken
02 – Tracing (Not yet contacted any source)
3A – Contacted, Interview Complete by Cohort Member
3B - Contacted, Interview Complete, Proxy/Informant
04 – Contacted, Interview Partially Complete or Rescheduled

05 – Contacted, Interview Refused
06 – Reported Alive, Will Continue to Attempt Contact This Year
07 – Reported Alive, Contact Not Possible This Year
08 – Reported Deceased
09 – Unknown
98 – Does Not Want Any Further AFU Contact

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