5 survey

FORM CODE: PHF
Version: A
06/05/07
ARIC ID: CY: < 00 > SEQ: <00>

ARIC Heart Failure Survey
Dear < Dr

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

>,

Your patient, <
Ms/Mr.
> who is a long time participant in the ARIC Study, has
indicated to ARIC study personnel that < s/he > has been diagnosed with heart failure. We have your
patient’s authorization to ask you to provide this information for our study records. We appreciate your
response to the following questions and request that you return this form in the enclosed envelope at
your earliest convenience (ideally within 2 weeks).
Thank you.
Sincerely,
<
Field center medical director

>

Patient Name < Ms/Mr.

Date <
>

Date letter is sent >

Patient Date of Birth < mm/dd/yyyy >

1. Has this patient ever had heart failure or cardiomyopathy of any type? … Yes … Unsure … No
(If response is NO, skip to question 3)

2. If the patient has or ever had heart failure or cardiomyopathy:
(a) Is this patient’s condition characterized as predominantly:
… Systolic dysfunction … Diastolic dysfunction … Mixed … Not determined
(b) Estimated LVEF (worst): ____%
(b.1.) If LVEF is not specifically available, estimate LV function:
… Normal
… Decreased mildly … Decreased moderately … Decreased severely
(c) Estimated date of onset or diagnosis: ___ / _______ (month/year)
3. Has this patient ever had (check all that apply):
… Atrial fibrillation on an ECG?
… Pulmonary rales on a physical examination?
… Rhonchi on a physical examination?

… Angina pectoris?
… Previous MI?
… Other coronary heart disease?
… None of the above
4. Was s/he prescribed treatment specifically for heart failure during the past year?
… Yes
… No
… Not known
5. Was this patient prescribed any of the following during the past year? (check all that apply)
… ACE inhibitors
… Beta blockers
… Alpha blockers
… Calcium channel blockers
… Aldosterone blocker
… Digitalis
… Amiodarone / Antiarrhythmics
… Diuretics
… Angiotensin II receptor blockers
… Hydralazine
… Anticoagulants
… Lipid-lowering agents
… Aspirin / Antiplatelets
… Nitrates
… Other antihypertensives
Form completed by:

Date:

___________________________

_______________________

(Signature or stamp )

(MM/ DD /YY)

ARIC Heart Failure Survey

O.M.B 0925-0281
Exp. 05/31/2010

Public reporting burden for this collection of information is estimated to average 4 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.