6 survey

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

ARIC

Atherosclerosis Risk in Communities

PHYSICIAN QUESTIONNAIRE
FORM

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 20892-7974, ATTN: PRA (0925-0281). Do not return the completed form
to this address.

ARIC Center use only

Version C: 05/22/07

Decedent's Name: _________________________________ Age: ____ Date of Birth: ___/___/_____ Date of Death: ___/___/_____
EVENT ID:

Sequence Number:

Physician's Name _____________________________

Please complete the following and return in the enclosed envelope.
A. MEDICAL HISTORY
1. Are you familiar with the decedent's medical history?
Yes

No
If No, skip to Item 5 on Page 3.

2. When did you last see the decedent? .....
Month

Year

3. Did the decedent have a history of any of the following?
Yes

No

Uncertain

a. Angina pectoris or coronary insufficiency ...
b. Valvular disease or cardiomyopathy ..........
c. Coronary bypass surgery ………………….
d. Coronary angioplasty ......................……….
e. Hypertension ............................……………
f. Myocardial infarction .....................………..
┌────────────────────────────────
│
g. If MI Yes, date of most recent event:
Month

Year

3. (cont'd) Did the decedent have a history of any of the following?
Yes

No

Uncertain

h. Other chronic ischemic heart disease:….
i. Stroke (CVA):…………………………

j. If Yes, date of most recent event:
Month

Year

k. Any non-cardiac condition that might Yes
No
Uncertain
have contributed to this death:
┌────────────────────────┘
│
└─ If Yes, specify: ______________________________________
Yes

No

Uncertain

l. Diabetes: ......................…………….
m. Cigarette smoking: .............………
4. Was the decedent taking any of the following medications
within four weeks prior to death?
Yes

No

Uncertain

a. Nitrates .................………….
b. Calcium channel blockers …..
c. Digitalis ................…………..
d. Beta-blockers ............………
d.1. Aspirin .............………….
d.2. ACE or Angiotensin II
inhibitors .....……..
e. Other cardiovascular drugs
┌──────────────────┘
└─ If Yes, specify: _______________________________________

B. DETAILS OF DEATH
5. Are you familiar with the events surrounding the decedent's death?
Yes

No

6. Did you witness the death?
Yes

If you answered No to both 5 & 6,
skip to Item 14 on page 4.
Otherwise, continue with Item 7.

No

7.a. Was there any pain in the chest, left arm or shoulder or jaw
within 72 hours of death?
Yes

No

Uncertain
If No or Uncertain, skip to item 8

b. Did the pain include the chest?
Yes

No

Uncertain

c. Did you think this pain was of a cardiac origin?
Yes

No

Uncertain

If No, specify what you think was the cause:
__________________________________________
8. Did the decedent take (or was he/she given) nitrates
at the time of the acute episode?
Yes

No

Uncertain

9. Was coronary reperfusion (intravenous or intracoronary streptokinase or
TPA, angioplasty, etc.) attempted during the acute episode?
Yes

No

Uncertain

10. Was CPR and/or cardioversion performed within 24 hours of death?
Yes

No

Uncertain

11. Please give time between onset of acute symptoms to death. (We are
defining death as the point where spontaneous breathing ceased and
the patient never recovered.)
More than 3 days (A)

At least 1 hour, (F)
but less than 4 hours

2 - 3 days (B)
Less than 1 hour (G)
1 day (C)
At least 12 hours, but less than 24 hours (D)
At least 4 hours, but less than 12 hours (E)

Death instantaneous,(H)
no symptoms
Unknown (I)

12. Would you classify the decedent's cause of death as due to CHD?
Yes

No

Uncertain

13. If No, what do you believe to
be the cause of death?
Yes

No Uncertain

a. Pulmonary embolism ..…..
b. Acute pulmonary edema ...
c. Stroke ..............……………
d. Pneumonia .............
e. Other ........….........
Specify: ___________________________________________
C. SIGNATURE
14.Form completed by: _______________________________________
Signature
15.Date:

-Month

-Day

Year

Thank you very much for your help. Please return this questionnaire in the
enclosed self-addressed envelope.
OFFICE USE ONLY: 16. Self (A)__ Interview (B)__ E.R. records (C) __