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pdfPublic reporting burden for this collection of information is estimated to average 30 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 (0925-0584). Do not return the completed form to this
address.
OMB#: 0925-0584
Exp. xx/xx/xxxx
HCHS/SOL Physician Questionnaire
FORM CODE: PQE
VERSION:1, 1/15/2014
ID NUMBER:
Contact
0
Occasion
SEQ #
ADMINISTRATIVE INFORMATION
0a.
/
Completion Date:
month
/
may
0b.
Staff ID:
year
Instructions: Please complete the following questions to the best of your ability by filling in the appropriate bubbles
or writing the answer in the blank provided. Please return completed forms in the self addressed stamped envelope
provided to the local HCHS/SOL field center.
DETAILS OF DEATH
1. Are you familiar with the events surrounding the decedent's death?
No
Yes
0
1
2. Did you witness the death?
No
Yes
0
1
If informant answered “Yes” to one or both of Items 1 and 2, please skip to Item 4.
3. If you answered "No" to both Questions, are you aware of another physician who could provide
information regarding the death?
No
Yes
0
1
Please sign and date the bottom of this form
3a. Provide contact information. Please then sign and date the bottom of this form.
Name of physician: ___________________________________
Address:
_______________________________________
_______________________________________
_______________________________________
PQE-Physician Qx_1-15-2014.doc
Page 1 of 5
ID
NUMBER:
FORM CODE: PQE
VERSION: 1, 1/15/2014
Contact
Occasion
0
SEQ
#
CIRCUMSTANCES SURROUNDING DEATH
4. What do you believe to be the underlying cause of death?
Acute Myocardial Infarction
Other Ischemic Heart Disease
Cerebrovascular Disease
Other Cardiovascular Disease
Emphysema, chronic bronchitis or chronic
obstructive pulmonary disease (COPD)
Pneumonia
Asthma
Other Lung Disease
Non Cardio - Pulmonary Disease
1
2
3
4
5
6
7
8
9
specify: ______________
specify: ______________
5. Please specify the time between the onset of the acute episode of symptoms and death. (We are defining
death as the point where spontaneous breathing ceased and the patient never recovered.) Please check the
appropriate time period.
Less than 5 minutes
5 minutes to 1 hour
1 hour to 24 hours
More than 24 hours
1 day to 3 days
More than 3 days
Unknown
1
2
3
4
5
6
9
6. Was there an acute episode of pain in the chest, left arm or jaw during the last 72 hours prior to death?
No
Yes
Unknown
0
1
9
7. Was there an acute episode of shortness of breath during the 72 hours prior to death?
No
Yes
Unknown
0
1
9
8. Was there an acute episode of wheezing during the 72 hours prior to death?
No
Yes
Unknown
0
1
9
PQE-Physician Qx_1-15-2014.doc
Page 2 of 5
ID
NUMBER:
FORM CODE: PQE
VERSION: 1, 1/15/2014
Contact
Occasion
0
SEQ
#
9. Did the decedent take or was s/he given nitrates or nitroglycerin at the time of the acute episode?
No
Yes
Unknown
0
1
9
MEDICAL HISTORY
10. Are you familiar with the decedent’s medical history?
No
Yes
0
1
End questionnaire
11. Did the decedent have a medical history of any of the following conditions prior to the acute event
which led to death?
11a. Myocardial Infarction (MI)?
No
Yes
Unknown
0
1
9
Skip to 11b
Skip to 11b
/
i. Date of most recent MI:
/
month
day
year
11b. Angina Pectoris, Coronary Insufficiency or Other Chronic Ischemic Heart Disease?
No
Yes
Unknown
0
1
9
Skip to 11c
Skip to 11c
/
i. Date of first diagnosis:
/
month
day
year
11c. Congestive Heart Failure (CHF) or Congestive Cardiomyopathy?
No
Yes
Unknown
0
1
9
Skip to 11d
Skip to 11d
/
i. Date of first exacerbation:
month
PQE-Physician Qx_1-15-2014.doc
/
day
year
Page 3 of 5
ID
NUMBER:
FORM CODE: PQE
VERSION: 1, 1/15/2014
Contact
Occasion
0
SEQ
#
11d. Stroke (CVA)?
No
Yes
Unknown
0
1
9
Skip to 11e
Skip to 11e
/
i. Date of most recent CVA:
/
month
day
year
11e. Transient Ischemic Attack (TIA)?
No
Yes
Unknown
0
1
9
Skip to 11f
Skip to 11f
/
i. Date of first diagnosis:
month
/
day
year
11f. Intermittent Claudication or Other Peripheral Arterial Disease (PAD)?
No
Yes
Unknown
0
1
9
Skip to 11g
Skip to 11g
11g. Lower Extremity Bypass, Angioplasty or Amputation Secondary to PAD?
No
Yes
Unknown
0
1
9
Skip to 11h
Skip to 11h
11h. Coronary Bypass Surgery?
No
Yes
Unknown
0
1
9
11i. Coronary Angioplasty?
No
Yes
Unknown
0
1
9
11j. Emphysema, chronic bronchitis, or Chronic Obstruction Pulmonary Disease (COPD)?
No
Yes
Unknown
0
1
9
PQE-Physician Qx_1-15-2014.doc
Skip to 11k
Skip to 11k
Page 4 of 5
ID
NUMBER:
FORM CODE: PQE
VERSION: 1, 1/15/2014
Contact
Occasion
/
i. Date of first exacerbation (or onset):
month
0
SEQ
#
/
day
year
11k. Asthma?
No
Yes
Unknown
0
1
9
i. Approximate age asthma first started:
12. If you saw the participant within one month of death, please fill out the following for the most recent
visit:
12a. Date of visit:
/
/
month
day
year
12b. Chief Complaint:____________________________________
____________________________________
12c. Primary Diagnosis:____________________________________
____________________________________
12d. Changes in Medical Management:____________________________________
_____________________________________
_____________________________________
Form completed by: _______________________________
PQE-Physician Qx_1-15-2014.doc
Date: ___________________
Page 5 of 5
| File Type | application/pdf |
| File Modified | 2014-05-30 |
| File Created | 2014-05-30 |