CURHAN Base Protocol Interviewers/Technicians Information

Adapted from Framingham Heart Study 2013


 

 Please complete this form for every participant
  
Interviewer/Technician Name:
Interviewer/Technician ID:
Job Title:
Date of Examination (MMDDYYYY):
Site of Examination
Are you part of the CURHAN research team?(Please circle): YES                NO

 

Click here if the whole page is empty(Specify reason: __________________________________________________)

 

 CHECK POINT
   
Is the informed consent signed? YES                NO
   
   
Do not proceed with examination without informed consent
   
 Questionnaire Checklist
 Tick the box if it is completed:
   
Basic information/Demographic Questionnaire
 
Medical History Questionnaire
 
Physical Activity Questionnaire
 
CES-D Questionnaire
 
Food Frequency Questionnaire
 
Sleep Questionnaire
 
Environmental Exposure Questionnaire
 
Home Digital Tools Monitoring

 

Click here if the whole page is empty(Specify reason: __________________________________________________)
   
Use the following code for the following table: 

1 Complete procedure
2 Split exam (exam completed in 2 visits)
3 Incomplete procedure
89 OffsiteNot applicable
   
                                       Procedure Checklist
 
Anthropometry   
 
Basic Physical Examination   
 
Blood Specimen   
 
Urine Specimen   
 
Sleep Study   
 
Neurological Examination   
 
Cardiovascular Examination   
 
Ankle-brachial blood pressure by Doppler   
 
Respiratory Examination   

 

Fill in this page for participants who wish to complete their exam on a second visit (Split Exam)(Otherwise, leave this page blank)
Date of second exam (MMDDYYYY):  
   
Use the following code for the following table: 

0 Procedure was not done on the second exam
1 Procedure complete
3 Incomplete exam
89 OffsiteNot applicable
   
                                       Procedure Checklist
 
Anthropometry   
 
Basic Physical Examination   
 
Blood Specimen   
 
Urine Specimen   
 
Sleep Study   
 
Neurological Examination   
 
Cardiovascular Examination   
 
Ankle-brachial blood pressure by Doppler   
 
Respiratory Examination   


 

Click here if the whole page is empty(Specify reason: __________________________________________________)
   
Use the following code for the following table:

0 No
1 Yes
89 OffsiteNot applicable

 

                                             Exit Interview
Questionnaire Checklist Reviewed   
 
Procedure Checklist Reviewed   
 
Referral to Specialists Confirmed   
 
Next Exam Visit Arranged   
 
Participant Left with all Belongings   
 
Participant Provided Feedback   

Feedback:

 

 

Use the following code for the following table:

0 No
1 Yes
9 Unknown

 

      For Clinic Visit Only             
 
Was there an adverse event in clinic that does not require further medical evaluation?   

 

      For Offsite Visit Only            
 
Was a physician contacted during the examination due to adverse exam finding?   

 

      End of Interviewer/Technician Form     
Interviewer/Technician Name:
Interviewer/Technician ID:

 


 

CURHAN Interviewers/Technicians Information Protocol, March 9, 2016

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About 陈馨雨

2014级本科生
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