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: __________________________________________________)
|
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| 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:
|
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| 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:
|
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| 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:
|
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| 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