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:
|
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