ID NUMBER:
FORM CODE: ASE
VERSION:A 01/27/10
Contact
Occasion
0 1 SEQ #
0a. Completion Date:
Month
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Day
/
Year
0b. Staff ID:
Instructions: The assessor/study coordinator asks the participant the questions on this form at the baseline visit. Affix the participant
ID label above.
PROMPT : “In the last week, have you experienced any of the following symptoms? If Yes , how frequently did you experience the symptom over the last week?
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In the last week, have you experienced…
Yes No Once
Occasionally
(2-4 times)
Frequently
1 Appetite, decreased     
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4
5
6
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8
9
10
11
12
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14
Appetite, increased
Drowsiness / Fatigue
Insomnia
Sexual side effects
Sweating
Tremors
Agitation
Anxiety / Nervousness
Diarrhea
Dry mouth
Indigestion
Nausea
Upset stomach
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Anticipated Side Effects and Health Status at Baseline Questionnaire (ASE) Page 1 of 3

ID #:
Instructions: When completing questions #15-26, have the participant answer with respect to the index event.
NO
CARDIOVASCULAR HEALTH STATUS CHANGES
15. Since your cardiac hospitalization on __/__/____ have you had chest pain? ... 
YES
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If yes:
15a. Is the chest pain more frequent .............................................................. 
15b. Is the chest pain more severe lately (last 2 weeks)................................. 
15c. Is the chest pain relieved by taking medications (eg nitroglycerin) .......... 
16. Have you had fatigue with minimal exertion or at rest that is new or worse since your cardiac hospitalization? ......................................... 
17. Have you had shortness of breath with normal life activities that is new or worse since your cardiac hospitalization? ............................................. 
18. Have you had shortness of breath when you’re lying down or sudden shortness of breath while sleeping that is new or worse since your cardiac hospitalization? .................................................................................... 
19. Since your cardiac hospitalization, have you been to the ER? ......................... 
20. Since your cardiac hospitalization, have you been admitted to a hospital? ....... 
20a. If Yes , how many times? ________ ( complete a Hospitalization form for each )
Continue to page 3.
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N/A
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Anticipated Side Effects and Health Status at Baseline Questionnaire (ASE) Page 2 of 3

ID #:
OTHER MEDICAL PROBLEMS
“Since your cardiac hospitalization on __/__/____, have you experienced any of the following?”
NO YES
21. GI problems (e.g., esophageal reflux, diverticulitis) ........................................... 
22. Pneumonia ....................................................................................................... 
23. COPD ............................................................................................................... 
24. Edema .............................................................................................................. 
25. Bleeding ........................................................................................................... 
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If Yes, complete a-e:
25a. GI ......................................................................................................... 
25b. Rectal ................................................................................................... 
25c. Vaginal ................................................................................................. 
25d. Other Internal ....................................................................................... 
25e. Nosebleeds .......................................................................................... 
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26. Are there any other changes/problems that you have had since your cardiac hospitalization? ................................................................... 
( This should be rare. Complete an Unanticipated Problem Report for each )
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Anticipated Side Effects and Health Status at Baseline Questionnaire (ASE) Page 3 of 3