Medical History Form
FORM CODE: MHX
VERSION:A 02/10/10
ID NUMBER:
Contact
Occasion
0
1
SEQ #
Administrative Information
/
0a. Completion Date:
Month
/
0b. Staff ID:
Day
Year
Part 1
Instructions: Part 1 of this form is completed by participant-response. Affix the participant ID label above.
1. Prior Angina .............................................................
No
Yes
[“Angina” refers to evidence or knowledge of symptoms before this acute event described as chest
pain or pressure, jaw pain, arm pain, or other equivalent discomfort suggestive of cardiac ischemia]
1a. If YES, then choose one of the following:
Existed > 2 weeks before admission
Existed ≤ 2 weeks before admission
2. Previous Myocardial Infarction ...............................
No
[Diagnosed by physician and hospitalized for myocardial infarction]
Yes
3. Prior Percutaneous Coronary Intervention ............
Yes
/
3a. If YES, most recent PCI date:
Month
/
Day
4. Prior Coronary Artery Bypass Surgery ..................
/
4a. If YES, most recent CABG date :
Month
No
Year
No
Yes
/
Day
5. History of Stroke......................................................
Year
No
5a. If YES, then answer the following: Hemiplegia: .........
Yes
No
Yes
6. History of TIA ...........................................................
No
Yes
[A focal neurological deficit (usually corresponding to the territory of a single vessel) that resolves
spontaneously without evidence of residual symptoms at 24 hours]
7. History of peripheral arterial disease ....................
No
Yes
[Peripheral arterial disease can include the following: (1) Claudication (pain in the muscles in the back of the
legs), either with exertion or at rest (2) Amputation for arterial vascular insufficiency (3) Vascular
reconstruction, bypass surgery, or percutaneous intervention to the extremities (4) Documented aortic
aneurysm (5) Positive noninvasive test (e.g., ankle brachial index less than 0.8).
Medical History (MHX)
Page 1 of 11
ID #:
8. Do you have a history of congestive heart failure? .....................
No
Yes
8a. If YES, then classify heart failure:
NYHA Class I – No symptoms and no limitation in ordinary physical activity (e.g. shortness of breath
when walking, climbing stairs etc).
NYHA Class II – Mild symptoms (mild shortness of breath and/or angina) and slight limitation during
ordinary activity.
NYHA Class III – Marked limitation in activity due to symptoms, even during less-than-ordinary
activity. Comfortable only at rest.
NYHA Class IV – Severe limitations. Experiences symptoms at rest. Inability to carry out physical
activity or symptoms at rest.
9. Do you currently smoke or have you smoked in the past? .
No
Yes
If YES, answer the following:
9a.
Current (within 1 month)
Recent (stopped 1 month to 1 year prior)
Former (stopped > 1 year prior)
9b. Years of smoking:
9c. Cigarettes smoked per day:
cigarettes per day (1 = 1 or fewer per day)
10. Do you have a family history of coronary disease? ...........
No
Yes
(As documented by direct blood relatives – parents, siblings, children – who have had any of the following
before age 55: 1) angina, or 2) myocardial infarction, or 3) sudden cardiac death without obvious cause)
In the seven days prior to this visit today:
11. Were you exercising regularly? ...............................................
No
Yes
12. Were you following a low-cholesterol, low-fat diet? .................
No
Yes
13. Were you participating in a cardiac rehabilitation program? ....
No
Yes
14. Many people do not take their medications perfectly. In the
past 7 days, did you ever miss taking your medications? ..........................
No
Yes
15. Did any medical professional discuss with you the
importance of taking your medications? ......................................................
No
Yes
16. Were you taking aspirin on a daily basis during the 7 days
before you came to the hospital? ................................................................
No
Yes
17. Were you taking vitamins or supplements? ................................................
No
Yes
If yes, please list: ________________________________________________________________
____________________________________________________________________________
Medical History (MHX)
Page 2 of 11
ID #:
Part 2
Instructions: Part 2 of this form is completed by chart abstraction.
A. RISK FACTORS
18. Height: ....................................
inches
19. Weight: ..................................
lbs
Note: For Questions 20 – 42, Unknown = No documentation of Positive or Negative History OR Unclear documentation.
20. Hypertension ........................................
No
Yes
Unknown
(As documented by 1) diagnosis by a health care provider, or 2) SBP > 140 or DBP > 90 mmHg on at
least 2 occasions, or 3) current use of antihypertensive medication)
21. Diabetes ...............................................
No
Yes
Unknown
(As documented by 1) diagnosis by a health care provider, or 2) current use of antidiabetic medication)
22. Dyslipidemia .........................................
No
Yes
Unknown
(As documented by (1) diagnosis by a health care provider, or (2) current use of hypolipidemic medication)
23. History of cigarette smoking .................
No
Yes
Unknown
If Yes, answer the following:
a.
Current (within 1 month)
Recent (stopped 1 month to 1 year prior)
Former (stopped > 1 year prior)
b. Years of smoking:
c. Cigarettes smoked per day:
Cigarettes per day (1 = 1 or fewer per day)
24. Family history of coronary disease .......
No
Yes
Unknown
(As documented by direct blood relatives – parents, siblings, children – who have had any of the following
before age 55: 1) angina, or 2) myocardial infarction, or 3) sudden cardiac death without obvious cause)
B. CARDIOVASCULAR DISEASE HISTORY
25. Angina ............................................................
No
Yes
Unknown
(As documented by evidence or knowledge of symptoms before the index ACS event described as chest
pain or pressure, jaw pain, arm pain, or other equivalent discomfort suggestive of cardiac ischemia)
Medical History (MHX)
Page 3 of 11
ID #:
26. Myocardial infarction.......................................
No
Yes
Unknown
(As documented by 1) physician diagnosis, or 2) hospitalization for MI)
/
26a. If Yes, most recent date:
Month
/
Day
Year
27. Percutaneous Coronary Intervention (PCI) .....
/
27a. If Yes, most recent date:
Month
No
/
Month
No
Unknown
Yes
Unknown
Yes
Unknown
/
Day
/
Month
Yes
Year
Year
29. Stroke .............................................................
29a. If Yes, most recent date:
Unknown
/
Day
28. Coronary Artery Bypass Surgery (CABG) .......
28a. If Yes, most recent date:
Yes
No
/
Day
30. TIA .................................................................
Year
No
(As documented by focal neurological deficit, usually corresponding to the territory of a single vessel, that
resolves spontaneously without evidence of residual symptoms at 24 hour)
31. Peripheral Arterial Disease .............................
No
Yes
Unknown
(As documented by 1) claudication, either with exertion or at rest, 2) amputation for arterial vascular
insufficiency, 3) vascular reconstruction, CABG, or PCI to the extremities, 4) aortic aneurysm, 5) positive
noninvasive test (e.g., ankle brachial index < 0.8))
32. Congestive heart failure ..................................
a. If Yes, NYHA class: ..
Medical History (MHX)
I
II
III
No
Yes
Unknown
IV
Page 4 of 11
ID #:
C. OTHER COMORBID ILLNESS HISTORY
33. Chronic lung disease ............................
No
Yes
Unknown
(As documented by 1) asthma, 2) chronic obstructive pulmonary disease, 3) chronic bronchitis, or 4) emphysema)
34. Kidney disease .....................................
No
Yes
Unknown
35. Liver disease ........................................
No
Yes
Unknown
35a. If Yes, severity:
Mild (e.g. chronic hepatitis, or cirrhosis without complications such as varices,
portal hypertension, encephalopathy, GI bleeding)
Moderate/Severe (e.g. cirrhosis with complications such as varices, portal
hypertension, encephalopathy, GI bleeding)
36. Rheumatologic disease ........................
No
Yes
Unknown
(As documented by lupus (SLE), polymyagia rheumatica (PMR), polymyositis, mixed connective tissue disease,
polymyalgia rheumatica, or rheumatoid arthritis (RA))
37. Peptic ulcer disease .............................
No
Yes
Unknown
(As documented by treatment for ulcer or history of GI bleed due to ulcer)
Note: gastritis without ulcer does not count as peptic ulcer disease
38. AIDS .....................................................
No
Yes
Unknown
No
Yes
Unknown
No
Yes
Unknown
Yes
Unknown
Note: not including those with asymptomatic HIV+
39. Any cancer treated in the past 5 years..
(e.g., breast, lung, colon, prostate, brain, etc.)
40. Leukemia (blood cancer) ......................
(e.g., AML, CML, ALL, CLL, polycythemia vera)
41. Lymphoma (lymph node cancer) .........
No
(e.g., Hodgkins, lymphosarcoma, Waldenstrom’s macroglobulinemia, myeloma, and other lymphomas)
42. Thyroid disease ...................................
a. If Yes, type: ......................................
43. Other co-morbid illness .........................
No
Yes
Hyperthyroidism
No
Unknown
Hypothyroidism
Yes
a. _______________________________
b. _______________________________
c. _______________________________
Medical History (MHX)
Page 5 of 11
ID #:
D. INDEX ACUTE CORONARY SYNDROME (ACS) EVENT
27. Hospital Name: ________________________________________
/
28. Hospital admission date:
/
Month
Day
29. Transferred from another hospital? ........
Year
No
Yes
If Yes:
a. Hospital Name: ________________________________________
/
b. If Yes, transfer date:
/
Month
Day
/
30. Date of ACS diagnosis:
/
Month
Day
/
31. Hospital discharge date:
Year
Year
/
Month
Day
Year
32. Heart rate at initial hospital presentation: .................................
bpm
33. SBP/DBP at initial presentation:...............................................
/
34. Killip class at initial presentation: ..........
I
35. Cardiac arrest at initial presentation?
No
II
III
mmHg
IV
Yes
36. Heart rate at discharge: ...........................................................
bpm
37. SBP/DBP at discharge: ............................................................
/
mmHg
E. ECG FINDINGS FOR INDEX ACS EVENT
38a. Admitting ECG available?
No
/
a. Date of ECG:
/
Month
Day
Year
:
b. Time of ECG:
Hour
38b. Pre-discharge ECG available?
AM / PM
Minute
(circle one)
No
Yes
/
a. Date of ECG:
Month
/
Day
:
b. Time of ECG:
Hour
Medical History (MHX)
Yes
Year
AM / PM
Minute
(circle one)
Page 6 of 11
ID #:
39. ECG changes? ....................
No
Yes
(If Yes, retain copy of ECG on which diagnosis is made, and a subsequent ECG after “evolution” of the
changes)
a. For the diagnostic ECG, indicate type(s) of ECG changes (check all that apply):
ST-segment elevation  0.1 mV elevation in 2 or more contiguous leads
Q waves greater  0.04 seconds in width and  0.1 mV in depth in at least 2 contiguous leads
ST-segment depression > 0.05 mV in 2 more contiguous leads (includes reciprocal changes)
T-wave inversion of at least 0.1 mV
b. For the ECG after evolution of the changes, indicate the pattern: .....
40. Paced rhythm? ...................
No
Yes
41. Atrial fibrillation or flutter? ...
No
Yes
42. Bundle branch block? .........
No
Yes
a. Type ...............................
RBBB
LBBB
b. Timing ............................
New
Old
Q wave
non-Q wave
Unknown
F. LABORATORY TESTS DURING HOSPITALIZATION FOR INDEX ACS EVENT
43. Troponin I or T performed? ............
a. Instrument: ...............
No
Yes
cTnI (cardiac troponin I)
cTnT (cardiac troponin T)
Other, specify: ________________
b. Assay: .....................
Abbott AxSYM ADV
Radiometer AQT90
Abbott Architect
Response RAMP
Abbott i-STAT
Roche E170
Beckman Access Accu
Roche Elecsys 2010
Beckman Access hs-cTnI
Siemens Centaur Ultra
bioMerieux Vidas Ultra
Siemens Dimension RxL
Innotrac Aio!
Siemens Immulite 2500
Inverness Biosite Triage
Siemens Stratus CS
Mitsubishi PATHFAST
Siemens VISTA
Nanosphere hs-cTnI
Singulex hs-cTnI
Ortho Vitros ECi ES
Tosoh AIA II
Other, specify: _____________________
Medical History (MHX)
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ID #:
c. Troponin at initial hospital presentation: ..............................
ng/mL
d. Troponin during hospitalization: ..........................................
ng/mL
(peak - prior to PCI or CABG if done)
‘INITIAL’ IS DEFINED AS THE FIRST VALUE RECORDED DURING THE INDEX ACS HOSPITALIZATION
44. Initial creatinine........................................................................
mg/dL
45. Initial total cholesterol: .............................................................
mg/dL
46. Initial triglycerides: ...................................................................
mg/dL
47. Initial LDL: ...............................................................................
mg/dL
48. Initial HDL: ...............................................................................
mg/dL
49. Initial hemoglobin A1c: .............................................................
%
G. PROCEDURES DURING HOSPITALIZATION FOR INDEX ACS EVENT
50. Stress test? ........................
No
Yes
If Yes, then answer the following:
/
a. Date of test:
Month
b. Stress test type ...............
/
Day
Exercise
If Exercise, to target heart rate? ................
Year
Pharmacological
No
Yes
c. Imaging type: ..................
EKG only
Nuclear
PET
d. Ischemia Result ..............
Positive
Negative
Equivocal
Present
Absent
e. Fixed defect indicating an old MI ..................
Echocardiogram
f. Other findings (e.g, hypotension, delayed hysteresis): __________________________
Medical History (MHX)
Page 8 of 11
ID #:
51. LV function assessed during hospitalization?
No
Yes
If Yes, then answer the following:
a. Initial LVEF:
% or check one
b. Mitral regurgitation noted? ..........
Normal/Low normal
Mildly reduced
Mild-moderately reduced
Moderately reduced
Moderate-severely reduced
Severely Reduced
No
Yes
c. EF method: (check one)
Echocardiography (by ultrasound)
Contract ventriculography (by cath/angiogram)
Radionuclide ventriculography or SPECT on stress testing (nuclear)
52. Diagnostic cardiac catheterization?
No
Yes
If Yes, then answer the following:
/
a. Date:
Month
/
Day
Year
b. Maximum stenosis (%):
LAD
LCx
RCx
LM
53. PCI performed? ...............................
No
Yes
If Yes, then answer the following:
/
a. Date:
Month
/
Day
Year
b. Stents placed:
c. Stent type: .........................
Bare metal
d. Complications of PCI? ................
If Yes, type (check all that apply):
Medical History (MHX)
No
Drug-eluting
Yes
Bleeding
Vascular complication
Cardiac tamponade
Arrhythmia
Stroke
Contrast reaction
Acute renal failure
Page 9 of 11
ID #:
54. Coronary Artery Bypass Surgery performed?
/
a. Date:
Month
Medical History (MHX)
No
Yes
/
Day
Year
Page 10 of 11
ID #:
H. CURRENT MEDICATIONS
No
Yes
Unknown
Name
Daily Dose
Units
55. ACE inhibitors ...............................
______________
_________
56. Angiotensin II receptor blockers .
______________
_________
57. Aspirin ............................................
______________
_________
58. Clopidogrel ....................................
______________
_________
59. Other antiplatelet agents .............
______________
_________
60. Anticoagulants (e.g., Warfarin) .......
______________
_________
61. Beta-blockers ................................
______________
_________
62. Calcium channel blockers ...........
______________
_________
63. Digitalis/Digoxin ............................
______________
_________
64. Other inotropic agent (not digitalis)
______________
_________
65. Diuretics .........................................
______________
_________
66. Statin lipid-lowering agents .........
______________
_________
67. Non-statin lipid-lowering agents .
______________
_________
68. Nitrates ...........................................
______________
_________
69. Vasodilators (not ACE inhibitors) .....
______________
_________
70. PO hypoglycemic antidiabetic ....
______________
_________
71. Insulin ...........................................
______________
_________
72. Antiarrhythmics .............................
______________
_________
73. Female hormone
replacement therapy ....................
______________
_________
74. Thyroid replacement therapy ......
______________
_________
75. Antipsychotics ...............................
______________
_________
76. Other drug class ...........................
______________
_________
77. Other drug class ...........................
______________
_________
78. Other drug class ...........................
______________
_________
79. Other drug class ...........................
______________
_________
80. Other drug class ...........................
______________
_________
81. Other drug class ...........................
______________
_________
Medical History (MHX)
Page 11 of 11