CARDIA 288 MONTH FOLLOW-UP SUPPLEMENTAL FORM (FORM B) HOSPITALIZATION CASE #: INTERVIEWER ID FY288BIVID2. Page 1 of 6 FY288BH4CN
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1 HOSPITALIZATION CASE #: H FY288BH4CN Has the participant indicated any of the following reasons for being admitted overnight for this case? 1. Suspected or confirmed problems with the heart, circulation, or a blood clot. FY288B4HCBC Go to Question 2 No For which specific problem? Chest pain from a heart problem (angina) FY288B4ANGI Heart failure (congestive heart failure or CHF) FY288B4CHF Heart bypass operation (coronary bypass or CABG) FY288B4CABG Blood clot in the lung (pulmonary embolism) FY288B4PEMB Procedure or operation to unblock narrowed blood vessels in neck (carotid endarterectomy or carotid angioplasty) FY288B4CRDA Aortic aneurysm FY288B4AORA Heart attack (coronary, myocardial infarction or MI) FY288B4MYOI Heart cath (cardiac catheterization) FY288B4CATH Procedure to unblock narrowed blood vessels to your heart muscle (PTCA, coronary angioplasty, stent, or atherectomy) FY288B4PTCA Blood clot in the leg (deep vein thrombosis or DVT) FY288B4DVT Poor blood circulation or blocked or narrowed blood vessels to the legs or feet (claudication, peripheral arterial disease, gangrene, or Buerger s disease) FY288B4CLAU Amputation of a part of a leg, including toes, because of poor blood circulation, gangrene, or diabetes FY288B4AMP Other (specify): FY288B4OTH FY288B4OTHX 2. Suspected or confirmed stroke or transient ischemic attack (TIA) FY288B4TIA 3. Kidney failure or transplant FY288B4KIDF 4. Chronic lung disease/copd/emphysema FY288B4COPD INTERVIEWER ID FY288BIVID2 Page 1 of 6
2 5. Hypertension/High Blood Pressure FY288B4HBP 6. Diabetes FY288B4DIA 7. Asthma FY288B4ASTH 8. Sleep apnea FY288B4SAPN 9. Bariatric surgery (e.g., gastric bypass or laparoscopic banding) FY288B4GBSS 10. Psychiatric Care FY288B4PSYC 1 No IF NO OTHER REASON FOR HOSPITALIZATION LISTED 11. Pregnancy/Delivery FY288B4PREG IF NO OTHER REASON FOR HOSPITALIZATION LISTED 12. Other (specify): FY288B4OTHE Go to Question 13 FY288B4OXTH Go to Question 12A 12A. Please Code Other Reasons Here (Check All That Apply) No a. Hysterectomy/oophorectomy/fibroid surgery FY288B4OTH1 b. Cervical spine surgery FY288B4OTH2 c. Lumbar spine surgery FY288B4OTH3 d. Other back surgery FY288B4OTH4 e. Knee replacement FY288B4OTH5 f. Hip replacement FY288B4OTH6 g. Bladder surgery FY288B4OTH7 h. Hernia repair FY288B4OTH8 i. Treatment for previously diagnosed cancer (e.g., Page 2 of 6
3 chemotherapy, radiation) FY288B4OTH9 Z. Other than listed above FY288B4OTH Did any of the problems or conditions include a yes response to Question 1(heart, circulation, or a blood clot) through Question 9 (bariatric surgery)? FY288B4BARI ANSWER NEXT QUESTION END OF HOSPITALIZATION. COLLECT 14. How many nights was this hospitalization? FY288B4NHOP 3 or fewer 4 or more Unknown 15. Did the problems or conditions include yes responses to Question 12A. responses a.(hysterectomy/oophorectomy/fibroid surgery) through i.(treatment for previously diagnosed cancer) as the only problem or condition reported? FY288B4YESR 1 NO END OF HOSPITALIZATION. COLLECT YES DO NOT COLLECT IF HOSPITALIZED 3 OR FEWER NIGHTS COLLECT IF HOSPITALIZED 4 OR MORE NIGHTS OR UNKNOWN Page 3 of 6
4 HOSPITALIZATION CASE #: H FY288BH5CN Has the participant indicated any of the following reasons for being admitted overnight for this case? 1. Suspected or confirmed problems with the heart, circulation, or a blood clot. FY288B5HCBC Go to Question 2 No For which specific problem? Chest pain from a heart problem (angina) FY288B5ANGI Heart failure (congestive heart failure or CHF) FY288B5CHF Heart bypass operation (coronary bypass or CABG) FY288B5CABG Blood clot in the lung (pulmonary embolism) FY288B5PEMB Procedure or operation to unblock narrowed blood vessels in neck (carotid endarterectomy or carotid angioplasty) FY288B5CRDA Aortic aneurysm FY288B5AORA Heart attack (coronary, myocardial infarction or MI) FY288B5MYOI Heart cath (cardiac catheterization) FY288B5CATH Procedure to unblock narrowed blood vessels to your heart muscle (PTCA, coronary angioplasty, stent, or atherectomy) FY288B5PTCA Blood clot in the leg (deep vein thrombosis or DVT) FY288B5DVT Poor blood circulation or blocked or narrowed blood vessels to the legs or feet (claudication, peripheral arterial disease, gangrene, or Buerger s disease) FY288B5CLAU Amputation of a part of a leg, including toes, because of poor blood circulation, gangrene, or diabetes FY288B5AMP Other (specify): FY288B5OTH FY288B5OTHX 2. Suspected or confirmed stroke or transient ischemic attack (TIA) FY288B5TIA 3. Kidney failure or transplant FY288B5KIDF 4. Chronic lung disease/copd/emphysema FY288B5COPD Page 4 of 6
5 5. Hypertension/High Blood Pressure FY288B5HBP 6. Diabetes FY288B5DIA 7. Asthma FY288B5ASTH 8. Sleep apnea FY288B5SAPN 9. Bariatric surgery (e.g., gastric bypass or laparoscopic banding) FY288B5GBSS 10. Psychiatric Care FY288B5PSYC 1 No IF NO OTHER REASON FOR HOSPITALIZATION LISTED 11. Pregnancy/Delivery FY288B5PREG IF NO OTHER REASON FOR HOSPITALIZATION LISTED 12. Other (specify): FY288B5OTHE Go to Question 13 FY288B5OXTH Go to Question 12A 12A. Please Code Other Reasons Here (Check All That Apply) No a. Hysterectomy/oophorectomy/fibroid surgery FY288B5OTH1 b. Cervical spine surgery FY288B5OTH2 c. Lumbar spine surgery FY288B5OTH3 d. Other back surgery FY288B5OTH4 e. Knee replacement FY288B5OTH5 f. Hip replacement FY288B5OTH6 g. Bladder surgery FY288B5OTH7 Page 5 of 6
6 h. Hernia repair FY288B5OTH8 i. Treatment for previously diagnosed cancer (e.g., chemotherapy, radiation) FY288B5OTH9 Z. Other than listed above FY288B5OT Did any of the problems or conditions include a yes response to Question 1(heart, circulation, or a blood clot) through Question 9 (bariatric surgery)? FY288B5BARI ANSWER NEXT QUESTION END OF HOSPITALIZATION. COLLECT 14. How many nights was this hospitalization? FY288B5NHOP 3 or fewer 4 or more Unknown 15. Did the problems or conditions include yes responses to Question 12A. responses a.(hysterectomy/oophorectomy/fibroid surgery) through i.(treatment for previously diagnosed cancer) as the only problem or condition reported? FY288B5YESR 1 NO END OF HOSPITALIZATION. COLLECT YES DO NOT COLLECT IF HOSPITALIZED 3 OR FEWER NIGHTS COLLECT IF HOSPITALIZED 4 OR MORE NIGHTS OR UNKNOWN Check here if more hospitalizations are reported and use supplemental form FY288BSUPH2 Page 6 of 6
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