Atherothrombosis in Greece

Date: Code

ATHEROTHROMBOSIS IN GREECE:

ESTIMATION OF PREVALENCE

ATHENS MARCH 09 Date: Code

AREA OF RESIDENCE □ City………….………………………………..

□ Address………..…………………………………..

GENDER □ Male

□ Female

BIRTH DATE (Year)

NATIONALITY …………………………………….…………..

□ Unemployed OCCUPATION □ Retired

□ University student

□ Housewife

□ Servant

□ Free launcher

□ Farmer ______□ Full time job

□ Part time job

□ Incapable of working

□ Married MARITAL STATUS □ Living together

□ Single

□ Divorced

□ Other ______Date: Code

EDUCATIONAL STATUS □ Illiterate

□ Elementary school

□ Gymnasium

□ Lyceum

□ University

□ MSc

□ PhD

□ Other ______

OTHER □ Weight (kg) / / □ Height (cm) / / □ Smoking / / / /

□ Number of cigarettes / /

/ / / Declare whether you have been diagnosed/ with any disease from the followings: / Disease / Date of diagnosis? Treatment (Month – Year) / □ Diabetes Medicine / ______/ ______□ Hypertension / ______/ ______□ Hypercholesterolemia (i.e. high cholesterol level, drug-treated) / / ______/ ______□ Claudication / ______/ ______□ Asymptomatic stenosis of peripheral vessel / ______/ Date: Code

Declare whether you have been diagnosed with any disease from the followings:

Date of diagnosis Diagnostic tests? Event (month – year)

□ Angina diagnosed by appropriate tests (i.e. angiocardiography, ______thallium , electrocardiogram ) and which is treated with drugs ______□ Myocardial infarction diagnosed by appropriate tests (i.e. ______angiocardiography, thallium, electrocardiogram) and which ______hospitalization was required ______Transient ischemic stroke diagnosed by neurologist and was full □ ______rehabilitated ______□ Ischemic stroke diagnosed by MRI or CT and for which ______hospitalization was required ______□ Peripheral arterial disease (that is disease of carotids, nether limbs, ______aorta, etc) diagnosed by appropriate tests (i.e. angiography, CT, etc ______

Declare whether and when you have been subjected to the following interventions

Intervention Date of intervention? Hospital

□ PTCI ______□ CABG ______/ ______Angioplasty of peripheral vessels □ ______□ Surgery of peripheral disease ______