Familial Aggregation of Atrial Fibrillation Index Questionnaire Stanford University
Index Case IndexControl Reference Index: Self Interviewer: Interview Date: Index Name: Marco Perez Family Case Family Control Index Study ID: Other: Study ID: MRN: SSN: Freezer Works ID: PATIENT INFORMATION Patient’s last name: First: Middle: Race: Hispanic Home Phone: White Asian African- Nat. Am. ( ) American Other: Hospital Status Birth Date: Age: Sex: Source: Patient Family Work Phone: Inpatent Outpatient / / M F Hosp Rec PCP Rec ( ) Street address: Cell Phone: ( ) City: State: Zip: Other Phone: ( ) Email: PCP:
Primary Cardiologist:
AF HISTORY Age at time of Diagnosis: Current Classification: Paroxysmal Persistent Permanent If Paroxysmal: Episodes - Total: Last Year: Date Last Episode: Duration of Last Episode: Subjective Triggers of AF: Strenuous Physical Exertion anger sexual activity morning awakening altered sleep pattern dehydration Emotional Stress physical exhaustion Other: Other: Termination of AF: Medication: Other: If Persistent: Well Rate Controlled (Current Resting HR < 100bpm) Poorly Rate Controlled (Current Resting HR > 100bpm) Symptoms Attributed to AF: None Palpitations Dizziness/Light-headedness Chest Pain SOB DOE Impaired PA Other: Hospitalizations for AF - Total: Last Year: ED Visits for AF - Total: Last Year: Cardioversions – Total: Last Year: Date of last Cardioversion: Current (Name and Start Date): Past: (Side Effects/If stopped, when and why?) Beta Blockers: Beta Blockers: CCB CCB Digoxin Digoxin Amiodarone: Amiodarone: Medical Treatments: Sotalol: Sotalol: Propafenone: Propafenone: Flecainide: Flecainide: Other: Other:
Stroke Prophylaxys: None ASA _mg Plavix Coumadin last INR: Other: Other Treatments: None AVN Ablation + Pacemaker AF Ablation MAZE: Other:
FAAF Index Quest (Ver 2006.08.29) 1 HOSPITALIZATION OR CLINIC ENCOUNTER Setting of Survey: Hospitalization Clinic Admit Date: Vital Signs on Admission or Clinic Visit: BP: Presenting Complaint: HR: Weight: Height: Admission diagnosis/Reason for Clinic Visit: History of Present Illness:
Therapies Received:
PAST MEDICAL HISTORY When Yes/No Qualifier Treatments Received Compliance Condition Diagnosed Hypertension Yes No
Diabetes Mellitus Yes No
Hyperlipidemia Yes No
Stroke Yes No
CAD Yes No
Myocardial Infarction Yes No
CHF Yes No
Valvular Heart Dz MR MS AS Yes No AR TR Other Rheumatic Heart Dz Yes No
Congenital Hearth Dz Yes No
Hypertrophic CMP Yes No
COPD Yes No
Pulmonary Embolism Yes No
Pulmonary HTN Yes No
Hyperthyroidism Yes No
Hypothyroidism Yes No
Obstructive Sleep Apnea Yes No
Prior Cardiac Surgery No CABG Other Other:
Other:
MEDICATIONS Medication Dose Started Compliance Notes
FAAF Index Quest (Ver 2006.08.29) 2 ENVIRONMENTAL EXPOSURES/HABBITS Marital Status: Single Married Divorced Widowed Children: Occupation - Retired Current: Prior: Alcohol: Never Former Current Age started: Age Quit: Average Amount: <1 drink/d _____ drinks/d Binges: Never Yes – Frequency: Amount: Coffee: Never Former Current Age started: Age Quit: Average Amount: <1cup/d _____ cups/d Decaf: Never Former Current Age started: Age Quit: Average Amount: <1cup/d _____ cups/d Cola: Never Former Current Age started: Age Quit: Average Amount: <1cup/d _____ cans/d Tea: Never Former Current Age started: Age Quit: Average Amount: <1cup/d _____ cups/d Tobacco: Never Former Current Age started: Age Quit: Average Packs per Day: Recreational Drug Use: None Substances: Activity Prior to AF Diagnosis: Sedentary lifestyle (Routinely ≤ 2 blocks/day) Active Lifestyle (Routinely walks > 2 blocks/day) Somewhat Active(Dedicated exercise, < 30 min activity, 3x/week) Active(> 30 min activity, 3x/week) Athletic(Vigorous Act. almost daily) Activity After AF Diagnosis: Sedentary lifestyle (Routinely ≤ 2 blocks/day) Active Lifestyle (Routinely walks > 2 blocks/day) Somewhat Active(Dedicated exercise, < 30 min activity, 3x/week) Active(> 30 min activity, 3x/week) Athletic(Vigorous Act. almost daily)
FAAF Index Quest (Ver 2006.08.29) 3 OTHER STUDIES Study Done Date Where Available ECG Yes No Stanford Other: Yes No Echo Yes No Stanford Other: Yes No Sleep Study Yes No Stanford Other: Yes No CXR Yes No Stanford Other: Yes No Holter Yes No Stanford Other: Yes No
LABS Date Lab Results Comments
______|______|______/ Basic Chemistries | | \
\______/ CBC / \
Ca Electrolytes Ph Mg TBili TP AP Alb Extended Chemistries AST ALT PT Coags INR PTT Ttotal Chol Triglycerides Lipids LDL HDL
CK Cardiac Enzymes CK-MB Tpn
FAAF Index Quest (Ver 2006.08.29) 4 FAMILY CONTACTS Atrial Fibrillation: Alive: Relationsip: Sibling Other: Age: Name Yes No Yes No Sex: M F Unknown Unknown Street address: Home Phone no.: ( ) City: State: Zip: Other phone no.: ( ) Atrial Fibrillation: Alive: Relationsip: Sibling Other: Age: Name Yes No Yes No Sex: M F Unknown Unknown Street address: Home Phone no.: ( ) City: State: Zip: Other phone no.: ( ) Atrial Fibrillation: Alive: Relationsip: Sibling Other: Age: Name Yes No Yes No Sex: M F Unknown Unknown Street address: Home Phone no.: ( ) City: State: Zip: Other phone no.: ( ) Atrial Fibrillation: Alive: Relationsip: Sibling Other: Age: Name Yes No Yes No Sex: M F Unknown Unknown Street address: Home Phone no.: ( ) City: State: Zip: Other phone no.: ( ) Atrial Fibrillation: Alive: Relationsip: Sibling Other: Age: Name Yes No Yes No Sex: M F Unknown Unknown Street address: Home Phone no.: ( ) City: State: Zip: Other phone no.: ( ) Atrial Fibrillation: Alive: Relationsip: Sibling Other: Age: Name Yes No Yes No Sex: M F Unknown Unknown Street address: Home Phone no.: ( ) City: State: Zip: Other phone no.: ( ) Atrial Fibrillation: Alive: Relationsip: Sibling Other: Age: Name Yes No Yes No Sex: M F Unknown Unknown Street address: Home Phone no.: ( ) City: State: Zip: Other phone no.: ( )
FAAF Index Quest (Ver 2006.08.29) 5