<p>Date: Code </p><p>STUDY</p><p>ATHEROTHROMBOSIS IN GREECE:</p><p>ESTIMATION OF PREVALENCE </p><p>ATHENS MARCH 09 Date: Code </p><p>AREA OF RESIDENCE □ City………….………………………………..</p><p>□ Address………..…………………………………..</p><p>GENDER □ Male</p><p>□ Female</p><p>BIRTH DATE (Year)</p><p>NATIONALITY …………………………………….…………..</p><p>□ Unemployed OCCUPATION □ Retired</p><p>□ University student </p><p>□ Housewife </p><p>□ Servant</p><p>□ Free launcher </p><p>□ Farmer ______□ Full time job </p><p>□ Part time job </p><p>□ Incapable of working</p><p>□ Married MARITAL STATUS □ Living together </p><p>□ Single </p><p>□ Divorced </p><p>□ Other ______Date: Code </p><p>EDUCATIONAL STATUS □ Illiterate </p><p>□ Elementary school</p><p>□ Gymnasium </p><p>□ Lyceum </p><p>□ University</p><p>□ MSc </p><p>□ PhD</p><p>□ Other ______</p><p>OTHER □ Weight (kg) / / □ Height (cm) / / □ Smoking / / / /</p><p>□ Number of cigarettes / /</p><p>/ / / 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 </p><p>Declare whether you have been diagnosed with any disease from the followings: </p><p>Date of diagnosis Diagnostic tests? Event (month – year) </p><p>□ 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 ______</p><p>Declare whether and when you have been subjected to the following interventions</p><p>Intervention Date of intervention? Hospital</p><p>□ PTCI ______□ CABG ______/ ______Angioplasty of peripheral vessels □ ______□ Surgery of peripheral disease ______</p>