<p> Familial Aggregation of Atrial Fibrillation Index Questionnaire Stanford University</p><p> 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: </p><p>Primary Cardiologist:</p><p>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:</p><p>Stroke Prophylaxys:  None  ASA _mg  Plavix  Coumadin last INR:  Other: Other Treatments:  None  AVN Ablation + Pacemaker  AF Ablation  MAZE:  Other:</p><p>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:</p><p>Therapies Received:</p><p>PAST MEDICAL HISTORY When Yes/No Qualifier Treatments Received Compliance Condition Diagnosed Hypertension  Yes  No</p><p>Diabetes Mellitus  Yes  No</p><p>Hyperlipidemia  Yes  No</p><p>Stroke  Yes  No</p><p>CAD  Yes  No</p><p>Myocardial Infarction  Yes  No</p><p>CHF  Yes  No</p><p>Valvular Heart Dz MR  MS  AS  Yes  No AR  TR Other Rheumatic Heart Dz  Yes  No</p><p>Congenital Hearth Dz  Yes  No</p><p>Hypertrophic CMP  Yes  No</p><p>COPD  Yes  No</p><p>Pulmonary Embolism  Yes  No</p><p>Pulmonary HTN  Yes  No</p><p>Hyperthyroidism  Yes  No</p><p>Hypothyroidism  Yes  No</p><p>Obstructive Sleep Apnea  Yes  No</p><p>Prior Cardiac Surgery  No  CABG  Other Other:</p><p>Other:</p><p>MEDICATIONS Medication Dose Started Compliance Notes</p><p>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)</p><p>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</p><p>LABS Date Lab Results Comments</p><p>______|______|______/ Basic Chemistries | | \</p><p>\______/ CBC / \</p><p>Ca Electrolytes Ph Mg TBili TP AP Alb Extended Chemistries AST ALT PT Coags INR PTT Ttotal Chol Triglycerides Lipids LDL HDL</p><p>CK Cardiac Enzymes CK-MB Tpn</p><p>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.: ( )</p><p>FAAF Index Quest (Ver 2006.08.29) 5</p>