CHS Data Collection Forms (Year 2-11)

 

Index of Forms

Note: Some of the files are Adobe Acrobat .pdf files.. You may download Adobe Acrobat Reader from the following link http://www.adobe.com/products/acrobat/readstep2.html

Record Type & Form NameNumber of Pages
Record 1 (Eligibility)3 pages
Record 3 (Quality of Life)2 pages
Record 4 (Physical Activity)2 pages
Record 5 (Stressful Life Events, Depression Scale)2 pages
Record 6 (Medications)2 pages
Record 7 (Baseline Medical History)20 pages
Record 8 (Baseline Personal History)7 pages
Record 9 (Physical Function)2 pages
Record 10 (Baseline Cognitive Function)2 pages
Record 11 (Spirometry)1 page
Record 12 (Baseline Phlebotomy)1 page
Record 12 (Years 5 & 6 Phlebotomy)1 page
Record 13 (Anthropometrics)1 page
Record 14 (Baseline Seated Blood Pressure)1 page
Record 14 (Year 3 Seated Blood Pressure)1 page
Record 14 (Years 4-6 Seated Blood Pressure)1 page
Record 15 (Supine Anlke-Arm Blood Pressure)1 page
Record 16 (Orthostatic Blood Pressure)1 page
Record 17 (Physical Exam)4 pages
Record 19 (Baseline Echocardiography)1 page
Record 19 (Year 7 Echocardiography)1 page
Record 20 (Ultrasound)1 page
Record 21 (Baseline ECG)1 page
Record 21 (Years 4-11 ECG)1 page
Record 22 (Neurological History)12 pages
Record 25 (Baseline Nutrition)4 pages
Record 27 (Performance-based Measurements)4 pages
Record 29 (Year 5 Medical & Personal History)30 pages
Record 31 (Baseline Phone Follow up)5 pages
Record 32 (Year 3 Phone Follow up)8 pages
Record 32 (Years 4-11 Phone Follow up)8 pages
Record 33 (Exit Summary)1 page
Record 34 (Cognitive Function)6 pages
Record 37 (Year 3 Medical History)25 pages
Record 38 (Year 3 Personal History)10 pages
Record 39 (Year 4 Medical & Personal History)
Adobe Acrobat (.pdf)		28 pages
Record 56 (Sleep and Asthma Questionnaire)6 pages
Record 57 (New Cohort Medical History)27 pages
Record 58 (New Cohort Personal History)13 pages
Record 59 (Years 6-9 Medical & Personal History)33 pages
Record 59 (Years 10-11 Medical & Personal History)
Adobe Acrobat (.pdf)		30 pages
Record 61-62 (Over the counter medications)
Adobe Acrobat (.pdf)		1 page
Record 65 (Year 8 Nutrition)4 pages
Record 67 (Telephone Interview for Cognitive Status, TICS)2 pages
Record 68 (Informant Questionnaire for Cognitive Decline, IQCODE)2 pages
Record 69 (Six-Minute Walk/Oximetry)3 pages
Record 71 (Spot Urine)1 page
Record 74 (Retinal Exam)4 pages
Record 79 (Audiometry)1 page
Record 80 (Trails A&B)1 page
Record 83 (Vibration/Tuning Fork)1 page

 

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