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CHS Data Collection Forms

 

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

All Stars Data Collection Forms

Record Type & Form Name Number 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 32 (Years 16 Phone Follow up)
Adobe Acrobat (.pdf)
7 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