Counseling African Americans To Control Hypertension (Caatch) Study

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Study ID:
CLINICAL DIRECTORS NETWORK, INC.
NYU SCHOOL of MEDICINE
Counseling African Americans To Control Hypertension (CAATCH) Study
RECORD REVIEW FORM
Review Date: (mm/dd/yy)
/
/
Time Start1:
Reviewer Code #
CHC Site and Code#
Chart #
Date Consented
/
/
Patient Demographics:
1.
DOB: (mm/dd/yy)
/
/
2.
Gender: ____Male ____Female
3.
Residence: County_____________ State_____
Zip Code________
4.
Race (check one only):
_____American Indian / Alaskan Native
_____Asian
_____Black
_____Native Hawaiian / Other Pacific Islander
_____White
_____Mixed
_____Other (Specify): _______________________________
_____Unknown / Not noted
5.
Ethnicity:
____African American
____Belizean
____Chinese
____Cuban
____Dominican
____Haitian
____Jamaican
____Japanese
____Mexican-American
____Middle Eastern
____Puerto Rican
____Trinidadian
____Vietnamese
____Other Central or S. American
____Other West Indian / Non-Latino Caribbean
____Other (Specify):_____________________________________
____Unknown / Not Noted
6.
Hispanic Origin ____Yes ____No
____Not Noted
7.
Place of Birth:
____ USA
____ Outside of USA, Country ______________________
____ Not Noted
8.
Marital Status (check one):
____Single
____Married
____Separated
____Divorced
____Member of an unmarried couple
____Widowed
____Not Noted
Study ID
Site #
Reviewer ID
G:CAATCHAssessmentsChart Review
1

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