Counseling African Americans To Control Hypertension (Caatch) Study Page 3

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Medical History / Co-morbidities:
16.
Diabetes
____Yes
_____No
______Not Noted
17.
Hypertension
____Yes
_____No
______Not Noted
18.
Heart Attack
____Yes
_____No
______Not Noted
Heart Failure – Hospitalization
19.
____Yes
_____No
______Not Noted
20.
Stroke
____Yes
_____No
______Not Noted
21.
Acute Cardiovascular Syndrome
____Yes
_____No
______Not Noted
22.
Kidney Failure
____Yes
_____No
______Not Noted
23.
Proteinuria
____Yes
_____No
______Not Noted
24.
Hyperlipidemia / Dyslipidemia
____Yes
_____No
______Not Noted
25.
Obesity
____Yes
_____No
______Not Noted
26.
Cholesterol/Lipid Disorder
____Yes
_____No
______Not Noted
27.
Impaired glucose tolerance /
Metabolic Syndrome
____Yes
_____No
______Not Noted
28.
Depression
____Yes
_____No
______Not Noted
29.
Cancer
____Yes
_____No
______Not Noted
30.
Smoker
____ Current Smoker
____Former Smoker _______ Never Smoked
____Not Noted ____/____/___ Date noted in chart
Most Recent Laboratory Tests: (Indicate dates of last test or circle NN for not noted)
Test Item
Date
Results
Test Item
Date
Results
Total Chol.
/
/
NN
FBS
/
/
NN
HDL
/
/
NN
RBS
/
/
NN
LDL
/
/
NN
Serum K+
/
/
NN
VLDL
/
/
NN
Serum Creat.
/
/
NN
Spot Protein /
Triglycerides
/
/
NN
Creatinine
/
/
NN
HbA1C
/
/
NN
24 hr. Microalb
/
/
NN
CRP
/
/
NN
EGFR
/
/
NN
Height
ft
in.
or
cm.
Weight
Lbs.
Last Laboratory Tests Prior to Study Enrollment: (Indicate dates of last test or circle NN for not noted)
Test Item
Date
Results
Test Item
Date
Results
Total Chol.
/
/
NN
FBS
/
/
NN
HDL
/
/
NN
RBS
/
/
NN
LDL
/
/
NN
Serum K+
/
/
NN
VLDL
/
/
NN
Serum Creat.
/
/
NN
Spot Protein /
Triglycerides
/
/
NN
Creatinine
/
/
NN
HbA1C
/
/
NN
24 hr. Microalb
/
/
NN
Height
ft
in
or
cm.
Weight
Lbs.
Study ID
Site #
Reviewer ID
G:CAATCHAssessmentsChart Review
3

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