Medical History



*Date Medical History Taken:Does the participant/subject have a history of any medical problems/conditions in the following body systems? FORMCHECKBOX Yes FORMCHECKBOX No (leave rest of form blank)Enter all significant medical history items, including surgeries, EXCEPT the problem/condition that is the focus of this study. Use only one line per description.*Use BODY SYSTEM categories for medical history table:Constitutional symptoms (e.g., fever, weight loss)EyesEars, Nose, Mouth, ThroatCardiovascular RespiratoryGastrointestinalGenitourinaryMusculoskeletalIntegumentary (skin and/or breast)NeurologicalPsychiatricEndocrineHematologic/LymphaticAllergic/Immunologic***Table of subject’s/participant’s medical history itemsBody SystemMedical History Term (one item per line)Start Date Ongoing?End Date Data to be entered by siteData to be entered by siteData to be entered by site FORMCHECKBOX Yes FORMCHECKBOX NoData to be entered by siteData to be entered by siteData to be entered by siteData to be entered by site FORMCHECKBOX Yes FORMCHECKBOX NoData to be entered by siteData to be entered by siteData to be entered by siteData to be entered by site FORMCHECKBOX Yes FORMCHECKBOX NoData to be entered by siteData to be entered by siteData to be entered by siteData to be entered by site FORMCHECKBOX Yes FORMCHECKBOX NoData to be entered by siteData to be entered by siteData to be entered by siteData to be entered by site FORMCHECKBOX Yes FORMCHECKBOX NoData to be entered by siteData to be entered by siteData to be entered by siteData to be entered by site FORMCHECKBOX Yes FORMCHECKBOX NoData to be entered by siteData to be entered by siteData to be entered by siteData to be entered by site FORMCHECKBOX Yes FORMCHECKBOX NoData to be entered by siteData to be entered by siteData to be entered by siteData to be entered by site FORMCHECKBOX Yes FORMCHECKBOX NoData to be entered by siteThe following interview questions can be used to help make sure a complete medical history is documented.Has a doctor or other medical professional ever told you that you have or have had the following?*Any stroke: FORMCHECKBOX Yes FORMCHECKBOX No (Skip to 2) FORMCHECKBOX Unknown (Skip to 2)Ischemic stroke: FORMCHECKBOX Yes FORMCHECKBOX No (Skip to 1B) FORMCHECKBOX Unknown (Skip to 1b)Number of ischemic strokes: FORMCHECKBOX None FORMCHECKBOX 1 FORMCHECKBOX ≥ 2 FORMCHECKBOX Unknown Recency of ischemic strokes: FORMCHECKBOX < 3 mos ago FORMCHECKBOX ≥ 3 mos ago FORMCHECKBOX Unknown Hemorrhagic stroke: FORMCHECKBOX Yes FORMCHECKBOX No (Skip to 2) FORMCHECKBOX Unknown (Skip to 2)If YES, indicate type(s): FORMCHECKBOX Intracerebral hemorrhage (ICH) FORMCHECKBOX Subarachnoid hemorrhage (SAH) FORMCHECKBOX Hemorrhage unspecified FORMCHECKBOX Unknown*Unruptured aneurysm: FORMCHECKBOX Yes FORMCHECKBOX No FORMCHECKBOX Unknown***Dural sinus thrombosis/cerebral venous thrombosis: FORMCHECKBOX Yes FORMCHECKBOX No FORMCHECKBOX Unknown**Transient ischemic attack (TIA): FORMCHECKBOX Yes FORMCHECKBOX No (Skip to 5) FORMCHECKBOX Unknown (Skip to 5)Number of TIAs: FORMCHECKBOX None FORMCHECKBOX 1 FORMCHECKBOX 2-10 FORMCHECKBOX >10 FORMCHECKBOX UnknownRecency of TIA: FORMCHECKBOX < 24h ago FORMCHECKBOX 24h - 7d ago FORMCHECKBOX 7d – 3 mos ago FORMCHECKBOX > 3 mos ago FORMCHECKBOX Unknown**Arteriovenous malformation (AVM): FORMCHECKBOX Yes FORMCHECKBOX No FORMCHECKBOX UnknownCavernous malformation: FORMCHECKBOX Yes FORMCHECKBOX No FORMCHECKBOX UnknownTransient monocular blindness: FORMCHECKBOX Yes FORMCHECKBOX No FORMCHECKBOX UnknownMigraine(s): FORMCHECKBOX Yes FORMCHECKBOX No FORMCHECKBOX UnknownIf YES, migraine(s) with aura: FORMCHECKBOX Yes FORMCHECKBOX No FORMCHECKBOX Unknown***Active migrane within last year? FORMCHECKBOX Yes FORMCHECKBOX Unknown FORMCHECKBOX No***Carotid stenosis: FORMCHECKBOX Yes FORMCHECKBOX No FORMCHECKBOX Unknown***Carotid endarterectomy: FORMCHECKBOX Yes FORMCHECKBOX No FORMCHECKBOX UnknownIf YES, indicate location: FORMCHECKBOX Left side FORMCHECKBOX Right side FORMCHECKBOX Both FORMCHECKBOX Unknown***Carotid artery stenting: FORMCHECKBOX Yes FORMCHECKBOX No FORMCHECKBOX UnknownIf YES, indicate location: FORMCHECKBOX Left side FORMCHECKBOX Right side FORMCHECKBOX Both FORMCHECKBOX UnknownHas a doctor or other medical professional ever told you that you have or have had the following?***Seizure episode: FORMCHECKBOX Yes FORMCHECKBOX No FORMCHECKBOX Unknown***Epilepsy/ Seizure disorder: FORMCHECKBOX Yes FORMCHECKBOX No FORMCHECKBOX Unknown***Central nervous system infection: FORMCHECKBOX Yes FORMCHECKBOX No FORMCHECKBOX Unknown***Meningitis FORMCHECKBOX Yes FORMCHECKBOX Unknown FORMCHECKBOX No***Dementia: FORMCHECKBOX Yes FORMCHECKBOX No FORMCHECKBOX Unknown***Current clinical depression: FORMCHECKBOX Yes FORMCHECKBOX No FORMCHECKBOX Unknown***Depressive disorder diagnosis: FORMCHECKBOX Yes FORMCHECKBOX No FORMCHECKBOX UnknownIf YES, age experienced first depressive episode/ diagnosed with depression (years):***Current clinical anxiety: FORMCHECKBOX Yes FORMCHECKBOX No FORMCHECKBOX Unknown***Anxiety disorder diagnosis: FORMCHECKBOX Yes FORMCHECKBOX No FORMCHECKBOX Unknown***Psychotic disorder: FORMCHECKBOX Yes FORMCHECKBOX No FORMCHECKBOX UnknownIf YES, indicate type(s):(choose all that apply) FORMCHECKBOX Schizophrenia FORMCHECKBOX Depression w/ psychotic features FORMCHECKBOX Bipolar disorder FORMCHECKBOX Dementia with psychotic ideation FORMCHECKBOX Other, specify:***Head trauma: FORMCHECKBOX Yes FORMCHECKBOX No FORMCHECKBOX UnknownIf YES, indicate if head trauma resulted in any of the following (choose all that apply): FORMCHECKBOX Loss of consciousness > 30 minutes FORMCHECKBOX Post traumatic amnesia > 24 hours FORMCHECKBOX Abnormal brain imaging findings FORMCHECKBOX None of the above***Neck trauma: FORMCHECKBOX Yes FORMCHECKBOX No FORMCHECKBOX Unknown If YES, indicate recency: FORMCHECKBOX < 8 days before current stroke/TIA FORMCHECKBOX 8 days- 4 weeks ago FORMCHECKBOX > 4 weeks ago FORMCHECKBOX Unknown***Atrial fibrillation (AF)/ flutter: FORMCHECKBOX Yes FORMCHECKBOX No (Skip to 27) FORMCHECKBOX Unknown (Skip to 27)***Other cause of AF: FORMCHECKBOX Yes FORMCHECKBOX No FORMCHECKBOX UnknownIf YES, specify other cause:***Rheumatic heart disease: FORMCHECKBOX Yes FORMCHECKBOX No FORMCHECKBOX Unknown***Coronary artery disease: FORMCHECKBOX Yes FORMCHECKBOX No FORMCHECKBOX UnknownHas a doctor or other medical professional ever told you that you have or have had the following?***Myocardial infarction: FORMCHECKBOX Yes FORMCHECKBOX No FORMCHECKBOX Unknown***Angina: FORMCHECKBOX Yes FORMCHECKBOX No FORMCHECKBOX Unknown***Valvular heart disease: FORMCHECKBOX Yes FORMCHECKBOX No FORMCHECKBOX Unknown***Cardiac surgery: FORMCHECKBOX Yes FORMCHECKBOX No (Skip to 33) FORMCHECKBOX Unknown (Skip to 29)Indicate type(s): FORMCHECKBOX Coronary artery bypass graft (CABG) FORMCHECKBOX Cardiac valve surgery, including non-open surgery (i.e., percutaneous valvuloplasty) FORMCHECKBOX Other, specify:Date of most recent cardiac surgery:Artificial valve: FORMCHECKBOX Yes FORMCHECKBOX No FORMCHECKBOX UnknownIf YES, indicate type: FORMCHECKBOX Biological/ Tissue valve FORMCHECKBOX Mechanical/ Non-tissue valve FORMCHECKBOX Valvuloplast FORMCHECKBOX Unknown type of valve***Coronary stent or PTCA: FORMCHECKBOX Yes FORMCHECKBOX No FORMCHECKBOX Unknown***Congestive heart failure: FORMCHECKBOX Yes FORMCHECKBOX No FORMCHECKBOX Unknown***Congenital heart disease: FORMCHECKBOX Yes FORMCHECKBOX No FORMCHECKBOX Unknown***Cardiac catheritization: FORMCHECKBOX Yes FORMCHECKBOX No FORMCHECKBOX UnknownIf YES, indicate recency: FORMCHECKBOX ≤ 2 weeks FORMCHECKBOX > 2 weeks ago FORMCHECKBOX Unknown***Peripheral arterial disease: FORMCHECKBOX Yes FORMCHECKBOX No FORMCHECKBOX Unknown**Aortic or thoracic aneurysm: FORMCHECKBOX Yes FORMCHECKBOX NoIf YES, specify type*Hypertension: FORMCHECKBOX Yes FORMCHECKBOX No FORMCHECKBOX UnknownIf YES, age hypertension first diagnosed (years): Average Blood Pressure(if checked before) FORMCHECKBOX <120/70 FORMCHECKBOX >140/<90 FORMCHECKBOX 120-140/70-90 FORMCHECKBOX >140/ 90 FORMCHECKBOX <140/>90***Past treatment for hypertension:Diabetes mellitus: FORMCHECKBOX Yes FORMCHECKBOX No (Skip to 43) FORMCHECKBOX Unknown (Skip to 37)Age diabetes first diagnosed (years):Complications of diabetes (choose all that apply): FORMCHECKBOX Nephropathy FORMCHECKBOX Neuropathy FORMCHECKBOX Retinopathy FORMCHECKBOX None of the above FORMCHECKBOX Other, specify:Treatment for diabetes (choose all that apply): FORMCHECKBOX Diet FORMCHECKBOX Oral medication FORMCHECKBOX Insulin FORMCHECKBOX None of the aboveHas a doctor or other medical professional ever told you that you have or have had the following?High blood cholesterol / Hypercholesterolemia: FORMCHECKBOX Yes FORMCHECKBOX No FORMCHECKBOX UnknownIf YES, indicate treatment(s): (choose all that apply) FORMCHECKBOX Diet FORMCHECKBOX Statins FORMCHECKBOX Other medicines FORMCHECKBOX None of the above***Hypertriglyceridemia: FORMCHECKBOX Yes FORMCHECKBOX No FORMCHECKBOX Unknown ***Cancer: FORMCHECKBOX Yes FORMCHECKBOX No (Skip to 46) FORMCHECKBOX Unknown (Skip to 46)Type(s) of cancer: FORMCHECKBOX Brain FORMCHECKBOX Breast FORMCHECKBOX Colorectal FORMCHECKBOX Endometrial FORMCHECKBOX Esophagus FORMCHECKBOX Lung FORMCHECKBOX Prostate FORMCHECKBOX Renal (kidney) FORMCHECKBOX Skin FORMCHECKBOX Other, specify:Did you receive head or neck radiation to treat the cancer? FORMCHECKBOX Yes FORMCHECKBOX No FORMCHECKBOX UnknownInfection within two weeks: FORMCHECKBOX Yes FORMCHECKBOX No FORMCHECKBOX UnknownIf YES, indicate type(s) (choose all that apply): FORMCHECKBOX Respiratory infection FORMCHECKBOX Urinary tract infection (UTI) FORMCHECKBOX Cellulitis FORMCHECKBOX Sepsis FORMCHECKBOX Otitis media FORMCHECKBOX Mastoiditis FORMCHECKBOX Viral gastroenteritis FORMCHECKBOX Fever lasting > 48 hours FORMCHECKBOX Other infection, specify:Dental disease: FORMCHECKBOX Yes FORMCHECKBOX Unknown FORMCHECKBOX NoIf YES, specify type:***Sickle cell anemia: FORMCHECKBOX Yes FORMCHECKBOX No FORMCHECKBOX UnknownIf YES, are blood transfusions used as treatment? FORMCHECKBOX Yes FORMCHECKBOX No FORMCHECKBOX Unknown***Hypercoagulable disorder: FORMCHECKBOX Yes FORMCHECKBOX No FORMCHECKBOX UnknownIf YES, specify type:Bleeding disorder: FORMCHECKBOX Yes FORMCHECKBOX No FORMCHECKBOX UnknownIf YES, specify type:***Lupus: FORMCHECKBOX Yes FORMCHECKBOX No FORMCHECKBOX Unknown***Other connective tissue disease: FORMCHECKBOX Yes FORMCHECKBOX No FORMCHECKBOX UnknownIf YES, specify type: ***Sleep apnea: FORMCHECKBOX Yes FORMCHECKBOX No FORMCHECKBOX UnknownIf YES, specify type:Has a doctor or other medical professional ever told you that you have or have had the following?Renal (kidney) failure: FORMCHECKBOX Yes FORMCHECKBOX No FORMCHECKBOX Unknown***Nephrotic syndrome: FORMCHECKBOX Yes FORMCHECKBOX No FORMCHECKBOX Unknown***Chronic liver failure: FORMCHECKBOX Yes FORMCHECKBOX No FORMCHECKBOX Unknown***Iron deficiency/ Anemia: FORMCHECKBOX Yes FORMCHECKBOX No FORMCHECKBOX Unknown***Inflammatory bowel disease: FORMCHECKBOX Yes FORMCHECKBOX No FORMCHECKBOX Unknown***Hemorrhoids: FORMCHECKBOX Yes FORMCHECKBOX Unknown FORMCHECKBOX No***Moyamoya disease (MMD): FORMCHECKBOX Yes FORMCHECKBOX No FORMCHECKBOX Unknown***Down syndrome: FORMCHECKBOX Yes FORMCHECKBOX No FORMCHECKBOX Unknown***Neurofibromatosis type I (NF1): FORMCHECKBOX Yes FORMCHECKBOX No FORMCHECKBOX Unknown***Sturge-Weber syndrome: FORMCHECKBOX Yes FORMCHECKBOX No FORMCHECKBOX Unknown ***Inborn error metabolism: FORMCHECKBOX Yes FORMCHECKBOX No FORMCHECKBOX Unknown ***Mitochondrial disease: FORMCHECKBOX Yes FORMCHECKBOX No FORMCHECKBOX Unknown If YES, do you have/ have you had Mitochondrial encephalomyopathy, lactic acidosis, and stroke-like episodes (MELAS)? FORMCHECKBOX Yes FORMCHECKBOX No FORMCHECKBOX Unknown***Hereditary hemorrhagic telangiectasia FORMCHECKBOX Yes FORMCHECKBOX Unknown FORMCHECKBOX NoEhlers-Danlos Syndrome Type IV FORMCHECKBOX Yes FORMCHECKBOX Unknown FORMCHECKBOX NoMarfan syndrome FORMCHECKBOX Yes FORMCHECKBOX Unknown FORMCHECKBOX No***Fibromuscular dysplasia FORMCHECKBOX Yes FORMCHECKBOX Unknown FORMCHECKBOX No***Coarctation of the aorta FORMCHECKBOX Yes FORMCHECKBOX Unknown FORMCHECKBOX No***Alpha1-antitrypsin deficiency FORMCHECKBOX Yes FORMCHECKBOX Unknown FORMCHECKBOX No***Pheochromocytoma FORMCHECKBOX Yes FORMCHECKBOX Unknown FORMCHECKBOX No***Menarche Age: ***Menopause Age:General InstructionsMedical history data are collected to help verify the inclusion and exclusion criteria (e.g., no history of cognitive disabilities), ensure the participant/ subject receives the appropriate care and describe the study population. Typically, the Medical History CRF captures conditions that EVER occurred at some point in time within a protocol-defined period (e.g., the last 12 months).Important note: The elements on this CRF are classified as supplemental (should only be collected if the research team considers them appropriate for their study), unless specified by asterisks as indicated below:*Element is classified as Core**Element is classified as Supplemental – Highly Recommended***Element is classified as ExploratorySpecific InstructionsPlease see the Data Dictionary for definitions for each of the data elements included in this CRF Module.Date Medical History Taken -- Record the date (and time) the medical history was taken. The date/time should be recorded to the level of granularity known (e.g., year, year and month, complete date plus hours and minutes, etc.) and in the format acceptable to the study database.Does this participant/subject have…? – Choose one. If this question is answered NO then the rest of the form is blank. If the question is answered YES then the medical history for at least one body system should be recorded.Body System – Record the appropriate body system for each line of medical history.Condition/Disease - Record one Medical History term per line. See the data dictionary for additional information on coding the condition using SNOMED CT.Start Date –Record the date the medical condition/disease started. The date/time should be recorded to the level of granularity known (e.g., year, year and month, complete date plus hours and minutes, etc.) and in the format acceptable to the study database.Ongoing? – Check Yes or No to indicate if the medical condition/disease is still present.End Date – If the condition is not ongoing, record the date (and time) the medical condition/disease stopped. The date/time should be recorded to the level of granularity known (e.g., year, year and month, complete date plus hours and minutes, etc.) and in the format acceptable to the study database. ................
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