| Watch 2 | |||||||||
| University of Massachusetts Medical School | |||||||||
| Division of Preventive & Behavioral Medicine | |||||||||
| Division of Cardiovascular Medicine | |||||||||
| Telephone Screening Interview | |||||||||
| Patient Information | |||||||||
| Patient Name: | MRN#: | ||||||||
| Work Phone: | Home Phone: | ||||||||
| Alternate Phone: | |||||||||
| Telephone Screening Interview | |||||||||
| Date: Contacted: | MD Appointment: | ||||||||
| Screening Questions | |||||||||
| Can you read, write and speak English? | O YES O No | ||||||||
| Are you at least 20 and not older than 75*? (on day of 1st visit)*not older than 75(criterion changed 4/23/00) | O YES O No | ||||||||
| Are you willing and able to come to the Shaw Building at UMass for 2 visits, one week apart? (if found eligible at 1st visit, otherwise only 1 visit is required) | O YES O No | ||||||||
| Are you willing to have blood tests? (1st Visit: 1 initial fingerstick to determine eligibility, and if eligible, a 2nd fingerstick and venous draw, 2nd Visit: 1 venous draw) | O YES O No | ||||||||
| Are you willing and able to FAST 12 HOURS for blood tests to be performed at the above visit(s)? | O YES O No | ||||||||
| Are you willing to be contacted by telephone periodically throughout the study? (Person must have a telephone at home) | O YES O No | ||||||||
| Are you willing to complete questionnaires periodically which may take up to one hour to complete? | O YES O No | ||||||||
| Have you been diagnosed with thyroid disease? (Eligible if currently on a stable dose of Synthroid or Levothroid for at least 6 months) | O YES O No | ||||||||
| Have you been on medication within the last 2 years specifically to reduce your cholesterol level? | O YES O No | ||||||||
| Have you been told that you have coronary heart disease? | O YES O No | ||||||||
| Have you ever had cancer? | O YES O No | ||||||||
| If yes, ask what type of cancer? | |||||||||
| (If it was skin cnacer (non-melanoma) they can participate. | |||||||||
| If the cancer was melanoma or a cancer other than skin cancer, it must have been in remission for 2 years or more in order to participate.) | |||||||||
| Have you been referred to a nutritionist within the past 2 years for cholesterol lowering diet? | O YES O No | ||||||||
| Do you plan to move out of the area within the study period? | O YES O No | ||||||||
| Do you plan to change physicians, other than a study physician? | O YES O No | ||||||||
| Do you have an illness or condition which would limit your ability to participate? | O YES O No | ||||||||
| Women: | |||||||||
| Are you on hormone replacement therapy or birth control (Eligible ONLY if on a stable dose for at least 6 months) | O YES O No | ||||||||
| Are you pregnant or have you nursed an infant within the last 3 months or plan to become pregnant in the next year? | O YES O No | ||||||||
| IS PATIENT ELIGIBLE? | |||||||||
| O YES O No | |||||||||
| IF YES, PLEASE SCHEDULE 1ST SCREENING APPOINTMENT! | |||||||||