| Basic demographics |
|---|
| 1. What is your biological sex? |
o Male
o Female
|
| 2. Where were you born (country)? |
o U.S.A.
o Mexico
o China
o India
o Philippines
o Other country |
| 3. What is your racial background? Check all that apply. |
o Black or African American
o White
o Asian (including South Asian and Asian Indian)
o Native Hawaiian or Pacific Islander
o American Indian or Alaska Native
o Some other race
o Don’t know
|
| 4. Are you of Hispanic, Latino or Spanish origin or ancestry? |
o No
o Yes, Mexican, Mexican American or Chicano
o Yes, Puerto Rican
o Yes, Cuban
o Yes, Other or Mixed Hispanic, Latino or Spanish origin
o Don’t know
|
| Medical history |
|---|
| 1. Hypertension |
o Yes
o No
o Don’t know
|
| 2. Diabetes? Do not include pre-diabetes. |
o Yes
o No
o Don’t know
|
| 3. Coronary artery disease (blockages in your heart vessels) or angina (chest pain)? |
o Yes
o No
o Don’t know
|
| 4. A heart attack? |
o Yes
o No
o Don’t know
|
| 5. Congestive Heart Failure (CHF, Heart Failure)? |
o Yes
o No
o Don’t know
|
| 6. Stroke or TIA (Transient Ischemic Attack or Mini-Stroke)? |
o Yes
o No
o Don’t know
|
| 7. Do you or have you ever had a congenital heart disease (a heart birth defect)? |
o Yes
o No
o Don’t know
|
| 8. Sleep apnea (obstructive sleep apnea, OSA)? |
o Yes
o No
o Don’t know
|
| 9.COPD (emphysema, chronic bronchitis, obstructive pulmonary disease)? |
o Yes
o No
o Don’t know
|
| 10. Asthma, to the point that you use inhalers daily or have been to the hospital for your asthma |
o Yes
o No
o Don’t know
|
| 11. A cardiac arrest? |
o Yes
o No
o Don’t know
|
| 12. Do you have an implanted device for your heart? If you have one, you were given a card which has this information on it. |
o No
o Pacemaker (not an ICD)
o ICD (Implantable Cardioverter-Defibrillator)
o Implanted Loop Recorder or rhythm monitor (e.g., Reveal, Confirm)
o Other
|
| Smoking history |
|---|
| 1. Have you ever smoked cigarettes regularly (at least 1 cigarette per day and a total of 100 cigarettes in your lifetime)? |
o Yes
o No
|
| 2. Do you smoke now? |
o Daily
o Some days
o No
|
| Alcohol history |
|---|
| 1. Did you drink any alcoholic beverages in the past year? |
o No
o Yes
o Don’t know
o I refuse to answer
|
| 2. Did you drink alcohol more than once or twice in the past? |
o No
o Yes
o Don’t know
o I refuse to answer
|
| 3. How many drinks of wine do you usually have per week? A drink is a 5-ounce glass. Round down. |
_____ drinks per week |
| 4. How many drinks of beer do you usually have per week? One beer is a 12-ounce glass, can, or bottle. Round down. |
_____ drinks per week |
| 5. How many drinks per week do you usually have of hard liquor? Count each shot, which is 1 ½ ounces, as one drink. Round down |
_____ drinks per week |
| 6. During the past 24 hours, how many drinks have you had? |
_____ drinks per week |
| 7. Approximately how many years ago did you stop drinking? Round do the nearest year except round ½ down; e.g., record 1 ½ as 1). |
_____ years |
| 8. What was the usual number of drinks you consumed per week before you stopped? Write in 00 if less than one drink per week. |
_____ drinks per week |
| Atrial fibrillation history |
|---|
| 1. Did you have any symptoms (such as palpitations, dizziness, shortness of breath, chest discomfort, difficulty exercising, or generalized ‘feeling bad’) when you were first diagnosed (or prior to)? |
o Yes
o No
o Don’t know
|
| 2. Are you in atrial fibrillation all the time? |
o Yes
o No. It comes and goes on its own
o No. It has stopped because of a shock to your heart or because of a medication
o Don’t know
|
| 3. Have you ever had a shock to your check or cardioversion? |
o Yes
o No
o Don’t know
|
| 4. Have you ever had an ablation for your atrial fibrillation? |
o Yes
o No
|
| 5. What symptoms do you have when you have atrial fibrillation? It’s OK if you only experience these symptoms sometimes. Check all that apply. |
o I never have symptoms
o Palpitations or irregular or “funny” heartbeats
o Shortness of breath of difficulty breathing
o Difficulty exercising or exerting
o Chest pain, pressure, or discomfort
o Dizziness
o Feeling generally tired
o Feeling generally “off” your normal self
o Other
o Don’t know
|
