Other, specify: Date of most recent cardiac surgery (M M/D D/Y Y Y Y): Artificial valve: Yes Unknown No If YES, indicate type: Biological/ Tissue valve Valvuloplast Mechanical/ Non-tissue valve Unknown type of valve Coronary stent or PTCA: Yes Unknown No Congestive heart failure: Yes Unknown No Congenital heart disease: Yes Unknown No Cardiac catheritization: Yes Unknown No If YES, indicate recency: 2 weeks Unknown ≤ > 2 weeks ago Peripheral arterial disease: Yes Unknown No Hypertension: Yes Unknown No If YES, age hypertension first diagnosed (years): Diabetes mellitus: Yes Unknown (Skip to 37) No (Skip to 37) Age diabetes first diagnosed (years): Complications of diabetes (choose all that apply): Nephropathy Retinopathy Neuropathy Other, specify: None of the above Treatment for diabetes (choose all the apply): Diet Insulin Oral medication None of the above High blood cholesterol / Hypercholesterolemia: Yes Unknown No If YES, indicate treatment(s): (choose all the apply) Diet Statins
Other, specify: Date of most recent cardiac surgery (M M/D D/Y Y Y Y): Artificial valve: Yes No Unknown If YES, indicate type: Biological/ Tissue valve Mechanical/ Non-tissue valve Valvuloplast Unknown type of valve Coronary stent or PTCA: Yes No Unknown Congestive heart failure: Yes No Unknown Congenital heart disease: Yes No Unknown Cardiac catheritization: Yes No Unknown If YES, indicate recency: ≤ 2 weeks > 2 weeks ago Unknown Peripheral arterial disease: Yes No Unknown Hypertension: Yes No Unknown If YES, age hypertension first diagnosed (years): Diabetes mellitus: Yes No (Skip to 37) Unknown (Skip to 37) Age diabetes first diagnosed (years): Complications of diabetes (choose all that apply): Nephropathy Neuropathy Retinopathy Other, specify: None of the above Treatment for diabetes (choose all the apply): Diet Oral medication Insulin None of the above High blood cholesterol / Hypercholesterolemia: Yes No Unknown If YES, indicate treatment(s): (choose all the apply) Diet Statins
F1152_Medical_History.docx