Annual Followup Form

Please answer the following questions to the best of your ability by checking the box nearest your answer. Your responses will help us better understand the effects of the treatment we provide to patients. Your responses will be kept confidential and will not affect in any way the care you receive from Seton Medical Center in the future.

Please answer the following questions about your current health status

1. In general, would you say your health is:

2. The following are items about activities you might do during a typical day. Does your health now limit you in these activities? If so, how much?

                                                                                Yes,                Yes.                No, not
                                                                                Limited           Limited          Limited
                                                                                A lot               A Little           At All

     Moderate activities, such as moving
     a table, pushing a vacuum cleaner,
     bowling, or playing golf

3. During the past four weeks, have you had any of the following problems with your work or other regular daily activities as a result of your physical health?

Accomplished less than you would like

Were limited in the kind of work or other activities

4. During the past four weeks, have you had any of the following problems with your work or other regular daily activities as a result of any emotional problems (such as feeling depressed or anxious)?

Accomplished less than you would like

Didn't do work or other activities as carefully as usual

5. During the past four weeks, how much did pain interfere with your normal work
(including both work outside the home and housework)?

Not at all A little bit Moderately Quite a bit Extremely

6. During the past four weeks, how much did chest pain interfere with your normal
work and activities?

Not at all A little bit Moderately Quite a bit Extremely

7. How often did you have chest pain during the past four weeks?

Never Once or twice Every week Several times a week Every day

8.    During the past four weeks, how much of the time has your physical health or
       emotional problems interfered with your social activities (like visiting with
       friends, relatives, etc.)?

All of Most of A good part Some of A little of None of
the time the time of the time the time the time the time

9.	These questions are about how you feel and how things have been with you during the past 4 weeks. For each question, please give the one answer that comes closest to the way you have been feeling. How much of the time during past four weeks:

All of Most of A good part Some of A little of None of
the time the time of the time the time the time the time

      Have you felt
      calm and
      peaceful?

      Have you felt
      downhearted
      and blue?

10. What is your current employment status?

Employed full-time Unemployed Homemaker Other (please specify)
Employed Part-time Retired Medically Disabled

11. If you are currently employed, were you out of work due to medical reasons
during the past 12 months?

12. Since our last contact with you, have you had any of the following heart tests?

                     Yes         No                          Month / Year                     Yes      No    Unsure

   Treadmill                      If yes, date Was it normal?

Nuclear
Thallium If yes, date Was it normal?

Stress
Echo If yes, date Was it normal?

Catheterization
(angiogram) If yes, date Was it normal?

13. Since our last contact with you, have you been hospitalized for any reason?

Yes
No (skip to #14)

If yes, can you give the date of the hospitalization?

            Do you know if the reason for your hospitalization was:
                                               heart related
                                               not related to my heart

14. Have you had any other treatment procedures?

Month / Year
If yes, can you give the date of procedure:

Do you remember the type of procedure(s) you had:

cath lab treatment (balloon angioplasty, etc.) other heart procedure
open heart surgery other procedure not related to the heart

15. Have you had to increase the frequency or dose of any of your medications since
leaving the hospital?

If Yes, do you know if the increase was for your:

                                                   heart medications
                                                   medications for problems other than the heart
                                                   both

                                                   No, I have never smoked (skip to #17)
                                                   No, but I used to smoke (skip to #17)
                                                   Yes, I am currently smoking

If Yes, about how many cigarettes do you smoke each day?

less than one pack a day one and a half packs a day

one pack a day more than 2 packs a day

17. Are you following a low cholesteral or low fat diet?

18. What is your current weight without shoes? Weight (lbs)

19.   Since our last contact with you, has your doctor told you that you have developed
        any of the medical problems listed below? If so, mark the boxes below for any
        condition that applies.

heart failure lung disease diabetes asthma

ulcers cancer kidney problems hypertension

other conditions not listed above (please specify)

20. Complete this item and items 21 and 22 only if you were hospitalized at Seton Medical Center
during the last 12 months. At six weeks after discharge from the hospital following your last
treatment procedure, were you:

            at home taking care of yourself                  in some home healthcare facility not described above
            re-hospitalized in an inpatient facility          at home but receiving support from home healthcare
            in a skilled nursing facility                          not sure

21. If you were hospitalized at Seton Medical Center during the last 12 months, were you
satisfied with the care you received?

                                         Yes           No

                                         It has been over a year since I was hospitalized at Seton

22. Were you satisfied with care you have received from physicians and staff from
Seton Medical Center since you were last hospitalized here or since our last
contact with you?

                                       Yes            No

                                       I haven't received any care through Seton physicians
                                             since the last hospitalization or contact

23.   If you answered no to either question 21 or 22, would you be willing to give us
        your comments below?

24.   Are there any general comments you would like to make about the care you
        have received or this survey?

Please look over this form to make sure your entries are correct, then use the
buttons below to submit this form or to reset the form in order to reenter all data.

San Francisco Heart & Vascular Institute Annual Follow-up Survey for Cardiac Patients

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Please look over this form to make sure your entries are correct, then use the buttons below to submit this form or to reset the form in order to reenter all data.

Please look over this form to make sure your entries are correct, then use the
buttons below to submit this form or to reset the form in order to reenter all data.