ANS testing eligibilityDec06

Persons using assistive technology may not be able to fully access information in this file. For assistance, e-mail [email protected] Include the Web site and filename in your message.
EDIC
EPIDEMIOLOGY OF
DIABETES INTERVENTIONS
AND COMPLICATIONS
December 8,, 2006
EDIC Form 55.3
Page 1 of 3
EPIDEMIOLOGY OF DIABETES INTERVENTIONS AND COMPLICATIONS
ANS Testing Eligibility
Complete this form prior to ANS testing.
If submitting studies electronically via FTP server, fax a copy of this form and form 59 to the Autonomic Reading Center
(ARC) at Mayo. If submitting studies via CD, send this form and form 59 along with the CD to the ARC. Send a copy of
this form to the Coordinating Center in your monthly mailing. Retain an electronic copy of the ANS study within the
clinic. Document all submissions to the ARC using form 59 OR via standard web-based tracking (when available). Make sure
to add Patient ID Number, EDIC Year, and Form Date to the top and bottom of page 2 and 3.
5. Any over-the-counter drugs since midnight
A. IDENTIFYING INFORMATION
__ __
1. Clinic Number:
2. Patient ID Number:
__ __ __ __ __
__ __ __
3. Patient's Initials:
4. Date Form Completed:
__ __/__ __ /__ __
Month
Day
Year
(aspirin, antihistamines, nasal spray,
No
etc)?
Yes
( 1)
( 2)
6. Any alcohol in the last 24 hours?
( 1)
( 2)
7. Any tobacco since midnight?
( 1)
( 2)
8. Any vigorous exercise in the last 24
hours? (Any exercise not part of patient’s
__ __
5. EDIC Follow-Up Year?
No
Yes
6. Is this subject a normal control?
( 1)
( 2)
7. Is this testing being performed
for ANS certification?
( 1)
( 2)
daily routine, i.e., routine jogging is O.K.,
but marathon running is not. NO exercise
morning of test.)
( 1)
( 2)
( 1)
( 2)
( 1)
( 2)
11. Any hypoglycemic episodes since midnight? ( 1)
( 2)
9. Any emotional upset in the last 24 hours?
(Depression, crying episodes, anxiety from
B. PREPAREDNESS FOR TESTING
personal trauma [death, divorce, car
accident, dentist, etc.])
If YES is answered to any of the questions below,
patient is ineligible for ANS testing today.
Reschedule the patient for testing another day and
discard this form.
No
1. Any food since midnight?
10. Acute illness in last 48 hours?
(cold, flu, measles, etc).
Yes
( 1)
( 2)
2. Any liquids (except water) since midnight? ( 1)
( 2)
3. Any caffeine since midnight?
( 1)
( 2)
( 1)
( 2)
4. Any medication since midnight
(excluding basal pump insulin)?
12. a) Fasting blood sugar value
(finger stick method is O.K.)
b) Below 50 or signs or symptoms of
hypoglycemia?
__ __ __ mg/dl
No
( 1)
Yes
( 2)
Patient ID _________
EDIC Year __ __
Date Form Completed __ __/__ __/__ __ __ __
C. PHYSICAL CONDITION
1.
Height
(cm)
__ __ __.__
2.
Weight
(kg)
__ __ __.__
3.
List any medications taken in the past 48 hours:
_______________________________________________
________________________________________________________
D.
BLOOD PRESSURES
1.
R-R (Subject is supine for all R-R blood pressures)
a.
b.
2.
Immediately prior to R-R
Immediately after R-R
i.
systolic
(mm Hg)
___ ___ ___
ii. diastolic (mm Hg)
___ ___ ___
i.
(mm Hg)
___ ___ ___
ii. diastolic (mm Hg)
___ ___ ___
systolic
3. Did postural hypotension occur(a drop of at least 10
mm Hg in diastolic blood pressure AND obvious signs and
symptoms)?
No ( 1) Yes( 2)
4.
E.
Instruct patient to stand
a.
i.
b.
c.
d.
e.
f.
1 minute
2 minute
3 minute
4 minute
5 minute
10 minute
systolic
(mm Hg)
___ ___ ___
ii. diastolic (mm Hg)
___ ___ ___
i.
(mm Hg)
___ ___ ___
ii. diastolic (mm Hg)
systolic
___ ___ ___
i.
(mm Hg)
___ ___ ___
ii. diastolic (mm Hg)
systolic
___ ___ ___
i.
(mm Hg)
___ ___ ___
ii. diastolic (mm Hg)
___ ___ ___
i.
(mm Hg)
___ ___ ___
ii. diastolic (mm Hg)
___ ___ ___
i.
(mm Hg)
___ ___ ___
ii. diastolic (mm Hg)
___ ___ ___
systolic
systolic
systolic
If yes, approximately how many minutes into the test
did the postural hypotension occur?
___ ___ minutes
TEST SUMMARY
1.
Was the R-R portion of the test completed?
No ( 1) Yes( 2)
If no, why not?
_____________________________________________________
_____________________________________________________
2.
Was the Postural Study completed?
No ( 1) Yes( 2)
If postural study not completed for ANY REASON OTHER
THAN POSTURAL HYPOTENSION, specify:
_____________________________________________________
_____________________________________________________
Postural Study (Subject is standing for all postural
study blood pressures)
0 minute
EDIC Form 055.3, Page 2 of 3
3.
Enter number of Valsalva studies attempted (enter “0”
if no Valsalva studies were attempted).
__________
4.
Enter number of Valsalva studies completed (enter “0”
if no Valsalva studies were completed).
__________
Patient ID _________
5.
EDIC Year __ __
Date Form Completed __ __/__ __/__ __ __ __
If the number listed in E4 is less than 2, select the
most appropriate reason from the list below(check
only 1):
c. Subject couldn’t adequately perform blowing
( 1)
e. Subject is undergoing or is scheduled
for LASER treatment
( 2)
f. Subject has a history of severe NPDR or worse
AND has not had an eye exam in the last 4
years
( 3)
Other (Specify):_________________________
( 4)
EDIC Form 055.3, Page 3 of 3
Include any additional comments related to test
performance on Page 3 and submit to the ANS reading
center.
Comments:
Check here if no comments
(1)
_________________________________________
_________________________________________
_________________________________________
_________________________________________
Comments Completer Certification number
Test Completer Certification number
__ __-__ __ __
__ __-__ __ __
Type or print name of person completing the comments:
Type or print name of person performing test:
____________________________________________________
___________________________________________________