Download Additional file 4

BASELINE AND FOLLOW-UP QUESTIONNAIRES
Baseline Interview
203.
ONSET OF SYMPTOMS
203.1 What acute physical discomfort were you having before you came to hospital? [Check all that apply]
□ Chest pain, pressure, tightness or other discomfort
□ Dizziness
□ Indigestion or stomach pain, pressure or other discomfort
□ Nausea
□ Pain or discomfort in neck, shoulder, arms or other discomfort
□ Palpitation
□ Shortness of breath
□ Sweating
□ Weakness or fatigue
□ Confusion
□ Other symptom, please specify: ________
□ None
□ Unknown
203.2
[if any acute symptoms] When did the acute symptoms happen: ________(YYYY/MM/DD HH:MM) or ___hours before the
admission ○ Unknown
203.3
[if any acute symptoms] When did you decide to go to hospital for help for the acute symptoms: ________(YYYY/MM/DD HH:MM)
or ___hours before the admission ○ Unknown
203.4
[if any acute symptoms] After the onset of symptoms, did you wait for a while before seeking medical care
○ Yes ○ No [go to C6] ○ Don’t Know [go to C6]
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203.5
[If C4 yes] What were the reason(s) that you decided to wait before seeking medical care?
[Check all that apply]
□ Didn’t have time to go to the doctor
□ Symptoms did not seem bad enough for emergency care
□ Symptoms would come and go over time (not persistent)
□ Transportation – waited for someone to drive me to office/hospital
□ A concerns about the cost
□ Embarrassment or fear
□ Others, please specify:
□ None
203.6
[if any acute symptoms] When you first started having these symptoms, did you think that something was wrong with your
heart?
○ Yes ○ No ○ Didn’t Know
203.7
[if any acute symptoms] After the symptom onset, did you take medicine before seeking medical care?
○ Yes ○ No [go to D1] ○ Don’t Know [go to D1]
203.8
[If C7 yes] which kinds of medicine you have taken before seeking medical care? [Check all that apply]
□ Aspirin
□ Nitrates
□ TCM with nitrate
□ TCM without nitrate
□ Statins
□ Others, please specify:
□ None
203.9 Have you ever been diagnosed as the following diseases? [Check all that apply]
□ CHD
□ Hypertension
□ Dyslipidemia
□ DM
□ Ischemic stroke
□ hemorrhagic stroke
□ Unclassified stroke
□ None
131 / 218
203.10 Before the administration, do you take the following medications routinely? [Check all that apply]
□ Aspirin
□ Statins
□ Beta blockers
□ ACEI or ARB
□ Nitrates
□ CCB
□ TCM
□ None
204.
CVD FUNCTIONAL STATUS (SAQ)
Please go over the activities listed below and indicate how much limitation you have had due to chest pain, chest tightness
or angina over the 4 weeks before the onset of the acute symptom this time?
Extremely
limited
Quite
a
bit
limited
Moderately
limited
Slightly limited
Not at all
limited
Limited for
other reasons
or did not do
activity
204.1 Dressing yourself
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204.2 Walking indoors on level ground
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204.3 Showering
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204.4 Climbing a hill or a flight of stairs
without stopping
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204.5 Gardening, vacuuming or carrying
groceries
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204.6 Walking more than a block at a
brisk pace
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204.7 Running or jogging
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204.8 Lifting or moving heavy objects
(e.g. furniture, children)
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Physical Activity
Refuse
to
answer
or
unknow
n
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204.9 Participating in strenuous sports
(e.g. swimming, tennis)
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204.10 Compared with 4 weeks ago, how often do you have chest pain, chest tightness or angina when doing your most strenuous activities?
○ Much more often ○ Slightly more often ○ About the same ○ Slightly less often ○ Much less often ○ None over the past 4 weeks
○ Refuse to answer or unknown
204.1 Over the past 4 weeks, on average, how many times have you had chest pain, chest tightness or angina?
○ ≥4 or more times per day
○ 1-3 times per day
○ 3-6 times per week
○ 1-2 times per week
○ Less than once a week
○ None over the past 4 weeks
○ Refuse to answer or unknown
204.12 Over the past 4 weeks, on average, how many times have you had to take nitroglycerin?
○ ≥4 or more times per day
○ 1-3 times per day
○ 3-6 times per week
○ 1-2 times per week
○ Less than once a week
○ None over the past 4 weeks
○ Refuse to answer or unknown
204.13 How bothersome is it for you to take pills for chest pain, chest tightness or angina as prescribed?
○ Extremely bothersome
○ Quite a bit bothersome
○ Moderately bothersome
○ Slightly bothersome
○ Not bothersome at all
○ My doctor has not prescribed pills
○ Refuse to answer or unknown
204.14 How satisfied are you that everything possible is being done to treat your chest pain, chest tightness or angina?
○Not satisfied at all
○ Mostly dissatisfied
○ Somewhat satisfied
○Mostly satisfied
○ Completely satisfied
○ Refuse to answer or unknown
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204.15 How satisfied are you with explanations your doctor has given about your chest pain, chest tightness or angina?
○Not satisfied at all
○ Mostly dissatisfied
○ Somewhat satisfied
○Mostly satisfied
○ Completely satisfied
○ Refuse to answer or unknown
204.16 Overall, how satisfied are you with the current treatment of your chest pain, chest tightness or angina?
○Not satisfied at all
○ Mostly dissatisfied
○ Somewhat satisfied
○Mostly satisfied
○ Completely satisfied
○ Refuse to answer or unknown
204.17 Over the past 4 weeks, how much has your chest pain, chest tightness or angina limited your enjoyment of life?
○ Extremely limited ○ Quite a bit limited ○ Moderately limited ○ Slightly limited ○ Not limited at all ○ Refuse to answer or
unknown
204.18 If you had to spend the rest of your life with your chest pain, chest tightness or angina the way it is before this admission, how would
you feel about this?
○ Not satisfied at all
○ Mostly dissatisfied
○ Somewhat satisfied
○ Mostly satisfied
○ Completely satisfied
○ Refuse to answer or unknown
204.19 How often do you think or worry that you may have a heart attack or die suddenly?
○ I can’t stop thinking or worrying about it
○ I often think or worry about it
○ I occasionally think or worry about it
○ I rarely think or worry about it
○ I never think or worry about it
○ Refuse to answer or unknown
205.
HEALTH-RELATED QUALITY OF LIFE (EQ-5D)
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The following questions ask about your health state before the onset of the acute symptom this time. In each of the
following categories, please indicate which statement best describes your own health state the week before the onset of the
acute symptom this time.
205.1 Mobility
○ I have no problems in walking about.
○ I have some problems in walking about.
○ I am confined to bed.
○ Refuse to answer or unknown
205.2 Self-care
○ I have no problems with self-care.
○ I have some problems washing or dressing myself.
○ I am unable to wash or dress myself.
○ Refuse to answer or unknown
205.3 Usual activities (e.g., work, study, housework, family or leisure activities)
○ I have no problems with performing my usual activities.
○ I have some problems with performing my usual activities.
○ I am unable to perform my usual activities.
○ Refuse to answer or unknown
205.4 Pain/discomfort
○ I have no pain or discomfort.
○ I have moderate pain or discomfort.
○ I have extreme pain or discomfort.
○ Refuse to answer or unknown
205.5 Anxiety/depression
○ I am not anxious or depressed.
○ I am moderately anxious or depressed.
○ I am extremely anxious or depressed.
○ Refuse to answer or unknown
205.6 Please score how good or bad your own health is the week before this admission. The best state you can imagine is 100 and the
worst health state you can imagine is 0. Overall, how would you score your own health today between 0 and 100?
Enter value between 0 and 100: _ _ _
○ Refuse to answer
206.
DEPRESSION
Over the last 2 weeks, how often have you been bothered by any of the following problems?
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Not
at all
Several
days
More than
half the
days
Nearly every day
Refuse to
answer or
unknown
206.1 Little interest or pleasure in doing things
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206.2 Feeling down, depressed or hopeless
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206.3 Trouble falling or staying asleep, or sleeping too much
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206.4 Feeling tired or having little energy
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206.5 Poor appetite or overeating
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206.6 Feeling bad about yourself, or that you are a failure or
have let yourself or your family down
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206.7 Trouble concentrating on things, such as reading the
newspaper or watching television
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206.8 Moving or speaking so slowly that other people could have
noticed. Or the opposite – being so fidgety or restless that
you have been moving around a lot more than usual
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207.
HEALTH CARE SERVICE
207.1 In the past 12 months before this admission, have you ever been to TCM clinics or seen TCM doctors for heart problem?
○ No [JUMP TO G4] ○ Yes ○ Unknown [JUMP TO G4] ○ Refuse to answer [JUMP TO G4]
207.2
[IF G1 “YES”] Which ones do you agree to? [Check all that apply]
□ The TCM doctors are easier to see
□ My family has always used TCM
□ Explanations from the TCM doctor are more satisfactory
□ The TCM approaches are more effective
□ The TCM approaches are safer
□ The TCM approaches are less expensive
□ I see TCM doctors just to recuperate
□ None above
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207.3
[IF G1 “YES”] In what way do you think TCM therapies could be helpful for your heart problem? [Check all that apply]
□ High blood pressure control, please specify the name of medication:
□ High blood cholesterol or lipid, please specify the name of medication:
□ High blood sugar, please specify the name of medication:
□ Chest pain, pressure, or tightness , please specify the name of medication:
□ Other diseases or disabilities
□ Not speci ic
□ Unknown
207.4 When you got similar symptoms before this admission, which clinics or doctors did you go to?
○ I had no similar symptoms before ○ TCM alone
○ Mostly TCM by times
○ TCM and western medicine equally by times ○ Mostly western medicine by times ○ Western medicine alone ○ Unknown ○
Refuse to answer
207.5 What types of medical insurance do you have? [Check all that apply]
□ Public health service
□ Medical insurance for urban workers/residents
□ Comprehensive arrangement for serious disease
□ Rural cooperative medical service
□ Other social medical insurance, please specify: ________
□ Commercial medical insurance
□ None
□ Unknown
207.6 Before this index admission, the total medical expense during the past year is approximately ____. ○ Unknown ○ Refuse to answer
207.7 Before this index admission, the medical expense paid out-of-pocket during the past year is approximately ______. ○ Unknown ○
Refuse to answer
207.8 In the past 12 month, have you ever borrowed money from others to pay for medical expense?
○ Yes ○ No ○ Unknown ○ Refuse to answer
207.9 In the past 12 month, have you ever avoided healthcare due to costs?
○ Yes ○ No ○ Unknown ○ Refuse to answer
207.10 What do you think of the burden of medical expense mentioned above?
○ Can not undertake ○ Almost undertake ○ Can undertake easily ○ Unknown ○ Refuse to answer
208.
SOCIOECONOMIC CHARACTER
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208.1 Your highest achieved education is:
○ Illiteracy/semi-illiteracy
○ Primary school
○ Junior high school
○ Senior high school (technical school or technical secondary school)
○ College (junior college)
○ Postgraduate
○ Unknown
○ Refuse to answer
208.2 Which of the following best describes your foreign language skills?
○ I can use more than one foreign languages
○ I can use one foreign language
○ I know a little about foreign language
○ I have learnt foreign language, but remember little now
○ I have never learnt foreign language
○ Unknown
○ Refuse to answer
208.3 Your current job status:
○ currently having a job ○ used to have a job ○ never have a job ○ Unknown ○ Refuse to answer
208.4
[If currently working or used to work] What is/was your primary occupation:
○ Farmer
○ Worker
○ Police/Administrative
○ Clerical
○ Medical related professional
○ Non-medical related professional
○ Business
○ Self-employed
○ Military
○ Others
○ Unknown
208.5
[If currently working] How often do you have to work during non-traditional working hours such as the evening or nights on
average?
○ 1 or more times/week ○ 1-3 times/month ○ Less than once/month ○ Never ○ Unknown ○ Refuse to answer
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208.6
[If not currently working or never work] What is the primary reason:
○ Unemployed/laid-off
○ Full-time homemaker
○ Retired
○ Unable to work
○ Prefer not to work
○ Others, please specify:
○ Unknown
○ Refuse to answer
208.7 Current marital status:
○ Married ○ Divorced /Separated ○ Widowed ○ Single ○ Unknown ○ Refuse to answer
208.8 Including you, there are currently _ _ people living together in your family (sharing the household income in the last year) ○ Refuse
to answer
208.9 Do you currently own a house or an apartment?
○ Yes ○ No ○ Unknown ○ Refuse to answer
208.10 Does your house have a private bathroom?
○ Yes ○ No ○ Unknown ○ Refuse to answer
208.1 Do you currently have a private telephone (phone or mobile)?
○ Yes ○ No ○ Unknown ○ Refuse to answer
208.12 Do you currently own a motor vehicle (tractor, motorcycle, electric vehicle, car)?
○ Yes ○ No ○ Unknown ○ Refuse to answer
208.13 During the past 5 years, have you ever had self-paid travel(s)?
○ Yes ○ No ○ Unknown ○ Refuse to answer
208.14 What was your total household income in the last year?
○ < ¥10000 ○ ¥10000 - 29999 ○¥ 30000 - 49999 ○ ¥50000 - 69999 ○ ¥70000 - 99999 ○≥ ¥100000 ○ Unknown ○ Refuse to
answer
208.15 Have you sent text messages using a cell phone?
○ Yes ○ No ○ Unknown ○ Refuse to answer
208.16 Do you browse the web?
○ Yes ○ No ○ Unknown ○ Refuse to answer
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208.17 What’s your primary way to gain health-related knowledge?
○ TV
○ Internet
○ Broadcast
○ Newspapers or magazines
○ Books or pamphlets
○ Posters
○ Lectures or lessons
○ Talking with others
○ None or unknown
○ Refuse to answer
208.18 Who’s your primary source of health-related knowledge?
○ Health professionals ○ Families ○ Friends ○ Others ○ Unknown ○ Refuse to answer
209.
RISK FACTORS
209.1 In your father and brothers, did anyone have a heart attack, balloon angioplasty, stent or heart bypass surgery before his 55?
○ Yes ○ No ○ Unknown ○ Refuse to answer
209.2 In your mother and sisters, did anyone have a heart attack, balloon angioplasty, stent or heart bypass surgery before her 65?
○ Yes ○ No ○ Unknown ○ Refuse to answer
209.3 Which of the following best describes your current cigarette smoking status?
○ Never smoked [go to I6]
○ I stopped smoking more than 1 year ago [go to I6]
○ I stopped smoking between 1 month and 1 year ago [go to I6]
○ Smoked in the past 30 days
○ Unknown [go to I6]
○ Refuse to answer [go to I6]
209.4
[If smoked in the past 30 days or stopped smoking more than 1 month ago] On average you smoke _ _ cigarettes per day in
the last month. ○ Unknown ○ Refuse to answer
209.5
[If smoked in the past 30 days or stopped smoking more than 1 month ago] How old were you when you began smoking
regularly? _ _ ○ Unknown ○ Refuse to answer
209.6 _ _ _ hours per week are you exposed to others’ tobacco smoke on average in the past month. ○ Unknown ○ Refuse to answer
209.7 How many hours per week do you spend doing your regular job before the hospitalization? __._ hours / week [“0” if do not work] ○
Unknown ○ Refuse to answer
140 / 218
209.8 How active are you at work before the hospitalization (including volunteer work and housework)?
○ Mainly sedentary / Mostly sitting / Desk job
○ Walking on one level, no heavy lifting
○ Mainly walking, including climbing stairs, or walking uphill or lifting heavy objects
○ Heavy physical labor
○ Do not work
○ Unknown
○ Refuse to answer
209.9 How many minutes per day do you spend commuting to work? _ _ _ minutes / day [“0” if do not work] ○ Unknown ○ Refuse to
answer
209.10 What mode of transportation to work do you usually use?
○ Walking ○ Bicycling ○ Bus/subway ○ Motorcycle ○ Taxi ○ Private car ○ Do not work ○ Unknown ○ Refuse to answer
209.1 How many hours per week do you spend doing home activities before the hospitalization? __._ hours / week ○ Unknown ○ Refuse
to answer
209.12 During the past 30 days, other than your regular job, commuting to work and home activities, did you participate in any physical
activities or exercise such as running, calisthenics, Tai Chi, bicycling, table tennis, or walking for exercise?
○ Yes ○ No [go to I16] ○ Unknown [go to I16] ○ Refuse to answer [go to I16]
209.13
[If I25 Yes] How much total time per week do you spend doing physical exercise? _ _._ hours / week ○ Unknown ○ Refuse to
answer
209.14
[If I25 Yes] How many days per week do you do physical exercise for at least 30 minutes? _ days / week
to answer
209.15
[If I25 Yes] What type of exercise did you usually participate, other than your job and commuting to work? [Check all that apply]
□ Brisk walking or jogging
□ Cycling
□ Dancing or calisthenics
□ Swimming
□ Tai Chi
□ Climbing hills or stairs
□ Ball games
□ Others
□ None
○ Unknown ○ Refuse
209.16 During the past 1 year, How often do you have a drink containing alcohol?
○ Never [go to I26] ○ Monthly or less ○ 2 to 4 times a month ○ 2 to 3 times a week ○ 4 or more times a week ○ Unknown
1 DRINK is 17ml pure alcohol, which equals to 120ml wine, or 360ml beer (half a bottle or 1 tin), or 45ml liquor (1 LIANG)
141 / 218
209.17
How many drinks containing alcohol do you have on a typical day when you are drinking?
○ 1 or 2 ○ 3 or 4 ○ 5 or 6 ○ 7, 8, or 9 ○ 10 or more ○ Unknown ○ Refuse to answer
209.18
How often do you have six or more drinks on one occasion?
○ Never ○ Less than monthly ○ Monthly ○ Weekly ○ Daily or almost daily ○ Unknown ○ Refuse to answer
Questions I24 if I17 “1 or 2” AND I18 “Never”]
[Skip to
How often during the last year have you found
Never
Less
than
monthly
Monthly
Weekly
Daily or
almost daily
Refuse to
answer or
unknown
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209.19
not able to stop drinking once you had started?
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209.20
failed to do what was normally expected from you
because of drinking?
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209.2
Needed a first drink in the morning to get yourself going
after a heavy drinking session?
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209.22
had a feeling of guilt or remorse after drinking?
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209.23
unable to remember what happened the night before
because of your drinking?
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209.24 Have you or someone else been injured as a result of your drinking?
○ No ○ Yes, but not in the last year ○ Yes, during the last year ○ Unknown ○ Refuse to answer
209.25 Has a relative or friend or a doctor or another health worker been concerned about your drinking or suggested you cut down?
○ No ○ Yes, but not in the last year ○ Yes, during the last year ○ Unknown ○ Refuse to answer
209.26 Did you believe that the following factors could make you more likely to suffer from CHD for now? [Check all that apply]
□ Smoking
□ High blood pressure
□ High blood lipid
□ High blood glucose
□ Physical inactivity
□ Heavily drink
□ Overweight
□ None above
209.27 Had a doctor or other health professional told you that the following factors could make you more likely to suffer from CHD for now
since the index hospitalization? [Check all that apply]
□ Smoking
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High blood pressure
High blood lipid
High blood glucose
Physical inactivity
Heavily drink
Overweight
None above
210. OBSTRUCTIVE SLEEP APNEA SYNDROME (MBQ)
210.1 Do you snore?
○ Yes ○ No [go to J5] ○ Don’t know [go to J5] ○ Refuse to answer
210.2
[If Yes] Your snoring is?
○ Slightly louder than breathing
○ As loud as talking
○ Louder than talking
○ Very loud can be heard in adjacent rooms
○ Refuse to answer or unknown
210.3
[If Yes] How often do you snore?
○ Nearly never
○ 1-2 times per month
○ 1-2 times per week
○ 3-4 times per week
○ Nearly every day
○ Refuse to answer or unknown
210.4
[If Yes] Has your snoring ever bothered other people?
○ Yes ○ No ○ Refuse to answer or unknown
Neve
r
Nearly
never
1-2
times /
month
1-2 times
/ week
3-4
times /
week
Nearly
every day
210.5 Has anyone noticed that you quit breathing
during your sleep?
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210.6 Do you choke while you are sleeping?
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210.7 How often do you feel tired or fatigued after
your sleep?
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Refuse to
answer or
unknown
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210.8 During your wake time do you feel tired,
fatigued or not up to at par?
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210.9 Have you ever fallen asleep while waiting in a
line to meet your doctor?
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210.10 Have you ever fallen asleep while watching
television at your home during daytime?
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210.1 Have you ever fallen asleep while waiting in a
line to pay your electricity and telephone bills?
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210.12 How many hours do you typically sleep each night?
○ Less than 4 ○ 4-5 ○ 6-7 ○ 8-9 ○ 10-11 ○ >=12 ○ Don’t know
211.
STRESS
The questions in this scale ask about your thoughts and feelings during the last month. In each case, you will be asked to
indicate how often you felt or thought a certain way. Although some of the questions are similar, there are differences
between them and you should treat each one as a separate question. The best approach is to answer each question fairly
quickly. That is, don’t try to count up the number of times you felt a particular way, but rather indicate the alternative that
seems most reasonable. For each question choose the following alternatives: never, almost never, sometimes, fairly often,
and very often.
Never
Almost never
Someti
mes
Fairly
often
Very
often
Refuse to
answer or
unknown
211.1 In the last month, how often have you felt that you were
unable to control the important things in your life?
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211.2 In the last month, how often have you felt confident in your
ability to handle your personal problems?
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211.3 In the last month, how often have you felt that things were
going your way?
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211.4 In the last month, how often have you felt difficulties were
piling up so high that you could not overcome them?
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212.
SOCIAL SUPPORT
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The following questions ask about other people who provide you with assistance and support.
None
of
the
time
A little
of the
time
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212.2 Is there someone available to you to give you
good advice about a problem?
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212.3 Is there someone available to you who shows
you love and affection?
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212.4 Is there someone available to you to help you
with daily chores?
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212.5 Can you count on anyone to provide you with
emotional support (talking over problems or
helping make difficult decisions)?
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212.6 Do you have as much contact as you would like
with someone you feel close to, someone in
whom you can trust and confide?
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212.1 Is there someone available to you whom you can
count on to listen to you when you need to talk?
213.
Some
time
of
the
Most
of
the time
All of the time
Refuse to
answer or
unknown
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COGNITION FUNCTION
Now I’d like to ask you some questions to check your memory. Don’t worry if you don’t know the answers.
213.1 What year is it?
○ Correct ○ Incorrect ○ Refuse to answer
213.2 What season is it?
○ Correct ○ Incorrect ○ Refuse to answer
213.3 What month is it?
○ Correct ○ Incorrect ○ Refuse to answer
213.4 What is the date today?
○ Correct ○ Incorrect ○ Refuse to answer
213.5 What day is it today?
○ Correct ○ Incorrect ○ Refuse to answer
145 / 218
213.6 Which state/country are we in?
○ Correct ○ Incorrect ○ Refuse to answer
213.7 Which city are we in?
○ Correct ○ Incorrect ○ Refuse to answer
213.8 What location are we in?
○ Correct ○ Incorrect ○ Refuse to answer
213.9 Which hospital are we in?
○ Correct ○ Incorrect ○ Refuse to answer
213.10 Which floor are we in?
○ Correct ○ Incorrect ○ Refuse to answer
213.1 Now I am going to name three objects, and please repeat them after I have said them: watch, pen, glasses
○ Correct ○ 1 error ○ 2 errors ○ All wrong ○ Refuse to answer
213.12 Please calculate 100 minus 7, and then continuous minus 7 for 5 times, the answers are? [The answers are 93, 86, 79, 72, 65 in
order]
○ Correct ○ 1 error ○ 2 errors ○ 3 errors ○ 4 errors ○ All wrong ○ Refuse to answer
213.13 Repeat the names of the three mentioned objects.
○ Correct ○ 1 error ○ 2 errors ○ All wrong ○ Refuse to answer
213.14 [Present a pen and a watch to the patient, and ask him / her what they are]
○ Correct ○ 1 error ○ All wrong ○ Refuse to answer
213.15 Now I am going to say three words, and please repeat them clearly. They are “if, and, but”.
○ Correct ○ Incorrect ○ Refuse to answer
213.16 [Give the patient a card written with “close your eyes” ] Please read the sentence on the card.
○ Correct ○ Incorrect ○ Refuse to answer
213.17 [Present the design to the patient] Please copy the design.
○ Correct ○ Incorrect ○ Refuse to answer
[Provide the patient with a blank paper, and ask him / her to follow a 3-stage command]
213.18 Please take a paper in your right hand
○ Correct ○ Incorrect ○ Refuse to answer
213.19 Please fold it in half
○ Correct ○ Incorrect ○ Refuse to answer
146 / 218
213.20 Please put it on your left leg.
○ Correct ○ Incorrect ○ Refuse to answer
213.2 Please write a complete sentence.
○ Correct ○ Incorrect ○ Refuse to answer
214.
SEXUAL ACTIVITY
Sometimes people who experience heart attacks or heart problems have concerns about how this might affect their sexual
lives. To round out our understanding of your experience, we would like to ask a few questions about your sexual life. By
“sex” or “sexual activity”, we mean any mutually voluntary activity with another person that involves sexual contact,
whether or not intercourse or orgasm occurs.
214.1 For some people, sex is a very important part of their lives and for others it is not very important at all. How important a part of your
life would you say that sex is?
○ Extremely Important
○ Very Important
○ Moderately Important
○ Somewhat Important
○ Not at all Important
○ Don’t Know
○ Refuse to answer
214.2 Did you have sex or sexual activity at any time in the 12 months prior to the hospitalization for your heart attack or heart problem?
○ Yes ○ No [go to the end] ○ Don’t Know [go to the end] ○ Refuse to answer [go to the end]
214.3
[If Yes] About how often did you have sex with a partner?
○ Once a day or more
○ 3-6 times a week
○ Once or twice a week
○ 2-3 times a month
○ Once a month or less
○ Don’t Know
○ Refuse to answer
X.
PHYSICAL MEASUREMENTS
X.1
Height: ___ cm ○ Unmeasured
X.2
Weight: ___ kg ○ Unmeasured
147 / 218
X.3
Waistline: ___ cm ○ Unmeasured
1 Month Follow-up Interview
A.
BASIC INFORMATION
A.1
Type of follow-up:
○ Face-to-face interview
○ Telephone interview [go to A4]
A.2
Was bio-sample collected?
○ No ○ Yes
A.3
ID of bio-sample: ________ [go to B1]
A.4
Did the participant answered the telephone interview by him/herself?
○ Yes ○ No, who: ___ [go to C1]
B.
FOLLOW-UP MEASUREMENTS
B.1
Weight: ___ kg ○ Unmeasured
B.2
Waistline: ___ cm ○ Unmeasured
B.3
Blood pressure 1st: ___/___mmHg
B.4
Blood pressure 2nd: ___/___mmHg
B.5
[if difference between 1st and 2nd >5mmHg] Blood pressure 3rd: ___/___mmHg ()
B.6
ID of bio-sample: ________
C.
OUTCOMES
Admission note 1
C.1
Date of hospitalization：_ _ /_ _/ _ _ _ _ ○ Unknown
C.2
Name of the hospital: ________________________
C.3
Admission status:
148 / 218
○ Emergency ○ Scheduled ○ Unknown
C.4
Main reason for hospitalization：
○ MI ○ Unstable angina pectoris ○ Stable angina pectoris ○ Valve dysfunction
○ Arrhythmia ○ Heart failure ○ New ischemic stroke ○ New hemorrhagic stroke
○ Transient ischemic attack ○ Diabetes ○ Kidney disease
○ Cardiac surgery related infections ○ Pericardial effusion or tamponade
○ Pulmonary embolism ○ Bleeding except hemorrhagic stroke ○ Others ○ Unknown
C.5
Therapies in hospitalization duration [Check all that apply]：
□ PCI □ CABG □ Thrombolysis □ Coronary angiography
□ Stroke thrombolysis □ Valve surgery □ LV assist device
□ Pacemaker or de ibrillator implantation □ Pulmonary embolism thrombolysis □ Dialysis
□ Cardiopulmonary resuscitation □ None above
C.6
Supportive documents were collected:
□ Face sheet
□ Discharge summary
□ CAG report
□ CAG imagine
□ CABG report
□ PCI report
□ CT report
□ MRI report
□ None above
Admission note 2
C.7
Date of hospitalization：_ _ /_ _/ _ _ _ _ ○ Unknown
C.8
Name of the hospital: ________________________
C.9
Admission status:
○ Emergency ○ Scheduled ○ Unknown
C.10 Main reason for hospitalization：
○ MI ○ Unstable angina pectoris ○ Stable angina pectoris ○ Valve dysfunction
○ Arrhythmia ○ Heart failure ○ New ischemic stroke ○ New hemorrhagic stroke
○ Transient ischemic attack ○ Diabetes ○ Kidney disease
○ Cardiac surgery related infections ○ Pericardial effusion or tamponade
○ Pulmonary embolism ○ Bleeding except hemorrhagic stroke ○ Others ○ Unknown
149 / 218
C.11 Therapies in hospitalization duration [Check all that apply]：
□ PCI □ CABG □ Thrombolysis □ Coronary angiography
□ Stroke thrombolysis □ Valve surgery □ LV assist device
□ Pacemaker or de ibrillator implantation □ Pulmonary embolism thrombolysis □ Dialysis
□ Cardiopulmonary resuscitation □ None above
C.12 Supportive documents were collected:
□ Face sheet
□ Discharge summary
□ CAG report
□ CAG imagine
□ CABG report
□ PCI report
□ CT report
□ MRI report
□ None above
D.
ADHERENCE
D.1
In the past month, how often did you forget to take one or more of your prescribed medications?
○ No prescribed medication [JUMP TO E1] ○ Never
○ Once
○ 2-3 times
○ Once per week
○ 2-5 times per week
○ Every day or nearly every day
○ Unknown
○ Refuse to answer
D.2
In the past month, how often did you miss a dose of ASPIRIN?
○ No prescribed this medication [JUMP TO D4] ○ Never [JUMP TO D4] ○ Once
○ 2-3 times
○ Once per week
○ 2-5 times per week
○ Everyday or nearly everyday
○ Unknown [JUMP TO D4] ○ Refuse to answer [JUMP TO D4]
D.3
[If you have ever missed a dose of ASPIRIN] The main reason is…
○ I Forgot to take it unintentionally
○ Doctors told me to stop taking it
○ I began feeling better, believed it was unnecessary to take it everyday
○ The drug seemed ineffective
○ I was worried about adverse reaction
○ I couldn’t afford it
○ I couldn’t access it easily
○ Others, please specify：
○ Unknown
○ Refuse to answer
150 / 218
D.4
D.5
In the past month, how often did you decide to skip CLOPIDOGREL?
○ No prescribed this medication [JUMP TO D6] ○ Never [JUMP TO D6] ○ Once
○ 2-3 times
○ Once per week
○ 2-5 times per week
○ Everyday or nearly everyday
○ Unknown [JUMP TO D6] ○ Refuse to answer [JUMP TO D6]
[If you have ever missed a dose of CLOPIDOGREL] The main reason is…
○ I Forgot to take it unintentionally
○ Doctors told me to stop taking it
○ I began feeling better, believed it was unnecessary to take it everyday
○ The drug seemed ineffective
○ I was worried about adverse reaction
○ I couldn’t afford it
○ I couldn’t access it easily
○ Others, please specify：
○ Unknown
○ Refuse to answer
D.6
In the past month, how often did you decide to skip STATINs?
○ No prescribed this medication [JUMP TO D9] ○ Never [JUMP TO D9] ○ Once
○ 2-3 times
○ Once per week
○ 2-5 times per week
○ Everyday or nearly everyday
○ Unknown [JUMP TO D9] ○ Refuse to answer [JUMP TO D9]
D.7
The drug name and dosage: ______
D.8
[If you have ever missed a dose of STATINs] The main reason is…
○ I Forgot to take it unintentionally
○ Doctors told me to stop taking it
○ I began feeling better, believed it was unnecessary to take it everyday
○ The drug seemed ineffective
○ I was worried about adverse reaction
○ I couldn’t afford it
○ I couldn’t access it easily
○ Others, please specify：
○ Unknown
○ Refuse to answer
D.9
In the past month, how often did you decide to skip BETA-BLOCKERs?
○ No prescribed this medication [JUMP TO D12] ○ Never [JUMP TO D12] ○ Once
○ 2-3 times
○ Once per week
○ 2-5 times per week
○ Everyday or nearly everyday
○ Unknown [JUMP TO D12] ○ Refuse to answer [JUMP TO D12]
D.10
The drug name and dosage: ______
151 / 218
D.11
[If you have ever missed a dose of BETA-BLOCKERs] The main reason is…
○ I Forgot to take it unintentionally
○ Doctors told me to stop taking it
○ I began feeling better, believed it was unnecessary to take it everyday
○ The drug seemed ineffective
○ I was worried about adverse reaction
○ I couldn’t afford it
○ I couldn’t access it easily
○ Others, please specify：
○ Unknown
○ Refuse to answer
D.12
In the past month, how often did you decide to skip ACEI/ARBs?
○ No prescribed this medication [JUMP TO E1] ○ Never [JUMP TO E1] ○ Once
○ 2-3 times
○ Once per week
○ 2-5 times per week
○ Everyday or nearly everyday
○ Unknown [JUMP TO E1] ○ Refuse to answer [JUMP TO E1]
D.13
The drug name and dosage: ______
D.14
E.
[If you have ever missed a dose of ACEI/ARBs] The main reason is…
○ I Forgot to take it unintentionally
○ Doctors told me to stop taking it
○ I began feeling better, believed it was unnecessary to take it everyday
○ The drug seemed ineffective
○ I was worried about adverse reaction
○ I couldn’t afford it
○ I couldn’t access it easily
○ Others, please specify：
○ Unknown
○ Refuse to answer
CVD FUNCTIONAL STATUS (SAQ)
Please go over the activities listed below and indicate how much limitation you have had due to chest pain ,chest
tightness or angina over the past 4 weeks?
Physical Activity
Extremel
y limited
Quite a bit
limited
Moderately
limited
Slight
ly
limit
ed
Not at all
limited
Limited for other
reasons or did
not do activity
Refuse
answer
unknown
to
or
152 / 218
E.1
Dressing yourself
○
○
○
○
○
○
○
E.2
Walking indoors on level
ground
○
○
○
○
○
○
○
E.3
Showering
○
○
○
○
○
○
○
E.4
Climbing a hill or a flight of
stairs without stopping
○
○
○
○
○
○
○
E.5
Gardening, vacuuming
carrying groceries
or
○
○
○
○
○
○
○
E.6
Walking more than a block
at a brisk pace
○
○
○
○
○
○
○
E.7
Running or jogging
○
○
○
○
○
○
○
E.8
Lifting or moving heavy
objects
(e.g.
furniture,
children)
○
○
○
○
○
○
○
E.9
Participating in strenuous
sports
(e.g.
swimming,
tennis)
○
○
○
○
○
○
○
E.10
Compared with 4 weeks ago, how often do you have chest pain, chest tightness or angina when doing your most strenuous
activities?
○ Much more often ○ Slightly more often ○ About the same ○ Slightly less often ○ Much less often ○ None over the past 4
weeks ○ Refuse to answer or unknown
E.11
Over the past 4 weeks, on average, how many times have you had chest pain, chest tightness or angina?
○ ≥4 or more times per day
○ 1-3 times per day
○ 3-6 times per week
○ 1-2 times per week
○ Less than once a week
○ None over the past 4 weeks
○ Refuse to answer or unknown
E.12
Over the past 4 weeks, on average, how many times have you had to take nitroglycerin?
○ ≥4 or more times per day
○ 1-3 times per day
153 / 218
○ 3-6 times per week
○ 1-2 times per week
○ Less than once a week
○ None over the past 4 weeks
○ Refuse to answer or unknown
E.13
How bothersome is it for you to take pills for chest pain, chest tightness or angina as prescribed?
○ Extremely bothersome
○ Quite a bit bothersome
○ Moderately bothersome
○ Slightly bothersome
○ Not bothersome at all
○ My doctor has not prescribed pills
○ Refuse to answer or unknown
E.14
How satisfied are you that everything possible is being done to treat your chest pain, chest tightness or angina?
○Not satisfied at all
○ Mostly dissatisfied
○ Somewhat satis ied
○Mostly satis ied
○ Completely satis ied
○ Refuse to answer or unknown
E.15
How satisfied are you with explanations your doctor has given about your chest pain, chest tightness or angina?
○Not satisfied at all
○ Mostly dissatis ied
○ Somewhat satis ied
○Mostly satis ied
○ Completely satis ied
○ Refuse to answer or unknown
E.16
Overall, how satisfied are you with the current treatment of your chest pain, chest tightness or angina?
○Not satisfied at all
○ Mostly dissatis ied
○ Somewhat satis ied
○Mostly satis ied
○ Completely satis ied
○ Refuse to answer or unknown
E.17
Over the past 4 weeks, how much has your chest pain, chest tightness or angina limited your enjoyment of life?
○ Extremely limited ○ Quite a bit limited ○ Moderately limited ○ Slightly limited ○ Not limited at all ○ Refuse to answer or
unknown
154 / 218
E.18
If you had to spend the rest of your life with your chest pain, chest tightness or angina the way it is right now, how would you feel
about this?
○ Not satis ied at all
○ Mostly dissatis ied
○ Somewhat satis ied
○ Mostly satis ied
○ Completely satis ied
○ Refuse to answer or unknown
E.19
How often do you think or worry that you may have a heart attack or die suddenly?
○ I can’t stop thinking or worrying about it
○ I often think or worry about it
○ I occasionally think or worry about it
○ I rarely think or worry about it
○ I never think or worry about it
○ Refuse to answer or unknown
F.
HEALTH-RELATED QUALITY OF LIFE (EQ-5D)
The following questions ask about your current health state. In each of the following categories, please indicate which statement
best describes your own health state today.
F.1
Mobility
○ I have no problems in walking about.
○ I have some problems in walking about.
○ I am confined to bed.
○ Refuse to answer or unknown
F.2
Self-care
○ I have no problems with self-care.
○ I have some problems washing or dressing myself.
○ I am unable to wash or dress myself.
○ Refuse to answer or unknown
F.3
Usual activities (e.g., work, study, housework, family or leisure activities)
○ I have no problems with performing my usual activities.
○ I have some problems with performing my usual activities.
○ I am unable to perform my usual activities.
○ Refuse to answer or unknown
F.4
Pain/discomfort
155 / 218
○ I have no pain or discomfort.
○ I have moderate pain or discomfort.
○ I have extreme pain or discomfort.
○ Refuse to answer or unknown
F.5
Anxiety/depression
○ I am not anxious or depressed.
○ I am moderately anxious or depressed.
○ I am extremely anxious or depressed.
○ Refuse to answer or unknown
F.6
Please score how good or bad your own health is today. The best state you can imagine is 100 and the worst health state you can
imagine is 0. Overall, how would you score your own health today between 0 and 100?
Enter value between 0 and 100: _ _ _ ○ Refuse to answer
G.
DEPRESSION
Over the last 2 weeks, how often have you been bothered by any of the following problems?
Not at
all
Several
days
More than
half the
days
Nearly every day
Refuse to answer
or unknown
G.1
Little interest or pleasure in doing things
○
○
○
○
○
G.2
Feeling down, depressed or hopeless
○
○
○
○
○
G.3
Trouble falling or staying asleep, or sleeping too much
○
○
○
○
○
G.4
Feeling tired or having little energy
○
○
○
○
○
G.5
Poor appetite or overeating
○
○
○
○
○
G.6
Feeling bad about yourself, or that you are a failure or
have let yourself or your family down
○
○
○
○
○
G.7
Trouble concentrating on things, such as reading the
newspaper or watching television
○
○
○
○
○
G.8
Moving or speaking so slowly that other people could
have noticed. Or the opposite – being so fidgety or
restless that you have been moving around a lot more
than usual
○
○
○
○
○
156 / 218
H.
RISK FACTORS
H.1
Did you believe that the following factors could make you more likely to suffer from CHD for now? [Check all that apply]
□ Smoking
□ High blood pressure
□ High blood lipid
□ High blood glucose
□ Physical inactivity
□ Heavily drink
□ Overweight
□ None above
H.2
Had a doctor or other health professional told you that the following factors could make you more likely to suffer from CHD for
now since the index hospitalization? [Check all that apply]
□ Smoking
□ High blood pressure
□ High blood lipid
□ High blood glucose
□ Physical inactivity
□ Heavily drink
□ Overweight
□ None above
I.
STRESS
The questions in this scale ask about your thoughts and feelings during the last month. In each case, you will be asked to
indicate how often you felt or thought a certain way. Although some of the questions are similar, there are differences
between them and you should treat each one as a separate question. The best approach is to answer each question fairly
quickly. That is, don’t try to count up the number of times you felt a particular way, but rather indicate the alternative
that seems most reasonable. For each question choose the following alternatives: never, almost never, sometimes, fairly
often, and very often.
Never
Almos
t
never
S
o
me
ti
me
Fairly
often
Very
often
Refuse to answer or
unknown
157 / 218
s
I.1
In the last month, how often have you felt that you
were unable to control the important things in your
life?
○
○
○
○
○
○
I.2
In the last month, how often have you felt confident
in your ability to handle your personal problems?
○
○
○
○
○
○
I.3
In the last month, how often have you felt that things
were going your way?
○
○
○
○
○
○
I.4
In the last month, how often have you felt difficulties
were piling up so high that you could not overcome
them?
○
○
○
○
○
○
N.
SEXUAL ACTIVITY
Sometimes people who experience heart attacks or heart problems have concerns about how this might affect their
sexual lives. To round out our understanding of your experience, we would like to ask a few questions about your sexual
life. By “sex” or “sexual activity”, we mean any mutually voluntary activity with another person that involves sexual
contact, whether or not intercourse or orgasm occurs.
N.1
For some people, sex is a very important part of their lives and for others it is not very important at all. How important a part of
your life would you say that sex is?
○ Extremely Important
○ Very Important
○ Moderately Important
○ Somewhat Important
○ Not at all Important
○ Don’t Know
○ Refuse to answer
N.2
Have you had sex or sexual activity since you were hospitalized for your heart attack or heart problem?
○ Yes ○ No [go to N5] ○ Don’t Know [go to N5] ○ Refuse to answer [go to N5]
N.3
[If N2 Yes] About how often did you have sex with a partner?
○ Once a day or more
○ 3-6 times a week
○ Once or twice a week
○ 2-3 times a month
○ Once a month or less
158 / 218
○ Don’t Know
○ Refuse to answer
N.4
[If N2 Yes] Please tell me whether you strongly agree, agree, disagree, or strongly disagree with the following statement: Since
my heart attack, I try to have less strenuous sex [PROMPT: you try to take a more passive role]
○ Strongly Agree ○ Agree ○ Disagree ○ Strongly Disagree ○ Don’t Know ○ Refuse to answer
Please tell me whether you strongly agree, agree, disagree, or strongly disagree with the following statement, since your
heart attack
Strongly
Agree
Agree
Disagree
Strongly
Disagree
Don’t Know
Refuse to answer
N.5
I am fearful that having sex could cause
me to have another heart attack.
○
○
○
○
○
○
N.6
I am more interested in being
emotionally close to my partner than in
having sex with him/her.
○
○
○
○
○
○
N.7
My partner is less likely to initiate
sexual activity with me.
○
○
○
○
○
○
N.8
Drugs I have been taking have a sexual
side effect
○
○
○
○
○
○
N.9
[If N8 Strongly agree or Agree] The name of the drug(s) is:
N.10
[If N8 Strongly agree or Agree] Have you ever stopped or skipped it in the past month since the index hospitalization?
○ Yes ○ No [go to N12] ○ Don’t Know [go to N12] ○ Refuse to answer [go to N12]
N.11
○ Don’t Know ○ Refuse to answer
[If N10 Yes] Did stopping the drug improve your sexual function?
○ Yes ○ No ○ Don’t Know ○ Refuse to answer
Sometimes people go through periods in which they are not interested in sex or are having trouble with sexual
gratification. We have just a few questions about whether during the past month since the index hospitalization there
has ever been a period of several months or more when you…
Yes
No
D
o
n’
t
K
n
o
Refuse
to
answe
r
[If Yes to each problem] How much did your… bother
you? [read response categories]
A lot
Somewhat
not
at all
Don’t
Know
Refuse to answer
159 / 218
w
N.12
Lacked interest in having sex
○
○
○
○
○
○
○
○
○
Ask the following questions only of people who say YES to N2
N.13
Were unable to climax (experience
orgasm)
○
○
○
○
○
○
○
○
○
N.14
[For male only] Came to a climax
(experienced orgasm) too quickly
○
○
○
○
○
○
○
○
○
N.15
Experienced chest pain, tightness, or
angina during sexual activity
○
○
○
○
○
○
○
○
○
N.16
Experienced difficulty breathing or
shortness of breath during sexual
activity
○
○
○
○
○
○
○
○
○
N.17
Experienced physical pain other
than angina symptoms during sexual
activity
○
○
○
○
○
○
○
○
○
N.18
Did not find sex pleasurable (even if
it
was not painful)
○
○
○
○
○
○
○
○
○
N.19
Felt anxious just before sex about
your ability to perform sexually
○
○
○
○
○
○
○
○
○
N.20
[For male only] Had trouble getting
or maintaining an erection
○
○
○
○
○
○
○
○
○
N.21
[For female only] Had trouble
lubricating (or with vaginal dryness)
○
○
○
○
○
○
○
○
○
N.22
[If any in N12-N21 Yes] Have you talked with your partner about the sexual problem(s) you mentioned?
○ Yes ○ No ○ Don’t Know ○ Refuse to answer
N.23
Have you discussed sex with your doctor since you were hospitalized for your heart attack or heart problem?
○ Yes ○ No [go to N27] ○ Don’t Know [go to N27] ○ Refuse to answer [go to N27]
N.24
[If N23 Yes] Who started the discussion – you or the doctor?
○ I ○ Doctor ○Both (can be on different occasions) ○ Don’t Know
N.25
[If N23 Yes] Did your doctor recommend…[Check all that apply]
□ To limit the frequency of sexual activity
○ Refuse to answer
160 / 218
□
□
□
□
□
□
□
To try to keep your heart rate down during sexual activity
To take a more passive role during sexual activity
To resume sexual activity without any limitations
To consider taking medication to help with sex
To consider relaxation techniques to help with sex
Other, please specify:
None above
N.26
[If any in N25 Yes] How satisfied are you with the explanations your doctor has given you about how heart problems or
heart-related symptoms might affect your sexual life?
○ Not at all satis ied ○ Mostly dissatis ied ○ Somewhat satisfied
○ Mostly satis ied ○ Completely satis ied ○ Don’t Know ○ Refuse to answer
N.27
Thinking about the doctor(s) you see most, how appropriate would it be for the doctor(s) to ask you about your sexual health or
sexual concerns?
○ Very appropriate ○ Somewhat appropriate ○ Somewhat inappropriate ○ Very inappropriate
○ Refuse to answer
N.28
How comfortable would you feel discussing sexual issues with a doctor？
○ Very comfortable ○ Somewhat comfortable ○ Somewhat uncomfortable ○ Very uncomfortable ○ Refuse to answer
O.
LAB TESTS
O.1
TC: ___ ○ Unmeasured
O.2
HDL-C: ___ ○ Unmeasured
O.3
LDL-C: ___ ○ Unmeasured
O.4
Blood glucose: ___ ○ Unmeasured
O.5
ALT: ___ ○ Unmeasured
O.6
Cr: ___ ○ Unmeasured
O.7
BUN: ___ ○ Unmeasured
O.8
CK: ___ ○ Unmeasured
O.9
hsCRP: ___ ○ Unmeasured
O.10 Hb: ___ ○ Unmeasured
O.11 HCT: ___ ○ Unmeasured
161 / 218
O.12 WBC: ___ ○ Unmeasured
O.13 PLT: ___ ○ Unmeasured
O.14 OB: ___ ○ Unmeasured
O.15 PRO: ___ ○ Unmeasured
162 / 218
6 Month Follow-up Interview
A.
BASIC INFORMATION
Type of follow-up:
○ Face-to-face interview
○ Telephone interview
Did the participant answered the telephone interview by him/herself?
○ Yes ○ No, who: ___ [go to C1]
B.
FOLLOW-UP MEASUREMENTS
Weight: ___ kg ○ Unmeasured
Waistline: ___ cm ○ Unmeasured
Blood pressure 1st: ___/___mmHg
Blood pressure 2nd: ___/___mmHg
[if difference between 1st and 2nd >5mmHg] Blood pressure 3rd: ___/___mmHg ()
C.
OUTCOMES
Admission note 1
C.1
Date of hospitalization：_ _ /_ _/ _ _ _ _ ○ Unknown
C.2
Name of the hospital: ________________________
C.3
Admission status:
○ Emergency ○ Scheduled ○ Unknown
C.4
Main reason for hospitalization：
○ MI ○ Unstable angina pectoris ○ Stable angina pectoris ○ Valve dysfunction
○ Arrhythmia ○ Heart failure ○ New ischemic stroke ○ New hemorrhagic stroke
○ Transient ischemic attack ○ Diabetes ○ Kidney disease
○ Cardiac surgery related infections ○ Pericardial effusion or tamponade
○ Pulmonary embolism ○ Bleeding except hemorrhagic stroke ○ Others ○ Unknown
163 / 218
C.5
Therapies in hospitalization duration [Check all that apply]：
□ PCI □ CABG □ Thrombolysis □ Coronary angiography
□ Stroke thrombolysis □ Valve surgery □ LV assist device
□ Pacemaker or de ibrillator implantation □ Pulmonary embolism thrombolysis □ Dialysis
□ Cardiopulmonary resuscitation □ None above
I.5
Supportive documents were collected:
□ Face sheet
□ Discharge summary
□ CAG report
□ CAG imagine
□ CABG report
□ PCI report
□ CT report
□ MRI report
□ None above
Admission note 2
C.6
Date of hospitalization：_ _ /_ _/ _ _ _ _ ○ Unknown
C.7
Name of the hospital: ________________________
C.8
Admission status:
○ Emergency ○ Scheduled ○ Unknown
C.9
Main reason for hospitalization：
○ MI ○ Unstable angina pectoris ○ Stable angina pectoris ○ Valve dysfunction
○ Arrhythmia ○ Heart failure ○ New ischemic stroke ○ New hemorrhagic stroke
○ Transient ischemic attack ○ Diabetes ○ Kidney disease
○ Cardiac surgery related infections ○ Pericardial effusion or tamponade
○ Pulmonary embolism ○ Bleeding except hemorrhagic stroke ○ Others ○ Unknown
C.10
Therapies in hospitalization duration [Check all that apply]：
□ PCI □ CABG □ Thrombolysis □ Coronary angiography
□ Stroke thrombolysis □ Valve surgery □ LV assist device
□ Pacemaker or de ibrillator implantation □ Pulmonary embolism thrombolysis □ Dialysis
□ Cardiopulmonary resuscitation □ None above
164 / 218
I.6
Supportive documents were collected:
□ Face sheet
□ Discharge summary
□ CAG report
□ CAG imagine
□ CABG report
□ PCI report
□ CT report
□ MRI report
□ None above
Admission note 3
C.11
Date of hospitalization：_ _ /_ _/ _ _ _ _ ○ Unknown
C.12
Name of the hospital: ________________________
C.13
Admission status:
○ Emergency ○ Scheduled ○ Unknown
C.14
Main reason for hospitalization：
○ MI ○ Unstable angina pectoris ○ Stable angina pectoris ○ Valve dysfunction
○ Arrhythmia ○ Heart failure ○ New ischemic stroke ○ New hemorrhagic stroke
○ Transient ischemic attack ○ Diabetes ○ Kidney disease
○ Cardiac surgery related infections ○ Pericardial effusion or tamponade
○ Pulmonary embolism ○ Bleeding except hemorrhagic stroke ○ Others ○ Unknown
C.15
Therapies in hospitalization duration [Check all that apply]：
□ PCI □ CABG □ Thrombolysis □ Coronary angiography
□ Stroke thrombolysis □ Valve surgery □ LV assist device
□ Pacemaker or de ibrillator implantation □ Pulmonary embolism thrombolysis □ Dialysis
□ Cardiopulmonary resuscitation □ None above
165 / 218
I.7
Supportive documents were collected:
□ Face sheet
□ Discharge summary
□ CAG report
□ CAG imagine
□ CABG report
□ PCI report
□ CT report
□ MRI report
□ None above
Admission note 4
C.16
Date of hospitalization：_ _ /_ _/ _ _ _ _ ○ Unknown
C.17
Name of the hospital: ________________________
C.18
Admission status:
○ Emergency ○ Scheduled ○ Unknown
C.19
Main reason for hospitalization：
○ MI ○ Unstable angina pectoris ○ Stable angina pectoris ○ Valve dysfunction
○ Arrhythmia ○ Heart failure ○ New ischemic stroke ○ New hemorrhagic stroke
○ Transient ischemic attack ○ Diabetes ○ Kidney disease
○ Cardiac surgery related infections ○ Pericardial effusion or tamponade
○ Pulmonary embolism ○ Bleeding except hemorrhagic stroke ○ Others ○ Unknown
C.20
Therapies in hospitalization duration [Check all that apply]：
□ PCI □ CABG □ Thrombolysis □ Coronary angiography
□ Stroke thrombolysis □ Valve surgery □ LV assist device
□ Pacemaker or de ibrillator implantation □ Pulmonary embolism thrombolysis □ Dialysis
□ Cardiopulmonary resuscitation □ None above
166 / 218
I.8
Supportive documents were collected:
□ Face sheet
□ Discharge summary
□ CAG report
□ CAG imagine
□ CABG report
□ PCI report
□ CT report
□ MRI report
□ None above
D.
ADHERENCE
D.1
In the past month, how often did you forget to take one or more of your prescribed medications?
○ No prescribed medication [JUMP TO E1] ○ Never
○ Once
○ 2-3 times
○ Once per week
○ 2-5 times per week
○ Every day or nearly every day
○ Unknown
○ Refuse to answer
D.2
In the past month, how often did you miss a dose of ASPIRIN?
○ No prescribed this medication [JUMP TO D4] ○ Never [JUMP TO D4] ○ Once
○ 2-3 times
○ Once per week
○ 2-5 times per week
○ Everyday or nearly everyday
○ Unknown [JUMP TO D4] ○ Refuse to answer [JUMP TO D4]
D.3
D.4
[If you have ever missed a dose of ASPIRIN] The main reason is…
○ I Forgot to take it unintentionally
○ Doctors told me to stop taking it
○ I began feeling better, believed it was unnecessary to take it everyday
○ The drug seemed ineffective
○ I was worried about adverse reaction
○ I couldn’t afford it
○ I couldn’t access it easily
○ Others, please specify：
○ Unknown
○ Refuse to answer
In the past month, how often did you decide to skip CLOPIDOGREL?
○ No prescribed this medication [JUMP TO D6] ○ Never [JUMP TO D6] ○ Once
○ 2-3 times
○ Once per week
○ 2-5 times per week
○ Everyday or nearly everyday
○ Unknown [JUMP TO D6] ○ Refuse to answer [JUMP TO D6]
167 / 218
D.5
[If you have ever missed a dose of CLOPIDOGREL] The main reason is…
○ I Forgot to take it unintentionally
○ Doctors told me to stop taking it
○ I began feeling better, believed it was unnecessary to take it everyday
○ The drug seemed ineffective
○ I was worried about adverse reaction
○ I couldn’t afford it
○ I couldn’t access it easily
○ Others, please specify：
○ Unknown
○ Refuse to answer
D.6
In the past month, how often did you decide to skip STATINs?
○ No prescribed this medication [JUMP TO D9] ○ Never [JUMP TO D9] ○ Once
○ 2-3 times
○ Once per week
○ 2-5 times per week
○ Everyday or nearly everyday
○ Unknown [JUMP TO D9] ○ Refuse to answer [JUMP TO D9]
D.7
The drug name and dosage: ______
D.8
[If you have ever missed a dose of STATINs] The main reason is…
○ I Forgot to take it unintentionally
○ Doctors told me to stop taking it
○ I began feeling better, believed it was unnecessary to take it everyday
○ The drug seemed ineffective
○ I was worried about adverse reaction
○ I couldn’t afford it
○ I couldn’t access it easily
○ Others, please specify：
○ Unknown
○ Refuse to answer
D.9
In the past month, how often did you decide to skip BETA-BLOCKERs?
○ No prescribed this medication [JUMP TO D12] ○ Never [JUMP TO D12] ○ Once
○ 2-3 times
○ Once per week
○ 2-5 times per week
○ Everyday or nearly everyday
○ Unknown [JUMP TO D12] ○ Refuse to answer [JUMP TO D12]
D.10
The drug name and dosage: ______
168 / 218
D.11
[If you have ever missed a dose of BETA-BLOCKERs] The main reason is…
○ I Forgot to take it unintentionally
○ Doctors told me to stop taking it
○ I began feeling better, believed it was unnecessary to take it everyday
○ The drug seemed ineffective
○ I was worried about adverse reaction
○ I couldn’t afford it
○ I couldn’t access it easily
○ Others, please specify：
○ Unknown
○ Refuse to answer
D.12
In the past month, how often did you decide to skip ACEI/ARBs?
○ No prescribed this medication [JUMP TO E1] ○ Never [JUMP TO E1] ○ Once
○ 2-3 times
○ Once per week
○ 2-5 times per week
○ Everyday or nearly everyday
○ Unknown [JUMP TO E1] ○ Refuse to answer [JUMP TO E1]
D.13
The drug name and dosage: ______
D.14
E.
[If you have ever missed a dose of ACEI/ARBs] The main reason is…
○ I Forgot to take it unintentionally
○ Doctors told me to stop taking it
○ I began feeling better, believed it was unnecessary to take it everyday
○ The drug seemed ineffective
○ I was worried about adverse reaction
○ I couldn’t afford it
○ I couldn’t access it easily
○ Others, please specify：
○ Unknown
○ Refuse to answer
CVD FUNCTIONAL STATUS (SAQ)
Please go over the activities listed below and indicate how much limitation you have had due to chest pain ,chest
tightness or angina over the past 4 weeks?
169 / 218
Slightly
limited
Not at
all
limited
Limited
for other
reasons or
did not do
activity
Refuse to answer or
unknown
Physical Activity
Extremely
limited
Quite
a
bit
limited
E.1
Dressing yourself
○
○
○
○
○
○
○
E.2
Walking
ground
○
○
○
○
○
○
○
E.3
Showering
○
○
○
○
○
○
○
E.4
Climbing a hill or a flight of
stairs without stopping
○
○
○
○
○
○
○
E.5
Gardening, vacuuming
carrying groceries
or
○
○
○
○
○
○
○
E.6
Walking more than a block at a
brisk pace
○
○
○
○
○
○
○
E.7
Running or jogging
○
○
○
○
○
○
○
E.8
Lifting or moving heavy
objects
(e.g.
furniture,
children)
○
○
○
○
○
○
○
E.9
Participating in strenuous
sports (e.g. swimming, tennis)
○
○
○
○
○
○
○
E.10
Compared with 4 weeks ago, how often do you have chest pain ,chest tightness or angina when doing your most strenuous
activities?
○ Much more often ○ Slightly more often ○ About the same ○ Slightly less often ○ Much less often ○ None over the past 4
weeks ○ Refuse to answer or unknown
indoors
on
level
Moderately
limited
170 / 218
E.11
Over the past 4 weeks, on average, how many times have you had chest pain, chest tightness or angina?
○ ≥4 or more times per day
○ 1-3 times per day
○ 3-6 times per week
○ 1-2 times per week
○ Less than once a week
○ None over the past 4 weeks
○ Refuse to answer or unknown
E.12
Over the past 4 weeks, on average, how many times have you had to take nitroglycerin?
○ ≥4 or more times per day
○ 1-3 times per day
○ 3-6 times per week
○ 1-2 times per week
○ Less than once a week
○ None over the past 4 weeks
○ Refuse to answer or unknown
E.13
How bothersome is it for you to take pills for chest pain, chest tightness or angina as prescribed?
○ Extremely bothersome
○ Quite a bit bothersome
○ Moderately bothersome
○ Slightly bothersome
○ Not bothersome at all
○ My doctor has not prescribed pills
○ Refuse to answer or unknown
E.14
How satisfied are you that everything possible is being done to treat your chest pain, chest tightness or angina?
○Not satisfied at all
○ Mostly dissatisfied
○ Somewhat satis ied
○Mostly satis ied
○ Completely satis ied
○ Refuse to answer or unknown
171 / 218
E.15
How satisfied are you with explanations your doctor has given about your chest pain, chest tightness or angina?
○Not satisfied at all
○ Mostly dissatis ied
○ Somewhat satis ied
○Mostly satis ied
○ Completely satis ied
○ Refuse to answer or unknown
E.16
Overall, how satisfied are you with the current treatment of your chest pain, chest tightness or angina?
○Not satisfied at all
○ Mostly dissatis ied
○ Somewhat satis ied
○Mostly satis ied
○ Completely satis ied
○ Refuse to answer or unknown
E.17
Over the past 4 weeks, how much has your chest pain, chest tightness or angina limited your enjoyment of life?
○ Extremely limited ○ Quite a bit limited ○ Moderately limited ○ Slightly limited ○ Not limited at all ○ Refuse to answer or
unknown
E.18
If you had to spend the rest of your life with your chest pain, chest tightness or angina the way it is right now, how would you
feel about this?
○ Not satis ied at all
○ Mostly dissatis ied
○ Somewhat satis ied
○ Mostly satis ied
○ Completely satis ied
○ Refuse to answer or unknown
E.19
How often do you think or worry that you may have a heart attack or die suddenly?
○ I can’t stop thinking or worrying about it
○ I often think or worry about it
○ I occasionally think or worry about it
○ I rarely think or worry about it
○ I never think or worry about it
○ Refuse to answer or unknown
F.
HEALTH-RELATED QUALITY OF LIFE (EQ-5D)
The following questions ask about your current health state. In each of the following categories, please indicate which statement
best describes your own health state today.
172 / 218
F.1
Mobility
○ I have no problems in walking about.
○ I have some problems in walking about.
○ I am confined to bed.
○ Refuse to answer or unknown
F.2
Self-care
○ I have no problems with self-care.
○ I have some problems washing or dressing myself.
○ I am unable to wash or dress myself.
○ Refuse to answer or unknown
F.3
Usual activities (e.g., work, study, housework, family or leisure activities)
○ I have no problems with performing my usual activities.
○ I have some problems with performing my usual activities.
○ I am unable to perform my usual activities.
○ Refuse to answer or unknown
F.4
Pain/discomfort
○ I have no pain or discomfort.
○ I have moderate pain or discomfort.
○ I have extreme pain or discomfort.
○ Refuse to answer or unknown
F.5
Anxiety/depression
○ I am not anxious or depressed.
○ I am moderately anxious or depressed.
○ I am extremely anxious or depressed.
○ Refuse to answer or unknown
F.6
Please score how good or bad your own health is today. The best state you can imagine is 100 and the worst health state you can
imagine is 0. Overall, how would you score your own health today between 0 and 100?
Enter value between 0 and 100: _ _ _ ○ Refuse to answer
G.
DEPRESSION
Over the last 2 weeks, how often have you been bothered by any of the following problems?
Not at
all
Several
days
More than
half the
days
Nearly
every
day
Refuse to answer or
unknown
173 / 218
G.1
Little interest or pleasure in doing things
○
○
○
○
○
G.2
Feeling down, depressed or hopeless
○
○
○
○
○
G.3
Trouble falling or staying asleep, or sleeping too much
○
○
○
○
○
G.4
Feeling tired or having little energy
○
○
○
○
○
G.5
Poor appetite or overeating
○
○
○
○
○
G.6
Feeling bad about yourself, or that you are a failure or
have let yourself or your family down
○
○
○
○
○
G.7
Trouble concentrating on things, such as reading the
newspaper or watching television
○
○
○
○
○
G.8
Moving or speaking so slowly that other people could
have noticed. Or the opposite – being so fidgety or restless
that you have been moving around a lot more than usual
○
○
○
○
○
H.
STRESS
The questions in this scale ask about your thoughts and feelings during the last month. In each case, you will be asked to
indicate how often you felt or thought a certain way. Although some of the questions are similar, there are differences
between them and you should treat each one as a separate question. The best approach is to answer each question
fairly quickly. That is, don’t try to count up the number of times you felt a particular way, but rather indicate the
alternative that seems most reasonable. For each question choose the following alternatives: never, almost never,
sometimes, fairly often, and very often.
Never
Almost
never
Sometimes
Fairly
often
Very
often
Refuse
to
answer or
unknown
H.1
In the last month, how often have you felt that you were
unable to control the important things in your life?
○
○
○
○
○
○
H.2
In the last month, how often have you felt confident in
your ability to handle your personal problems?
○
○
○
○
○
○
H.3
In the last month, how often have you felt that things
were going your way?
○
○
○
○
○
○
H.4
In the last month, how often have you felt difficulties
were piling up so high that you could not overcome
○
○
○
○
○
○
174 / 218
them?
I.
COGNITION FUNCTION
Now I’d like to ask you some questions to check your memory. Don’t worry if you don’t know the answers.
I.1
What year is it?
○ Correct ○ Incorrect ○ Refuse to answer
I.2
What season is it?
○ Correct ○ Incorrect ○ Refuse to answer
I.3
What month is it?
○ Correct ○ Incorrect ○ Refuse to answer
I.4
What is the date today?
○ Correct ○ Incorrect ○ Refuse to answer
I.5
What day is it today?
○ Correct ○ Incorrect ○ Refuse to answer
I.6
Which state/country are we in?
○ Correct ○ Incorrect ○ Refuse to answer
I.7
Which city are we in?
○ Correct ○ Incorrect ○ Refuse to answer
I.8
What location are we in?
○ Correct ○ Incorrect ○ Refuse to answer
I.9
Which hospital are we in?
○ Correct ○ Incorrect ○ Refuse to answer
I.10
Which floor are we in?
○ Correct ○ Incorrect ○ Refuse to answer
I.11
Now I am going to name three objects, and please repeat them after I have said them: watch, pen, glasses
○ Correct ○ 1 error ○ 2 errors ○ All wrong ○ Refuse to answer
I.12
Please calculate 100 minus 7, and then continuous minus 7 for 5 times, the answers are? [The answers are 93, 86, 79, 72, 65 in
order]
○ Correct ○ 1 error ○ 2 errors ○ 3 errors ○ 4 errors ○ All wrong ○ Refuse to answer
I.13
Repeat the names of the three mentioned objects.
○ Correct ○ 1 error ○ 2 errors ○ All wrong ○ Refuse to answer
175 / 218
I.14
[Present a pen and a watch to the patient, and ask him / her what they are]
○ Correct ○ 1 error ○ All wrong ○ Refuse to answer
I.15
Now I am going to say three words, and please repeat them clearly. They are “if, and, but”.
○ Correct ○ Incorrect ○ Refuse to answer
I.16
[Give the patient a card written with “close your eyes” ] Please read the sentence on the card.
○ Correct ○ Incorrect ○ Refuse to answer
I.17
[Present the design to the patient] Please copy the design.
○ Correct ○ Incorrect ○ Refuse to answer
[Provide the patient with a blank paper, and ask him / her to follow a 3-stage command]
I.18
Please take a paper in your right hand
○ Correct ○ Incorrect ○ Refuse to answer
I.19
Please fold it in half
○ Correct ○ Incorrect ○ Refuse to answer
I.20
Please put it on your left leg.
○ Correct ○ Incorrect ○ Refuse to answer
I.21
Please write a complete sentence.
○ Correct ○ Incorrect ○ Refuse to answer
176 / 218
12 Month Follow-up Interview
A.
BASIC INFORMATION
Type of follow-up:
○ Face-to-face interview
○ Telephone interview [go to A4]
Was bio-sample collected?
○ No ○ Yes
ID of bio-sample: ________ [go to B1]
Did the participant answered the telephone interview by him/herself?
○ Yes ○ No, who: ___ [go to C1]
B.
FOLLOW-UP MEASUREMENTS
Weight: ___ kg ○ Unmeasured
Waistline: ___ cm ○ Unmeasured
Blood pressure 1st: ___/___mmHg
Blood pressure 2nd: ___/___mmHg
[if difference between 1st and 2nd >5mmHg] Blood pressure 3rd: ___/___mmHg ()
ID of bio-sample: ________
C.
OUTCOMES
Admission note 1
C.1
Date of hospitalization：_ _ /_ _/ _ _ _ _ ○ Unknown
C.2
Name of the hospital: ________________________
C.3
Admission status:
○ Emergency ○ Scheduled ○ Unknown
C.4
Main reason for hospitalization：
○ MI ○ Unstable angina pectoris ○ Stable angina pectoris ○ Valve dysfunction
177 / 218
○ Arrhythmia ○ Heart failure ○ New ischemic stroke ○ New hemorrhagic stroke
○ Transient ischemic attack ○ Diabetes ○ Kidney disease
○ Cardiac surgery related infections ○ Pericardial effusion or tamponade
○ Pulmonary embolism ○ Bleeding except hemorrhagic stroke ○ Others ○ Unknown
C.5
Therapies in hospitalization duration [Check all that apply]：
□ PCI □ CABG □ Thrombolysis □ Coronary angiography
□ Stroke thrombolysis □ Valve surgery □ LV assist device
□ Pacemaker or de ibrillator implantation □ Pulmonary embolism thrombolysis □ Dialysis
□ Cardiopulmonary resuscitation □ None above
I.22
Supportive documents were collected:
□ Face sheet
□ Discharge summary
□ CAG report
□ CAG imagine
□ CABG report
□ PCI report
□ CT report
□ MRI report
□ None above
Admission note 2
C.6
Date of hospitalization：_ _ /_ _/ _ _ _ _ ○ Unknown
C.7
Name of the hospital: ________________________
C.8
Admission status:
○ Emergency ○ Scheduled ○ Unknown
C.9
Main reason for hospitalization：
○ MI ○ Unstable angina pectoris ○ Stable angina pectoris ○ Valve dysfunction
○ Arrhythmia ○ Heart failure ○ New ischemic stroke ○ New hemorrhagic stroke
○ Transient ischemic attack ○ Diabetes ○ Kidney disease
○ Cardiac surgery related infections ○ Pericardial effusion or tamponade
○ Pulmonary embolism ○ Bleeding except hemorrhagic stroke ○ Others ○ Unknown
C.10
Therapies in hospitalization duration [Check all that apply]：
□ PCI □ CABG □ Thrombolysis □ Coronary angiography
□ Stroke thrombolysis □ Valve surgery □ LV assist device
□ Pacemaker or de ibrillator implantation □ Pulmonary embolism thrombolysis □ Dialysis
178 / 218
□ Cardiopulmonary resuscitation □ None above
I.23
Supportive documents were collected:
□ Face sheet
□ Discharge summary
□ CAG report
□ CAG imagine
□ CABG report
□ PCI report
□ CT report
□ MRI report
□ None above
Admission note 3
C.11
Date of hospitalization：_ _ /_ _/ _ _ _ _ ○ Unknown
C.12
Name of the hospital: ________________________
C.13
Admission status:
○ Emergency ○ Scheduled ○ Unknown
C.14
Main reason for hospitalization：
○ MI ○ Unstable angina pectoris ○ Stable angina pectoris ○ Valve dysfunction
○ Arrhythmia ○ Heart failure ○ New ischemic stroke ○ New hemorrhagic stroke
○ Transient ischemic attack ○ Diabetes ○ Kidney disease
○ Cardiac surgery related infections ○ Pericardial effusion or tamponade
○ Pulmonary embolism ○ Bleeding except hemorrhagic stroke ○ Others ○ Unknown
C.15
Therapies in hospitalization duration [Check all that apply]：
□ PCI □ CABG □ Thrombolysis □ Coronary angiography
□ Stroke thrombolysis □ Valve surgery □ LV assist device
□ Pacemaker or de ibrillator implantation □ Pulmonary embolism thrombolysis □ Dialysis
□ Cardiopulmonary resuscitation □ None above
179 / 218
I.24
Supportive documents were collected:
□ Face sheet
□ Discharge summary
□ CAG report
□ CAG imagine
□ CABG report
□ PCI report
□ CT report
□ MRI report
□ None above
Admission note 4
C.16
Date of hospitalization：_ _ /_ _/ _ _ _ _ ○ Unknown
C.17
Name of the hospital: ________________________
C.18
Admission status:
○ Emergency ○ Scheduled ○ Unknown
C.19
Main reason for hospitalization：
○ MI ○ Unstable angina pectoris ○ Stable angina pectoris ○ Valve dysfunction
○ Arrhythmia ○ Heart failure ○ New ischemic stroke ○ New hemorrhagic stroke
○ Transient ischemic attack ○ Diabetes ○ Kidney disease
○ Cardiac surgery related infections ○ Pericardial effusion or tamponade
○ Pulmonary embolism ○ Bleeding except hemorrhagic stroke ○ Others ○ Unknown
C.20
Therapies in hospitalization duration [Check all that apply]：
□ PCI □ CABG □ Thrombolysis □ Coronary angiography
□ Stroke thrombolysis □ Valve surgery □ LV assist device
□ Pacemaker or de ibrillator implantation □ Pulmonary embolism thrombolysis □ Dialysis
□ Cardiopulmonary resuscitation □ None above
180 / 218
I.25
Supportive documents were collected:
□ Face sheet
□ Discharge summary
□ CAG report
□ CAG imagine
□ CABG report
□ PCI report
□ CT report
□ MRI report
□ None above
D.
ADHERENCE
D.1
In the past month, how often did you forget to take one or more of your prescribed medications?
○ No prescribed medication [JUMP TO E1] ○ Never
○ Once
○ 2-3 times
○ Once per week
○ 2-5 times per week
○ Every day or nearly every day
○ Unknown
○ Refuse to answer
D.2
In the past month, how often did you miss a dose of ASPIRIN?
○ No prescribed this medication [JUMP TO D4] ○ Never [JUMP TO D4] ○ Once
○ 2-3 times
○ Once per week
○ 2-5 times per week
○ Everyday or nearly everyday
○ Unknown [JUMP TO D4] ○ Refuse to answer [JUMP TO D4]
D.3
D.4
[If you have ever missed a dose of ASPIRIN] The main reason is…
○ I Forgot to take it unintentionally
○ Doctors told me to stop taking it
○ I began feeling better, believed it was unnecessary to take it everyday
○ The drug seemed ineffective
○ I was worried about adverse reaction
○ I couldn’t afford it
○ I couldn’t access it easily
○ Others, please specify：
○ Unknown
○ Refuse to answer
In the past month, how often did you decide to skip CLOPIDOGREL?
○ No prescribed this medication [JUMP TO D6] ○ Never [JUMP TO D6] ○ Once
○ 2-3 times
○ Once per week
○ 2-5 times per week
○ Everyday or nearly everyday
○ Unknown [JUMP TO D6] ○ Refuse to answer [JUMP TO D6]
181 / 218
D.5
D.6
D.7
[If you have ever missed a dose of CLOPIDOGREL] The main reason is…
○ I Forgot to take it unintentionally
○ Doctors told me to stop taking it
○ I began feeling better, believed it was unnecessary to take it everyday
○ The drug seemed ineffective
○ I was worried about adverse reaction
○ I couldn’t afford it
○ I couldn’t access it easily
○ Others, please specify：
○ Unknown
○ Refuse to answer
In the past month, how often did you decide to skip STATINs?
○ No prescribed this medication [JUMP TO D9] ○ Never [JUMP TO D9] ○ Once
○ 2-3 times
○ Once per week
○ 2-5 times per week
○ Everyday or nearly everyday
○ Unknown [JUMP TO D9] ○ Refuse to answer [JUMP TO D9]
[If you have ever missed a dose of STATINs] The main reason is…
○ I Forgot to take it unintentionally
○ Doctors told me to stop taking it
○ I began feeling better, believed it was unnecessary to take it everyday
○ The drug seemed ineffective
○ I was worried about adverse reaction
○ I couldn’t afford it
○ I couldn’t access it easily
○ Others, please specify：
○ Unknown
○ Refuse to answer
D.8
In the past month, how often did you decide to skip BETA-BLOCKERs?
○ No prescribed this medication [JUMP TO E1] ○ Never [JUMP TO E1] ○ Once
○ 2-3 times
○ Once per week
○ 2-5 times per week
○ Everyday or nearly everyday
○ Unknown [JUMP TO E1] ○ Refuse to answer [JUMP TO E1]
D.9
The drug name and dosage: ______
D.10
[If you have ever missed a dose of BETA-BLOCKERs] The main reason is…
○ I Forgot to take it unintentionally
○ Doctors told me to stop taking it
○ I began feeling better, believed it was unnecessary to take it everyday
○ The drug seemed ineffective
182 / 218
○ I was worried about adverse reaction
○ I couldn’t afford it
○ I couldn’t access it easily
○ Others, please specify：
○ Unknown
○ Refuse to answer
I.26
In the past month, how often did you decide to skip ACEI/ARBs?
○ No prescribed this medication [JUMP TO D12] ○ Never [JUMP TO D12] ○ Once
○ 2-3 times
○ Once per week
○ 2-5 times per week
○ Everyday or nearly everyday
○ Unknown [JUMP TO D12] ○ Refuse to answer [JUMP TO D12]
I.27
The drug name and dosage: ______
I.28
[If you have ever missed a dose of ACEI/ARBs] The main reason is…
○ I Forgot to take it unintentionally
○ Doctors told me to stop taking it
○ I began feeling better, believed it was unnecessary to take it everyday
○ The drug seemed ineffective
○ I was worried about adverse reaction
○ I couldn’t afford it
○ I couldn’t access it easily
○ Others, please specify：
○ Unknown
○ Refuse to answer
E.
HEALTH CARE SERVICE
E.1
After the index hospitalization, have you ever been to TCM clinics or seen TCM doctors for heart problem?
○ No ○ Yes ○ Unknown ○ Refuse to answer
E.2
After the index hospitalization, when you got chest tightness or pain after the index hospitalization, which kind of clinics or
doctors did you go to?
○ No chest tightness or pain before ○ TCM alone
○ Mostly TCM
○ TCM and western medicine equally ○ Mostly western medicine ○ Western medicine alone ○ Unknown ○ Refuse to answer
E.3
After the index hospitalization, have you ever taken TCM medications?
○ No [JUMP TO E5] ○ Yes ○ Unknown [JUMP TO E5] ○ Refuse to answer
E.4
[IF E3 “YES”] After the index hospitalization, have you ever taken TCM medications for heart problems?
○ No ○ Yes, please specify:
○ Unknown ○ Refuse to answer
183 / 218
E.5
After the index hospitalization, have you ever accepted TCM physiotherapy (acupuncture, massage, cupping, etc.)?
○ No [JUMP TO E8] ○ Yes ○ Unknown [JUMP TO E8] ○ Refuse to answer [JUMP TO E8]
E.6
[IF E5 “YES”] After the index hospitalization, have you ever accepted TCM physiotherapy (acupuncture, massage, cupping,
etc.) for heart problems?
○ No ○ Yes ○ Unknown ○ Refuse to answer
E.7
[IF E3 or E5 “YES”] After the index hospitalization, have you ever decided to stop or skip medications because you are using
TCM medications and interventions instead?
○ No ○ Yes ○ Unknown ○ Refuse to answer
E.8
What types of medical insurance do you have? [Check all that apply]
□ Public health service
□ Medical insurance for urban workers/residents
□ Comprehensive arrangement for serious disease
□ Rural cooperative medical service
□ Other social medical insurance
□ Commercial medical insurance
□ None
□ Unknown
E.9
The total medical expense during the past year is approximately ____.
E.10
The medical expense paid out-of-pocket during the past year is approximately ______.
E.11
In the past 12 month, have you ever borrowed money from others to pay for medical expense?
○ Yes ○ No ○ Unknown ○ Refuse to answer
E.12
In the past 12 month, have you ever avoided healthcare due to costs?
○ Yes ○ No ○ Unknown ○ Refuse to answer
E.13
What do you think of the burden of medical expense mentioned above?
○ Can not undertake ○ Almost undertake ○ Can undertake easily ○ Unknown ○ Refuse to answer
F.
CVD FUNCTIONAL STATUS (SAQ)
○ Unknown ○ Refuse to answer
○ Unknown ○ Refuse to answer
Please go over the activities listed below and indicate how much limitation you have had due to chest pain ,chest
tightness or angina over the past 4 weeks?
Physical Activity
Extremely
limited
Quite a
bit
limited
Moderately
limited
Slightly
limited
Not at
all
limited
Limited for other
reasons or did
not do activity
Refuse
answer
unknown
to
or
184 / 218
F.1
Dressing yourself
F.2
Walking
ground
F.3
○
○
○
○
○
○
○
○
○
○
○
○
○
○
Showering
○
○
○
○
○
○
○
F.4
Climbing a hill or a flight of
stairs without stopping
○
○
○
○
○
○
○
F.5
Gardening, vacuuming
carrying groceries
or
○
○
○
○
○
○
○
F.6
Walking more than a block at
a brisk pace
○
○
○
○
○
○
○
F.7
Running or jogging
○
○
○
○
○
○
○
F.8
Lifting or moving heavy
objects
(e.g.
furniture,
children)
○
○
○
○
○
○
○
F.9
Participating in strenuous
sports (e.g. swimming, tennis)
○
○
○
○
○
○
○
F.10
Compared with 4 weeks ago, how often do you have chest pain, chest tightness or angina when doing your most strenuous
activities?
○ Much more often ○ Slightly more often ○ About the same ○ Slightly less often ○ Much less often ○ None over the past 4
weeks ○ Refuse to answer or unknown
F.11
Over the past 4 weeks, on average, how many times have you had chest pain, chest tightness or angina?
○ ≥4 or more times per day
○ 1-3 times per day
○ 3-6 times per week
○ 1-2 times per week
○ Less than once a week
○ None over the past 4 weeks
○ Refuse to answer or unknown
F.12
Over the past 4 weeks, on average, how many times have you had to take nitroglycerin?
○ ≥4 or more times per day
○ 1-3 times per day
○ 3-6 times per week
indoors
on
level
185 / 218
○ 1-2 times per week
○ Less than once a week
○ None over the past 4 weeks
○ Refuse to answer or unknown
F.13
How bothersome is it for you to take pills for chest pain, chest tightness or angina as prescribed?
○ Extremely bothersome
○ Quite a bit bothersome
○ Moderately bothersome
○ Slightly bothersome
○ Not bothersome at all
○ My doctor has not prescribed pills
○ Refuse to answer or unknown
F.14
How satisfied are you that everything possible is being done to treat your chest pain, chest tightness or angina?
○Not satisfied at all
○ Mostly dissatis ied
○ Somewhat satis ied
○Mostly satis ied
○ Completely satis ied
○ Refuse to answer or unknown
F.15
How satisfied are you with explanations your doctor has given about your chest pain, chest tightness or angina?
○Not satisfied at all
○ Mostly dissatisfied
○ Somewhat satis ied
○Mostly satis ied
○ Completely satis ied
○ Refuse to answer or unknown
F.16
Overall, how satisfied are you with the current treatment of your chest pain, chest tightness or angina?
○Not satisfied at all
○ Mostly dissatis ied
○ Somewhat satis ied
○Mostly satis ied
○ Completely satis ied
○ Refuse to answer or unknown
F.17
Over the past 4 weeks, how much has your chest pain, chest tightness or angina limited your enjoyment of life?
○ Extremely limited ○ Quite a bit limited ○ Moderately limited ○ Slightly limited ○ Not limited at all ○ Refuse to answer or
unknown
186 / 218
F.18
If you had to spend the rest of your life with your chest pain, chest tightness or angina the way it is right now, how would you
feel about this?
○ Not satisfied at all
○ Mostly dissatis ied
○ Somewhat satis ied
○ Mostly satis ied
○ Completely satis ied
○ Refuse to answer or unknown
F.19
How often do you think or worry that you may have a heart attack or die suddenly?
○ I can’t stop thinking or worrying about it
○ I often think or worry about it
○ I occasionally think or worry about it
○ I rarely think or worry about it
○ I never think or worry about it
○ Refuse to answer or unknown
G.
HEALTH-RELATED QUALITY OF LIFE (EQ-5D)
The following questions ask about your current health state. In each of the following categories, please indicate which statement
best describes your own health state today.
G.1
Mobility
○ I have no problems in walking about.
○ I have some problems in walking about.
○ I am confined to bed.
○ Refuse to answer or unknown
G.2
Self-care
○ I have no problems with self-care.
○ I have some problems washing or dressing myself.
○ I am unable to wash or dress myself.
○ Refuse to answer or unknown
G.3
Usual activities (e.g., work, study, housework, family or leisure activities)
○ I have no problems with performing my usual activities.
○ I have some problems with performing my usual activities.
○ I am unable to perform my usual activities.
○ Refuse to answer or unknown
G.4
Pain/discomfort
187 / 218
○ I have no pain or discomfort.
○ I have moderate pain or discomfort.
○ I have extreme pain or discomfort.
○ Refuse to answer or unknown
G.5
Anxiety/depression
○ I am not anxious or depressed.
○ I am moderately anxious or depressed.
○ I am extremely anxious or depressed.
○ Refuse to answer or unknown
G.6
Please score how good or bad your own health is today. The best state you can imagine is 100 and the worst health state you can
imagine is 0. Overall, how would you score your own health today between 0 and 100?
Enter value between 0 and 100: _ _ _ ○ Refuse to answer
H.
DEPRESSION
Over the last 2 weeks, how often have you been bothered by any of the following problems?
Not at
all
Several
days
More than
half the
days
Nearly every
day
Refuse to
answer or
unknown
H.1
Little interest or pleasure in doing things
○
○
○
○
○
H.2
Feeling down, depressed or hopeless
○
○
○
○
○
H.3
Trouble falling or staying asleep, or sleeping too much
○
○
○
○
○
H.4
Feeling tired or having little energy
○
○
○
○
○
H.5
Poor appetite or overeating
○
○
○
○
○
H.6
Feeling bad about yourself, or that you are a failure or
have let yourself or your family down
○
○
○
○
○
H.7
Trouble concentrating on things, such as reading the
newspaper or watching television
○
○
○
○
○
H.8
Moving or speaking so slowly that other people could
have noticed. Or the opposite – being so fidgety or restless
that you have been moving around a lot more than usual
○
○
○
○
○
188 / 218
I.
SOCIOECONOMIC CHARACTER
I.1
Your current job status:
○ currently having a job ○ used to have a job ○ never have a job ○ Unknown ○ Refuse to answer
I.2
[If currently working] What is/was your primary occupation in the past year:
○ Farmer
○ Worker
○ Police/Administrative
○ Clerical
○ Medical related professional
○ Non-medical related professional
○ Business
○ Self-employed
○ Military
○ Others
○ Refuse to answer
I.3
[If currently working] How often do you have to work through the night as a shift worker on average in the past year?
○ 1 or more times/week ○ 1-3 times/month ○ Less than once/month ○ Never ○ Unknown ○ Refuse to answer
I.4
[If used to work or never work] What is the primary reason for not working currently:
○ Unemployed/laid-off
○ Full-time homemaker
○ Retired
○ Unable to work
○ Prefer not to work
○ Others, please specify:
○ Unknown
○ Refuse to answer
I.5
[If used to work] Have you stopped working since your heart attack or heart problem?
○ Yes ○ No ○ Unknown ○ Refuse to answer
I.6
Current marital status:
○ Married ○ Divorced /Separated ○ Widowed ○ Single ○ Unknown ○ Refuse to answer
I.7
Including you, there are currently _ _ people living together in your family (sharing the household income in the last year) ○
Refuse to answer
I.8
What was your total household income in the last year?
○ < ¥10000 ○ ¥10000 - 29999 ○¥ 30000 - 49999 ○ ¥50000 - 69999 ○ ¥70000 - 99999 ○≥ ¥100000 ○ Unknown ○ Refuse
to answer
189 / 218
J.
J.1
J.2
RISK FACTORS
Have you ever smoked in the past 1 month?
○ Never [go to J3] ○ Yes [go to J3] ○ Unknown [go to J3] ○ Refuse to answer [go to J3]
[If smoked in the past 30 days] On average you smoke _ _ cigarettes per day in the last month. ○ Unknown ○ Refuse to
answer
J.3
_ _ _ hours per week are you exposed to others’ tobacco smoke in the past 6 months. ○ Unknown ○ Refuse to answer
J.4
How many hours per week do you spend doing your regular job in the past 6 months? __._ hours / week [“0” if do not work] ○
Unknown ○ Refuse to answer
J.5
How active are you at work in the past 6 months (including volunteer work and housework)?
○ Mainly sedentary / Mostly sitting / Desk job
○ Walking on one level, no heavy lifting
○ Mainly walking, including climbing stairs, or walking uphill or lifting heavy objects
○ Heavy physical labor
○ Do not work
○ Unknown
○ Refuse to answer
J.6
How many minutes per day do you spend commuting to work in the past 6 months? _ _ _ minutes / day [“0” if do not work] ○
Unknown ○ Refuse to answer
J.7
What mode of transportation to work do you usually use in the past 6 months?
○ Walking ○ Bicycling ○ Bus/subway ○ Motorcycle ○ Taxi ○ Private car ○ Do not work ○ Unknown ○ Refuse to answer
J.8
How many hours per week do you spend doing home activities in the past 6 months? __._ hours / week ○ Unknown ○ Refuse to
answer
J.9
During the past 30 days, other than your regular job, commuting to work and home activities, did you participate in any physical
activities or exercise such as running, calisthenics, Tai Chi, bicycling, table tennis, or walking for exercise in the past 6 months?
○ Yes ○ No [go to J13] ○ Unknown [go to J13] ○ Refuse to answer [go to J13]
J.10
[If J9 Yes] How much total time per week do you spend doing physical exercise? _ _._ hours / week ○ Unknown ○ Refuse to
answer
J.11
[If J9 Yes] How many days per week do you do physical exercise for at least 30 minutes? _ days / week
Refuse to answer
○ Unknown ○
190 / 218
J.12
J.13
[If J9 Yes] What type of exercise did you usually participate, other than your job and commuting to work? [Check all that
apply]
□ Brisk walking or jogging
□ Cycling
□ Dancing or calisthenics
□ Swimming
□ Tai Chi
□ Climbing hills or stairs
□ Ball games
□ Others
□ None
During the past 1 year, How often do you have a drink containing alcohol?
○ Never [go to K1] ○ Monthly or less ○ 2 to 4 times a month ○ 2 to 3 times a week ○ 4 or more times a week ○ Unknown
1 DRINK is 17ml pure alcohol, which equals to 120ml wine, or 360ml beer (half a bottle or 1 tin), or 45ml liquor (1
LIANG)
J.14
How many drinks containing alcohol do you have on a typical day when you are drinking?
○ 1 or 2 ○ 3 or 4 ○ 5 or 6 ○ 7, 8, or 9 ○ 10 or more ○ Unknown ○ Refuse to answer
J.15
How often do you have six or more drinks on one occasion?
○ Never ○ Less than monthly ○ Monthly ○ Weekly ○ Daily or almost daily ○ Unknown ○ Refuse to answer [Skip to
Questions J21 if J14 “1 or 2” AND J15 “Never”]
How often during the last year have you found
Neve
r
Less
than
monthly
Monthly
Weekl
y
Daily or
almost daily
Refuse to
answer or
unknown
○
J.16
not able to stop drinking once you had started?
○
○
○
○
○
J.17
failed to do what was normally expected from
you because of drinking?
○
○
○
○
○
J.18
Needed a first drink in the morning to get
yourself going after a heavy drinking session?
○
○
○
○
○
J.19
had a feeling of guilt or remorse after drinking?
○
○
○
○
○
J.20
unable to remember what happened the night
before because of your drinking?
○
○
○
○
○
○
○
○
○
191 / 218
J.21
Have you or someone else been injured as a result of your drinking?
○ No ○ Yes, but not in the last year ○ Yes, during the last year ○ Unknown ○ Refuse to answer
J.22
Has a relative or friend or a doctor or another health worker been concerned about your drinking or suggested you cut down?
○ No ○ Yes, but not in the last year ○ Yes, during the last year ○ Unknown ○ Refuse to answer
K.
STRESS
The questions in this scale ask about your thoughts and feelings during the last month. In each case, you will be asked to
indicate how often you felt or thought a certain way. Although some of the questions are similar, there are differences
between them and you should treat each one as a separate question. The best approach is to answer each question
fairly quickly. That is, don’t try to count up the number of times you felt a particular way, but rather indicate the
alternative that seems most reasonable. For each question choose the following alternatives: never, almost never,
sometimes, fairly often, and very often.
Never
Almost
never
So
metim
es
Fairly
often
Very often
Refuse
answer
unknown
K.1
In the last month, how often have you felt that you were
unable to control the important things in your life?
○
○
○
○
○
○
K.2
In the last month, how often have you felt confident in
your ability to handle your personal problems?
○
○
○
○
○
○
K.3
In the last month, how often have you felt that things
were going your way?
○
○
○
○
○
○
K.4
In the last month, how often have you felt difficulties
were piling up so high that you could not overcome
them?
○
○
○
○
○
○
L.
SOCIAL SUPPORT
to
or
The following questions ask about other people who provide you with assistance and support.
L.1
Is there someone available to you whom you
None of
the time
A little
of
the
time
Some of
the time
Most of
the
time
All of the time
○
○
○
○
○
Refuse
answer
unknown
to
or
○
192 / 218
can
count on to listen to you when you need to talk?
L.2
Is there someone available to you to give you
good advice about a problem?
○
○
○
○
○
○
L.3
Is there someone available to you who shows
You love and affection?
○
○
○
○
○
○
L.4
Is there someone available to you to help you
with daily chores?
○
○
○
○
○
○
L.5
Can you count on anyone to provide you with
emotional support (talking over problems or
helping make difficult decisions)?
○
○
○
○
○
○
L.6
Do you have as much contact as you would like
with someone you feel close to, someone in
whom you can trust and confide?
○
○
○
○
○
○
M.
COGNITION FUNCTION
Now I’d like to ask you some questions to check your memory. Don’t worry if you don’t know the answers.
M.1
What year is it?
○ Correct ○ Incorrect ○ Refuse to answer
M.2
What season is it?
○ Correct ○ Incorrect ○ Refuse to answer
M.3
What month is it?
○ Correct ○ Incorrect ○ Refuse to answer
M.4
What is the date today?
○ Correct ○ Incorrect ○ Refuse to answer
M.5
What day is it today?
○ Correct ○ Incorrect ○ Refuse to answer
M.6
Which state/country are we in?
○ Correct ○ Incorrect ○ Refuse to answer
M.7
Which city are we in?
○ Correct ○ Incorrect ○ Refuse to answer
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M.8
What location are we in?
○ Correct ○ Incorrect ○ Refuse to answer
M.9
Which hospital are we in?
○ Correct ○ Incorrect ○ Refuse to answer
M.10
Which floor are we in?
○ Correct ○ Incorrect ○ Refuse to answer
M.11
Now I am going to name three objects, and please repeat them after I have said them: watch, pen, glasses
○ Correct ○ 1 error ○ 2 errors ○ All wrong ○ Refuse to answer
M.12
Please calculate 100 minus 7, and then continuous minus 7 for 5 times, the answers are? [The answers are 93, 86, 79, 72, 65 in
order]
○ Correct ○ 1 error ○ 2 errors ○ 3 errors ○ 4 errors ○ All wrong ○ Refuse to answer
M.13
Repeat the names of the three mentioned objects.
○ Correct ○ 1 error ○ 2 errors ○ All wrong ○ Refuse to answer
M.14
[Present a pen and a watch to the patient, and ask him / her what they are]
○ Correct ○ 1 error ○ All wrong ○ Refuse to answer
M.15
Now I am going to say three words, and please repeat them clearly. They are “if, and, but”.
○ Correct ○ Incorrect ○ Refuse to answer
M.16
[Give the patient a card written with “close your eyes” ] Please read the sentence on the card.
○ Correct ○ Incorrect ○ Refuse to answer
M.17
[Present the design to the patient] Please copy the design.
○ Correct ○ Incorrect ○ Refuse to answer
[Provide the patient with a blank paper, and ask him / her to follow a 3-stage command]
M.18
Please take a paper in your right hand
○ Correct ○ Incorrect ○ Refuse to answer
M.19
Please fold it in half
○ Correct ○ Incorrect ○ Refuse to answer
M.20
Please put it on your left leg.
○ Correct ○ Incorrect ○ Refuse to answer
M.21
Please write a complete sentence.
○ Correct ○ Incorrect ○ Refuse to answer
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N.
SEXUAL ACTIVITY
Sometimes people who experience heart attacks or heart problems have concerns about how this might affect their
sexual lives. To round out our understanding of your experience, we would like to ask a few questions about your
sexual life. By “sex” or “sexual activity”, we mean any mutually voluntary activity with another person that involves
sexual contact, whether or not intercourse or orgasm occurs.
N.1
For some people, sex is a very important part of their lives and for others it is not very important at all. How important a part of
your life would you say that sex is?
○ Extremely Important
○ Very Important
○ Moderately Important
○ Somewhat Important
○ Not at all Important
○ Don’t Know
○ Refuse to answer
N.2
Have you had sex or sexual activity since your last interview 11 months ago?
○ Yes ○ No [go to N5] ○ Don’t Know [go to N5] ○ Refuse to answer [go to N5]
N.3
[If N2 Yes] About how often did you have sex with a partner?
○ Once a day or more
○ 3-6 times a week
○ Once or twice a week
○ 2-3 times a month
○ Once a month or less
○ Don’t Know
○ Refuse to answer
N.4
[If N2 Yes] Please tell me whether you strongly agree, agree, disagree, or strongly disagree with the following statement:
Since my heart attack, I try to have less strenuous sex [PROMPT: you try to take a more passive role]
○ Strongly Agree ○ Agree ○ Disagree ○ Strongly Disagree ○ Don’t Know ○ Refuse to answer
Please tell me whether you strongly agree, agree, disagree, or strongly disagree with the following statement, since
your heart attack
Strongly
Agree
Agre
e
Disagree
Strongly
Disagree
Don’t
Kno
w
Refuse to answer
N.5
I am fearful that having sex could cause
me to have another heart attack.
○
○
○
○
○
○
N.6
I
○
○
○
○
○
○
am
more
interested
in
being
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emotionally close to my partner than in
having sex with him/her.
N.7
My partner is less likely to initiate
sexual activity with me.
○
○
○
○
○
○
N.8
Drugs I have been taking have a sexual
side effect
○
○
○
○
○
○
N.9
[If N8 Strongly agree or Agree] The name of the drug(s) is:
N.10
[If N8 Strongly agree or Agree] Have you ever stopped or skipped it in the past 11 months?
○ Yes ○ No [go to N12] ○ Don’t Know [go to N12] ○ Refuse to answer [go to N12]
N.11
○ Don’t Know ○ Refuse to answer
[If N10 Yes] Did stopping the drug improve your sexual function?
○ Yes ○ No ○ Don’t Know ○ Refuse to answer
Sometimes people go through periods in which they are not interested in sex or are having trouble with sexual
gratification. We have just a few questions about whether during the past 11 months after the 1 month follow-up visit
there has ever been a period of several months or more when you…
Yes
N.12
Lacked interest in having sex
○
No
○
Don’t
Kno
w
Refuse
to
answe
r
○
○
[If Yes to each problem] How much did your… bother you?
[read response categories]
A
lot
Some
what
not
at all
Don’t
Kno
w
Refuse to answer
○
○
○
○
○
Ask the following questions only of people who say YES to N2
N.13
Were unable to climax (experience
orgasm)
○
○
○
○
○
○
○
○
○
N.14
[For male only] Came to a climax
(experienced orgasm) too quickly
○
○
○
○
○
○
○
○
○
N.15
Experienced chest pain, tightness,
or angina during sexual activity
○
○
○
○
○
○
○
○
○
N.16
Experienced difficulty breathing or
shortness of breath during sexual
activity
○
○
○
○
○
○
○
○
○
N.17
Experienced physical pain other
○
○
○
○
○
○
○
○
○
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than angina symptoms
sexual activity
during
N.18
Did not find sex pleasurable (even if
it was not painful)
○
○
○
○
○
○
○
○
○
N.19
Felt anxious just before sex about
your ability to perform sexually
○
○
○
○
○
○
○
○
○
N.20
[For male only] Had trouble
getting or maintaining an erection
○
○
○
○
○
○
○
○
○
N.21
[For female only] Had trouble
lubricating
(or with vaginal
dryness)
○
○
○
○
○
○
○
○
○
N.22
N.23
[If any in N12-N21 Yes] Have you talked with your partner about the sexual problem(s) you mentioned?
○ Yes ○ No ○ Don’t Know ○ Refuse to answer
During the past 11 months after the 1 month follow-up visit, have you discussed sex with a doctor?
○ Yes ○ No [go to N27] ○ Don’t Know [go to N27] ○ Refuse to answer [go to N27]
N.24
[If N23 Yes] Who started the discussion – you or the doctor?
○ I ○ Doctor ○Both (can be on different occasions) ○ Don’t Know
N.25
[If N23 Yes] Did your doctor recommend…[Check all that apply]
□ To limit the frequency of sexual activity
□ To try to keep your heart rate down during sexual activity
□ To take a more passive role during sexual activity
□ To resume sexual activity without any limitations
□ To consider taking medication to help with sex
□ To consider relaxation techniques to help with sex
□ Other, please specify:
□ None above
○ Refuse to answer
N.26
[If any in N25 Yes] How satisfied are you with the explanations your doctor has given you about how heart problems or
heart-related symptoms might affect your sexual life?
○ Not at all satis ied ○ Mostly dissatis ied ○ Somewhat satisfied
○ Mostly satis ied ○ Completely satis ied ○ Don’t Know ○ Refuse to answer
N.27
Thinking about the doctor(s) you see most, how appropriate would it be for the doctor(s) to ask you about your sexual health or
sexual concerns?
○ Very appropriate ○ Somewhat appropriate ○ Somewhat inappropriate ○ Very inappropriate
○ Refuse to answer
N.28
How comfortable would you feel discussing sexual issues with a doctor？
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○ Very comfortable ○ Somewhat comfortable ○ Somewhat uncomfortable ○ Very uncomfortable ○ Refuse to answer
P.
LAB TESTS
P.1
TC: ___ ○ Unmeasured
P.2
HDL-C: ___ ○ Unmeasured
P.3
LDL-C: ___ ○ Unmeasured
P.4
Blood glucose: ___ ○ Unmeasured
P.5
ALT: ___ ○ Unmeasured
P.6
Cr: ___ ○ Unmeasured
P.7
BUN: ___ ○ Unmeasured
P.8
CK: ___ ○ Unmeasured
P.9
hsCRP: ___ ○ Unmeasured
P.10
Hb: ___ ○ Unmeasured
P.11
HCT: ___ ○ Unmeasured
P.12
WBC: ___ ○ Unmeasured
P.13
PLT: ___ ○ Unmeasured
P.14
OB: ___ ○ Unmeasured
P.15
PRO: ___ ○ Unmeasured
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