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Exam 1: Forms

All documents are in Acrobat format (.pdf). If you do not have the Adobe Acrobat Reader, download the program for free from the Adobe website

Recruitment Forms
  • Household Enumeration
  • Screening
  • Non-Participant
  • Participant Contact


    • Clinic Examination Data Forms
  • Clinic Reception
  • Clinic Check-off Sheet
  • Anthropometry
  • Seated Blood Pressure
  • Ankle-Arm Blood Pressure
  • MRI Exclusion


    • Questionnaire Data Forms
  • Personal History
  • Medical History
  • Physical Activity
  • Neighborhood
  • Health & Life
  • Medications
  • Dietary Intake & Nutritional Supplements


    • Reading Center Data Completion Forms
  • Resting 12 - Lead ECG
  • Phlebotomy
  • Lab Processing
  • Urine Collection
  • Ultrasound Carotid IMT
  • Ultrasound Distensibility
  • Ultrasound Endothelial Function
  • Arterial Pulse Wave
  • MRI Exam Completion
  • CT Exam Completion
  • Dietary Intake Cover Sheet


    • Reading Center Data Collection Forms
  • Non-Coronary CT Alerts

    • Exam 2: Forms

    Clinic Examination Data Forms
  • Clinic Reception
  • Anthropometry
  • Seated Blood Pressure
  • MRI Exclusion


    • Questionnaire Data Forms
  • Personal History
  • Family History
  • Medical History
  • Sleep History
  • Eye Vision History
  • Physical Activity
  • Health & Life
  • Medications


    • Reading Center Data Completion Forms
  • Phlebotomy
  • Spot Urine Collection
  • MRI Exam Completion
  • CT Exam Completion


    • Ancillary Study Forms
  • Ultrasound IMT
  • Eye Vision History
  • Retinal Completion
  • Vision Completion
  • MRI Tagging Completion
  • Neighborhood Activities
  • Residential History Questionnaire
  • Residential History Supplement

    • Exam 3: Forms

    Clinic Examination Data Forms
  • Clinic Reception
  • Clinic Check-Off Sheet
  • Anthropometry
  • Seated Blood Presure
  • Ankle-Arm Blood Pressure


    • Questionnaire Data Forms
  • Personal History
  • Medical History
  • Physical Activity
  • Health & Life
  • Medications


    • Reading Center Data Completion Forms
  • Phlebotomy
  • Spot Urine Collection
  • CT Exam Completion


    • Ancillary Study Forms
  • Ultrasound IMT
  • Seated Blood Substudy - Mercury
  • Seated Blood Substudy - Dinamap
  • Neighborhood Activities
  • Residential History Questionnaire
  • Residential History Supplement
  • Spirometry Questionnaire
  • Spirometry Questionnaire Supplement
  • Spirometry Completion

    • Exam 4: Forms

    Clinic Examination Data Forms
  • Clinic Reception
  • Clinic Check-Off Sheet
  • Anthropometry
  • Seated Blood Presure


    • Questionnaire Data Forms
  • Personal History
  • Medical History
  • Health & Life
  • Medications
  • Sleep Questionnaire


    • Reading Center Data Completion Forms
  • Phlebotomy
  • CT Exam Completion


    • Ancillary Study Forms
  • MRI Exclusion Form
  • MRI Completion Form
  • MRI Tagging Completion Form
  • Ultrasound IMT Completion
  • MESA Stress - Health & Life Supplement
  • Spirometry Questionnaire
  • Spirometry Questionnaire Supplement
  • Spirometry Completion

    • Exam 5: Forms

    Ancillary Study Forms
  • Home Information Questionnaire
  • COPD MRI Completion
  • COPD Questionnaire
  • MESA Spirometry

    • MESA Stress 2 - English MESA Stress 2 - Spanish

    Clinic Examination Data Forms
  • Ankle Brachial Index
  • Check-off Sheet
  • Clinic Reception
  • Arterial Wave
  • Phlebotomy Type 1
  • Phlebotomy Type 2
  • Phlebotomy Type 3
  • Phlebotomy Type 4
  • Phlebotomy Type 5
  • Phlebotomy Type 6
  • Resting 12-Lead ECG
  • Seated Blood Pressure
  • Ultrasound IMT


    • Questionnaire Data Forms
  • Eye History
  • Health & Life
  • Medications
  • CASI
  • Diet Supplements
  • Digit Span Test
  • Digit-Symbol Task
  • Erectile Dysfunction
  • Food Frequency Questionnaire
  • Medical History
  • MRI Exclusion
  • Personal History
  • Physical Activity


    • Reading Center Data Completion Forms
  • CT Exam - Cardiac
  • CT Exam - Lung
  • CT Exam
  • MRI Completion
  • Retina Completion
  • Ultrasound Completion

    • First Follow-up Call Forms

  • Contact Log
  • Contact Cover Sheet
  • Participant Tracking
  • General Health
  • Specific Medical Conditions
  • Other Admissions
  • Specific Medical Procedures

    • Second Follow-up Call Forms

  • Participant Tracking
  • General Health
  • Specific Medical Conditions
  • Other Admissions
  • Specific Medical Procedures

    • Third Follow-up Call Forms

  • Follow-up 3 Contact Cover (English 03-06-2004).pdf
  • Follow-up 3 Contact Log (English 03-06-2004).pdf


  • Follow-up 3 Death Information (Chinese 11-10-03).pdf
  • Follow-up 3 Death Information (English 03-06-2004.pdf
  • Follow-up 3 Death Information (Spanish 03-6-04).pdf


  • Follow-up 3 General Health (Chinese 11-10-03).pdf
  • Follow-up 3 General Health (English 03-06-2004).pdf
  • Follow-up 3 General Health (Spanish 04-02-04).pdf


  • Follow-up 3 General Health Death (Chinese 11-10-03).pdf
  • Follow-up 3 General Health Death (English 03-06-2004).pdf
  • Follow-up 3 General Health Death (Spanish 4-2-04).pdf


  • Follow-up 3 Other Admissions (Chinese 11-10-03).pdf
  • Follow-up 3 Other Admissions (English 03-06-2004).pdf
  • Follow-up 3 Other Admissions (Spanish 03-6-04).pdf


  • Follow-up 3 Specific Medical Conditions (Chinese 11-10-03).pdf
  • Follow-up 3 Specific Medical Conditions (English 03-06-2004).pdf
  • Follow-up 3 Specific Medical Conditions (Spanish 4-2-04).pdf


  • Follow-up 3 Specific Medical Procedures (Chinese 9-6-2004).pdf
  • Follow-up 3 Specific Medical Procedures (English 9-6-2004).pdf
  • Follow-up 3 Specific Medical Procedures (Spanish 9-6-2004).pdf


  • Follow-up 3 Tracking (English 03-06-2004).pdf

    • Fourth Follow-up Call Forms

  • Follow-up 4 Contact Cover (English 03-06-2004).pdf
  • Follow-up 4 Contact Log (English 03-06-2004).pdf


  • Follow-up 4 Death Information (Chinese 11-10-03).pdf
  • Follow-up 4 Death Information (English 03-06-2004).pdf
  • Follow-up 4 Death Information (Spanish 03-6-04).pdf


  • Follow-up 4 General Health (Chinese 4-9-04).pdf
  • Follow-up 4 General Health (English 04-02-2004).pdf
  • Follow-up 4 General Health (Spanish 04-02-04).pdf


  • Follow-up 4 General Health Death (Chinese 11-10-03).pdf
  • Follow-up 4 General Health Death (English 03-06-04).pdf
  • Follow-up 4 General Health Death (Spanish 4-2-04).pdf


  • Follow-up 4 Other Admissions (Chinese 11-10-03).pdf
  • Follow-up 4 Other Admissions (English 12-14-2004).pdf
  • Follow-up 4 Other Admissions (Spanish 12-14-2004).pdf


  • Follow-up 4 Specific Medical Conditions (Chinese 11-10-03).pdf
  • Follow-up 4 Specific Medical Conditions (English 03-06-04).pdf
  • Follow-up 4 Specific Medical Conditions (Spanish 4-2-04).pdf


  • Follow-up 4 Specific Medical Procedures (Chinese 9-6-2004).pdf
  • Follow-up 4 Specific Medical Procedures (English 9-6-2004).pdf
  • Follow-up 4 Specific Medical Procedures (Spanish 9-6-2004).pdf


  • Follow-up 4 Tracking (English 03-06-04).pdf

    • Fifth Follow-up Call Forms

  • Follow-up 5 Contact Cover (English 8-31-2004).pdf
  • Follow-up 5 Contact Log (English 8-31-2004).pdf


  • Follow-up 5 Death Information (Chinese 11-9-2004).pdf
  • Follow-up 5 Death Information (English 8-31-2004).pdf
  • Follow-up 5 Death Information (Spanish 11-9-2004).pdf


  • Follow-up 5 General Health Death (Chinese 9-22-2004).pdf
  • Follow-up 5 General Health Death (English 8-31-2004).pdf
  • Follow-up 5 General Health Death (Spanish 9-22-2004).pdf


  • Follow-up 5 General Health (Chinese 9-22-2004).pdf
  • Follow-up 5 General Health (English 8-31-2004).pdf
  • Follow-up 5 General Health (Spanish 9-22-2004).pdf


  • Follow-up 5 Medical Conditions (Chinese 9-22-2004).pdf
  • Follow-up 5 Medical Conditions (English 8-31-2004).pdf
  • Follow-up 5 Medical Conditions (Spanish 9-22-2004).pdf


  • Follow-up 5 Medical Procedures (Chinese 9-22-2004).pdf
  • Follow-up 5 Medical Procedures (English 9-6-2004).pdf
  • Follow-up 5 Medical Procedures (Spanish 9-22-2004).pdf


  • Follow-up 5 Other Admissions (Chinese 9-22-2004).pdf
  • Follow-up 5 Other Admissions (English 12-14-200).pdf
  • Follow-up 5 Other Admissions (Spanish 12-14-2004).pdf


  • Follow-up 5 Participant Tracking (English 8-31-2004).pdf

    • Sixth Follow-up Call Forms

  • Follow-up 6 Contact Cover (English 6-2005).pdf
  • Follow-up 6 Contact Log.pdf


  • Follow-up 6 Death Information.pdf
  • Follow-up 6 Death Information (Spanish_9-26-2005).pdf


  • Follow-up 6 General Health.pdf
  • Follow-up 6 General Health Spanish.pdf
  • Follow-up 6 General Health (Chinese 10-20-2005).pdf


  • Follow-up 6 General Health Death.pdf
  • Follow-up 6 General Health Death (Spanish 9-26-2005).pdf
  • Follow-up 6 General Health Death (Chinese 10-11-2005).pdf


  • Follow-up 6 Other Admissions.pdf
  • Follow-up 6 Other Admissions (Spanish 9-26-2005).pdf
  • Follow-up 6 Other Admissions (Chinese 10-11-2005).pdf


  • Follow-up 6 Specific Medical Conditions.pdf
  • Follow-up 6 Specific Medical Conditions (Spanish 9-26-2005).pdf
  • Follow-up 6 Specific Medical Conditions (Chinese 10-11-2005).pdf


  • Follow-up 6 Specific Medical Procedures.pdf
  • Follow-up 6 Specific Medical Procedures (Spanish 9-26-2005).pdf
  • Follow-up 6 Specific Medical Procedures (Chinese 10-11-2005).pdf


  • Follow-up 6 Tracking.pdf

    • Seventh Follow-up Call Forms

  • Follow-up 7 Specific Medical Procedures (November 2007)
  • Follow-up 7 Contact Cover (November 2007)
  • Follow-up 7 Contact Log (November 2007)
  • Follow-up 7 Death Information (November 2007)
  • Follow-up 7 General Health (November 2007)
  • Follow-up 7 General Health Death (November 2007)
  • Follow-up 7 Other Admissions (November 2007)
  • Follow-up 7 Specific Medical Conditions (November 2007)


    • Eighth Follow-up Call Forms

  • Follow-up 8 Contact Cover (November 2007)
  • Follow-up 8 Contact Log (November 2007)
  • Follow-up 8 Death Information (November 2007)
  • Follow-up 8 General Health (November 2007)
  • Follow-up 8 General Health Death (November 2007)
  • Follow-up 8 Other Admissions (November 2007)
  • Follow-up 8 Specific Medical Conditions (November 2007)
  • Follow-up 8 Specific Medical Procedures (November 2007)


    • Events Forms

  • MESA Stroke Review Form
  • MESA Cardiac Review Form
  • MESA Mortality Review Form


  • Cardiac-PVD Death Physician Questionnaire (English 11-09-04).pdf
  • Cardiac-PVD Hospital Abstraction (English 07-20-10).pdf


  • Cardiac-PVD Interview (English 02-25-02).pdf
  • Cardiac-PVD Interview (Chinese 11-10-03).pdf
  • Cardiac-PVD Interview (Spanish 2-13-04).pdf


  • Cardiac-PVD Physician Questionnaire (English 11-09-2004).pdf
  • Eligibility (English 05-11-2010).pdf
  • Eligibility Addendum (English 2-25-02).pdf
  • Events Contact Log (English 03-05-2004).pdf
  • Final Notification (English 03-04-2005).pdf


  • Informant Interview (Chinese 11-9-04).pdf
  • Informant Interview (English 11-9-04).pdf
  • Informant Interview (Spanish 11-9-04).pdf


  • Informant Interview Narrative (English 12-13-01).pdf
  • Initial Notification (English 3-20-04).pdf


  • Interview for Stroke-TIA Symptoms (Chinese 3-26-04).pdf
  • Interview for Stroke-TIA Symptoms (English 3-26-04).pdf
  • Interview for Stroke-TIA Symptoms (Spanish 6-15-04).pdf


  • Stroke-TIA Abstractor Receipt (English 2-12-04).pdf
  • Stroke-TIA Additional docs to scan (English 2-12-04).pdf
  • Stroke-TIA Coversheet (English 02-12-04).pdf
  • Stroke-TIA Hospital Abstraction (English 8-5-2004).pdf


  • Stroke-TIA Narrative (Chinese 3-8-04).pdf
  • Stroke-TIA Narrative (English 10-7-03).pdf
  • Stroke-TIA Narrative (Spanish 6-15-04).pdf


  • Stroke-TIA Packing-Confirmation (English 2-12-04).pdf
  • Stroke-TIA Physician Questionnaire (English 11-9-04).pdf

    • MESA Coordinating Center, Seattle, WA
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