| I. Data Abstraction Form Last-First names: …………………………………………… Identification number: ……………………………….............. Address: …………………………………………...................... Person/persons to contact: …………………………………… | Date of birth: |__|__|/|__|__|/|__|__||__|__| DAY/MONTH/YEAR Age: Date: |__|__|/|__|__|/|__|__||__|__| | ||||||||
| SECTION 1: SOCIO-DEMOGRAPHIC DATA | |||||||||
| 101 | Gender: 1. Male |__| 2. Female |__| | |__| |
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| 102 | Marital Status: 1. Married |__| 2. Single |__| 3. Divorced |__| 4. Widowed |__| | |__| |
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| 103 | Level of education: 1. Primary |__| 2. Secondary |__| 3. University |__| 4. Never been to school |__| | |__| |
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| 104 | Occupation: 1. Employed |__| 2. Student |__| 3. Unemployed |__| 4. Self-employed |__| | |__| |
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| 105 | Income: 1. <50,000 |__| 2. 50,000 - 200,000 |__| 3. 200,000 - 500,000 |__| 4. >500,000 |__| |
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| SECTION 2: CLINICAL DATA | |||||||||
| Past Medical History | |||||||||
| 201 | Have you been diagnosed with RA? YES/NO |
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| 202 | If yes in which year were you diagnosed of RA/disease duration? <6 Months, 6 Months - 1 year, 1 - 5 years, 5 - 10 years, >10 years | |__ | |
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| 203 | Hypertension 1. Yes |__| 2. No |__| | |__| |
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| 204 | Diabetes 1. Yes |__| 2. No |__| | |__| |
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| 205 | Dyslipidemia 1. Yes |__| 2. No |__| |
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| Chronic inflammatory diseases? 1. Yes |__| 2. No |__| If yes, which? |
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| 206 | Any other chronic illness 1. Yes |__| 2. No |__| If yes which? …………………………… | |__| |
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| 207 | Any family History of Cardiovascular Disease? 1. Yes |__| 2. No |__| If yes please state ………………………………………………….. | |__| |
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| Social History | |||||||||
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| Smoking | ||||||||
| 208 | Do you smoke? 1. Yes |__| 2. No |__| | |__| |
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| 209 | How long have you been smoking or stopped (if current or ex-smoker)? | |_______| |
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| 210 | How many of these do you smoke per day? | |_______| |
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| 211 | Quantity in Pack per year? <5, 5 - 10, 10 - 15, 15 - 20, >20 | |_______| |
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| Alcohol Consumption: | ||||||||
| 212 | Do you take any alcoholic drinks like beer, wine, and whisky? 1. Yes |__| 2. No |__| | |__| |
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| 213 | How often do you take alcoholic drinks? 1. ≥5 days/week |__|; 2. 1 - 4 days a week |__|; 3. 1 - 3 days/month |__|; 4. less than once per month |__| | |__| |
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| 214 | What quantity do you drink in one week? Number of units | |__| |
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| 215 | Alcoholic index: <5, 5 - 10, 10 - 15, 15 - 20, >20 |
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