I. Date of examination**

Date of examination**

II. Quality level*

1.1. Sex**

1.2. Date of birth**

1.3. Height**

Height**

Height**

1.4. Weight**

Weight**

Weight**

1.5. Ethnicity: Caucasian**

1.6. Family history of myocardial infarction or stroke in parents, siblings or children under the age of 65 for women or under 60 for men**

2.1. Diabetes mellitus**

2.2. Arterial hypertension**

2.3. Dyslipidemia**

2.4. Smoker**

Ex-smoker since**

Smoker**

Pack years*

Smoker**

2.5. Drinks per week*

Drinks per week

2.6. Medically diagnosed alcoholism*

2.7. Renal failure*

2.7.1. Degree of renal dysfunction*

2.8. Current dialysis dependency**

3.1. Coronary heart disease**

3.2. Condition post myocardial infarction**

3.3. Cardiomyopathy** If the response to this question is ?yes?, please complete the ?Cardiomyopathy Diagnostics? form.

3.4. Heart failure**

3.4.1. S.p. decompensation*

3.4.2. Initial diagnosis of heart failure*

Heart failure**

3.4.3. Current NYHA class*

3.5. Atrial fibrillation/flutter**

3.6. Current or previous medical diagnosis of heart valve disease**

3.7. Medically diagnosed endocarditis*

3.8. Physician diagnosed congenital heart defect**

4.1. Interventional coronary revascularization**

4.1.1. If yes, date of last intervention*

Interventional coronary revascularization**

4.2. Peripheral revascularization*

4.2.1. If yes, date of last intervention*

Peripheral revascularization*

4.3. Coronary bypass operation**

4.3.1. If yes, date of last intervention*

Coronary bypass operation**

4.4. Other vascular operation*

4.4.1. If yes, date of last intervention*

Other vascular operation*

4.5. Heart valve operation**

4.5.1. If yes, date of last intervention*

Heart valve operation**

4.5.2. Type of last intervention*

If open surgery*

Aortic valve*

If more than one procedure on one valve was performed, please provide details of the last Op (= current state)*

Pulmonic valve*

Mitral valve*

Triscuspid valve*

4.6. Implantable pacemaker or defibrillator**

4.6.1. If yes, what was implanted?*

4.6.2. If yes, date of last event (implantation/exchange)*

Implantable pacemaker or defibrillator**

4.6.3. If pacemaker, please give pacemaker type*

4.7. Other devices*

4.7.1. Cardiac contractility modulation (CCM)*

4.7.2. Intra-aortic balloon pump (IABP)*

4.7.3. Other devices*

4.8. S.p. myocardial biopsy*

4.8.1. Date of myocardial biopsy*

Status post myocardial biopsy*

4.8.2. Biopsy sites*

5.1. PAOD**

5.1.1. Fontaine stage*

5.1.2. Acute ischaemic occlusion*

5.2. Stroke/TIA**

5.2.1. Date*

Stroke/TIA**

5.2.2. Aetiology*

5.2.3. Diagnosis*

5.2.4. Stroke severity*

5.2.5. Consequences of the stroke*

5.3. Chronic lung disease**

5.4. Primary pulmonary Hypertension*

5.5. Depression**

5.6. Cancer more than 5 years ago**

5.7. Cancer within the last 5 years**

6.1. Systolic**

Blood pressure after 5 minutes at rest

6.2. Diastolic**

Blood pressure after 5 minutes at rest

7.1. Heart rate**

Heart rate**

8.1. Exertional Dyspnea*

8.2. Dyspnea at rest*

8.3. Peripheral edema*

8.4. Jugular venous distention*

8.5. Pulmonary rales*

9.1. Date blood sample was taken**

In clinically stable individuals, these values may be no more than one week old, and must be determined again thereafter.

9.2. Hemoglobin**

Hemoglobin**

Unit**

9.3. Creatinine (serum, heparin plasma)**

Creatinine (serum, heparin plasma)**

Unit**

9.4. Total cholesterol**

Total cholesterol**

Unit**

10.1. Menopause?**