Uganda Congestive Heart Failure Registry (UCHF)

BASELINE VISIT

Export patients information
PATIENT CONTACT INFORMATION
Centre No.
Patient No.
Year
Month
Day
PARTICIPANT CONTACT INFORMATION
  1. Name of participant
  2. Address of participant
  3. Participant main phone number
ALTERNATIVE CONTACT (SPOUSE, NEXT OF KIN, OTHER RELATIVE)
  1. Name of alternate contact
  2. Alternative contact phone number
FACILITY INPATIENT OR OUT PATIENT IDENTIFICATION NUMBER
A. ENROLMENT
  1. Patient location at the time of enrolment

    Inpatient (check one location only)

    Outpatient (check one location only)

B. STUDY ELIGIBILITY
  1. Inclusion Criteria – (Must be YES to all 3 question below)
    1. Has the patient provided written informed consent?
    2. Does the patient have a clinical diagnosis of heart failure?
    3. Is the patient 18 years old or older?
C. DEMOGRAPHICS
  1. Sex
    If Female: Has patient been pregnant within the last year?:
  2. Occupation Status
  3. Marital Status
  4. Living Arrangement
  5. Education Level
  6. Distance from patient’s home to the nearest doctor/health care facility:
    (Kms)
  7. What is the total family/household monthly income?
    (UGX)
  8. Ethnicity:
  9. Source of payment for medical services (check what applies)
    If Out of pocket: Who is paying for the services?:
D. MEDICAL HISTORY

Answer whether the patient has a history of each of the specified conditions

  1. Previous diagnosis of heart failure
    The duration of known heart failure
    year
  2. Family History of Heart Failure
  3. Hypertension
  4. Hyperlipidemia
  5. Myocardial infarction (MI)
  6. Hospitalisation within the past 2 years prior to enrolment into UCHF

    If Yes

    Specify diagnosis for the most recent hospitalisation:

    Year
    Month
    Day
  7. Percutaneous cardiac procedures
    If Yes (Please choose all that apply below)
  8. Cardiac surgery
    If Yes (Please choose all that apply below)
  9. Implantable cardiac devices
    If Yes (Please choose all that apply below)
  10. Stroke/TIA
    If Yes (Please choose all that apply below)
  11. Venous thromboembolism
    If Yes (Please choose all that apply below)
  12. Valve disease
    If Yes (Please choose all that apply below)
  13. Peripheral Artery Disease
  14. Coronary Artery disease
  15. Atrial Fibrillation/atrial flutter
  16. Chronic Obstructive pulmonary Disorder (COPD)
  17. Chronic Kidney Disease
    If Yes (Are they on dialysis)
  18. Diabetes Mellitus
    If Yes (Chose type)
  19. Influenza or Pneumococcal vaccine within the past 2 years.
  20. Human Immunodeficiency Virus (HIV)
  21. History of Tuberculosis (TB)
  22. Cancer requiring treatment.
    If Yes (Specify the primary location if known)
  23. Prior/current therapy for cancer
    If Yes (Please choose all the types that apply)
  24. Major infections within the last year.
    If Yes (Indicate the type of infection if known)

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