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Roll no.

218

Name: Malik Qistas Ahmad

Dated: 17-03-14

RESEARCH CONSENT FORM AND


QUESTIONNAIRE
This informed consent form is for male and female patients (of age >25 years) who
are attending Mayo Hospital, and who we are inviting to participate in Research on
Stroke. The topic of our Research Project is Frequency of Risk Factors of
Stroke in patients presenting to Mayo Hospital, Lahore. This study is being
done under supervision of Dr. Saira Afzal, Head of Department, Community
Medicine, King Edward Medical University, Lahore.
From the information collected and studied in this research, we hope to learn more
about stroke. The study doesnt involve any treatment. There are no anticipated
risks associated with this study. We do not guarantee you will receive any benefit
from this study. Your participation in this research is entirely voluntary. The
information we collect will be kept confidential and used for educational purposes
only. We will publish the results in order so that other interested people may learn
from our research.

Certificate of Consent
FOR LITERATE PATIENT
I have read the foregoing information, or it has been read to me. I have had the opportunity to ask
questions about it and any questions that I have asked have been answered to my satisfaction. I
consent voluntarily to participate as a participant in this research. I am willingly ready to answer
the concerned questions. Ive been assured that my identity will be kept confidential.

Print Name of Participant__________________


Signature of Participant ___________________
Date ___________________________
FOR ILLITERATE PATIENT (we need a witness)
I have witnessed the accurate reading of the consent form to the potential participant, and the
individual has had the opportunity to ask questions. I confirm that the individual has given consent
freely.

Print name of witness_____________________


Signature of witness ______________________

AND

Thumb print of participant

Date ________________________
Day/month/year
STATEMENT BY THE RESEARCHER/PERSON TAKING CONSENT

I confirm that the participant was given an opportunity to ask questions about
the study, and all the questions asked by the participant have been answered correctly and
to the best of my ability. I confirm that the individual has not been coerced into giving
consent, and the consent has been given freely and voluntarily.

A copy of this ICF has been provided to the participant.

Print Name of Researcher/person taking the consent________________________

Signature of Researcher /person taking the consent__________________________


Date ___________________________
Day/month/year

QUESTIONNAIRE
Patients name:
Age:
Gender: Male / Female
Education:
Occupation:
Monthly Income:
Marital Status:

Married (No. of Children= )

Unmarried

Socioeconomic status:

Patients allocated number:

Religion:
Registration No:
Address:

Rural

Urban

Contact #:_____________________
Ethnic Group : _____________________
Determinants/ Variables

Questions

Response/ Answers

NON MODIFIABLE FACTORS


AGE

Are you a female over the Yes / No


age of 55?
Are you a male over the age
Yes / No
of 45?

Heredity/ Family History

Has your mother, father, Yes / No / No idea


grand parent or brother,
sister had a stroke?
Does any member of your
family have sickle cell
Yes / No / Not sure
disease
or
leukoencephalopathy?

Gender

Has your mother had a Yes /No /Not sure


stroke attack ever?
Has your mother had a
family history of stroke?
Yes / No/ Not sure
Does your mother smoke or
having a long history of Yes /No /Not sure
smoking?

MODIFIABLE FACTORS
Hypertension
(ideal Do you have high blood Yes /No
120/80mmHg, high blood pressure?
pressure is > 140/90mmHg.
Do you take any medication
Yes /No
for high blood pressure?
Did you ever have extreme
blood pressure readings i-e
of
hypertensive
crisis?
Yes /No /Not sure
(>180/110mmHg)
Did you get your blood
pressure
readings
monitored regularly in the Yes/ No
past?
Cardiac Diseases (mostly Did you ever have
include AF, valvular heart irregular heart beat?
disease and MI)

an Yes / No / Sometimes

Did
you
ever
have
symptoms like ankle or Yes / No
abdomen
swelling,
Ask for each of these
palpitations, shortness of
symptoms mentioned.
breath, difficulty catching
your breath, chest pain or loss
of consciousness?

Did you get any treatment


like angioplasty, cardiac Yes / No / Not sure
catheterization?
Hypercholesterolemia

Do
you
have
high Yes / No / Not sure
cholesterol or do you take
any medication for high
cholesterol?
Cholesterol levels (if known)
HDL.. LDL. Total

Date tested..
Have you been undergone
routine
screening
procedures
for
blood
cholesterol tests?

Yes / No

Did you used to take diet


rich in animal fats/ saturate
fats in past?
Yes / No

Obesity

Diabetes Mellitus (type 1 and 2)

Cigarette Smoking

Do you have a BMI greater


than normal or a greater than
normal deposition of fat in
abdomen?
Did you have obesity in
childhood?
Did you have a history of sleep
apnea?
Are you overweight by 20
pounds or more?
Are you a diabetic or are you
on any insulin therapy or
regular
exercise
recommendation?
Are you undergoing regular
blood glucose monitoring (4-6
times for type 1 and twice a
week for type 11)?
Do you have a parent or sibling
with diabetes?
On previous testing, did you
have an impaired glucose
tolerance or disturbed fasting
tolerance?
Do you smoke regularly or have
a long history of smoking?
Were you a light smoker (<10
cigarettes a day) or heavy

Yes / No /Not sure

Yes /No /Not sure


Yes / No
Yes / No
Yes / No

Yes / No

Yes / No

Yes / No / No idea

Yes / No

Illicit Drug Use Including Oral


Contraceptives and Alcoholism

Life Style

Number of Yes Responses .

smoker (a pack per day i-e 20


cigarettes)?
Did you take any medication i-e
nicotine patches or gums etc?
For cessation?
Have you been in drug abuse
(Ask
individually
about
cocaine,
marijuana,
amphetamines, and heroin and
cold remedies?
Have you been on traditional
highestrogen
pills
or
combined low dose pills?
Are you an alcoholic?
Do you consume at least three
beverages per day? (Criteria
for calling heavy drinkers)
Are you sedentary in life style
or active?
If yes for sedentary, ask if you
exercise less than 3 times per
week for 20-30 minutes a time?
Did you involve in any of the
exercises
like
jogging,
swimming, brisk walking?
Are you having a stressful life
or feeling energetic?
Number of No Responses .

Yes / No

Yes / No /Quit the habit slowly


Yes / No

Yes / No /Dont have idea


Yes / No

Yes / No
Yes / No

Yes / No

Yes / No
Stressed / Energetic /Healthful

(Yes for a specific variable being present , No or Dont know for not being present.)