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Address
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Phone #
?
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Permission text messages
?
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Social Security #
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Secondary contact name
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Contact Phone #
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Contact email address
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Race
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Hispanic or Latino
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Medicare enrollment status:Find:Pt:^Patient:Nom:
?
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Primary insurance
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Ins group num
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Pt ID
?
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Pt ID assign auth
?
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Current smoker
E
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Aspirin usage^pre enrollment in ADAPTABLE study:Find:Pt:^Patient:Ord:ADAPTABLE
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Year aspirin regimen began
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{yyyy}
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Aspirin dose^pre enrollment in ADAPTABLE study:Mass:Pt:Dose:Qn:ADAPTABLE
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mg
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Aspirin usage^post enrollment in ADAPTABLE study:Find:Pt:^Patient:Ord:ADAPTABLE
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Aspirin dose^post enrollment in ADAPTABLE study:Mass:Pt:^Patient:Qn:ADAPTABLE
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mg
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Enteric coated aspirin
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Reason for discontinuing aspirin use:Find:Pt:^Patient:Nom:
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Date aspirin discontinued
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{mm/dd/yyyy}
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Blood thinning med used
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NSAID used several times a week
?
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Stomach upset meds
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Hospitalization^post enrollment in ADAPTABLE study:Find:Pt:^Patient:Ord:ADAPTABLE
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Hospital Name
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Address:Addr:Pt:Facility:Nom:
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Admission date
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{mm/dd/yyyy}
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Reason for hospitalization
?
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Events^during hospitalization:Find:RptPeriod:^Patient:Nom:ADAPTABLE
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