Appendix 1
Questionnaire
Patient number (sequential) – _______________
Date of questionnaire – ___/____/_______
DEMOGRAPHICS 
Gender: M___ F___
Age: ____ years
Weight:____kg
Height:_.___m
Body mass index:_____kg/m2
LIFESTYLE 
Alcohol consumption
	<1 drink per day
	 -1-2 drinks per day
	 - 3 or more drinks per day
Smoking
	 - non-smoker
	- former smoker
	 - active smoker (___ pack/years)
SIGNIFICANT MEDICAL HISTORY
Diabetes – yes/no
If yes, type (1 or 2)
Date of diagnosis
	 - <1 year
	- >1 and <5 years
	- >5 and <10 years
	- >10 years
Previous stroke/transient ischemic attack – yes/no 
Date of diagnosis
	 - <1 year
	- >1 and <5 years
	- >5 and <10 years
	- >10 years 
Previous myocardial infarction – yes/no
Date of diagnosis
	 - <1 year
	- >1 and <5 years
		- >5 and <10 years
		- >10 years
Previous percutaneous coronary intervention – yes/no
Date
	 - <1 year
	- >1 and <5 years
	- >5 and <10 years
	- >10 years
Previous heart failure – yes/no
Date of diagnosis
	 - <1 year
	- >1 and <5 years
	- >5 and <10 years
	- >10 years
Previous chronic kidney disease - yes/no/unknown 
Date of diagnosis - <1 year
	- >1 and <5 years
	- >5 and <10 years
	- >10 years
Previous hypertension – yes/no
Date of diagnosis - <1 year
	- >1 and <5 years
	- >5 and <10 years
	- >10 years
Previous peripheral arterial disease – yes/no
Date of diagnosis - <1 year
	- >1 and <5 years
	- >5 and <10 years
	- >10 years
Previous dyslipidemia – yes/no
Date of diagnosis - <1 year
	- >1 and <5 years
	- >5 and <10 years
	- >10 years
CONCOMITANT MEDICATION
Duration (for each) - <1 year
	- >1 and <5 years
	- >5 and <10 years
	- >10 years
Angiotensin-converting enzyme inhibitor
Angiotensin receptor blocker
Diuretic 
Beta-blocker
Aldosterone antagonist
Calcium channel blocker
Nitrates
Direct renin inhibitor
Aspirin
Clopidogrel/prasugrel/ticagrelor 
Nicorandil
Ivabradine
Vitamin K antagonist – if yes, which, dose level and TTR (if available)
New oral anticoagulant – if yes, which, dose level and number of doses per day
Statin 
Ezetimibe
Fibrate
Niacin
Digoxin
Amiodarone
Other antiarrhythmic – if yes, which
RELEVANT LABORATORY TESTS
Creatinine - ____mg/dl
International normalized ratio - _____
Hemoglobin - _____g/dl
Electrocardiogram
Rhythm: ________
Heart rate - ____/min
Other significant findings ________________________
RISK SCORES
CHA2DS2-VASc__________
HAS-BLED________
OTHER QUESTIONS
Regarding your long-term medication, which is most important?
	- Price 
	- Number of tablet per day
	- Efficacy
	- Safety
	- Other________
Have you ever decided to stop taking a long-term medication on your own initiative?
Yes___
No___
If yes, why?
- Price
- Side effect
- Opinion of a relative or friend
- Other _________
Have you ever experienced bleeding that you believe was caused by medication?
Yes____
No____
If yes, indicate its severity:
1. Mild
2. Moderate
3. Severe
4. Severe with need for transfusion 
5. Severe with need for hospitalization
HOLTER MONITORING (if applicable)
Baseline rhythm: ________
If baseline rhythm other than atrial fibrillation or atrial flutter:
Paroxysmal atrial fibrillation – yes/no
Paroxysmal atrial flutter – yes/no
Mean heart rate - ____beats/min
Minimum heart rate - ____beats/min
Maximum heart rate - ____beats/min
Other significant findings________________________
EVENT RECORDER (if applicable)
Paroxysmal atrial fibrillation – yes/no
Paroxysmal atrial flutter – yes/no
Mean heart rate - ____beats/min
Minimum heart rate - ____beats/min
Maximum heart rate - ____beats/min
Other significant findings________________________