IJCS | Volume 31, Nº5, September / October 2018

479 Oliveira et al. Mortality and survival in aortic arch surgeries Int J Cardiovasc Sci. 2018;31(5)466-482 Original Article Appendix Appendix A - Standardized data collection form DATA COLLECTION FORM FILE ____________ 1. Demographic data Hospital: ___________________________________________________________________________________ Medical record (number): _____________________ Date of admission: ______/______/_________ Name of patient: _____________________________________________________________________________ Date of birth: ______/______/_________ Age (years) _______________ Sex: ( ) female ( ) male ( ) NI Skin color: ( ) white ( ) pardo ( ) yellow ( ) black ( ) other ____________ ( ) NI 2. Clinical data a. Risk factors (at admission) Family history CAD: ( ) yes ( ) no ( ) NI Sudden death: ( ) yes ( ) no ( ) NI Diabetes mellitus: ( ) yes ( ) no ( ) NI Glycemia: ______________ Use of medication: ( ) yes ( ) no ( ) NI Time of disease ______(years) ( ) NI SAH ( ) yes ( ) no ( ) NI Sys: _________ Day: _________ Use of medication: ( ) yes ( ) no ( ) NI Time of disease ______(years) ( ) NI Dyslipidemia: ( ) yes ( ) no ( ) NI Total Chol ______ LDL ______ HDL ______ TG ______ Use of medication: ( ) yes ( ) no ( ) NI Obesity: ( ) yes ( ) no ( ) NI BMI ______ weight ______ (kg) Height ______ (cm) ( ) NI Smoking: ( ) current smoker ( ) ex-smoker ( ) never smoker ( ) NI Current – time of smoking ______ (years)( ) NI Cigarettes per day ____________ ( ) NI Ex-smoker – time since quitting ____________ (years) ( ) NI Time of smoking ________ (years) ( ) NI Cigarettes per day _________ ( ) NI Sedentary lifestyle: ( ) yes ( ) no ( ) NI Marfan syndrome: ( ) yes ( ) no ( ) NI Rheumatic fever: ( ) yes ( ) no ( ) NI Collagenosis: ( ) yes ( ) no ( ) NI b. Comorbidities (past events) Ischemic stroke: ( ) yes ( ) no ( ) NI Recent: ( ) yes ( ) no ( ) NI Hemorrhagic stroke: ( ) yes ( ) no ( ) NI Recent: ( ) yes ( ) no ( ) NI Unspecified stroke: ( ) yes ( ) no ( ) NI Recent: ( ) yes ( ) no ( ) NI Motor incapacity caused by musculoskeletal or neurological dysfunction: ( ) yes ( ) no ( ) NI Higher creatinine before the procedure: __________________ Date: ______/______/_________ Chronic kidney failure: ( ) yes ( ) no ( ) NI Hemodialysis or peritoneal dialysis: ( ) yes ( ) no ( ) NI COPD: ( ) yes ( ) no ( ) NI Peripheral vascular disease: ( ) yes ( ) no ( ) NI