Genetic Studies Cohort of U.S. Radiologic Technologist

OMB No.: 0925-0405 Expires: xx/xx/2010

Study ID:

U.S. Radiologic Technologists Study

GENETIC STUDIES QUESTIONNAIRE
A collaborative effort between the University of Minnesota School of Public Health,
National Cancer Institute, and American Registry of Radiologic Technologists.
CONFIDENTIALITY:
Please be assured that all information you provide will be kept confidential and will not be disclosed to anyone but the
researchers conducting this study, except as otherwise required by law. Any published results from this study will be reported
in statistical summaries only and will never include a participant’s name. Your participation in this study is completely voluntary
and failure to answer any particular question or the information collection as a whole will not affect your future contacts with the
University of Minnesota, the American Registry of Radiologic Technologists, or the National Institutes of Health.

-

Today’s date:
MONTH

DAY

YEAR

SECTION A: FAMILY HISTORY
In this section we are interested to learn more about the health history of some of your female family members. Please
include only relatives who are related to you by blood, including half-siblings. Do not include adopted or step-relatives.
1. How many blood-related sisters (full and half) do you have,
including any who have died? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

NUMBER

2. How many biological daughters do you have, including any
who have died? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
NUMBER

3. Please complete the chart below for any of your first-degree female relatives (mother, sisters, or daughters)
who have been diagnosed with breast or ovarian cancer. Use a separate row for each person.

0 None of my female relatives have been diagnosed with breast or ovarian cancer. [GO TO SECTION B, PAGE 2.]
a. How is this person related to you?

b. What type of cancer did she have? How old
was she when first diagnosed with this cancer?

(Only include relatives who have been diagnosed
with breast or ovarian cancer.)

1st
relative

2nd
relative

3rd
relative

0 Mother
0 Sister
0 Daughter
0 Sister
0 Daughter
0 Sister
0 Daughter

Is this a full or
half sibling?

0 0

0 Breast cancer
0 Ovarian cancer

Is this a full or
half sibling?

0 0

0 Breast cancer
0 Ovarian cancer

0 0

0 Breast cancer
0 Ovarian cancer

Is this a full or
half sibling?

FULL

FULL

FULL

HALF

HALF

HALF

Age first diagnosed

AGE

Age first diagnosed

AGE

Age first diagnosed

AGE

Age first diagnosed

AGE

Age first diagnosed

AGE

Age first diagnosed

AGE

Please list additional female relatives diagnosed with breast or ovarian cancer on a separate piece of paper and return with this form.
Public reporting burden for this collection of information is estimated to average 20 minutes per response, including the time for reviewing instructions, searching
existing data sources, gathering and maintaining the data needed, and completing and reviewing the collection of information. An agency may not conduct or sponsor, and a person is not required to respond to, a collection of information unless it displays a currently valid OMB control number. Send comments regarding this
burden estimate or any other aspect of this collection of information, including suggestions for reducing this burden, to: NIH, Project Clearance Branch, 6705
Rockledge Drive, MSC 7974, Bethesda, MD20892-7974, ATTN: PRA (0925-0405). Do not return the completed form to this address.

SECTION B: REPRODUCTIVE HISTORY (WOMEN

ONLY)

Barcode

MEN - GO TO SECTION C, PAGE 3

PREGNANCY OUTCOMES
4. Please fill in the chart below for each pregnancy you have had. Please use more than one
line if a pregnancy resulted in multiple births (twins, triplets, etc.)

0 I have never been pregnant.
Pregnancy When did this

pregnancy end?
MONTH

YEAR

First
Second
Third
Fourth
Fifth
Sixth
Seventh
Eighth
Ninth

[GO TO QUESTION 5 BELOW.]

Did this pregnancy
result in a live birth?

Did you breast-feed
this baby?

How many
months?

NO YES

00
00
00
00
00
00
00
00
00

0 NO
0 NO
0 NO
0 NO
0 NO
0 NO
0 NO
0 NO
0 NO

0 YES
0 YES
0 YES
0 YES
0 YES
0 YES
0 YES
0 YES
0 YES

Please list additional pregnancies on a separate piece of paper and return with this form.
5. Have your menstrual periods stopped permanently?

0 Never menstruated
0 Still having menstrual periods
0 Not sure, periods are irregular or using hormone supplements
0 Menstrual periods have stopped permanently.

Age menstrual periods
stopped permanently

6. Have you had surgery to remove your uterus or one or both of your ovaries? [Mark all that apply.]

0 No
0 Yes, removal of uterus
0 Yes, one ovary removed
0 Yes, both ovaries removed

Age when removed

1st ovary

2nd ovary

-2-

SECTION C: PERSONAL MEDICAL RADIATION EXPOSURE
In this section we are interested in radiation exposure YOU RECEIVED AS A PATIENT,
NOT procedures performed by you. Please indicate how frequently you had any of the
following procedures during each time period listed since 1980. Please count the
number of times you had the procedure, NOT the number of individual films taken.
Please provide as much information as possible, including estimates if you cannot
remember the exact number of procedures.
7. Chest X-RAYS or Mammography
performed on YOU
Chest X-ray
Mammography

Between
1980 - 1989?

Between
1990 - 1999?

zero 1-3 4-7 8-10 11+

2000 to the
present?

zero 1-3 4-7 8-10 11+ zero 1-3 4-7 8-10 11+

00000 00000 00000
00000 00000 00000

8. Other FILM X-RAYS
performed on YOU

Between
1980 - 1989?
zero 1 2-4 5+

Between
1990 - 1999?
zero 1
2-4 5+

2000 to the
present?
zero 1
2-4 5+

Face or neck

00
00
00
00
00

0
0
0
0
0

0
0
0
0
0

0
0
0
0
0

0
0
0
0
0

0
0
0
0
0

0
0
0
0
0

0
0
0
0
0

0
0
0
0
0

0
0
0
0
0

0
0
0
0
0

00
00
00
00
00
00
00

0
0
0
0
0
0
0

0
0
0
0
0
0
0

0
0
0
0
0
0
0

0
0
0
0
0
0
0

0
0
0
0
0
0
0

0
0
0
0
0
0
0

0
0
0
0
0
0
0

0
0
0
0
0
0
0

0
0
0
0
0
0
0

0
0
0
0
0
0
0

Spine or back:
Thoracic (upper) spine plain film
Full spine plain film
Lumbar (lower) spine plain film
Myelogram
Gastrointestinal (GI) tract or abdomen:
Abdominal plain film
Upper gastrointestinal exam with contrast
Gallbladder exam with contrast
Barium swallow or meal with contrast
Barium enema with contrast
Urinary system
(e.g. pyelogram, urethrogram, cystogram)

Bony pelvis or hip
9. SPECIAL PROCEDURES
performed on YOU

Between
1980 - 1989?
zero 1 2-4 5+

Between
1990 - 1999?
zero 1
2-4 5+

2000 to the
present?
zero 1
2-4 5+

Cerebral arteriogram

0000 0000
0000 0000

0000
0000

0000 0000
0000 0000
0000 0000

0000
0000
0000

0000 0000

0000

Coronary angiogram or cardiac catheterization
(including angioplasty)

Carotid arteriogram
Pulmonary arteriogram
Renal arteriogram
Other fluoroscopy exam of the chest
(specify___________________________________)

-3-

Between
1980 - 1989?
zero 1 2-4 5+

10. CT SCANS
performed on YOU

0000
0000
0000
0000
0000
0000

Head or neck
Chest
Abdomen
Pelvis
Upper back or spine
Lower back or spine

Between
1990 - 1999?
zero 1 2-4 5+

2000 to the
present?
zero 1 2-4 5+

Barcode

0000 0000
0000 0000
0000 0000
0000 0000
0000 0000
0000 0000

11. THERAPEUTIC X-RAY SERIES
performed on YOU

Between
1980 - 1989?
zero 1 2-4 5+

Between
1990 - 1999?
zero 1
2-4 5+

2000 to the
present?
zero 1
2-4 5+

00
00
00
00
00
00
00

00
00
00
00
00
00
00

00
00
00
00
00
00
00

Note: If your treatment involved a course of multiple radiation
treatments over time (such as 1 treatment per day, 5 days per week
for 4-6 weeks), this should be counted as “1” series. If you later
received a course of radiation treatments for a new cancer, a recurrence,
or a metastasis, please count that as a separate series. We are
interested in the number of series, not the number of sessions.

Treatment series to breast
Treatment series to chest other than breast
Treatment series to abdomen
Treatment series to pelvis
Treatment series to thyroid or other part of neck
Treatment series to head
Treatment series to extremities

0
0
0
0
0
0
0

0
0
0
0
0
0
0

0
0
0
0
0
0
0

0
0
0
0
0
0
0

SECTION D: CHEMOTHERAPY
12. Have you ever had CHEMOTHERAPY for cancer, leukemia, lymphoma, a brain tumor or malignancy, or
other condition? If yes, please report each year you received chemotherapy and the reason for the
treatment. Please include treatment you received for a recurrence or metastasis.
NO YES

YEAR(S)

TYPE OF CANCER AND/OR REASON FOR TREATMENT

00

This is the end of the questionnaire. Please return completed questionnaire in
postage-paid envelope provided as soon as possible. If you have any questions,
please call the USRT Study office toll-free at 1-800-447-6466.

Thank you for your participation
GQ-Sub 3/27/06

-4-

0
0
0
0
0
0
0

0
0
0
0
0
0
0