Form 1 33 Medical History Update

Ver. 11
OMB #0925-0414 Exp: XX/XXXX

Form 33 - Medical History Update
MARKING INSTRUCTIONS
• Use a No. 2 pencil only.
• Darken the oval completely next to the answer you choose.
• Erase cleanly any marks you wish to change.
• Do not make any stray marks on this form.
CORRECT MARK

INCORR ECT MARKS

X .• •



This form asks about any health problems and health care since:
____________
month

, 20
day

year

Do not report hospital admissions, medical problems or tests that happened before this
date. However, if you are not sure of the date and don't think that you have reported the
problem to us before, please do answer the questions about that problem.
Public reporting burden for this collection of information is estimated to average 5 + 12 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, MD 20892-7974, ATTN: PRA (0925-0414). Do not return
the completed form to this address.

OFFICE USE ONLY

1. Date Received:
-

-

(MM/DD/YY)

2. Reviewed By:
4. Visit Type:

3. Contact Type:

1 Phone
2 Mail
8 Other

3 Annual
4 Non-Routine
5. Language:

 FCA

 OU1

1

 OU2

E

2
S

[Serial code #s]

C:\Documents and Settings\ludlams\Desktop\OMB 2010\Forms\11-20 forms\F33-33D_Combined_11-19-09.doc

Draft 11/16/09

1

WHI

1.

Form 33 - Medical History Update

What is today’s date? (Write the date in the space provided and mark the corresponding
bubbles below.)
Mo
Yr___
___
___- ___Day
___ - ___
Please mark only
one bubble per line:

2.

Ver 11

Month
Day
Year

Who is completing this form?

1 Self - Women's Health Initiative (WHI) Extension Study participant
4 Other (on behalf of the WHI participant, specify): _______________________
3.

Since the date on the front of this form, have you had any of the following exams, tests,
or procedures done by a doctor or other health care provider?
No
Yes
0
1 Breast exam

0
0

1
1

Mammogram

0
0

1
1

Other breast examination tests such as MRI or ultrasound

0

1

Tube inserted into your bowel to check for bowel problems
(sigmoidoscopy or colonoscopy).

0
0
0

1
1
1

Hysterectomy (surgery to remove the uterus or womb)

Test of breast tissue or fluid for disease (breast biopsy or aspiration)

Test for the presence of blood in your stool or bowel movement
(hemoccult, guaiac)

Endometrial biopsy
Bone density scan (DEXA)

Go to the next page.

C:\Documents and Settings\ludlams\Desktop\OMB 2010\Forms\11-20 forms\F33-33D_Combined_11-19-09.doc

Draft 11/16/09

2

WHI

4.

Form 33 - Medical History Update

Since the date on the front of this form, has a doctor or other health care provider told
you for the first time that you have any of the following specific conditions?
No

Yes

0
0
0
0
0
0
0

5.

1

Chronic obstructive pulmonary disease (COPD), emphysema, or
chronic bronchitis

1
1
1
1
1
1

Osteoarthritis or arthritis associated with aging
Macular degeneration with aging
Parkinson's disease
Intestine or colon polyps or adenomas
Moderate or severe memory problems (dementia or Alzheimer's)
Systemic lupus erythematosus (lupus)

Since the date on the front of this form, has a doctor or other health care provider prescribed
any of the following treatments for diabetes for the first time?
No

0
0
0
6.

Ver 11

Yes

1
1
1

Insulin
Pills or medications other than insulin
Diet and/or physical activity

Since the date on the front of this form, has a doctor or other health care provider
prescribed pills for high blood pressure or hypertension for the first time?

0 No

1 Yes

Go to the next page.

C:\Documents and Settings\ludlams\Desktop\OMB 2010\Forms\11-20 forms\F33-33D_Combined_11-19-09.doc

Draft 11/16/09

3

WHI

7.

Form 33 - Medical History Update

Since the date on the front of this form, how many times did you fall and land on the
floor or ground?

0 None
1 1 time
8.

Ver 11

2 2 times
3 3 or more times

Since the date on the front of this form, has a doctor or other health care provider newly
diagnosed or treated any of the following, OR have you been hospitalized for two or
more nights for any reason?
No

Yes

0
0
0
0

1
1
1
1

Cancer, malignant growth or tumor

0
0

1
1

Blood clots in your lungs or legs

0

1

Hospitalized for two or more nights for any reason

Broken, fractured or crushed bone
Stroke or transient ischemic attack (TIA)
Heart disease, including heart attack, heart failure, atrial fibrillation
(afib), or other heart conditions

Blocked or narrowed arteries to the legs causing poor circulation (not
varicose veins)

If you answered “yes” to one or more of the items in
question 8, please go to the next page..
If you answered NO to all of the items in question 8, you are done with this
form. Thank you.

C:\Documents and Settings\ludlams\Desktop\OMB 2010\Forms\11-20 forms\F33-33D_Combined_11-19-09.doc

Draft 11/16/09

4

WHI

Form 33 - Medical History Update

Ver 11

Questions on New Cancers, Malignant Growths or Tumors
9.

Since the date on the front of this form, has a doctor or other health care provider told you that
you have a new cancer, malignant growth or tumor? (Do not include benign tumors.)
0 No
If no, go to question 10 on page 8.
1 Yes
9.1

What type of cancer? (Mark all that apply.)

1
2
3
4
5

Breast
Ovary
Endometrium (lining of the uterus or womb)
Cervix
Other female genital organs (not ovary,
endometrium, or cervix)
Colon or rectum
Bladder or urinary tract
Brain
Esophagus
Gallbladder or bile ducts
Kidney
Leukemia; specify ___________________
Liver
Lung
Lymphoma: Hodgkin’s disease
Lymphoma: Non Hodgkin’s
Specify _______________________
Melanoma
Multiple myeloma
Pancreas
Skin cancer (not melanoma)
Stomach
Thyroid
Other cancer or malignant tumor not listed
above, specify:____________________
Unknown or don’t know

6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24

9.2

C:\Documents and Settings\ludlams\Desktop\OMB 2010\Forms\11-20 forms\F33-33D_Combined_11-19-09.doc

Date you were told you had
this cancer (mo-day-yr)
___ ___- ___ ___ - ___ ___
___ ___- ___ ___ - ___ ___
___ ___- ___ ___ - ___ ___
___ ___- ___ ___ - ___ ___
___ ___- ___ ___ - ___ ___
___ ___- ___ ___ - ___ ___
___ ___- ___ ___ - ___ ___
___ ___- ___ ___ - ___ ___
___ ___- ___ ___ - ___ ___
___ ___- ___ ___ - ___ ___
___ ___- ___ ___ - ___ ___
___ ___- ___ ___ - ___ ___
___ ___- ___ ___ - ___ ___
___ ___- ___ ___ - ___ ___
___ ___- ___ ___ - ___ ___
___ ___- ___ ___ - ___ ___
___ ___- ___ ___ - ___ ___
___ ___- ___ ___ - ___ ___
___ ___- ___ ___ - ___ ___
___ ___- ___ ___ - ___ ___
___ ___- ___ ___ - ___ ___
___ ___- ___ ___ - ___ ___
___ ___- ___ ___ - ___ ___
___ ___- ___ ___ - ___ ___
Draft 11/16/09

5

WHI

Form 33 - Medical History Update

Ver 11

Questions on New Cancers, Malignant Growths or Tumors, continued
Please provide contact information for the doctor or other health care providers that
diagnosed or treated the first cancer you reported on the previous question. If you have
been recently diagnosed with more than one cancer, record the contact information for
any other doctors or hospitals and the dates of admission and discharge in the Comments
section at the end of this form.
9.3

How was the cancer first diagnosed? (Mark all that apply.)

9.4

Who was the doctor or other health care provider who diagnosed your
cancer?
Provider name:
Street address:
City
Phone number: (

9.5

State

Office use only

Yr___ 5 PET or other imaging scan
1 Biopsy, date:___Mo___- ___Day
___ - ___
2 CT or CAT scan
6 Other, specify: __________________
____________________________________
3 Blood draw or lab results
4 Bone marrow biopsy
8 Unknown or don’t know

Zip Code

)

In what hospital, radiology center, clinic, or other medical facility was your
cancer first diagnosed?

City
Phone number: (

State

Office use only

Place name:
Street address:
Zip Code

)
Mo

Day

Yr

9.6 Date you entered the hospital (if unsure, estimate the date):

___ ___- ___ ___ - ___ ___

9.7 Date you left the hospital (if unsure, estimate the date):

___ ___- ___ ___ - ___ ___

C:\Documents and Settings\ludlams\Desktop\OMB 2010\Forms\11-20 forms\F33-33D_Combined_11-19-09.doc

Mo

Draft 11/16/09

Day

Yr

6

WHI

Form 33 - Medical History Update

Ver 11

Questions on New Cancers, Malignant Growths or Tumors, continued

9.8

Have you had any cancer-related surgeries after the cancer was first diagnosed? (Do not
include surgery if it was done during the hospital stay reported on the previous page.)
0 No
9.9 If no, are any planned? 0 No 1 Yes
1 Yes
Go to question 10 on the next page.

9.10 Number of cancer-related surgeries you have had:
9.11 Type(s) of cancer-related surgery, specify: _____________________________
9.12 Date of first cancer-related surgery after the cancer was diagnosed:
Mo Day Yr
___ ___- ___ ___ - ___ ___
9.13 Where did you have your cancer-related surgery?
Street address:
City
Phone number: (

State

Zip Code

Office use only

Place name:

)

C:\Documents and Settings\ludlams\Desktop\OMB 2010\Forms\11-20 forms\F33-33D_Combined_11-19-09.doc

Draft 11/16/09

7

WHI

Form 33 - Medical History Update

Ver 11

Questions on New Fractures

10.

Since the date on the front of this form, has a doctor or other health care provider told
you that you have a new broken, fractured, or crushed bone?

0 No
1 Yes

If no, go to question 11 on page 10.

10.1 Which bone(s) did you break, fracture, or crush?
(Mark all that apply.)

1
2

Hip
Upper leg (not hip)

3
4
5
6
7
8
9
10
11
12
13
14
15
16

Pelvis
Knee (patella)
Lower leg or ankle
Foot (not toe)
Tailbone (coccyx)
Spine or back (vertebra)
Upper arm or shoulder
Elbow
Lower arm or wrist
Hand (not finger)
Finger or toe
Jaw, nose, face, and/or skull
Ribs and/or chest or breast bone
Other, specify: ________________________

Go to the next page.

C:\Documents and Settings\ludlams\Desktop\OMB 2010\Forms\11-20 forms\F33-33D_Combined_11-19-09.doc

Go to question 11
on page 10.

Draft 11/16/09

8

WHI

Form 33 - Medical History Update

Ver 11

Questions on New Fractures
10.2 Was this broken, fractured, or crushed hip or upper leg bone first diagnosed or treated
during a hospital stay?

0 No
1 Yes

If no, go to question 10.6 below.

10.3 In what hospital or medical facility were you diagnosed or treated for the broken,
fractured, crushed hip or upper leg bone?

City
Phone number: (

State

Office use only

Place name:
Street address:
Zip Code

)

10.4 Date you entered the hospital (if unsure, estimate the date):___
Mo
Day
___- ___
___ - ___Yr
___
10.5 Date you left the hospital (if unsure, estimate the date):

Mo

Day

Yr

___ ___- ___ ___ - ___ ___

10.6 Was an outpatient X-ray or imaging scan (MRI) taken to diagnose the broken, fractured,
or crushed hip or upper leg bone (not already reported above)?

0 No
1 Yes

If no, go to the next page.

Place name:
Street address:
City
Phone number: (

State

Zip Code

Office use only

10.7 In what hospital or medical facility was your outpatient X-ray or imaging scan
(MRI) taken:

)

10.8 Date of X-ray or other imaging scan
(if unsure, estimate the date):

Mo
Day
___
___- ___
___ - ___Yr
___

C:\Documents and Settings\ludlams\Desktop\OMB 2010\Forms\11-20 forms\F33-33D_Combined_11-19-09.doc

Draft 11/16/09

9

WHI

Form 33 - Medical History Update

Ver 11

Information on New Hospitalized Stroke, Heart, and Circulation Problems
11.

Since the date on the front of this form, have you been admitted to a hospital for one or
more nights for any of the following health problems or procedures? (Do not include
outpatient visits.)
0 No
If no, go to question 12 on page 12.
1 Yes
No

0
0
0
0
0

Yes

1
1
1
1
1

Stroke
Transient ischemic attack (TIA)
MI, heart attack (coronary, myocardial infarction)
Heart bypass operation (coronary bypass surgery or CABG)
Procedure or surgery to unblock narrowed blood vessels to your heart
(opening the arteries of the heart with a stent, balloon, laser, or other
device. Also called PTCA, angioplasty, coronary intervention, or PCI)

0 1

Procedure or surgery to unblock narrowed blood vessels in your neck
(carotid endarterectomy, carotid angioplasty, or carotid stent)

0 1
0 1
0 1

Heart failure (congestive heart failure [CHF] or HF)

0
0
0
0
0

Heart valve problem or surgery to repair or replace a heart valve

1
1
1
1
1

0 1

Angina (chest pain from a heart problem)
Atrial fibrillation, or atrial flutter, irregular heart beat, requiring
medications or a procedure (electrical shock, cardioversion, ablation, or
surgery) to control.

Abdominal aortic aneurysm (AAA) requiring surgery or stent
Blood clots in the veins of your legs (deep vein thrombosis or DVT)
Blood clots in your lungs (pulmonary embolism or PE)
Poor blood circulation or blocked or narrowed arteries to your legs or feet
(claudication, peripheral arterial disease, gangrene, or Buerger’s disease;
not varicose veins or blood clots in veins)
Other heart or circulation problems: _______________________________

C:\Documents and Settings\ludlams\Desktop\OMB 2010\Forms\11-20 forms\F33-33D_Combined_11-19-09.doc

Draft 11/16/09

10

WHI

Form 33 - Medical History Update

Ver 11

Information on New Hospitalized Stroke, Heart, and Circulation Problems, continued
Please give the details of the first two hospital stay(s) for your stroke, heart, or circulation
problems or procedures that you marked on the previous page.
11.2 First hospital admission

City
Phone number: (

State

Office use only

Hospital name:
Street address:
Zip Code

)

11.3 Date you entered the hospital (if unsure, estimate the date):

Mo
Day
Yr___
___
___- ___
___ - ___

11.4 Date you left the hospital (if unsure, estimate the date):

Mo
Day
Yr___
___
___- ___
___ - ___

11.5 Second hospital admission

City
Phone number: (

State

Office use only

Hospital name:
Street address:
Zip Code

)

11.6 Date you entered the hospital (if unsure, estimate the date):

Mo
Day
Yr___
___
___- ___
___ - ___

11.7 Date you left the hospital (if unsure, estimate the date):

Mo
Day
Yr___
___
___- ___
___ - ___

11.8 Did you have any other hospital stays for health problems or procedures for your stroke,
heart or circulation problems?
0 No
Go to the next page.
1 Yes
11.9 How many other hospital stays?

1 1 stay 2 2 stays

3 3 or more stays

Please record additional provider information (hospital name, address and phone
number and dates of admission and discharge) in the Comments section at the end
of this form.

C:\Documents and Settings\ludlams\Desktop\OMB 2010\Forms\11-20 forms\F33-33D_Combined_11-19-09.doc

Draft 11/16/09

11

WHI

Form 33 - Medical History Update

Ver 11

Information on New Outpatient Stroke, Heart, and Circulation Problems, continued
12. Since the date on the front of this form, have you been diagnosed or treated as an
outpatient (not admitted to a hospital overnight) for any of the following conditions or
procedures not already reported in Question 11?
No

Yes

0 1

Stroke

0 1

Procedure to unblock narrowed blood vessels to your heart
(opening the arteries of the heart with a stent, balloon, laser, or
other device. Also called PTCA, angioplasty, coronary
intervention, or PCI)

0 1

Electrical shock, cardioversion or ablation procedure to correct
atrial fibrillation (afib) or atrial flutter

0 1

Stent, surgery or angioplasty to open blocked or narrowed arteries
to your legs or feet

0 1

Stent for aortic abdominal aneurysm (AAA)

0 1

Blood clots in the veins of your legs (deep vein thrombosis or DVT)

0 1

Shots (such as Lovenox, Arixtra, or heparin) for blood clots in the
veins of your legs (usually followed by blood thinning pills such
as Coumadin or warfarin)

If you checked “yes” to one or more items, please provide contact information for the
outpatient doctor or other health care provider (for the first box checked above). If
you marked more than one box, enter additional provider information in the
Comments section at the end of the form.
12.1 Date you were diagnosed or treated
(if unsure, estimate the date):

Mo

Day

Yr

___ ___- ___ ___ - ___ ___

Place name:
Street address:
City
Phone number: (

State

Zip Code

Office use only

12.2 Where did you receive your first diagnosis or treatment?

)

C:\Documents and Settings\ludlams\Desktop\OMB 2010\Forms\11-20 forms\F33-33D_Combined_11-19-09.doc

Draft 11/16/09

12

WHI

Form 33 - Medical History Update

Ver 11

Information on Hospital Stays (not already reported on this form)
13.

Since the date on the front of this form, have you been admitted to a hospital for two or
more nights? (Do not include an overnight stay that you have already reported on this
form.)

0 No
1 Yes

If no, go to the instructions at the end of the next page.

13.1 How many hospital stays of two or more nights?

1 1 2 2 3 3 or more

13.2 First hospital admission of two or more nights.
Hospital name:
Street address:

Phone number: (

City
)

State

Zip Code

Office use only

Please give the details of your first two hospital stay(s) since the date on the front of
this form. If you have any other two night hospital stays, please record the contact
information and dates of admission and discharge in the Comments section at the
end of the form.

13.3 Date you entered the hospital (if unsure, estimate the date):___
Mo
Day
Yr___
___- ___
___ - ___
13.4 Date you left the hospital (if unsure, estimate the date):

Mo
Day
Yr___
___
___- ___
___ - ___

13.5 Reason for this hospital admission: (Mark all that apply.)

1
2
3
4
5
6
7
88
13.6

9

Appendectomy or removal of appendix
Back surgery such as laminectomy, spinal fusion
Bowel or intestinal obstruction (not cancer)
Gallbladder attack or gallbladder surgery
Hernia repair
Joint repair or replacement
Non-cancer gynecologic surgeries: such as bladder suspension; vaginal,
uterine, rectal prolapse; stress incontinence
Other reasons: (Specify)____________________________________
Office use only

C:\Documents and Settings\ludlams\Desktop\OMB 2010\Forms\11-20 forms\F33-33D_Combined_11-19-09.doc

Draft 11/16/09

13

WHI

Form 33 - Medical History Update

Ver 11

Information on Hospital Stays (not already reported on this form)

Hospital name:
Street address:

Phone number: (

City
)

State

Zip Code

Office use only

13.7 Second hospital admission of two or more nights.

13.8 Date you entered the hospital (if unsure, estimate the date):___
Mo
Day
___- ___
___ - ___Yr
___
13.9 Date you left the hospital (if unsure, estimate the date):

Mo
Day
___
___- ___
___ - ___Yr
___

13.10 Reason for this hospital admission: (Mark all that apply.)

1
2
3
4
5
6
7
88
13.11

9

Appendectomy
Back surgery such as laminectomy, spinal fusion
Bowel or intestinal obstruction (not cancer)
Gallbladder attack or gallbladder surgery
Hernia repair
Joint repair or replacement
Non-cancer gynecologic surgeries: such as bladder suspension; vaginal,
uterine, rectal prolapse; stress incontinence
Other reasons: (Specify) __________________________________
Office use only

Please complete and sign the Authorization to Release Medical Records
on the back of this form.
Thank you. Please take a moment to review any questions you may have missed.
Feel free to write any comments on the next page.

You may receive a follow-up call to clarify your answers on this form.

C:\Documents and Settings\ludlams\Desktop\OMB 2010\Forms\11-20 forms\F33-33D_Combined_11-19-09.doc

Draft 11/16/09

14

WHI

Form 33 - Medical History Update

Ver 11

Please report comments and additional provider information below.

C:\Documents and Settings\ludlams\Desktop\OMB 2010\Forms\11-20 forms\F33-33D_Combined_11-19-09.doc

Draft 11/16/09

15

AUTHORIZATION TO RELEASE MEDICAL RECORDS
(Protected Health Information)
Name of facility/provider:_________________________________________________
The Women's Health Initiative (WHI) Extension Study is a national study sponsored by
the National Institutes of Health (NIH) whose ongoing purpose is to learn about the
health of post-menopausal women. By signing this form, I give permission to the named
facility to give information about my health care and health conditions to: the
investigators at the WHI Clinical Coordinating Center (CCC) and the Regional Center
affiliates.
Women’s Health Initiative
Clinical Coordinating Center
Fred Hutchinson Cancer
Research Center
1100 Fairview Ave. N.
PO Box 19024, M3-A410
Seattle, WA 98109-1024
1-800-xxx-xxx

WHI Regional Centers
To Be Named

The information released will only be used for research purposes by the WHI and will be
held in strict confidence. Examples of medical information to be requested:
Discharge summary
Emergency room records
Lab tests and results
History and physical
Operative reports
Consultations
Radiology/imaging
Procedure reports
Outpatient/short stay records
Pathology reports/specimens
MD notes/progress notes
By signing, I acknowledge that I have read and understood the following:
• Signing this authorization is voluntary.
• I have the right to revoke (cancel) this authorization at any time by notifying the WHI
in writing. If I do this, it will be in effect immediately as soon as it is received and no
further information about my health care and health conditions will be requested. If I
revoke this authorization, it will have no effect whatsoever on my enrollment or
participation in WHI.
• The above medical records may be shared with researchers at the WHI CCC at the
Fred Hutchinson Cancer Research Center, WHI Regional Centers or their affiliates,
the NIH (study sponsor), and regulatory agencies and review boards who watch over
the safety, effectiveness and conduct of the research. The HIPAA Privacy Rule may
no longer protect the information but the WHI, as a nationally funded research study,
has established continued protection for the disclosed information.
• WHI cannot further use or disclose the information in my medical records without my
consent.
• This authorization shall remain valid for the duration of the WHI Extension Study
(2010-2015).
• A photocopy or facsimile of this document is as valid as the original.

_____________________________________________
Signature of WHI Participant (or Authorized Representative)

__ __/__ __/20 __ __
Today’s Date

_____________________________________________
Printed Name of WHI Participant (or Legally Authorized
Representative and relationship to participant)

__ __/__ __/19 __ __
Date of Birth

C:\Documents and Settings\ludlams\Desktop\OMB 2010\Forms\11-20 forms\F33-33D_Combined_11-19-09.doc

Draft 11/16/09

16

Form 33
Spanish translation under way.
Instructions to WHI staff under way.