I.D. # __ - __ - __ __ __ __ __ __ |
__________________________________________________________________________
OMB# 0925-XXXX
Expiration Date: XX / XX / XXXX
Attachment #6
Name: Main Case-Control Questionnaire
BURDEN STATEMENT:
Public reporting burden for this collection of information is estimated to average 1 hour 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-XXXX). Do not return the completed form to this address. |
PRIVACY STATEMENT:
Statement Of Privacy Act Applicability You will be asked to participate in the research study “Resource Collection and Evaluation of Human Tissues from Donors with an Epidemiological Profile for NCI Contract # NO2-RC-2010-00117”. The study will collect and use health information that can identify you. The authority to collect this information is under 42 USC 285 for the National Cancer Institute, National Institutes of Health. The Privacy Act from 1974 applies to the information collection. Federal laws require researchers to protect the privacy of your health information. The collection of health information by this study “Resource Collection and Evaluation of Human Tissues from Donors with an Epidemiological Profile for NCI Contract # NO2-RC-2010-00117” is covered by the Privacy Act and is in compliance with the Privacy Act System of Records Notice (SORN) # 09-25-0200 http://oma.od.nih.gov/ms/privacy/pa-files /0200, which covers clinical, basic, and population-based research studies of the National Cancer Institute and the National Institutes of Health. |
MARYLAND
LUNG AND PROSTATE CANCER
STUDY AND MULTI-ORGAN
STUDIES
QUESTIONNAIRE
National Cancer Institute
Building 37, Third Floor
Bethesda, Maryland 20892
Phone (301) 496-2048 Fax (301) 402-0497
University of Maryland School of Medicine
Howard Hall, Third Floor, Suite 322
660 West Redwood Street
Baltimore, Maryland 21201-1596
Phone (410) 706-5129 Fax (410) 706-5173
TABLE OF CONTENTS
A. IDENTIFIER SHEET 4
B. SOCIO-ECONOMIC INFORMATION 6
C. NUTRITIONAL SUPPLEMENTS 7
D. TOBACCO HISTORY 10
E. ALCOHOL HISTORY 19
F. MEDICAL HISTORY 21
G. FAMILY HISTORY 24
H. REPRODUCTIVE HISTORY 29
I. OCCUPATIONAL HISTORY 34
J. RESIDENTIAL HISTORY 36
K. EXERCISE 38
L. GENERAL INFORMATION 40
M. ADMINISTRATIVE INFORMATION 42
N. INTERVIEWER REMARKS 42
O. NUTRITION SUPPLEMENT 44
Date: __ __ / __ __ / __ __ __ __
Interviewer’s name:________________ Interviewer’s ID __ __
3. Hospital:_____________________________________
4. Doctor’s Name:___________________________
5. Patient’s Medical Record # ______________________
6. Patient’s Ethnicity ( )1 Hispanic/Latino ( )2 Non Hispanic/Latino
7. Patient’s Race ( )1 White
( )2 Black/African American
( )3 Asian
( )4 Native Hawaiian/Other Pacific Islander
( )5 American Indian/Alaska Native
8. Gender ( )1 Male
( )2 Female
9. Time started: __ __:__ __ ( )1 AM
( )2 PM
OFFICE USE ONLY
Review
Reviewer’s initials: ___ ___ ___ Date reviewed: __ __ / __ __ / __ __ __ __
Coding and Editing
Coder’s Initials: ___ ___ ___ Date coded: __ __ / __ __ / __ __ __ __
Data Entry
First Entry Initials: ___ ___ ___ Date Entered: __ __ / __ __ / __ __ __ __
Second Entry Initials: ___ ___ ___ Date Entered: __ __ / __ __ / __ __ __ __
IDENTIFIER SHEET
What is your name?________________/______________/_________________
First Middle Last
What is your date of birth? __ __ / __ __ / __ __ __ __
What is your address?
____________________________________________________________
Street Apt. No.
_______________________ ___ ___ __ __ __ __ __- __ __ __ __
City State Zip code
What is your telephone number? Home:( __ __ __) __ __ __ - __ __ __ __
Work: ( __ __ __) __ __ __ - __ __ __ __
Ext. __ __ __ __
5. Who is interviewed: ( )0 Patient (skip to A.8)
( )1 Other
( )2 No interview is possible
Name of person interviewed if other than the patient
______________________________________________________________
Last First Middle
Relationship to patient: ( )0 Spouse
( )1 Parent
( )2 Child
( )3 Brother or sister
( )4 Friend
( )5 Other -Specify________________________
8. What is the name, address and telephone number of a person who can help us contact you in the future, or your next-of-kin (or person who was interviewed if other than patient)?
____________________________________ __________________________
Name Relationship to patient
_______________________________________________ __________
Street Apt. No.
____________________________ ___ ___ __ __ __ __ __- __ __ __ __
City State Zip Code
Home telephone number # ( __ __ __) __ __ __ - __ __ __ __
TYPE
OF STUDY PARTICIPANT (
)1
Lung Cancer Case
( )2
Prostate Cancer Case
( )3
Hospital Control
( )4
Population Control
( )5
Multi-organ patient
SOCIO-ECONOMIC INFORMATION
Now I would like to ask you some general information about you.
What is your marital status? ( )1 Single, never married
( )2 Married
( )3 Divorced
( )4 Separated
( )5 Has a partner, living as married
( )6 Widowed
Do you consider yourself Hispanic/Latino or Not Hispanic/Latino? ( )1 Hispanic/Latino
( )2 Not Hispanic/Latino
Do you consider yourself to be:
( )1 Black or African American
( )2 White
( )3 Asian
( )4 Native Hawaiian or Other Pacific Islander
( )5 American Indian/Alaska Native
Most people in the United States have ancestors who came from other parts of the world. Please tell me what country or countries your ancestors came from.
5. In what religion were you raised?
SOCIO-ECONOMIC
INFO. ( )1
Very good ( )2
Good ( )3
Fair ( )4
Poor
NUTRITIONAL SUPPLEMENTS
Now I would like to learn more about your typical eating and drinking habits.
During the last 7 days, have you taken any vitamins or calcium?
( )0 No (Skip to C. 3) ( )1 Yes
2. |
Did you take: |
How many tablets in the past 7 days? |
a. |
Multivitamins, one-a-day type, such as Centrum ( )0 No (Skip to 2b) ( )1 Yes |
___ ___ ___ |
b. |
Multivitamins, stress tabs ( )0 No (Skip to 2c) ( )1 Yes |
___ ___ ___ |
c.
|
Multivitamins, therapeutic type such as Theragram ( )0 No (Skip to 2d) ( )1 Yes |
___ ___ ___ |
d.
|
Multivitamins, other ( )0 No (Skip to 2e) ( )1 Yes If yes, (specify) If yes, (specify)
|
___ ___ ___
___ ___ ___ |
e.
|
Vitamin A ( )0 No (Skip to 2f) ( )1 Yes |
___ ___ ___ |
f.
|
Vitamin E ( )0 No (Skip to 2g) ( )1 Yes |
___ ___ ___ |
g. |
Vitamin C ( )0 No (Skip to 2h) ( )1 Yes |
___ ___ ___ |
h.
|
Beta Carotene ( )0 No (Skip to 2i) ( )1 Yes |
___ ___ ___ |
i.
|
Calcium ( )0 No (Skip to 2j) ( )1 Yes |
___ ___ ___ |
j.
|
Other vitamins ( )0 No (Skip to 3) ( )1 Yes If yes, (specify) If yes, (specify) |
___ ___ ___
___ ___ ___ |
k. |
Other vitamins ( )0 No (Skip to 3) ( )1 Yes If yes, (specify) If yes, (specify) |
___ ___ ___
___ ___ ___ |
l. |
Other vitamins ( )0 No (Skip to 3) ( )1 Yes If yes, (specify) If yes, (specify) |
___ ___ ___
___ ___ ___ |
During the past seven days, have you eaten any special foods, food supplements such as those purchased through a natural food store or health food store?
( )0 No (Skip to C.5) ( )1 Yes
Please tell me what those foods, food supplements or vitamins were:
_____________________________________________
_____________________________________________
5. Please answer the following questions about supplements that you may have taken regularly during the past 5 years, at least 1 pill/week for 2 months.
Have you taken the following regularly - at least 1/week for 2 months during the past 5 years? |
How many pills per day or week did you take regularly, during the past 5 years? |
How long did you take regularly, during the past 5 years? |
Did you take regularly one year prior to interview? |
a. Aspirin or aspirin containing compounds (such as Bufferin, Anacin, Ascriptin, Excedrin) ( )0 no ( )1 yes ( )8 Don’t know |
___ # pills per: ( )1 day ( )2 week ( )8 Don’t know |
__ __ ( )1 weeks ( )2 months ( )3 years ( )8 Don’t know |
( )0 no ( )1 yes ( )8 Don’t know
|
b. Tylenol and acetaminophen compounds (such as Tylenol or Aspirin-free Anacin, or Excedrin-PM) ( )0 no ( )1 yes ( )8 Don’t know |
___ # pills per: ( )1 day ( )2 week ( )8 Don’t know |
__ __ ( )1 weeks ( )2 months ( )3 years ( )8 Don’t know
|
( )0 no ( )1 yes ( )8 Don’t know
|
c. Pain relievers not containing aspirin or Tylenol (such as Aleve, Ibuprofen, Motrin, Advil, Nuprin, Naprosyn, Feldene, Indocin, Clinoril) ( )0 no ( )1 yes ( )8 Don’t know |
___ # pills per: ( )1 day ( )2 week ( )8 Don’t know |
__ __ ( )1 weeks ( )2 months ( )3 years ( )8 Don’t know |
( )0 no ( )1 yes ( )8 Don’t know
|
SUPPLEMENT
INFO. ( )1
Very good ( )2
Good ( )3
Fair ( )4
Poor
TOBACCO HISTORY
Next, I would like to ask you some questions about any smoking history you may have.
Have you ever smoked more than 100 cigarettes, which is equivalent to five packs, in your life? ( )0 No (Skip to D. 18)
( )1 Yes
Please tell me about your smoking history. I will be asking you questions about any times you may have stopped or changed your patterns.
Period |
1 |
2 |
3 |
4 |
5 |
6 |
a. In what year did you start smoking cigarettes or change your patterns? |
__ __ __ __ |
__ __ __ __
|
__ __ __ __ |
__ __ __ __ |
__ __ __ __ |
__ __ __ __ |
b. What was the average number of cigarettes or packs per day you smoked during this time? |
__ __ __ __ ( )1cigarettes ( )2 packs |
__ __ __ __ ( )1cigarettes ( )2 packs |
__ __ __ __ ( )1cigarettes ( )2 packs |
__ __ __ __ ( )1cigarettes ( )2 packs |
__ __ __ __ ( )1cigarettes ( )2 packs |
__ __ __ __ ( )1cigarettes ( )2 packs |
c. After starting, did you change your patterns or stop smoking for more than 6 months? |
( )0 No (D3) ( )1 Stopped smoking ( )2 changed pattern |
( )0 No (D3) ( )1 Stopped smoking ( )2 changed pattern |
( )0 No (D3) ( )1 Stopped smoking ( )2 changed pattern |
( )0 No (D3) ( )1 Stopped smoking ( )2 changed pattern |
( )0 No (D3) ( )1 Stopped smoking ( )2 changed pattern |
( )0 No (D3) ( )1 Stopped smoking ( )2 changed pattern |
d. In what year did you stop smoking or change your patterns for more than six months? |
__ __ __ __ If this is a change of pattern, skip to D2a |
__ __ __ __ If this is a change of pattern, skip to D2a |
__ __ __ __ If this is a change of pattern, skip to D2a |
__ __ __ __ If this is a change of pattern, skip to D2a |
__ __ __ __ If this is a change of pattern, skip to D2a |
__ __ __ __
|
e. Did you start smoking again? |
( )0 No (D3) ( )1Yes (D2a) |
( )0 No (D3) ( )1Yes (D2a) |
( )0 No (D3) ( )1Yes (D2a) |
( )0 No (D3) ( )1Yes (D2a) |
( )0 No (D3) ( )1Yes (D2a) |
( )0 No (D3) ( )1Yes (D2a) |
If R stopped smoking more than 6 months ago, Skip to D. 6
3. Have you increased or decreased your amount of cigarette smoking in the last 6 months? ( )0 No (Skip to D6)
( )1 Yes
Period |
1 |
2 |
3 |
|
4. |
How long ago did you change your level of smoking? |
__ __ ( )1 weeks ( )2 months |
__ __ ( )1 weeks ( )2 months |
__ __ ( )1 weeks ( )2 months |
5a. |
Since then, what is the average amount of cigarettes you smoked per day? |
__ __ ( )1 cigarettes ( )2 packs |
__ __ ( )1 cigarettes ( )2 packs |
__ __ ( )1 cigarettes ( )2 packs |
5b. |
Did you change your level of smoking again? |
( )0 No (D6) ( )1 Yes (D4) |
( )0 No (D6) ( )1 Yes (D4) |
( )0 No (D6) ( )1 Yes (D6) |
For Case-Control Patients ONLY, Multi-organ patients skip to question #18.
How many cigarettes have you smoked in the last 48 hours?
__ __ __
Can you tell me the brand name of the cigarettes that you smoked the longest?
_______________________
What is the most recent brand that you smoked?
_______________________
When you were last smoking regularly, can you tell me, how soon after you (wake/woke) up (do/did) you smoke your first cigarette? (Read Responses)
( )1 Within 5 minutes
( )2 6 - 30 minutes
( )3 31 - 60 minutes
( )4 After 60 minutes
(Do/Did) you find it difficult not to smoke in places where it is forbidden, such as a church, library, or public building?
( )0 No ( )1 Yes
Which cigarette would you (hate/have hated) most to give up?
( )0 None/can’t decide
( )1 The first one in the morning
( )2 All others
( )3 After Meals
(Do /Did) you smoke more frequently during the first hours after waking than during the rest of the day? ( )0 No
( )1 Yes
(Do\did) you smoke if you (are/were) so ill that you (are/were) in bed most of the day?
( )0 No
( )1 Yes
During periods when you smoke(d), (do/did) you usually smoke filter or non-filter cigarettes?
( )1 Filter
( )2 Non-Filter
( )3 Both
During periods when you smoke(d), (do/did) you usually smoke menthol or non-menthol cigarettes?
( )1 Menthol
( )2 Non-Menthol
( )3 Both
When smoking cigarettes, do/did you usually inhale?
( )0 No (Skip to D. 18)
( )1 Yes
Did you inhale slightly, moderately, or deeply?
( )1 Slightly
( )2 Moderately
( )3 Deeply
Have you ever smoked at least one cigar a month for more than 6 months?
( )0 No
( )1 Yes
19. Have you ever smoked a pipe on a daily basis for more than 6 months?
( )0 No
( )1 Yes
20. During your childhood, until you moved out of your childhood home, did anyone in your home smoke cigarettes?
( )0 No ( Skip to D. 23)
( )1 Yes
21. How many people smoked in your home?
__ __
22. Who smoked in your home during childhood? (For Case-Control Participants Only. Multi-organ patients skip to question 23)
|
1 |
2 |
3 |
4 |
|
Please tell me their first names. |
|
|
|
|
|
a. |
What is their relationship to you? |
|
|
|
|
b. |
Would you say they smoked lightly, moderately, heavy or you do not know? |
( )1 light ( )2 moderate ( )3 heavy ( )8 DK |
( )1 light ( )2 moderate ( )3 heavy ( )8 DK |
( )1 light ( )2 moderate ( )3 heavy ( )8 DK |
( )1 light ( )2 moderate ( )3 heavy ( )8 DK |
c. |
On the average, how many cigars, pipes, cigarettes or packs per day (does/did) (he/she) smoke at home? |
__ __ __ ( )1 cigarettes ( )2 packs ( )3 cigars ( )4 pipes |
__ __ __ ( )1 cigarettes ( )2 packs ( )3 cigars ( )4 pipes |
__ __ __ ( )1 cigarettes ( )2 packs ( )3 cigars ( )4 pipes |
__ __ __ ( )1 cigarettes ( )2 packs ( )3 cigars ( )4 pipes |
d. |
For how many years did (he/she) smoke while you were in the home? |
__ __
< 1 year = 1 year |
__ __
< 1 year = 1 yr |
__ __
< 1 year = 1 yr |
__ __
< 1 year = 1 yr |
|
5 |
6 |
7 |
8 |
|
22. Con’t: Please tell me their first names. |
|
|
|
|
|
e. |
What is their relationship to you? |
|
|
|
|
f. |
Would you say they smoked lightly, moderately, heavy or you do not know? |
( )1 light ( )2 moderate ( )3 heavy ( )8 DK |
( )1 light ( )2 moderate ( )3 heavy ( )8 DK |
( )1 light ( )2 moderate ( )3 heavy ( )8 DK |
( )1 light ( )2 moderate ( )3 heavy ( )8 DK |
g. |
On the average, how many cigars, pipes, cigarettes or packs per day (does/did) (he/she) smoke at home? |
__ __ __ ( )1 cigarettes ( )2 packs ( )3 cigars ( )4 pipes |
__ __ __ ( )1 cigarettes ( )2 packs ( )3 cigars ( )4 pipes |
__ __ __ ( )1 cigarettes ( )2 packs ( )3 cigars ( )4 pipes |
__ __ __ ( )1 cigarettes ( )2 packs ( )3 cigars ( )4 pipes |
h. |
For how many years did (he/she) smoke while you were in the home? |
__ __
< 1 year = 1 yr |
__ __
< 1 year = 1 yr |
__ __
< 1 year = 1 yr |
__ __
< 1 year = 1 yr |
23. As an adult, does or did your (wife/husband/partner) or anyone else smoke or smoked cigarettes in your home? (If smoking is done only outside the home, then do not include.)
( )0 No (Skip to D.26)
( )1 Yes
24. How many people smoke or smoked in your home?
__ __
25. Who smoked in your home as an adult? (For Case-Control Participants Only. Multi-organ patients skip to question 26)
|
1 |
2 |
3 |
4 |
|
Please tell me their first names. |
|
|
|
|
|
a. |
What is their relationship to you? |
|
|
|
|
b. |
Would you say they smoked lightly, moderately, heavy or you do not know? |
( )1 light ( )2 moderate ( )3 heavy ( )8 DK |
( )1 light ( )2 moderate ( )3 heavy ( )8 DK |
( )1 light ( )2 moderate ( )3 heavy ( )8 DK |
( )1 light ( )2 moderate ( )3 heavy ( )8 DK |
c. |
On the average, how many cigars, pipes, cigarettes or packs per day (does/did) (he/she) smoke at home? |
__ __ __ ( )1 cigarettes ( )2 packs ( )3 cigars ( )4 pipes |
__ __ __ ( )1 cigarettes ( )2 packs ( )3 cigars ( )4 pipes |
__ __ __ ( )1 cigarettes ( )2 packs ( )3 cigars ( )4 pipes |
__ __ __ ( )1 cigarettes ( )2 packs ( )3 cigars ( )4 pipes |
d. |
For how many years did (he/she) smoke while you were in the home? |
__ __
< 1 year = 1 yr |
__ __
< 1 year = 1 yr |
__ __
< 1 year = 1 yr |
__ __
< 1 year = 1 yr |
e. |
Did (he/she) stop smoking while you were in the house? |
( )0 No (25g) ( )1 Yes |
( )0 No (25g) ( )1 Yes |
( )0 No (25g) ( )1 Yes |
( )0 No (25g) ( )1 Yes |
f. |
How long ago did (he/she) stop smoking? |
__ __ ( )1 months ( )2 years ( )3 weeks |
__ __ ( )1 months ( )2 years ( )3 weeks |
__ __ ( )1 months ( )2 years ( )3 weeks |
__ __ ( )1 months ( )2 years ( )3 weeks |
g. |
During the last thirty days, how many cigars, pipes, or cigarettes per day did (he/she) smoke at home? |
__ __
66= Deceased 77=Not living in the house |
__ __
66= Deceased 77=Not living in the house |
__ __
66= Deceased 77=Not living in the house |
__ __
66= Deceased 77=Not living in the house |
25. Smoked in your home as an adult (continued)
|
5 |
6 |
7 |
8 |
|
Please tell me their first names. |
|
|
|
|
|
h. |
What is their relationship to you? |
|
|
|
|
i. |
Would you say they smoked lightly, moderately, heavy or you do not know? |
( )1 light ( )2 moderate ( )3 heavy ( )8 DK |
( )1 light ( )2 moderate ( )3 heavy ( )8 DK |
( )1 light ( )2 moderate ( )3 heavy ( )8 DK |
( )1 light ( )2 moderate ( )3 heavy ( )8 DK |
j. |
On the average, how many cigars, pipes, cigarettes or packs per day (does/did) (he/she) smoke at home? |
__ __ __ ( )1 cigarettes ( )2 packs ( )3 cigars ( )4 pipes |
__ __ __ ( )1 cigarettes ( )2 packs ( )3 cigars ( )4 pipes |
__ __ __ ( )1 cigarettes ( )2 packs ( )3 cigars ( )4 pipes |
__ __ __ ( )1 cigarettes ( )2 packs ( )3 cigars ( )4 pipes |
k. |
For how many years did (he/she) smoke while you were in the home? |
__ __
< 1 year = 1 yr |
__ __
< 1 year = 1 yr |
__ __
< 1 year = 1 yr |
__ __
< 1 year = 1 yr |
l. |
Did (he/she) stop smoking while you were in the house? |
( )0 No (25n) ( )1 Yes |
( )0 No (25n) ( )1 Yes |
( )0 No (25n) ( )1 Yes |
( )0 No (25n) ( )1 Yes |
m. |
How long ago did (he/she) stop smoking? |
__ __ ( )1 months ( )2 years ( )3 weeks |
__ __ ( )1 months ( )2 years ( )3 weeks |
__ __ ( )1 months ( )2 years ( )3 weeks |
__ __ ( )1 months ( )2 years ( )3 weeks |
n. |
During the last thirty days, how many cigars, pipes, or cigarettes per day did (he/she) smoke at home? |
__ __
66= Deceased 77=Not living in the house |
__ __
66= Deceased 77=Not living in the house |
__ __
66= Deceased 77=Not living in the house |
__ __
66= Deceased 77=Not living in the house |
26. Were you exposed to cigarette smoke in your work place during the last 48 hours? ( )0 No
( )1 Yes
( )2 Not at work in the last 48 hours
( )3 Not currently working (or retired)
27. In your workplace, were you employed at a job or jobs for more than five years where co-workers smoked cigarettes in your immediate area?
( )0 No
( )1 Yes
28. For how many years were you working a job where people smoked regularly in your immediate work area?
___ ___ ( If 00, skip to Section E)
29. How long ago has it been since you were working at a job where people smoked regularly in your immediate work area?
( )1 Today
( )2 __ __ Day(s)
( )3 __ __ Month(s)
( )4 __ __ Year(s)
30. Would you say you were exposed at work to cigarette smoke lightly, moderately, heavy or you do not know?
( )1 Lightly
( )2 Moderately
( )3 Heavy
( )4 Do not know
TOBACCO
HISTORY ( )1
Very good ( )2
Good ( )3
Fair ( )4
Poor
E. ALCOHOL HISTORY
Now, I would like to ask you some questions about any alcoholic beverages you may drink on a regular basis.
1. In your entire life, have you ever consumed more than 12 alcoholic beverages per year, such as beer, wine, wine coolers or liquor? ( )0 No (Skip to E.3)
( )1 Yes
2. Tell me about the types of alcohol and when you were drinking them.
Period |
1 |
2 |
3 |
4 |
5 |
6 |
7 |
a. At what age did you first start to drink/when you next began to drink? |
___ ___ |
___ ___
|
___ ___ |
___ ___ |
___ ___ |
___ ___ |
___ ___ |
b. How many cans, bottles or 12 oz of beer did/do you drink? |
___ ___ ( )1 Per day ( )2 Per wk. ( )3 Per mo. ( )4 Per yr. |
___ ___ ( )1 Per day ( )2 Per wk. ( )3 Per mo. ( )4 Per yr. |
___ ___ ( )1 Per day ( )2 Per wk. ( )3 Per mo. ( )4 Per yr. |
___ ___ ( )1 Per day ( )2 Per wk. ( )3 Per mo. ( )4 Per yr. |
___ ___ ( )1 Per day ( )2 Per wk. ( )3 Per mo. ( )4 Per yr. |
___ ___ ( )1 Per day ( )2 Per wk. ( )3 Per mo. ( )4 Per yr. |
___ ___ ( )1 Per day ( )2 Per wk. ( )3 Per mo. ( )4 Per yr. |
c. How many 4 oz glasses of wine did/do you drink? |
___ ___ ( )1 Per day ( )2 Per wk. ( )3 Per mo. ( )4 Per yr. |
___ ___ ( )1 Per day ( )2 Per wk. ( )3 Per mo. ( )4 Per yr. |
___ ___ ( )1 Per day ( )2 Per wk. ( )3 Per mo. ( )4 Per yr. |
___ ___ ( )1 Per day ( )2 Per wk. ( )3 Per mo. ( )4 Per yr. |
___ ___ ( )1 Per day ( )2 Per wk. ( )3 Per mo. ( )4 Per yr. |
___ ___ ( )1 Per day ( )2 Per wk. ( )3 Per mo. ( )4 Per yr. |
___ ___ ( )1 Per day ( )2 Per wk. ( )3 Per mo. ( )4 Per yr. |
d. How many 1 ½ oz. shots of liquor, by itself or in a drink did/do you drink? |
___ ___ ( )1 Per day ( )2 Per wk. ( )3 Per mo. ( )4 Per yr. |
___ ___ ( )1 Per day ( )2 Per wk. ( )3 Per mo. ( )4 Per yr. |
___ ___ ( )1 Per day ( )2 Per wk. ( )3 Per mo. ( )4 Per yr. |
___ ___ ( )1 Per day ( )2 Per wk. ( )3 Per mo. ( )4 Per yr. |
___ ___ ( )1 Per day ( )2 Per wk. ( )3 Per mo. ( )4 Per yr. |
___ ___ ( )1 Per day ( )2 Per wk. ( )3 Per mo. ( )4 Per yr. |
___ ___ ( )1 Per day ( )2 Per wk. ( )3 Per mo. ( )4 Per yr. |
e. Have you ever stopped drinking or changed your patterns for more than 12 months? |
( )0 No (E3) ( )1 Stopped ( )2 Changed pattern |
( )0 No (E3) ( )1 Stopped ( )2 Changed pattern |
( )0 No (E3) ( )1 Stopped ( )2 Changed pattern |
( )0 No (E3) ( )1 Stopped ( )2 Changed pattern |
( )0 No (E3) ( )1 Stopped ( )2 Changed pattern |
( )0 No (E3) ( )1 Stopped ( )2 Changed pattern |
( )0 No (E3) ( )1 Stopped ( )2 Changed pattern |
f. What age did you stop drinking or change your patterns for more than 12 months? |
___ ___ |
___ ___ |
___ ___ |
___ ___ |
___ ___ |
___ ___ |
___ ___
|
3. Have you had any alcoholic beverages such as beer, wine or liquor in the last 7 days?
( )0 No (Skip to Section F)
( )1 Yes
|
Number: |
a. Cans, bottles or 12 oz. glass of beer |
__ __ __ |
b. 4 oz. glasses of wine |
__ __ __ |
c. 1 ½ oz. shots of hard liquor or drinks containing a shot of hard liquor |
__ __ __ |
ALCOHOL
HISTORY ( )1
Very good ( )2
Good ( )3
Fair ( )4
Poor
F. MEDICAL HISTORY
Now I would like to ask you some questions about your medical history and your health.
1. |
Did a doctor ever tell you that you had?: |
Yes/No |
How old were you when you were first diagnosed? DK = 888, condition at birth =000 |
a. |
Chronic bronchitis |
( )0 No (Skip to 1b) ( )1 Yes |
___ ___ ___ |
b. |
Emphysema |
( )0 No (Skip to 1c) ( )1 Yes |
___ ___ ___ |
c. |
Asthma during adult years
|
( )0 No (Skip to 1d) ( )1 Yes |
___ ___ ___ |
d. |
Tuberculosis
|
( )0 No (Skip to 1e) ( )1 Yes |
___ ___ ___ |
e.
|
Asbestosis |
( )0 No (Skip to 1f) ( )1 Yes |
___ ___ ___ |
1. |
(Cont.) Did a doctor ever tell you that you had: |
Yes/No |
How old were you when you were first diagnosed? DK = 888, condition at birth =000 |
f.
|
Lung disease, other than cancer (specify) *do not include current lung cancer |
( )0 No (Skip to 1g) ( )1 Yes |
___ ___ ___ |
g.
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Liver disease, such as chronic hepatitis or cirrhosis |
( )0 No (Skip to 1h) ( )1 Yes |
___ ___ ___ |
h.
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Kidney disease |
( )0 No (Skip to 1i) ( )1 Yes |
___ ___ ___ |
i.
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Heart disease |
( )0 No (Skip to 1j) ( )1 Yes |
___ ___ ___ |
j.
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Diabetes |
( )0 No (Skip to 1k) ( )1 Yes |
___ ___ ___ |
k. |
Lupus |
( )0 No (Skip to 1l) ( )1 Yes |
___ ___ ___ |
l. |
Rheumatoid arthritis |
( )0 No (Skip to 1m) ( )1 Yes |
___ ___ ___ |
m |
Thyroid condition (specify) |
( )0 No (Skip to 1n) ( )1 Yes |
___ ___ ___ |
n.
|
Anemia (chronic anemia, not one episode) |
( )0 No (Skip to 1o) ( )1 Yes |
___ ___ ___
|
o. |
Stroke |
( )0 No (Skip to 2) ( )1 Yes |
___ ___ ___
|
2. Have you taken any prescription or non prescription medicines in the last 3 months?
( )0 No (Skip to F.3)
( )1 Yes
What is the name of the medicine? |
Medication code (office use) |
When was the last time you took it?
|
What is it for? |
Indication code (office use) |
a. |
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__ __ / __ __ / __ __ __ __ |
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b. |
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__ __ / __ __ / __ __ __ __ |
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c. |
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d. |
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__ __ / __ __ / __ __ __ __ |
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e. |
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__ __ / __ __ / __ __ __ __ |
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f. |
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__ __ / __ __ / __ __ __ __ |
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g. |
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h. |
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i. |
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j. |
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k. |
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l. |
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m. |
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3. What is your current weight?
___ ___ ___ lbs
4. What was your weight 10 years ago?
___ ___ ___ lbs
5. What was your weight 2 years ago?
___ ___ ___ lbs
6. How tall are you?
______feet ___ ___ inches
MEDICAL
HISTORY ( )1
Very good ( )2
Good ( )3
Fair ( )4
Poor
G. FAMILY HISTORY
Now, I would like to learn more about the members of your family. First, I need to get some background about the structure of your family.
1. I would like to ask how many children you have had. Please include only those children related to you by blood.
____ ____
# Children
2. Were you adopted?
( )0 No
( )1 Yes
3. Counting only the brothers and sisters related to you by blood, how many brothers and sisters have you had? Please include half brothers and sisters.
___ ___ ___ ___
# Brothers # Sisters
Counting only the aunts and uncles related to you by blood, how many aunts and uncles have you had?
___ ___ ___ ___
# Uncles # Aunts
Has anyone in your family that is related to you by blood, ever been told they have cancer, include children, parents, grandparents, brothers, sisters, great grand parents, cousins or immediate aunts or uncles? (Include description of maternal or paternal relative) ( )0 No (Skip to G.7) ( )1 Yes
6. Which relative? |
First name |
Where did the cancer start? DK = 888 |
How old were they when they were diagnosed? |
a.
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( )1 <20 ( )5 50-59 ( )2 20-29 ( )6 60-69 ( )3 30-39 ( )7 > 70 ( )4 40-49 ( )8 Don’t know |
b.
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( )1 <20 ( )5 50-59 ( )2 20-29 ( )6 60-69 ( )3 30-39 ( )7 > 70 ( )4 40-49 ( )8 Don’t know |
c.
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( )1 <20 ( )5 50-59 ( )2 20-29 ( )6 60-69 ( )3 30-39 ( )7 > 70 ( )4 40-49 ( )8 Don’t know |
d.
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( )1 <20 ( )5 50-59 ( )2 20-29 ( )6 60-69 ( )3 30-39 ( )7 > 70 ( )4 40-49 ( )8 Don’t know |
e.
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( )1 <20 ( )5 50-59 ( )2 20-29 ( )6 60-69 ( )3 30-39 ( )7 > 70 ( )4 40-49 ( )8 Don’t know |
f.
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( )1 <20 ( )5 50-59 ( )2 20-29 ( )6 60-69 ( )3 30-39 ( )7 > 70 ( )4 40-49 ( )8 Don’t know |
g.
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( )1 <20 ( )5 50-59 ( )2 20-29 ( )6 60-69 ( )3 30-39 ( )7 > 70 ( )4 40-49 ( )8 Don’t know |
h.
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( )1 <20 ( )5 50-59 ( )2 20-29 ( )6 60-69 ( )3 30-39 ( )7 > 70 ( )4 40-49 ( )8 Don’t know |
i.
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( )1 <20 ( )5 50-59 ( )2 20-29 ( )6 60-69 ( )3 30-39 ( )7 > 70 ( )4 40-49 ( )8 Don’t know |
j.
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( )1 <20 ( )5 50-59 ( )2 20-29 ( )6 60-69 ( )3 30-39 ( )7 > 70 ( )4 40-49 ( )8 Don’t know |
k.
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( )1 <20 ( )5 50-59 ( )2 20-29 ( )6 60-69 ( )3 30-39 ( )7 > 70 ( )4 40-49 ( )8 Don’t know |
7. For the next questions, I’d like you to think about all those members of your family, who have medical problems other than cancer. (Include spouse, children, siblings, or parents.)
|
Did a doctor ever tell any member of your family that he or she had . . . |
Which relatives had the problem? |
First name |
How old were they when they were diagnosed? DK=888 |
a. |
Chronic bronchitis? ( )0 No (Skip to 7b) ( )1 Yes |
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__ __ __ |
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__ __ __ |
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__ __ __ |
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b. |
Emphysema ( )0 No (Skip to 7c) ( )1 Yes |
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__ __ __ |
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__ __ __ |
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__ __ __ |
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__ __ __ |
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c. |
Asthma during adult years ( )0 No (Skip to 7d) ( )1 Yes |
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__ __ __ |
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__ __ __ |
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__ __ __ |
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__ __ __ |
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d. |
Tuberculosis ( )0 No (Skip to 7e) ( )1 Yes
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__ __ __ |
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__ __ __ |
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e.
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Asbestosis ( )0 No (Skip to 7f) ( )1 Yes |
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__ __ __ |
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__ __ __ |
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f.
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Other lung disease specify:__________ ( )0 No (Skip to H ) ( )1 Yes |
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__ __ __ |
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__ __ __ |
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g.
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Other lung disease specify:_________ ( )0 No (Skip to H ) ( )1 Yes |
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__ __ __ |
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__ __ __ |
FAMILY
HISTORY ( )1
Very good ( )2
Good ( )3
Fair ( )4
Poor
H. REPRODUCTIVE HISTORY (IF MALE, SKIP TO SECTION I, P.35)
This next set of questions may seem personal, but remember that your answers are very important to us.
1. Have you ever been pregnant? ( )0 No (Skip to H. 7)
( )1 Yes
2. How many times have you been pregnant? ___ ___
|
1 |
2 |
3 |
4 |
5 |
6 |
7 |
8 |
9 |
10 |
11 |
12 |
3. How old were when you became pregnant? (Should be chronological) |
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4. What was the outcome of this pregnancy? (Check one for each pregnancy) |
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01 Single live birth |
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02 Multiple live birth, any living |
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03 Multiple birth, none living |
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04 Stillbirth |
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05 Miscarriage |
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06 Induced Abortion |
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07 Ectopic or tubal |
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08 Currently pregnant |
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09 Other (specify)________ |
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If R had no live births, Skip to H.7 |
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1 |
2 |
3 |
4 |
5 |
6 |
7 |
8 |
9 |
10 |
11 |
12 |
5. Did you breast feed any of these babies for at least two weeks or longer? ( )0 No (Skip to H.7) ( )1 Yes |
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6. For how many weeks did you breast feed these babies, until you stopped all together? |
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7. At what age did you have your first menstrual period? ___ ___
At what age did your menstrual periods become regular? ___ ___
(77 = period never became regular)
9. Have you used birth control, or family planning during your life?
( )0 No (Skip to H.11) ( )1 Yes
For Case-Control Participants ONLY, MULTI-ORGAN patients answer only 10a and then skip to question #11
10. What type of birth control or family planning, if any, have you used during your life?
|
At what age did you start? |
At what age did you stop? 77= still using |
a. Birth control pills ( )0 No (Skip to 11b) ( )1 Yes |
__ __ |
__ __ |
__ __ |
__ __ |
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__ __ |
__ __ |
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b. Birth control shots or injections ( )0 No (Skip to 11c) ( )1 Yes |
__ __ |
__ __ |
__ __ |
__ __ |
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__ __ |
__ __ |
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c. Implants, such as Norplant ( )0 No (Skip to 11d) ( )1 Yes |
__ __ |
__ __ |
__ __ |
__ __ |
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__ __ |
__ __ |
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d. Condoms or rubbers ( )0 No (Skip to 11e) ( )1 Yes |
__ __ |
__ __ |
__ __ |
__ __ |
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__ __ |
__ __ |
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e. Diaphragm, cap or sponge ( )0 No (Skip to 11f) ( )1 Yes |
__ __ |
__ __ |
__ __ |
__ __ |
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__ __ |
__ __ |
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f. Foam, jelly, cream or suppositories ( )0 No (Skip to 11g) ( )1 Yes |
__ __ |
__ __ |
__ __ |
__ __ |
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__ __ |
__ __ |
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g. Rhythm, calendar, ovulation or withdrawal ( )0 No (Skip to 11h) ( )1 Yes
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__ __ |
__ __ |
__ __ |
__ __ |
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__ __ |
__ __ |
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h. IUD, intrauterine devise, such as a loop or coil ( )0 No (Skip to H.12) ( )1 Yes |
__ __ |
__ __ |
__ __ |
__ __ |
11. Did you ever have your tubes tied, sterilization?
( )0 No (Skip to H.13)
( )1 Yes
12. When did the surgery take place?
__ __ / __ __ /__ __ __ __
13. Did your partner ever have a vasectomy, male sterilization or surgery?
( )0 No (Skip to H.15)
( )1 Yes
14. When did the surgery take place?
__ __ / __ __ /__ __ __ __
15. Did you ever use birth control pills, shots or implants for any reason other than birth control?
( )0 No (Skip to H.17)
( )1 Yes
16. What was the reason? Please answer yes or no to the following.
a. Regulate periods ( )0 No ( )1 Yes
b. Acne ( )0 No ( )1 Yes
c. Cramps or painful ovulation ( )0 No ( )1 Yes
d. Menopausal symptoms ( )0 No ( )1 Yes
e. Other ( )0 No ( )1 Yes
(specify)
17. Have you had a menstrual period in the last 6 weeks?
( )0 No
( )1 Yes
18. Are you still menstruating?
( )0 No
( )1 Yes (Skip to H. 22)
19. At what age was your last menstrual period?
___ ___
20. What was the reason that your menstrual periods stopped?
( )1 Change of life or natural Menopause
( )2 Hysterectomy, still has ovaries
( )3 Hysterectomy, ovaries removed
( )4 Hysterectomy, don’t know whether ovaries removed
( )5 Currently pregnant
( )6 Other reason (specify why): _______________________________________________
21. Has a doctor or other health professional ever told you that you had completed menopause or the change in life?
( )0 No
( )1 Yes
22. Have you ever used hormonal medications just before, during or after menopause, such as pills, vaginal creams, shots, suppositories or skin patches?
( )0 No (Skip to Section I)
( )1 Yes
|
|
At what age did you start to use them? |
Total number of years used? 77= still using |
a. Estrogen pills (Premarin, Estrace, Estratab, Ogen) |
( )0 No ( )1 Yes |
__ __ |
__ __ |
b. Progresterone pills (Progestins, Provera, Megace) |
( )0 No ( )1 Yes |
__ __ |
__ __ |
c. Estrogen and progesterone pills (Prempo) |
( )0 No ( )1 Yes |
__ __ |
__ __ |
d. Estrogen and testerone (Estratest) |
( )0 No ( )1 Yes |
__ __ |
__ __ |
e. Estrogen vaginal cream |
( )0 No ( )1 Yes |
__ __ |
__ __ |
f. Estrogen shots |
( )0 No ( )1 Yes |
__ __ |
__ __ |
g. Estrogen skin patches (Estraderm) |
( )0 No ( )1 Yes |
__ __ |
__ __ |
h. Estrogen patch and progesterone pills |
( )0 No ( )1 Yes |
__ __ |
__ __ |
i. Suppository |
( )0 No ( )1 Yes |
__ __ |
__ __ |
j. Other __________________ |
( )0 No ( )1 Yes |
__ __ |
__ __ |
REPRODUCTIVE
HISTORY (
)1
Very good ( )2
Good ( )3
Fair ( )4
Poor
I. OCCUPATIONAL HISTORY
Next, I would like to ask you some questions about your current and past jobs.
Are you currently employed?
( )0 No (Skip to I. 3)
( )1 Yes
What is your current job title?
___________________________________________________
What is or was your usual occupation for your adult life? That is, what occupation did you work at the longest during your adult life? (If R never worked, Skip to J)
G Never worked
___________________________________________________
What is or was your usual activities in this job? (Relates to Question 3)
________________________________________________________
In what kind of business or industry did you work the longest in your life?
____________________________________________________
6. Have you ever had a job in the following industries? |
Fill in Yes or No |
What was your job title? (Code ) |
In what year did you start working there? |
What year were you last employed there? Still employed=7777 |
a. Shipbuilding |
( )0 No ( )1 Yes |
|
__ __ __ __ |
__ __ __ __ |
b. Construction |
( )0 No ( )1 Yes |
|
__ __ __ __ |
__ __ __ __ |
c. Fishing |
( )0 No ( )1 Yes |
|
__ __ __ __ |
__ __ __ __ |
d. Lumber, wood, furniture, manufacturing or paper |
( )0 No ( )1 Yes |
|
__ __ __ __ |
__ __ __ __ |
e. Petrochemical |
( )0 No ( )1 Yes |
|
__ __ __ __ |
__ __ __ __ |
f. Metal refining, manufacturing, polishing or plating |
( )0 No ( )1 Yes |
|
__ __ __ __ |
__ __ __ __ |
g. Chemical manufacturing |
( )0 No ( )1 Yes |
|
__ __ __ __ |
__ __ __ __ |
h. Cement manufacture |
( )0 No ( )1 Yes |
|
__ __ __ __ |
__ __ __ __ |
i. Demolition |
( )0 No ( )1 Yes |
|
__ __ __ __ |
__ __ __ __ |
j. Steel mill or foundry |
( )0 No ( )1 Yes |
|
__ __ __ __ |
__ __ __ __ |
k. Dye industry |
( )0 No ( )1 Yes |
|
__ __ __ __ |
__ __ __ __ |
l. Hazardous waste removal |
( )0 No ( )1 Yes |
|
__ __ __ __ |
__ __ __ __ |
OCCUPATIONAL
HISTORY
( )1
Very good ( )2
Good ( )3
Fair ( )4
Poor
J. RESIDENTIAL HISTORY
Where were you born?______________________ ___ ___
City State
How many months or years did you live in the city or town where you were born?
____ ____ ( )1 months
( )2 years
If R lived here all his/her life, Skip to Section K
(R needs to live in location 6 months to constitute residence.)
Please tell me about each of the cities or town that you have lived in during your life. ( ) Military (check box)
Period |
1. |
2. |
3. |
4. |
|
a. Where did you live next?
Code country |
City/town |
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State |
___ ___ |
___ ___ |
___ ___ |
___ ___ |
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Country |
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Did you move from here? |
Fill in Yes or No |
( )0 No (K) ( )1 Yes |
( )0 No (K) ( )1 Yes |
( )0 No (K) ( )1 Yes |
( )0 No (K) ( )1 Yes |
At what age did you move from here? |
___ ___ |
___ ___ |
___ ___ |
___ ___ |
Period |
5. |
6. |
7. |
8. |
|
a. Where did you live next?
Code country |
City/town |
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State |
___ ___ |
___ ___ |
___ ___ |
___ ___ |
|
Country |
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Did you move from here? |
Fill in Yes or No |
( )0 No (K) ( )1 Yes |
( )0 No (K) ( )1 Yes |
( )0 No (K) ( )1 Yes |
( )0 No (K) ( )1 Yes |
At what age did you move from here? |
___ ___ |
___ ___ |
___ ___ |
___ ___ |
Period |
9. |
10. |
11. |
12. |
|
a. Where did you live next?
Code country |
City/town |
|
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|
State |
___ ___ |
___ ___ |
___ ___ |
___ ___ |
|
Country |
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|
Did you move from here? |
Fill in Yes or No |
( )0 No (K) ( )1 Yes |
( )0 No (K) ( )1 Yes |
( )0 No (K) ( )1 Yes |
( )0 No (K) ( )1 Yes |
At what age did you move from here? |
___ ___ |
___ ___ |
___ ___ |
___ ___ |
RESIDENTIAL
HISTORY (
)1
Very good ( )2
Good ( )3
Fair ( )4
Poor
K. EXERCISE
For Case-Control Participants ONLY. Multi-organ patients skip to section L
Please tell me about the kinds of activities you do during the week.
1. How would you describe your usual activity during your work in the past year?
( )0 Hard physical effort (ex. heavy lifting, digging).
Activities that make you breathe much harder than normal.
( )1 Moderate physical effort (ex. carrying light loads).
Activities that make you breathe somewhat harder than normal.
( )2 Less physical effort (ex. sitting at a desk, reading, working at a
computer.)
( )3 Not working.
( )8 Don’t Know
How would you describe your usual leisure time activity in the past year?
( )0 Hard physical effort (ex. heavy lifting, aerobics, or fast
bicycling).
Activities that make you breathe much harder than normal.
( )1 Moderate physical effort (ex. carrying light loads, bicycling at a
regular pace, gardening, or taking walks).
Activities that make you breather somewhat harder than normal.
( )2 Less physical effort (ex. sitting at a desk, reading, visiting friends,
or watching television.)
( )8 Don’t Know
How would you describe your usual activity during your work 20 years ago?
( )0 Hard physical effort (ex. heavy lifting, digging).
Activities that make you breathe much harder than normal.
( )1 Moderate ph ysical effort (ex. carrying light loads).
Activities that make you breathe somewhat harder than normal.
( )2 Less physical effort (ex. sitting at a desk, reading, working at a computer.)
( )3 Not working.
( )8 Don’t Know
How would you describe your usual leisure time activity 20 years ago?
( )0 Hard physical effort (ex. heavy lifting, aerobics, or fast
bicycling).
Activities that make you breathe much harder than normal.
( )1 Moderate physical effort (ex. carrying light loads, bicycling at a
regular pace, gardening, or taking walks).
Activities that make you breather somewhat harder than normal.
( )2 Less physical effort (ex. sitting at a desk, reading, visiting friends,
or watching television.)
( )8 Don’t Know
EXERCISE (
)1
Very good ( )2
Good ( )3
Fair ( )4
Poor
L. GENERAL INFORMATION:
What was the highest level of education that you completed:
( )1 Elementary School (5th or 6th grade)
( )2 Middle or Junior High School (7th, 8th or 9th grade)
( )3 10th or 11th grade
( )4 High School or GED (12th grade)
( )5 Some College (includes AA degree)
( )6 Technical School
( )7 College
( )8 Professional School (includes MS, PhD, MD, etc)
We need your social security number for the purposes of using it as a unique identifier. May I please have your social security number?
___ ___ ___ - ___ ___ - ___ ___ ___ ___
Fill in with 8s for Don’t Know/Refused.
What is your current level of household income per year?
( )1 Less than $10,000
( )2 $10,000-29,999
( )3 $30,000-59,999
( )4 $60,000-90,000
( )5 Greater than $90,000
( )8 Don’t Know/Refused
How many people are currently supported in your household?
___ ___
Fill in with 8s for Don’t Know/Refused.
What was the current level of household income in your home twenty years ago?
( )1 Less than $10,000
( )2 $10,000-29,999
( )3 $30,000-59,999
( )4 $60,000-90,000
( )5 Greater than $90,000
( )8 Don’t Know/Refused
Twenty years ago, how many people were supported in your household?
___ ___
ASK LUNG AND PROSTATE CANCER CASE PATIENTS ONLY (Questions 7-9)
Are you having any surgery in the near future?
( )0 No (Skip to Ending)
( )1 Yes
What kind of surgery are you having?
___________________________________________.
When are you having this surgery?
___ ___ / ___ ___ /___ ___ ___ ___
FOR ALL PARTICIPANTS
May we contact you again later if we need to clarify any of the information you have provided. ( )0 No
( )1 Yes
Time ended: __ __ : __ ___ ( )1 AM
( )2 PM
For Case-Control Participants ONLY – First get specimen samples and then provide reimbursement of $50.00.
Blood Specimen Collected
Urine Specimen Collected
M. ADMINISTRATIVE INFORMATION
Date form completed: __ __ / __ __ / __ __ __ __
Name of Interviewer _______________/___________/_____________
Interviewer ID number: __ __
Interviewer’s Signature: _______________________________
N. INTERVIEWER REMARKS
Interview was conducted:
( )1 Home
( )2 Hospital - inpatient (specify)________________
( )3 Hospital - outpatient (specify)_______________
( )4 Non-residential, non-hospital location
(specify) _____________________________
( )5 One of the Study Offices
( )6 Other (specify) ________________________
Respondent’s cooperation was: ( )1 Very good
( )2 Good
( )3 Fair
( )4 Poor
The overall quality of the interview was: ( )1 Very good
( )2 Good
( )3 Fair
( )4 Poor
Did any of the following occur during the interview?
a. R did not know enough information regarding the topics ( )0 No ( )1 Yes
b. R did not want to be more specific ( )0 No ( )1 Yes
c. R did not understand or speak English well ( )0 No ( )1 Yes
d. R was upset or depressed ( )0 No ( )1 Yes
e. R had poor hearing or speech ( )0 No ( )1 Yes
f. R was confused by frequent interruptions ( )0 No ( )1 Yes
g. R was emotionally unstable ( )0 No ( )1 Yes
h. Others helped with the answers ( )0 No ( )1 Yes
i. R required a lot of probing ( )0 No ( )1 Yes
j. Patient was reserved ( )0 No ( )1 Yes
k. R was physically ill ( )0 No ( )1 Yes
l. Other, specify ________________________________ ( )0 No ( )1 Yes
Comments/Remarks:
______________________________________________________________
______________________________________________________________
______________________________________________________________
______________________________________________________________
O. Supplemental Nutrition Section
Now I would like to learn more about your typical eating and drinking habits.
Time began: __ __ : __ ___ ( )1 AM
( )2 PM
1. During the past 6 months, how often have you eaten meat? (Includes chicken, beef, pork and lamb but not fish)
( )0 daily
( )1 4-6 per week
( )2 2-3 per week
( )3 once per week
( )4 1-3 per month
( )5 never or less than once a month
2. Two years ago, how often did you eat meat? (Includes chicken, beef, pork and lamb but not fish)
( )0 as frequently as it has been in the past 6 months
( )1 daily
( )2 4-6 per week
( )3 2-3 per week
( )4 once per week
( )5 1-3 per month
( )6 never or less than once a month
3. How much meat do you usually eat per serving?(Includes chicken, beef, pork and lamb but not fish)
For help: three ounces of meat is about the size of a cassette tape or a deck of
cards.
( )0 more than 12 ounces
( )1 7-12 ounces
( )2 3-6 ounces
( )3 less than 3 ounces, but still eats meat
( )4 never eats meat
4. During the past 6 months, how often have you eaten beef or lamb (includes steaks, stew, hamburger, roast, or hotdog)?
( )0 daily
( )1 4-6 per week
( )2 2-3 per week
( )3 once per week
( )4 1-3 per month
( )5 never or less than once a month
5. During the past 6 months, how often have you eaten pork (includes bacon, chops, roast, or sausage)?
( )0 daily
( )1 4-6 per week
( )2 2-3 per week
( )3 once per week
( )4 1-3 per month
( )5 never or less than once a month
6. During the past 6 months, how often have you eaten poultry (includes chicken, turkey, or duck)?
( )0 daily
( )1 4-6 per week
( )2 2-3 per week
( )3 once per week
( )4 1-3 per month
( )5 never or less than once a month
7. How is your meat usually cooked? (Includes chicken, beef, pork and lamb but not fish) (Code all that apply)
( )0 never eats meat (skip to question 8)
( )1 eats meat (skip to question 7a)
|
How is your meat usually cooked? |
|
a. |
baked |
( )0 no ( )1 yes |
b. |
boiled |
( )0 no ( )1 yes |
c. |
fried |
( )0 no ( )1 yes |
d. |
grilled |
( )0 no ( )1 yes |
e. |
steamed |
( )0 no ( )1 yes |
f. |
microwaved |
( )0 no ( )1 yes |
e. |
broiled |
( )0 no ( )1 yes |
8. Which method do you use most often? (Includes chicken, beef, pork and lamb but not fish)
( )0 baked
( )1 boiled
( )2 fried
( )3 grilled
( )4 steamed
( )5 microwaved
( )6 broiled
( )7 never eats meat
9. The red meat you eat is usually (Includes beef and pork)
( )0 well done
( )1 medium
( )2 rare
( )3 never eats meat
10. How often do you eat fish? (Fresh fish, not canned fish)
( )0 daily
( )1 4-6 per week
( )2 2-3 per week
( )3 once per week
( )4 1-3 per month
( )5 never or less than once a month
11. How much fish do you usually eat per serving?
For help: three ounces of grilled fish is the size of a typical checkbook.
( )0 more than 12 ounces
( )1 7-12 ounces
( )2 3-6 ounces
( )3 less than 3 ounces
12. What kinds of fat is used in the foods you eat? (Code all that apply)
( )0 none (skip to question 13)
( )1 eats fat (skip to question 12a)
|
What kinds of fat used in the foods you eat? |
|
a. |
butter |
( )0 no ( )1 yes |
b. |
bacon-fat |
( )0 no ( )1 yes |
c. |
margarine |
( )0 no ( )1 yes |
d. |
olive oil |
( )0 no ( )1 yes |
e. |
canola oil |
( )0 no ( )1 yes |
f. |
other oils |
( )0 no ( )1 yes |
13. During the past 6 months, how often did you have bacon-fat or drippings in your meals (includes breakfast, lunch, dinner)?
( )0 two-times or more per day
( )1 once per day
( )2 4-6 per week
( )3 2-3 per week
( )4 once per week
( )5 less than once per week
( )6 none or less than once per month
14. Two years ago, how often did you have bacon-fat or drippings in your meals?
( )0 as frequently as it has been in the past 6 months
( )1 twice per day
( )2 once per day
( )3 4-6 per week
( )4 2-3 per week
( )5 once per week
( )6 less than once per week
( )7 none or less than once per month
15. During the past 6 months, how much butter have you eaten per week?
For help: eight tablespoons of butter are equal to a stick of butter
( )0 more than 24 tablespoons (or more than 3 sticks)
( )1 17-24 tablespoons (or 2-3 sticks)
( )2 9-16 tablespoons (or 1-2 sticks)
( )3 8 tablespoons or less (or less than a stick)
( )4 none
16. Two years ago, how much butter did you eat per week?
( )0 more than 24 tablespoons (or more than 3 sticks)
( )1 17-24 tablespoons (or 2-3 sticks)
( )2 9-16 tablespoons (or 1-2 sticks)
( )3 8 tablespoons or less (or less than 1 stick)
( )4 none
17. During the past 6 months, how often have you eaten vegetables (includes garlic, onions)?
( )0 daily
( )1 4-6 per week
( )2 2-3 per week
( )3 once per week
( )4 1-3 per month
( )5 never or less than once a month
18. Two years ago, how often did you eat vegetables (includes garlic, onions)?
( )0 as frequently as it has been in the past 6 months
( )1 daily
( )2 4-6 per week
( )3 2-3 per week
( )4 once per week
( )5 1-3 per month
( )6 never or less than once a month
19. How many vegetables do you usually eat per serving?
For help: Your fist is approximately one cup.
( )0 2 cups or more
( )1 between 1 and 2 cups
( )2 ½ cup to 1 cup
( )3 less than ½ a cup
( )4 none
20. How are your vegetables usually cooked?
( )0 steamed
( )1 sauteed
( )2 boiled
( )3 fried
( )4 microwaved
( )5 fresh/uncooked
( )6 never eats vegetables
21. Over the past 6 months, how often did you eat broccoli (fresh or frozen)?
( )0 never (Skip to question O.23)
( )1 less than once per month
( )2 2-3 times per month
( )3 1 time per week
( )4 2 times per week
( )5 3-4 times per week
( )6 5-6 times per week
( )7 1 time per day
( )8 2 or more times per day
22. Each time you ate broccoli, how much did you usually eat?
For help: Your fist is approximately one cup.
( )0 Less than 1/4 cup
( )1 1/4 to 1 cup
( )2 More than 1 cup
23. During the past 6 months, how often have you eaten garlic?
( )0 daily
( )1 4-6 per week
( )2 2-3 per week
( )3 once per week
( )4 1-3 per month
( )5 never or less than once a month
24. Two years ago, how often did you eat garlic?
( )0 as frequently as it has been in the past 6 months
( )1 daily
( )2 4-6 per week
( )3 2-3 per week
( )4 once per week
( )5 1-3 per month
( )6 never or less than once a month
25. How much fresh garlic do you have in your food per week?
( )0 more than 2 heads
( )1 2 heads
( )2 1 head
( )3 half a head
( )4 a clove
( )5 none
26. During the past 6 months, how often have you eaten onions?
( )0 daily
( )1 4-6 per week
( )2 2-3 per week
( )3 once per week
( )4 1-3 per month
( )5 never or less than once a month
27. Two years ago, how often did you eat onions?
( )0 as frequently as it has been in the past 6 months
( )1 daily
( )2 4-6 per week
( )3 2-3 per week
( )4 once per week
( )5 1-3 per month
( )6 never or less than once a month
28. How many onions do you eat with your food per week?
( )0 more than 4 onions
( )1 3-4 onions
( )2 2 onions
( )3 1 onion
( )4 half an onion or less
( )5 none
29. How often do you eat other types of allium vegetables such as leek, chives or scallions?
( )0 daily
( )1 4-6 per week
( )2 2-3 per week
( )3 once per week
( )4 1-3 per month
( )5 never or less than once a month
30. During the past 6 months, how often have you eaten fresh tomatoes?
( )0 daily
( )1 4-6 per week
( )2 2-3 per week
( )3 once per week
( )4 1-3 per month
( )5 never or less than once a month
31. Two years ago, how often did you eat fresh tomatoes?
( )0 as frequently as it has been in the past 6 months
( )1 daily
( )2 4-6 per week
( )3 2-3 per week
( )4 once per week
( )5 1-3 per month
( )6 never or less than once a month
32. How many fresh tomatoes do you eat per week?
( )0 more than 10
( )1 6-10
( )2 3-5
( )3 1-2
( )4 less than one
33. How often do you eat food with processed tomatoes (puree, sauce)?
Examples are: spaghetti or pizza with tomato sauce.
( )0 daily
( )1 4-6 per week
( )2 2-3 per week
( )3 once per week
( )4 1-3 per month
( )5 never or less than once a month
34. How often do you have ketchup with your food?
( )0 daily
( )1 4-6 per week
( )2 2-3 per week
( )3 once per week
( )4 1-3 per month
( )5 never or less than once a month (Skip to end)
35. How much ketchup do you usually eat per meal?
( )0 more than 6 tablespoons
( )1 4-6 tablespoons
( )2 1-3 tablespoons
( )3 less than 1 tablespoon
This completes this portion of the interview.
Time ended __ __ : __ ___ ( )1 AM
( )2 PM
NUTRITION
( )1
Very good ( )2
Good ( )3
Fair ( )4
Poor
This completes our interview. I would like to now take the blood and urine sample. I want to thank you very much for the time you have spent in answering my questions today.
MLCS-MD
1.9 May 6, 2010 Page
File Type | application/msword |
Author | Registered User |
Last Modified By | Vivian Horovitch-Kelley |
File Modified | 2010-11-20 |
File Created | 2010-03-17 |