Attachment 2- Testing Instrument/2010 NHIS Cancer Supplement
OMB #0920-0222; Expiration Date: 02/28/10
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Diet [Ask all] |
1. During the PAST 12 MONTHS, did you take any MULTI-vitamins, such as One-A-Day, Theragran, or Centrum, etc? *Read if necessary: There are a number of vitamin and mineral combinations now available. The ways in which nutrients can be combined into pill form is almost infinite. Any combination of 3 or more vitamins and minerals should be included in the MULTI-vitamin category. Combinations labeled as "stress" or "antioxidant" supplements are common and should be included as MULTI-vitamins. Do NOT include combinations of herbal or botanical substances, or combinations of just 2 nutrients (e.g., calcium with vitamin D, etc.) in this question. Yes No Refused Don't know |
2.
During the PAST 12 MONTHS, did you take any calcium supplements
or pills? [fill1: Do NOT include any calcium in the MULTI-vitamins
you told me about.] |
3.
During the PAST 12 MONTHS, did you take any vitamin D supplements
or pills? [fill1: Do NOT include calcium supplements that contain
vitamin D or MULTI-vitamins you told me about.] |
3a. Thinking about the past 12 months, in how many of those MONTHS did you take vitamin D supplements?
_______________ number of months
|
3b. Now, thinking only about that month, on how many DAYS during that month did you take vitamin D supplements? / Now, thinking only about those months, on how many DAYS PER MONTH did you usually take vitamin D supplements?
_______________ days per month
|
3c.
On the DAY(S) you took vitamin D supplements, was the amount you
took usually less than 800 international units (IU), or 800
international units or more? |
Tobacco [Ask All] |
1. Have you smoked at least 100 cigarettes in your ENTIRE LIFE? Yes No [go to next section] Refused Don't know
1a. Thinking back over the years you have smoked regularly, about how many cigarettes did you usually smoke each day?
___________ (number per day)
1b. What is the average number of cigarettes that you smoked daily during the longest period that you smoked?
___________ (number per day)
|
2. Do you NOW smoke cigarettes every day, some days or not at all? Every day [go to next section] Some days [go to next section] Not at all Refused Don't know |
3.
Thinking back to when you stopped smoking completely, did you use
ANY of the following PRODUCTS: |
b.
A nicotine patch? |
c.
Any of these other nicotine products---nasal spray, inhaler, or
lozenge? |
d.
A prescription pill called Chantix or Varenicline? |
e.
A prescription pill other than Chantix or vareniclene, such
as Zyban, Buproprion, or Wellbutrin? |
f.
A telephone help line or quit line? |
g.
A stop smoking clinic, class, support group, or
one-on-one
counseling?
|
Pap/HPV [Ask all women] |
1. Have you EVER HAD a Pap smear or Pap test? * Read if necessary: A Pap smear or Pap test is a routine test for women in which the doctor examines the cervix, takes a cell sample from the cervix with a small stick or brush, and sends it to the lab. Yes No [go to question 10] Refused Don't know |
____________ age in years
|
3. When did you have your MOST RECENT Pap test?
___________ (month/day/year)
|
4.
Did you get the results of your MOST RECENT Pap
test? |
5.
Have you had a Pap test in the LAST 3 YEARS where the results were
NOT normal?
|
6.
Because of these results, was it recommended that you have
more follow-up exams or tests? Refused |
7.
Did you follow the recommendation to have more follow-up
exams or tests? |
8.
What is the most important reason that you DID NOT follow the
recommendation to have more follow-up exams or tests? [go to question 11] |
9.
Because of these follow-up exams or tests did you have
surgery or other treatment? No [go to question 12] Refused |
10. What is the most important reason you have [Fill1: NEVER had a Pap test/NOT had a Pap test in the LAST 3 YEARS]? No reason/never thought about it Didn't need it/didn't know I needed this type of test Doctor didn't order it/didn't say I needed it Haven't had any problems Put it off/didn't get around to it Too expensive/no insurance/cost Too painful, unpleasant, or embarrassing Had hysterectomy Don't have doctor Had an HPV DNA test Had HPV vaccine Other Refused Don't know |
11.
When, if ever, did you last get a reminder from a doctor or other
health professional to have a Pap test? |
12. Have you had a hysterectomy? A hysterectomy is when the uterus or womb is removed, not just having your tubes tied to prevent pregnancy. Yes No Refused Don’t know
|
13. Have you EVER had BOTH ovaries removed, either as part of a hysterectomy or as one or more separate surgeries? Yes No [go to question 14] Refused Don’t know |
13a. How old were you when you had BOTH of your ovaries removed?
_______________ age in years
|
14.
Have you ever heard of HPV? HPV stands for human papillomavirus
(pap-uh-LOW-muh-vi-rus).
|
15. Do you think HPV can cause cervical cancer? Yes No Refused Don't know |
16.
To the best of your knowledge, do you think you can get HPV
through sexual contact? |
17.
A vaccine to prevent HPV infection is available and is called
the HPV shot, cervical cancer vaccine, or GARDASIL®. Before
this survey, have you ever heard of the HPV shot or cervical
cancer vaccine?
|
18.
Have you ever received the HPV shot or cervical cancer
vaccine? |
19. How many HPV shots did you receive? 1 2 3 More than 3 Refused Don’t know
|
20. Have you finished the series of HPV shots that was recommended by your doctor? Yes No Refused Don’t know [go to next section] |
21.
Would you be interested in getting the HPV vaccine? |
22.
What is the MAIN reason you would NOT want to get the
vaccine? |
Breast Cancer Screening [Ask women 40 and over] |
1.
Have you EVER HAD a mammogram? *Read if necessary. A mammogram is
an x-ray taken only of the breast by a machine that presses
against the breast.
|
1a. When did you have your MOST RECENT mammogram?
______________ (month/day/year)
|
2.
After your MOST RECENT mammogram, was it recommended that you
have more tests? *Read if necessary: More tests may include
another mammogram, a sonogram or ultrasound, an MRI, a biopsy, or
something else to check for problems in your breasts. |
3.
Did you follow the recommendation to have more tests? |
4.
What is the most important reason why you DID NOT follow the
recommendation to have more tests? |
5. As a result of these additional tests after your [fill1: mammogram/mammograms] were you diagnosed with cancer? Yes No [go to question 7] Refused Don't know |
6.
How was your breast cancer found? |
7.
Have you EVER HAD a biopsy to test or remove a lump in your
breast that was found NOT to be cancer? No
[go
to question 9] Refused
[go
to question 9] |
8.
What is the most important reason why you have [fill1: NEVER had
a mammogram/NOT had a mammogram in the PAST 2 YEARS]? |
9.
A breast MRI, or magnetic resonance image, shows what is inside
the breast, like a mammogram, but does not require squeezing the
breast. Before getting a breast MRI, you are given a dye through
a needle in the arm. During the test, your lie on your stomach
and the bed moves into a tunnel-shaped machine. Refused
|
9a. When did you have your MOST RECENT breast MRI?
_______________ (month/day/year)
|
10.
What was the MAIN reason you had this breast MRI? |
PSA |
1. Have you ever had a PSA test?
Yes No [go to question 3]
1a. When did you have your most recent PSA test?
______________ (month/day/year)
2.
What was the MAIN reason you had this PSA test - was it part of a
routine exam, because of a problem, or some other reason? Because
of a problem [go
to question 5] |
3.
What is the MAIN reason you have not had a PSA test? |
4. Are any of the following statements reasons why you have not had a PSA test?
a. I haven’t had time for it Yes
Yes
c.
I can’t afford it
d.
I’ve read or heard conflicting recommendations about it
e. I don’t think it would help me Yes
f. I don’t know enough about it Yes
|
5.
[{Before you had the PSA test}] did a doctor EVER talk with you
about the advantages and disadvantages of [{it} / the PSA
test]? |
6.
[{Before you had the PSA test}] did a doctor EVER tell you that
some doctors recommend [{it} / the PSA test] and others do
not? |
Colorectal
Cancer Screening |
1.
Sigmoidoscopy and colonoscopy are exams in which a doctor inserts
a tube into the rectum to look for polyps or cancer. For a
sigmoidoscopy, the doctor checks only part of the colon and you
are fully awake. For a colonoscopy, the doctor checks the entire
colon, and you are given medication through a needle in your arm
to make you sleepy, and told to have someone drive you home.
|
2.
Recall that a colonoscopy is similar to a sigmoidoscopy but the
doctor checks the entire colon, and you are given medication
through a needle in your arm to make you sleepy, and told to have
someone drive you home.
|
3
. Virtual colonoscopy, also known as CT colonography, is a new
type of test that looks for polyps or cancer in the colon. The
day before the test, you take laxatives to clean out your colon.
During the test, your colon is filled with air and you are moved
through a donut-shaped X-ray machine as you lie on your back and
then on your stomach. You do not need medication to make you
sleepy during this test. |
4.
Have you EVER HAD a virtual colonoscopy or CT colonography? |
4a.. When did you have your MOST RECENT virtual colonoscopy or CT colonography?
_____________ (month/day/year)
|
5.
What was the MAIN reason you had this virtual colonoscopy or CT
colonography - was it part of a routine exam, because of a
problem, as a follow-up test of an earlier test or screening exam,
or some other reason? |
6.
During the past 10 years did a doctor tell you that you had a
polyp in your colon or rectum? |
7.
The following questions are about the blood stool or occult blood
test, a test to determine whether you have blood in your stool or
bowel movement. The blood stool test can be done at home using a
kit. You use a stick or brush to obtain a small amount of stool at
home and send it back to the doctor or lab. Have
you EVER HAD a blood stool test, using a HOME test kit? |
8.
Have you had a HOME blood stool test in the LAST 3 YEARS where the
results were NOT normal? |
9.
Because of these results, what additional tests or surgery did you
have? |
10.
Have you EVER been given a HOME blood stool test kit that you did
not complete and return to the doctor or laboratory? |
11
. (For
respondents who had not had colonoscopy in the past 10 years,
sigmoidoscopy in the past 5 years, CT colonography in the past 5
years, or FOBT in the last year) |
12
. Did the doctor or other health professional recommend to you
any particular tests? |
13.
Which tests to check for colon cancer did the doctor or other
health professional recommend to you? Possible tests include
stool blood or fecal occult blood test; sigmoidoscopy;
colonoscopy; CT colonography or virtual colonoscopy; or other.
[CODE ALL THAT APPLY] |
14.
(For
respondents who had not had colonoscopy in the past 10 years,
sigmoidoscopy in the past 5 years, CT colonography in the past 5
years, or FOBT in the last year) |
15. Are any of the following statements reasons why you have [never had any kind of test to look for problems in your colon or rectum//not had any kind of test recently]?
a. I haven’t had time for it Yes No Refused Don’t know
b. My doctor didn’t order it/say I needed it Yes No Refused Don’t know
c. I didn’t think that I needed it/know I needed this type of test Yes No Refused Don’t know
d. I can’t afford it/my insurance doesn’t cover it Yes No Refused Don’t know
e. Testing is too painful, unpleasant, or embarrassing Yes No Refused Don’t know
f. I don’t know enough about it Yes No Refused Don’t know
|
Survivorship |
1.1 Have you ever been told by a doctor or other health professional that you had cancer or a malignancy of any kind?
Yes No [END INTERVIEW]
|
2.
In general, how would you rate your physical health:…. |
3.
In general, how would you rate your mental health, including your
mood and your ability to think? |
4.
In general, how would you rate your satisfaction with your social
activities and relationships? |
5.
In general, please rate how well you carry out your usual social
activities and roles. (This includes activities at home, at work
and in your community, and responsibilities as a parent, child,
spouse, employee, friend, etc.) |
6.
To what extent are you able to carry out your everyday physical
activities such as walking, climbing stairs, carrying groceries,
or moving a chair? |
7.
In the past 7 days, how often have you been bothered by emotional
problems such as feeling anxious, depressed, or irritable? |
8.
(In the past 7 days) How would you rate your fatigue on
average? |
9. (In the past 7 days) How would you rate your pain on average? Use a scale of 0-10 with 0 being no pain and 10 being the worst imaginable pain. |
Now,
I will ask you some questions about your experiences with cancer.
|
11.
How often do you worry that your cancer may come back or get
worse? Would you say… |
12.
At any time since you were first diagnosed with cancer, did a
doctor or other health professional tell you that your cancer had
come back (that is, you had a recurrence)? |
12B. IF YES: What was the year of your most recent recurrence?
_________ year
|
13.
In the last 12 months have you received any treatment for your
cancer? By treatment, we mean surgery, radiation therapy,
chemotherapy, or bone marrow or stem cell transplant. Do not
include surgical biopsy, insertion of medication ports, such as a
Hickman, or long-term hormonal treatments such as tamoxifen or
aromatase inhibitors (e.g. Arimidex or Femara) for breast cancer.
Alternative: When was the last time you received surgery, radiation therapy, chemotherapy, bone marrow transplant, or stem cell transplant to treat cancer?
|
13B.
Are you currently in active treatment now? |
14.
To the best of your knowledge, are you now free of cancer (that
is, at this time, you don’t have cancer in any part of your
body)? |
If
you’ve had more than one cancer diagnosis, please think
about your most recent cancer diagnosis for the next few
questions. |
16.
At the completion of your cancer treatment, did you receive a
written summary from your doctor(s) or medical care providers that
described or explained the treatment you had received? |
17.
Have you EVER received advice from a doctor, nurse, or other
healthcare professional about where you should return or who you
should see for routine cancer check-ups after completing treatment
for cancer? |
17B.
IF YES: Was this information written down, printed on paper, or
provided in an electronic format for you? |
18.
Did you have any public or private health insurance that paid for
all or part of your cancer treatment? (Examples of insurance
include Medicare, Medicaid, insurance offered through an employer,
the military, or a policy you bought on your own) |
19.
After you were diagnosed with cancer, did your doctor, nurse or
other health professional talk with you about how cancer may
affect your emotions or your relationships with other people? |
19B.
Would you have liked it if your doctor had initiated a discussion
about these topics with you? |
20.
How satisfied were you, overall, with how well your doctor,
nurse, or other health professional, met your emotional and social
needs related to your cancer diagnosis and treatment? |
21.
After your cancer was diagnosed, did you receive professional
counseling or join a support group to help you cope? |
21B.
What was the main reason you did not get professional counseling
or join a support group? |
21C.
Would you have been interested in receiving professional
counseling or joining a support group if you had known about it? |
For
the next few questions, please answer based on all of your
experiences since the first time you were diagnosed with cancer.
|
23.
Were you EVER denied health insurance or life insurance coverage
because of your cancer? |
24.
To what degree has cancer caused financial problems for you and
your family? |
| File Type | application/msword |
| File Title | Attachment 2- Testing Instrument/2010 NHIS Cancer Supplement |
| Author | Karen Roberta Whitaker |
| Last Modified By | mxm3 |
| File Modified | 2008-08-15 |
| File Created | 2008-08-15 |