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pdfSupporting Statement A
Attachment 2
OS Participant Questionnaires
OBSERVATIONAL STUDY
PARTICIPANT QUESTIONNAIRES
Medical History Update (English)
Medical History Update (Spanish)
Activities of Daily Life (English)
Activities of Daily Life (Spanish)
Health Follow-Up by Proxy (English)
Health Follow-Up by Proxy (Spanish)
Medication and Supplement Inventory (English)
(Spanish version currently being translated)
Breast Cancer Prevention and Treatment Medications (English)
(Spanish version currently being translated)
Ver. 8.1
OMB #0925-0414 Exp: 5/09
Form 33 - Medical History Update
WHI Extension
#33-8#
MARKING INSTRUCTIONS
PERF
• Use a pencil only.
• Darken the circle completely next to the answer you choose.
• Erase cleanly any marks you wish to change.
• Do not make any stray marks on this form.
INCORRECT MARKS
CORRECT MARK
✓ ✗
This form asks about any health problems and health care since:
month
day
,-20
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 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:
Month
Day
Year
2. Reviewed By:
AFFIX LABEL BETWEEN LINES
BAR CODE HERE
PERF
3. Contact Type:
1 Phone
2 Mail
8 Other
4. Visit Type:
3 Annual
4 Non-Routine
5. Language:
FCA
OU1
OU2
1
E
2
S
SERIAL #
PLEASE MAKE NO MARKS IN THIS AREA
R:\DOC\FORMS\ENG\CURRENT\F1-199\F33V8_1.DOC 5/15/06
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WHI
1.
Ver. 8.1
Form 33 - Medical History Update
First, please tell us who is completing this form:
1
2
3
8
Women’s Health Initiative (WHI) Extension Study participant (self)
Family or friend of WHI Extension Study participant
Health care provider for WHI Extension Study participant
Other (Specify):
2.
Since the date on the front of this form, have you been admitted to a hospital for a stay of 2 nights
or more?
0 No
1 Yes
3.
Since the date on the front of this form, have you been diagnosed or treated because of heart problems,
blocked or narrowed blood vessels, stroke or other problems with your blood circulation (for example,
blood clots in the legs or lungs)?
0
1
No
Yes
Go to Question 4 on the next page.
3.1. For which of the following heart or circulation problems were you diagnosed or treated?
(Mark all that apply.)
1
Heart attack (coronary, myocardial
infarction or MI)
2
Heart failure (congestive heart failure or
CHF)
3
Chest pain from a heart problem (angina)
4
Heart bypass operation (coronary bypass
surgery or CABG)
5
6
Procedure to unblock narrowed vessels to
your heart (opening the arteries of the heart
with a balloon or other device, sometimes
called a PTCA, coronary angioplasty,
coronary stent, or laser)
Stroke
7
Transient ischemic attack (TIA)
8
Procedure or operation to unblock narrowed blood
vessels in your neck (carotid endarterectomy,
carotid angioplasty, or carotid stent)
9
Blood clots in your legs (deep vein
thrombosis or DVT)
10
Blood clots in your lungs (pulmonary
embolism or PE)
11
Poor blood circulation or blocked or
narrowed blood vessels to your legs or feet
(claudication, peripheral arterial disease,
gangrene, or Buerger’s disease)
88
Other heart or circulation problems
3.2. For any item marked above, were you admitted to a hospital for at least one night?
0
No
1
Yes
Please Go On to the Next Page
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WHI
Form 33 - Medical History Update
4.
Ver. 8.1
Since the date on the front of this form, has a doctor told you for the first time that you have
a new cancer or malignant tumor?
0
No
1
Yes
4.1. What type of cancer? (Mark all that apply.)
1 Skin cancer (not melanoma)
8 Other cancer or malignant tumor
5.
Since the date on the front of this form, has a doctor told you for the first time that you have
a new broken, fractured, or crushed bone?
0
No
1
Yes
5.1. Which bone(s) did you break, fracture, or crush?
(Mark all that apply.)
1
2
3
4
5
6
7
8
9
6.
Hand (not finger)
Elbow
12 Upper arm or shoulder
13 Jaw, nose, face, and/or skull
14 Finger or toe
15 Ribs and/or chest or breast bone
16 Cervical spine/neck
88 Other (Specify):
Hip
Upper leg (not hip)
Pelvis
Knee (patella)
Lower leg or ankle
Foot (not toe)
Tailbone (coccyx)
Spine or back (vertebra)
Lower arm or wrist
10
11
Since the date on the front of this form, has a doctor prescribed for the first time any of
the following pills or treatments? (Mark all that apply. If none apply, mark “None.”)
1
Pills for diabetes
2
Insulin shots for diabetes
3
4
5
6
7
Pills for osteoporosis other than
calcium supplements
8
Calcium supplements for
osteoporosis
9
Pills for high cholesterol
10
Estrogen or estrogen combination
pills
99
None
I have not been prescribed any of
the pills or treatments listed in
either column in Question 6 since
the date on the front of this form.
Diet and/or physical activity for
diabetes
Pills for high blood pressure or
hypertension
Treatment for depression
(pills or therapy)
Treatment for anxiety, panic, or
phobia (pills or therapy)
Please Go On to the Next Page
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WHI
Since the date on the front of this form, has a doctor told you for the first time that you have any
of the following specific conditions? (Mark all that apply. If none apply, mark “None.”)
1
2
3
Osteoarthritis or arthritis associated
with aging
Intestine or colon polyps or adenomas
Systemic lupus erythematosus (lupus)
99
8.
5
6
Macular degeneration
Parkinson’s disease
Moderate or severe memory problems
(for example, dementia or Alzheimer’s).
None
I have not had any of the conditions listed in
Question 7 since the date on the front of this form.
Since the date on the front of this form, which of the following exams, tests, or procedures have
you had done by a healthcare professional? (Mark all that apply. If none apply, mark
“None.”)
1
2
3
4
5
6
7
8
9.
4
Breast exam
Mammogram
Test of breast tissue or fluid for disease
(breast biopsy or aspiration)
PERF
7.
Ver. 8.1
Form 33 - Medical History Update
Dilation and Curettage (D & C, womb
scrape)
10 Removal of the uterus or womb
(hysterectomy)
11 Endometrial biopsy
9
Other breast examination tests such as
MRI or ultrasound
Rectal exam
Test for the presence of blood in your
stool or bowel movement (hemoccult,
guaiac)
Tube inserted into your bowel to check
for bowel problems (sigmoidoscopy,
flex. sig., or colonoscopy)
Barium enema X-ray
12
Bone density scan (e.g., DEXA)
99
None
I have not had any of the exams, tests,
or procedures listed in either column in
Question 8 since the date on the front
of this form.
What is the date that you finished answering this form? (Write the date in the space provided and
mark the corresponding bubbles below.)
Month
Day
Year
Please mark only one bubble per line:
1
2
3
4
5
6
7
8
9
10 11 12
1
2
3
4
5
6
7
8
9
10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31
05 06 07 08 09 10
PERF
Month
Day
Year
Use this space if you have additional information about your answers on this form.
SERIAL #
PLEASE MAKE NO MARKS IN THIS AREA
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U.S. GOVERNMENT PRINTING OFFICE:2006–576-258/40045
Pg. 4 of 4
Ver. 8.1
OMB #0925-0414 Exp: 5/09
Form 33S - Actualización del Historial Clínico
Extensión de WHI
#33S-8#
INSTRUCCIONES SOBRE COMO RESPONDER
PERF
• Solamente utilice un lápiz.
• Marque completamente negro el círculo que pertenece a la
respuesta que Ud. elige.
• Borre completamente cualquier repuesta que desea cambiar.
• No haga marcas o rayas adicionales en este formulario.
MARCAS INCORRECTAS
CORRECTA
✓ ✗
Este formulario le pregunta sobre cualquier problema de la salud y el cuidado de su salud desde:
mes
día
-20
año
No informe sobre estancias en hospitales, ni problemas ni exámenes médicos que hayan
ocurrido antes de esta fecha. Sin embargo, si no está segura de la fecha y no cree que nos haya
avisado del problema antes, favor de contestar las siguientes preguntas sobre ese problema.
El informe público por medio de estos datos colectivos se calcula tomar 5 minutos por cada respuesta, incluyendo el tiempo que tarde repasar las
instrucciones, investigado las fuentes de datos que existen actualmente, colectando y manteniendo los datos necesarios y completar y repasar el cuestionario.
A ninguna agencia se le permitirá llevar ni patrocinar una serie de datos colectivos, a menos que aparezca el número de control OMB válido; y al igual a
ninguna persona se le requirere resonder a lo mismo. Favor de dirigir sus comentarios sobre esta estimación de labor o cualquier otro aspecto de estos datos
colectivos, incluyendo sugerencias para reducir esta labor, al siguiente: NIH, Project Clearance Branch, 6705 Rockledge Drive, MSC 7974, Bethesda, MD
20892-7974, ATTN: PRA (0925-0414). Favor de no enviar estos cuestionarios completados a dichas direcciones.
PARA USO
EXCLUSIVO DE LA
OFICINA
1. Date Received:
Month
Day
Year
2. Reviewed By:
AFFIX LABEL BETWEEN LINES
BAR CODE HERE
PERF
3. Contact Type:
1 Phone
2 Mail
8 Other
4. Visit Type:
3 Annual
4 Non-routine
5. Language:
FCA
OU1
OU2
1
E
2
S
SERIAL #
Por favor, no haga ninguna marca en esta area.
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Pág. 1 de 4
WHI
1.
Form 33S - Actualización del Historial Clínico
Ver. 8.1
Primero, díganos quién completa este formulario:
1
2
3
8
Participante del Estudio de Extensión de La Mujer y su Salud (WHI) (usted misma)
Familiar o amigo(a) de la participante del Estudio de Extensión de la WHI
Proveedor de cuidados médicos de la participante del Estudio de Extensión de la WHI
Otro (especifíquelo):
2.
Desde la fecha citada en la portada de este formulario, ¿ha estado ingresada en un hospital para
una permanencia de 2 noches o más?
0 No
1 Sí
3.
Desde la fecha citada en la portada de este formulario, ¿le han diagnosticado o recibió tratamiento por
problemas cardíacos, vasos sanguíneos obstruidos o estrechos, apoplejías u otros problemas de circulación
sanguínea (por ejemplo, coágulos de sangre en las piernas o en los pulmones)?
0
1
No
Sí
Pase a la Pregunta 4 de la página siguiente.
3.1. ¿Para cuáles de los problemas cardíacos o de circulación recibió un diagnóstico o tratamiento?
(Marque todas las que correspondan.)
1
Ataque cardíaco (coronario, infarto de
miocardio o myocardial infarction, MI)
2
Insuficiencia cardíaca (insuficiencia cardíaca
congestiva o congestive heart failure, CHF)
3
Dolor en el pecho por un problema cardíaco
(angina)
Operación de bypass cardíaco (cirugía de
bypass coronario o coronary bypass surgery,
CABG)
Procedimiento para desobstruir vasos
estrechos hacia el corazón (apertura de las
arterias cardíacas con un globo u otro
dispositivo, a veces llamado PTCA,
angioplastia coronaria, endoprótesis
coronaria o láser)
7
8
4
5
6
Apoplejía
9
10
Ataque isquémico transitorio (transient
ischemic attack, TIA)
Procedimiento u operación para desobstruir
vasos sanguíneos estrechos en el cuello
(endarterectomía de carótida, angioplastia de
carótida o endoprótesis de carótida)
Coágulos de sangre en las piernas (trombosis de
vena profunda o deep vein thrombosis, DVT)
Coágulos de sangre en los pulmones
(embolia pulmonar o pulmonary embolism, PE)
Circulación sanguínea deficiente o vasos
sanguíneos estrechos u obstruidos hacia
las piernas o pies (claudicación,
enfermedad arterial periférica, gangrena, o
mal de Buerger)
88 Otros problemas de corazón o circulación
11
3.2. Para cualquiera de las opciones marcadas arriba, ¿fue hospitalizado(a) durante al menos 1 noche?
0
No
1
Sí
Pase a la siguiente página
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WHI
Form 33S - Actualización del Historial Clínico
4.
Ver. 8.1
Desde la fecha citada en la portada de este formulario, ¿le ha informado un doctor, por primera
vez, que tiene un nuevo cáncer o tumor maligno?
0
No
1
Sí
4.1. ¿Qué tipo de cáncer? (Marque todos los que correspondan.)
1 Cáncer de piel (sin contar el melanoma)
8 Otro tipo de cáncer o tumor maligno
5.
Desde la fecha citada en la portada de este formulario, ¿le ha informado el médico, por
primera vez, que tiene un nuevo hueso quebrado, fracturado, o aplastado?
0
No
1
Sí
5.1. ¿Qué hueso o huesos se quebró, aplastó, o fracturó?
(Marque todas las que correspondan.)
1 Cadera
10 Mano (sin contar los dedos)
2 Pierna superior (sin contar la cadera)
11 Codo
3 Pelvis
12 Brazo superior u hombro
4 Rodilla (rótula)
13 Mandíbula, nariz, rostro o cráneo
5 Pierna inferior o tobillo
14 Dedo de la mano o el pie
6 Pie (sin contar los dedos)
15 Costillas o hueso del tórax o pecho
7 Hueso de la cola (cóccix)
16 Columna cervical/cuello
8 Columna o espalda (vértebra)
88 Otro (especifíquelo):
9 Brazo inferior o muñeca
6.
Desde la fecha citada en la portada de este formulario, ¿le ha recetado algún médico, por
primera vez, alguna de las siguientes píldoras o tratamientos? (Marque todos los que
correspondan. Si no corresponde, marque “Ninguno(a).”)
1
Píldoras para la diabetes
2
Inyecciones de insulina para la
diabetes
Dieta o actividad física para la
diabetes
3
4
5
6
Píldoras para la presión arterial alta o
hipertensión
Tratamiento para la depresión
(píldoras o terapia)
Tratamiento para la ansiedad, pánico,
o fobia (píldoras o terapia)
7
Píldoras para la osteoporosis que no
sean suplementos de calcio
8
Suplementos de calcio para la
osteoporosis
9
Píldoras para el colesterol alto
10
Píldoras de estrógenos o
combinación de estrógenos
99
Ninguno(a)
No me han recetado ninguna de
las píldoras o tratamientos que se
indican en cualquiera de las
columnas de la Pregunta 6 desde
la fecha que aparece en la portada
del formulario.
Pase a la siguiente página
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WHI
Desde la fecha citada en la portada de este formulario, ¿le ha informado un médico, por
primera vez, que tiene alguna de las siguientes condiciones específicas? (Marque todos los
que correspondan. Si no corresponde, marque “Ninguno(a).”)
1
2
3
Osteoartritis o artritis asociadas con el
envejecimiento
Pólipos o adenomas del intestino o colon
Lupus eritematoso sistémico (lupus)
99
8.
5
6
Degeneración macular
Mal de Parkinson
Problemas de memoria moderados o severos
(por ejemplo, demencia o mal de Alzheimer).
Ninguno(a)
No he tenido ninguna de las afecciones que se enumeran en la
Pregunta 7 desde la fecha que aparece en la portada del formulario.
Desde la fecha citada en la portada de este formulario, ¿cuáles de los siguientes exámenes, análisis,
o procedimientos le realizó un médico o enfermera? (Marque todos los que correspondan. Si
no corresponde, marque “Ninguno(a).”)
1
2
3
4
5
6
7
8
9.
4
Exámen del seno
Mamograma
Exámen de los tejidos o fluidos del seno
para detectar alguna enfermedad
(biopsia o aspiración del seno)
Otros exámenes del seno tales como
MRI o ultrasonido
Examen rectal
Análisis para detectar la presencia de sangre
en las heces o movimientos intestinales
(hemoccult, guayaco bacteriológico)
Tubo introducido en el recto para detectar
problemas intestinales (sigmoidoscopía,
sigmoidoscopía flexible, o colonoscopía)
Rayos X a base de un enema de bario
PERF
7.
Ver. 8.1
Form 33S - Actualización del Historial Clínico
Dilatación y Legrado (D & C, raspado
del interior del útero o matriz)
10 Extirpación del útero o matriz
(histerectomía)
11 Biopsia endométrica
9
12
Barrido de densidad ósea (por ej.,
DEXA)
99
Ninguno(a) Nunca me han hecho
ninguno de los exámenes, análisis, o
procedimientos que se enumeran en
cualquiera de las columnas de la
Pregunta 8 desde la fecha citada en la
portada de este formulario.
¿En qué fecha completó usted este formulario? (Escriba la fecha en el espacio provisto y
marque las burbujas correspondientes abajo.)
mes
día
año
Por favor marque solamente un círculo por línea.
1
2
3
4
5
6
7
8
9
10 11 12
1
2
3
4
5
6
7
8
9
10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31
05 06 07 08 09 10
Use este espacio si tiene información adicional en cuanto a sus respuestas en este formulario:
SERIAL #
Por favor,
PLEASE
no DO
haga
NOT
ninguna
WRITE
marca
IN THIS
en AREA
esta area.
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Pág. 4 de 4
PERF
Mes
Día
Año
WHI
Form 33D - Medical History Update (Detail)
WHI Extension
Date Received:
-
-
Ver. 9
OMB # 0925-0414 Exp: 5/09
- Affix label here-
(M/D/Y)
Participant ID: __ __
Reviewed By:
-
__ __ - ___ ___ ___ - __
First Name ________________________M.I.______
Last Name _________________________________
Contact Type:
1 Phone
2 Mail
8 Other
Visit Type:
3 Annual
4 Non-Routine
OFFICE USE ONLY
Public reporting for this collection of information is estimated to average 10 minutes per response, including the time for reviewing instructions, searching
existing data sources, gathering and maintaining the information 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 is 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.
In Form 33 - Medical History Update, you said you had some medical problems that are important
for us to know about in more detail.
The questions on this form ask about hospital admissions, medical problems, and medical tests that
you have had since:
, 20
month
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.
1.
First, please tell us who is completing this form:
1 Women’s Health Initiative (WHI) Extension Study participant (self)
2 Family or friend of WHI Extension Study participant
3 Health care provider for WHI Extension Study participant
8 Other (Specify):
Please answer the
following questions
about the WHI
Extension Study
participant.
Go to the next page.
R:\Doc\Forms\English\Current\F1-199\F33DV9.doc 3/30/07
Page 1 of 12
WHI
Form 33D - Medical History Update (Detail)
WHI Extension
Ver. 9
Information on New Broken, Fractured, or Crushed Bone
2.
Since the date on the front of this form, has a doctor told you that you had a broken, fractured, or
crushed hip or upper leg bone?
1
2.1
Go to Question 3 on the next page.
Hip
Upper leg
Was this broken, fractured, or crushed hip or upper leg bone first diagnosed or treated
during a hospital stay?
1
2.3.
No
Where was the fracture? (Mark all that apply.)
1
2
2.2.
0
Yes
0
Yes
No
Go to Question 2.6 below.
What is the name, address, and phone number of the medical facility where you were treated
for the broken, fractured, or crushed hip or upper leg bone?
Place name:
Street address:
Office Use Only
Provider ID
City
Phone number: (
2.4.
State
)
Date you entered the hospital:
-
-
month
2.5.
Zip Code
Date you left the hospital:
day
-
year
-
month
day
year
2.6. Was an X-ray or imaging scan (MRI) taken to diagnose the broken, fractured, or crushed hip or
upper leg bone?
1
2.7.
Yes
0
No
Go to Question 3 on the next page.
Where was your X-ray or imaging scan (MRI) taken?
Office Use Only
Place name:
Street address:
Provider ID
City
Phone number: (
2.8.
State
Do not key enter if
identical to
provider ID in 2.3
Zip Code
)
What was the date of the visit? (If you had more
than one visit, give the date of the first visit.)
R:\Doc\Forms\English\Current\F1-199\F33DV9.doc 3/30/07
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month
day
year
WHI
Form 33D - Medical History Update (Detail)
WHI Extension
Ver. 9
Information on New Cancers or Malignant Tumors
3.
Since the date on the front of this form, has a doctor told you that you have a new cancer or malignant
growth or tumor? (Do not include benign tumors or cancers first diagnosed before the date on the
front of this form.)
1
3.1.
Yes
0
No
Go to Question 4 on page 5.
What kind of cancer or malignant tumor was it? (Mark all that apply.)
1
2
3
4
5
6
7
8
Breast
Ovary
Endometrium (lining of the uterus or womb)
Cervix (opening to the uterus or womb)
Colon, rectum, bowel, or intestine
Skin cancer (not melanoma)
9
10
11
12
13
88
Liver
Bone
Lymphoma or Hodgkin’s disease
Leukemia
Meningioma
Other cancer or malignant tumor
Melanoma
(Specify): ____________________
Lung
_____________________________
If you have checked more than one new cancer or malignant tumor above, write the medical provider
information below for the first cancer you were treated for.
If additional cancer sites were treated at different medical facilities, record the additional provider
information in the comments section on the last page.
3.2. Was this cancer or malignant tumor diagnosed or treated during a hospital stay of one or more nights?
1
3.3.
Yes
0
No
Go to Question 3.6 on the next page.
What is the name, address, and phone number of the place where the medical records
of the cancer are kept?
Place name:
Street address:
Office Use Only
Provider ID
City
Phone number: (
3.4.
State
)
Date you entered the hospital:
month
3.5.
Zip Code
Date you left the hospital:
day
month
year
-
day
year
Go to the next page.
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WHI
Form 33D - Medical History Update (Detail)
WHI Extension
3.6.
3.7.
What is the date when your cancer or
malignant tumor was first diagnosed?
Ver. 9
month
day
year
What is the name, address, and phone number of the place where your cancer
or malignant tumor was first diagnosed?
Office Use Only
Place name:
Street address:
Provider ID
City
Phone number: (
3.8.
State
Zip Code
Do not key enter if
identical to
provider ID in 3.3
)
What is the name, address, and phone number of the place where any other
tests or procedures for your cancer or malignant tumor were done?
Office Use Only
Place name:
Street address:
Provider ID
City
Phone number: (
State
)
Zip Code
Do not key enter if
identical to
provider ID in 3.3
or 3.7
Go to the next page.
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Page 4 of 12
WHI
Form 33D - Medical History Update (Detail)
WHI Extension
Ver. 9
Information on Hysterectomy
4.
Since the date on the front of this form, have you had a hysterectomy (operation to remove the uterus or
womb)?
1
Yes
0
No
Go to Question 5 on the next page.
-
-
4.1.
What was the date of the operation?
4.2.
What is the name, address, and phone number of the place where the operation was done?
month
day
year
Place name:
Street address:
Office Use Only
Provider ID
City
Phone number: (
4.3.
State
Zip Code
)
What is the name of the doctor who did the operation?
Office Use Only
Provider ID
Doctor’s name:
Street address:
City
Phone number: (
State
Zip Code
Do not key enter if
identical to
provider ID in 4.2
)
Go to the next page.
R:\Doc\Forms\English\Current\F1-199\F33DV9.doc 3/30/07
Page 5 of 12
WHI
Form 33D - Medical History Update (Detail)
WHI Extension
Ver. 9
Information on heart problems, blocked or narrowed blood vessels, stroke, blood clots in the legs or
lungs, and other blood circulation problems or related operations and/or procedures.
5.
Since the date on the front of this form, have you been diagnosed or treated for heart problems, blocked or
narrowed blood vessels, stroke, or other problems with your blood circulation (for example, blood clots in
your legs or lungs)?
1
Yes
0
No
Go to Question 9 on page 10.
5.1. Since the date on the front of this form, was this heart problem, blocked or narrowed blood vessels, stroke,
or other problems with your circulation (for example, blood clots in your legs or lungs) diagnosed or
treated during a hospital stay of one or more nights?
1
5.2.
Yes
0
No
Go to Question 6 on page 8.
For which of the following heart or circulation problems or procedures were you admitted?
(Mark all that apply.)
1
Heart attack (coronary, myocardial
infarction or MI)
5
Stroke
2
Heart bypass operation (coronary bypass
surgery or CABG)
6
Blood clots in your legs (deep vein
thrombosis or DVT)
3
Procedure to unblock narrowed vessels to
your heart (opening the arteries of the heart
with a balloon or other device, sometimes
called a PTCA, coronary angioplasty,
coronary stent, or laser)
7
Blood clots in your lungs (pulmonary
embolism or PE)
8
Poor blood circulation or blocked or
narrowed blood vessels to your legs or
feet (claudication, peripheral arterial
disease, gangrene, or Buerger’s
disease)
4
Procedure or operation to unblock
narrowed blood vessels in your neck
(carotid endarterectomy, carotid
angioplasty, or carotid stent)
88 Other heart or circulation problems
Go to the next page.
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Page 6 of 12
WHI
Form 33D - Medical History Update (Detail)
WHI Extension
Ver. 9
Please give the details of the first two hospital stay(s) where you were admitted for the heart
problems, blocked or narrowed blood vessels, stroke, blood clots in the legs (DVT) or lungs (PE), or
other blood circulation problems since the date on the front of this form.
Record additional provider information in the comments section on the last page.
5.3.
First hospital admission of one or more nights for heart or circulation problems
or procedures.
Hospital name:
Street address:
Office Use Only
Provider ID
City
Phone number: (
5.4.
State
)
Date you entered the hospital:
-
-
month
5.5.
Date you left the hospital:
day
-
year
-
month
5.6.
Zip Code
day
year
Second hospital admission of one or more nights for heart or circulation problems
or procedures.
Hospital name:
Street address:
Office Use Only
Provider ID
City
Phone number: (
5.7.
State
)
Date you entered the hospital:
month
5.8.
Zip Code
Date you left the hospital:
day
month
year
-
day
year
Go to the next page.
R:\Doc\Forms\English\Current\F1-199\F33DV9.doc 3/30/07
Page 7 of 12
WHI
Form 33D - Medical History Update (Detail)
WHI Extension
Ver. 9
Heart, Stroke, Blood Clots in the Legs (DVT) (Outpatient)
6.
Since the date on the front of this form, have you ever been treated by a doctor or a nurse with shots at
home or as an outpatient (usually followed by blood thinning pills such as Coumadin or warfarin)
for blood clots in your legs, called deep vein thrombosis or DVT?
1
6.1.
6.2.
Yes
0
No
Go to Question 7 on the next page.
On what date did the shots start (shots such
as as Lovenox, Arixtra, or heparin)?
month
day
year
What is the name, address, and phone number of the doctor who treated you
for blood clots in your leg?
Office Use Only
Doctor’s name:
Street address:
Provider ID
City
Phone number: (
State
Zip Code
)
6.3. Since the date on the front of this form, have you ever had outpatient test(s) performed for blood clots in
your legs (called deep vein thrombosis or DVT)?
1
6.4.
Yes
0
No
Go to Question 7 on the next page.
On what date was the test performed?
month
6.5.
day
year
What is the name, address, and phone number of the place where you had the
outpatient test performed for blood clots in your legs?
Office Use Only
Place name:
Street address:
Provider ID
City
Phone number: (
State
)
Zip Code
Do not key enter if
identical to
provider ID in 6.2.
Go to the next page.
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Page 8 of 12
WHI
7.
Form 33D - Medical History Update (Detail)
WHI Extension
Ver. 9
Since the date on the front of this form, have you been diagnosed or treated as an outpatient for a stroke?
1
7.1.
Yes
0
No
Go to Question 8 below.
What was the date you were diagnosed or treated?
month
7.2.
day
year
What is the name, address, and phone number of the place where you were first diagnosed or
treated for a stroke?
Place name:
Street address:
Office Use Only
Provider ID
City
Phone number: (
8.
State
Zip Code
)
Since the date on the front of this form, have you had an outpatient or day surgery procedure to
unblock narrowed vessels to your heart (opening the arteries of the heart with a balloon or other device,
sometimes called a PTCA, coronary angioplasty, coronary stent, or laser)?
1
Yes
0
No
Go to Question 9 on the next page.
-
8.1.
What was the date of the procedure or surgery?
8.2.
What is the name, address, and phone number of the place where the
procedure or surgery was performed?
month
day
Place name:
Street address:
Office Use Only
Provider ID
City
Phone number: (
year
State
Zip Code
)
Go to the next page.
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Page 9 of 12
WHI
Form 33D - Medical History Update (Detail)
WHI Extension
Ver. 9
Hospital Stay of Two or More Nights and Not Already Reported on this Form.
9.
Since the date on the front of this form, have you been admitted to the hospital for two or more nights?
(Do not include an overnight stay that you have already reported on this form.)
1
0
Yes
No
Go to Question 10 on the last page.
Please give the details of the first three hospital stays where you were admitted for two or more
nights since the date on the front of this form.
Please record additional provider information in the comments section on the last page.
9.1. First hospital admission of two or more nights.
Hospital name:
Street address:
Office Use Only
City
Phone number: (
State
Zip Code
Provider ID
)
9.2. Date you entered the hospital:
month
9.3. Date you left the hospital:
day
month
year
-
day
year
9.4. Reason for this hospital admission: (Mark all that apply.)
1
2
3
4
88
9.5.
5
Non cancer gynecologic surgeries: e.g., bladder suspension, vaginal/uterine/rectal
prolapse, stress incontinence
Gallbladder attack or gallbladder surgery
Cataract surgery
Joint repair or replacement
Other reasons: (Specify) ___________________________________________________
Office use only
Go to the next page.
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Page 10 of 12
WHI
Form 33D - Medical History Update (Detail)
WHI Extension
Ver. 9
9.6. Second hospital admission of two or more nights.
Hospital name:
Street address:
Office Use Only
Provider ID
City
Phone number: (
State
Zip Code
)
9.7. Date you entered the hospital:
month
9.8. Date you left the hospital:
day
month
year
-
day
year
9.9. Reason for this hospital admission: (Mark all that apply.)
1
2
3
4
88
9.10.
5
Non cancer gynecologic surgeries: e.g., bladder suspension, vaginal/uterine/rectal
prolapse, stress incontinence
Gallbladder attack or gallbladder surgery
Cataract surgery
Joint repair or replacement
Other reasons: (Specify) ___________________________________________________
Office use only
9.11. Third hospital admission of two or more nights.
Hospital name:
Street address:
Office Use Only
Provider ID
City
Phone number: (
State
Zip Code
)
9.12. Date you entered the hospital:
month
9.13. Date you left the hospital:
day
month
year
-
day
year
9.14. Reason for this hospital admission: (Mark all that apply.)
1 Non cancer gynecologic surgeries: e.g., bladder suspension, vaginal/uterine/rectal
prolapse, stress incontinence
2 Gallbladder attack or gallbladder surgery
3
4
88
9.15.
5
Cataract surgery
Joint repair or replacement
Other reasons: (Specify) ___________________________________________________
Go to the next page.
Office use only
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Page 11 of 12
WHI
10.
Form 33D - Medical History Update (Detail)
WHI Extension
What was the date that you finished answering this form?
Ver. 9
month
day
year
Please report comments and additional provider information below.
__________________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
Thank you. Please take a moment to review any questions you may have missed.
Feel free to write any comments above.
R:\Doc\Forms\English\Current\F1-199\F33DV9.doc 3/30/07
Page 12 of 12
WHI
Formulario 33DS - Actualización del Historial Clínico (Detalles)
Ver. 9
Extensión de WHI
OMB # 0925-0414 Exp:5/09
Date received:
-
-
- Affix label here-
(M/D/Y)
Participant ID: __ __
Reviewed by:
-
__ __ - ___ ___ ___ - __
First Name _______________________M.I. ______
Last Name _________________________________
Contact type:
1 Phone
2 Mail
8 Other
Visit Type:
3 Annual
4 Non-Routine
PARA USO EXCLUSIVO DE LA OFICINA
El informe público por medio de estos datos colectivos se calcula tomar 10 minutos por cada respuesta, incluyendo el tiempo que tarde repasar las
instrucciones, investigado las fuentes de datos que existen actualmente, colectando y manteniendo los datos necesarios y completar y repasar el cuestionario.
A ninguna agencia se le permitirá llevar ni patrocinar una serie de datos colectivos, a menos que aparezca el número de control OMB válido; y al igual a
ninguna persona se le requirere resonder a lo mismo. Favor de dirigir sus comentarios sobre esta estimación de labor o cualquier otro aspecto de estos datos
colectivos, incluyendo sugerencias para reducir esta labor, al siguiente: NIH, Project Clearance Branch, 6705 Rockledge Drive, MSC 7974, Bethesda, MD
20892-7974, ATTN: PRA (0925-0414). Favor de no enviar estos cuestionarios completados a dichas direcciones.
En el Formulario 33S - Actualización del Historial Clínico, usted indicó que ha tenido algunos
problemas médicos sobre los cuales es importante que nos informe en más detalle.
Este formulario incluye preguntas acerca de las estadías en el hospital, problemas médicos, y
exámenes médicos que hayan tenido lugar desde:
de 20
mes
día
año
No informe sobre estadías en el hospital, problemas médicos, ni exámenes que hayan tenido lugar
antes de esta fecha. Sin embargo, si no está segura de la fecha y cree que no nos ha informado del
problema anteriormente, responda las siguientes preguntas sobre ese problema.
1.
En primer lugar, díganos quién completa este formulario:
1
2
Participante del Estudio de Extensión de La Mujer y Su Salud (WHI) (usted misma)
Familiar o amigo de la participante del Estudio de
Extensión de WHI
3
Proveedor de cuidados de la salud de la participante del
Estudio de Extensión de WHI
8
Otro (Especifique):
R:\Doc\Forms\Spanish\Current\F1-199\F33DSV9.doc 03/30/07
Página 1 de 12
Responda las
siguientes
preguntas acerca
de la participante
del Estudio de
Extensión de WHI.
WHI
Formulario 33DS - Actualización del Historial Clínico (Detalles)
Extensión de WHI
Ver. 9
Información sobre el hueso de la cadera quebrado, fracturado, o con fractura por aplastamiento
2.
Desde la fecha citada en la portada de este formulario, ¿algún médico le ha informado que tenía un hueso
de la cadera o de la parte superior de la pierna quebrado, fracturado, o con fractura por aplastamiento?
1
Sí
0
No
Pase a la Pregunta 3 en la siguiente página.
2.1 ¿Dónde fue la fractura? (Marque todas las que correspondan.)
1 Cadera
2
2.2.
Parte superior de la pierna
¿Este hueso de la cadera o de la parte superior de la pierna quebrado, fracturado, o con fractura
por aplastamiento fue diagnosticado o tratado por primera vez durante una estadía en el hospital?
Pase a la Pregunta 2.6 a continuación.
1 Sí
0 No
2.3. ¿Cuál es el nombre, la dirección, y el número de teléfono del centro médico donde recibió
tratamiento para el hueso de la cadera o de la parte superior de la pierna quebrado, fracturado, o
con fractura por aplastamiento?
Nombre del lugar:
Dirección:
Para Uso Exlusivo
de la Oficina
Provider ID
Ciudad
Número de teléfono: (
Estado
Código postal
)
2.4. Fecha en la que ingresó en el hospital:
mes
2.5. Fecha en la que salió del hospital:
día
mes
año
-
día
año
2.6. ¿Le realizaron una radiografía o un estudio de diagnóstico por imágenes (resonancia magnética) para
diagnosticar el hueso de la cadera o de la parte superior de la pierna quebrado, fracturado, o con fractura
por aplastamiento?
1
Sí
0
No
Pase a la Pregunta 3 en la siguiente página.
2.7. ¿Dónde le realizaron la radiografía o el estudio de diagnóstico por imágenes (resonancia magnética)?
Nombre del lugar:
Dirección:
Para Uso Exlusivo
de la Oficina
Provider ID
Ciudad
Número de teléfono: (
Estado
Código postal
)
2.8. ¿En qué fecha realizó la visita? (Si tuvo más
de una visita, proporcione la fecha de la
primera visita).
R:\Doc\Forms\Spanish\Current\F1-199\F33DSV9.doc 03/30/07
Página 2 de 12
Do not key enter if
identical to
provider ID in 2.3
mes
día
año
WHI
Formulario 33DS - Actualización del Historial Clínico (Detalles)
Extensión de WHI
Ver. 9
Información sobre nuevos cánceres o tumores malignos
3.
Desde la fecha citada en la portada de este formulario, ¿algún médico le ha informado que tiene un nuevo
cáncer o tumor maligno? (No incluya los cánceres ni los tumores benignos diagnosticados por
primera vez antes de la fecha que figura en la portada de este formulario).
1
Sí
0
No
Pase a la Pregunta 4 en la página 5.
3.1. ¿Qué tipo de cáncer o tumor maligno era? (Marque todas las opciones que correspondan.)
1
2
3
4
5
6
7
8
9
10
11
12
13
88
Del seno
De ovario
Del endometrio (recubrimiento del útero)
Cuello uterino (abertura del útero o matriz)
Colon, recto, o intestino
Cáncer de piel (sin incluir el melanoma)
Hepático
De hueso
Linfoma o enfermedad de Hodgkin
Leucemia
Meningioma
Otro tipo de cáncer o tumor maligno
Melanoma
(Especifique):_________________
De pulmón
_____________________________
Si marcó más de un nuevo cáncer o tumor maligno, escriba a continuación la información del proveedor
médico correspondiente al primer cáncer para el que recibió tratamiento.
Si recibió tratamiento para otros cánceres en otros centros médicos, incluya la información adicional
sobre el proveedor en la sección de comentarios en la última página.
3.2. ¿Este cáncer o tumor maligno fue diagnosticado o tratado durante una estadía en el hospital de una o más
noches?
1
Sí
0
No
Pase a la Pregunta 3.6 en la siguiente página.
3.3. ¿Cuál es el nombre, la dirección, y el número de teléfono del lugar donde se conservan sus registros
médicos del cáncer?
Nombre del lugar:
Dirección:
Para Uso Exlusivo
de la Oficina
Provider ID
Ciudad
Número de teléfono: (
Estado
Código postal
)
3.4. Fecha en la que ingresó en el hospital:
mes
3.5. Fecha en la que salió del hospital:
mes
R:\Doc\Forms\Spanish\Current\F1-199\F33DSV9.doc 03/30/07
día
Página 3 de 12
año
-
día
año
WHI
Formulario 33DS - Actualización del Historial Clínico (Detalles)
Extensión de WHI
3.6. ¿En qué fecha le diagnosticaron el cáncer o
tumor maligno por primera vez?
mes
Ver. 9
día
año
3.7. ¿Cuál es el nombre, la dirección, y el número de teléfono del lugar donde le diagnosticaron el
cáncer o tumor maligno por primera vez?
Nombre del lugar:
Dirección:
Para Uso Exlusivo
de la Oficina
Provider ID
Ciudad
Número de teléfono: (
Estado
Código postal
Do not key enter if
identical to
provider ID in 3.3
)
3.8. ¿Cuál es el nombre, la dirección, y el número de teléfono del lugar donde se realizaron otros
exámenes o procedimientos relacionados con su cáncer o tumor maligno?
Para Uso Exlusivo
de la Oficina
Nombre del lugar:
Dirección:
Provider ID
Ciudad
Número de teléfono:
(
Estado
)
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Página 4 de 12
Código postal
Do not key enter if
identical to
provider ID in
3.3 or 3.7
WHI
Formulario 33DS - Actualización del Historial Clínico (Detalles)
Extensión de WHI
Ver. 9
Información sobre histerectomía
4.
Desde la fecha citada en la portada de este formulario, ¿le han realizado una histerectomía (operación para
extraer el útero o la matriz)?
1
Sí
0
No
Pase a la Pregunta 5 en la siguiente página.
4.1. ¿En qué fecha se realizó la operación?
mes
día
año
4.2. ¿Cuál es el nombre, la dirección, y el número de teléfono del lugar donde se realizó la operación?
Nombre del lugar:
Dirección:
Para Uso Exlusivo
de la Oficina
Provider ID
Ciudad
Número de teléfono: (
Estado
Código postal
)
4.3. ¿Cuál es el nombre del médico que realizó la operación?
Nombre del médico:
Dirección:
Para Uso Exlusivo
de la Oficina
Provider ID
Ciudad
Número de teléfono: (
Estado
Do not key enter if
identical to
provider ID in 4.2
)
R:\Doc\Forms\Spanish\Current\F1-199\F33DSV9.doc 03/30/07
Código postal
Página 5 de 12
WHI
Formulario 33DS - Actualización del Historial Clínico (Detalles)
Extensión de WHI
Ver. 9
Información sobre problemas cardíacos, vasos sanguíneos obstruidos o estrechados, ataque de apoplejía,
coágulos sanguíneos en las piernas o los pulmones, otros problemas de circulación sanguínea u
operaciones o procedimientos relacionados.
5.
Desde la fecha citada en la portada de este formulario, ¿le han diagnosticado o recibió tratamiento por
problemas cardíacos, vasos sanguíneos obstruidos o estrechados, ataque de apoplejía u otros problemas de
circulación sanguínea (por ejemplo, coágulos sanguíneos en las piernas o los pulmones)?
1
Sí
0
No
Pase a la Pregunta 9 en la página 10.
5.1. Desde la fecha citada en la portada de este formulario, ¿este problema cardíaco, vasos sanguíneos
obstruidos o estrechados, ataque de apoplejía u otro problema de circulación (por ejemplo, coágulos
sanguíneos en las piernas o los pulmones) fue diagnosticado o tratado durante una estadía en el hospital de
una o más noches?
1
Sí
0
No
Pase a la Pregunta 6 en la página 8.
5.2. ¿Por cuáles de los siguientes problemas o procedimientos cardíacos o de circulación fue
admitida? (Marque todas las opciones que correspondan.)
1
2
3
4
Ataque cardíaco (coronario, infarto de
miocardio o MI)
Operación de derivación cardíaca (cirugía
de derivación coronaria, o CABG)
Procedimiento para desobstruir vasos
estrechados que se dirigen al corazón
(apertura de las arterias del corazón con un
balón u otro dispositivo, algunas veces
llamada PTCA, angioplastia coronaria,
stent coronario, o láser)
5
6
Ataque de apoplejía
Coágulos sanguíneos en las piernas
(trombosis venosa profunda o DVT)
7
Coágulos sanguíneos en los pulmones
(embolia pulmonar o PE)
8
Mala circulación sanguínea, vasos
sanguíneos obstruidos o estrechados que
se dirigen a las piernas o los pies
(claudicación, enfermedad arterial
periférica, gangrena, o enfermedad de
Buerger)
Procedimiento u operación para desobstruir
vasos sanguíneos estrechados del cuello
(endarterectomía carotídea, angioplastia
carotídea, o stent carotídeo)
88 Otros problemas cardíacos o de
circulación
Pase a la siguiente página.
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Página 6 de 12
WHI
Formulario 33DS - Actualización del Historial Clínico (Detalles)
Extensión de WHI
Ver. 9
Proporcione los detalles de las dos primeras estadías en el hospital en el que la admitieron por
problemas cardíacos, vasos sanguíneos obstruidos o estrechados, ataque de apoplejía, coágulos
sanguíneos en las piernas (DVT) o los pulmones (PE) o por otros problemas de circulación
sanguínea, desde la fecha citada en la portada de este formulario.
Incluya información adicional sobre el proveedor en la sección de comentarios en la última página.
5.3. Primera estadía en el hospital de una o más noches por problemas o procedimientos
cardíacos o de circulación.
Nombre del hospital:
Dirección:
Para Uso Exlusivo
de la Oficina
Provider ID
Ciudad
Número de teléfono: (
Estado
Código postal
)
5.4. Fecha en la que ingresó en el hospital:
mes
5.5. Fecha en la que salió del hospital:
día
mes
año
-
día
año
5.6. Segunda estadía en el hospital de una o más noches por problemas o procedimientos
cardíacos o de circulación.
Nombre del hospital:
Dirección:
Para Uso Exlusivo
de la Oficina
Provider ID
Ciudad
Número de teléfono:
(
Estado
Código postal
)
5.7. Fecha en la que ingresó en el hospital:
mes
5.8. Fecha en la que salió del hospital:
mes
R:\Doc\Forms\Spanish\Current\F1-199\F33DSV9.doc 03/30/07
día
Página 7 de 12
año
-
día
año
WHI
Formulario 33DS - Actualización del Historial Clínico (Detalles)
Extensión de WHI
Ver. 9
Problemas cardíacos, ataque de apoplejía, coágulos sanguíneos en las piernas (DVT)
(Pacientes ambulatorios)
6.
Desde la fecha citada en la portada de este formulario, ¿alguna vez algún médico o enfermero le ha
aplicado inyecciones en el hogar o como paciente ambulatorio (seguidas normalmente de píldoras
que diluyen la sangre, como el Coumadin o la warfarina) para tratar coágulos sanguíneos en las
piernas, afección que se conoce como trombosis venosa profunda o DVT?
1
Sí
0
No
Pase a la Pregunta 7 en la siguiente página.
6.1. ¿En qué fecha comenzaron las inyecciones
(como Lovenox, Arixtra, o heparina)?
mes
día
año
6.2. ¿Cuál es el nombre, la dirección, y el número de teléfono del médico que le brindó tratamiento
para los coágulos sanguíneos en las piernas?
Nombre del médico:
Dirección:
Para Uso Exlusivo
de la Oficina
Provider ID
Ciudad
Número de teléfono: (
Estado
Código postal
)
6.3. Desde la fecha citada en la portada de este formulario, ¿alguna vez le han realizado exámenes
ambulatorios para determinar la presencia de coágulos sanguíneos en las piernas (afección que se conoce
como trombosis venosa profunda o DVT)?
1
Sí
0
No
Pase a la Pregunta 7 en la siguiente página.
6.4. ¿En qué fecha se realizó el examen?
mes
día
año
6.5. ¿Cuál es el nombre, la dirección, y el número de teléfono del lugar donde le realizaron
el examen ambulatorio para determinar la presencia de coágulos sanguíneos en las piernas?
Para Uso Exlusivo
de la Oficina
Nombre del lugar:
Dirección:
Provider ID
Ciudad
Número de teléfono:
(
Estado
)
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Página 8 de 12
Código postal
Do not key enter if
identical to
provider ID in 6.2
WHI
7.
Formulario 33DS - Actualización del Historial Clínico (Detalles)
Extensión de WHI
Ver. 9
Desde la fecha citada en la portada de este formulario, ¿le han diagnosticado un ataque de apoplejía o
recibió tratamiento como paciente ambulatorio por un ataque de apoplejía?
1
Sí
0
No
Pase a la Pregunta 8 a continuación.
7.1. ¿En qué fecha le diagnosticaron la afección o recibió
tratamiento?
mes
día
año
7.2. ¿Cuál es el nombre, la dirección y el número de teléfono del lugar donde le diagnosticaron el
ataque de apoplejía o recibió tratamiento por un ataque de apoplejía por primera vez?
Nombre del lugar:
Dirección:
Para Uso Exlusivo
de la Oficina
Provider ID
Ciudad
Número de teléfono: (
8.
Estado
Código postal
)
Desde la fecha citada en la portada de este formulario, ¿le han realizado un procedimiento ambulatorio o
una cirugía de día para desbloquear vasos estrechados que se dirigen a su corazón (apertura de las
arterias del corazón con un balón u otro dispositivo, a veces llamada PTCA, angioplastia coronaria, stent
coronario, o láser)?
1
Sí
0
No
Pase a la Pregunta 9 en la siguiente página.
8.1. ¿En qué fecha se realizó el procedimiento o la cirugía?
mes
día
año
8.2. ¿Cuál es el nombre, la dirección y el número de teléfono del lugar donde se realizó
el procedimiento o la cirugía?
Nombre del lugar:
Dirección:
Para Uso Exlusivo
de la Oficina
Provider ID
Ciudad
Número de teléfono: (
Estado
)
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Página 9 de 12
Código postal
WHI
Formulario 33DS - Actualización del Historial Clínico (Detalles)
Extensión de WHI
Ver. 9
Estadía en el Hospital de Dos o Más Noches y Que Aún No se ha Informada en este Formulario.
9.
Desde la fecha citada en la portada de este formulario, ¿ha sido admitida en el hospital por dos o más
noches? (No incluya una estadía de una noche que ya haya informado en este formulario.)
1
0
Sí
No
Pase a la Pregunta 10 en la última página.
Proporcione detalles de las tres primeras estadías en el hospital en las que haya sido admitida
por dos o más noches, desde la fecha citada en la portada de este formulario.
Incluya información adicional sobre el proveedor en la sección de comentarios en la última
página.
9.1. Primera estadía en el hospital de dos o más noches.
Nombre del hospital:
Dirección:
Para Uso Exlusivo
de la Oficina
Provider ID
Ciudad
Número de teléfono: (
Estado
Código postal
)
9.2. Fecha en la que ingresó en el hospital:
mes
9.3. Fecha en la que salió del hospital:
día
mes
año
-
día
año
9.4. Razón de esta estadía en el hospital: (Marque todas las opciones que correspondan.)
1
2
3
4
88
9.5.
5
Cirugías ginecológicas que no sean por cáncer: p. ej., suspensión de la vejiga, prolapso
vaginal/uterino/rectal, incontinencia por estrés
Ataque de la vesícula biliar o cirugía de la vesícula biliar
Cirugía de cataratas
Reparación o reemplazo articular
Otras razones: (Especifique) ________________________________________________
For Office Use Only
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Página 10 de 12
WHI
Formulario 33DS - Actualización del Historial Clínico (Detalles)
Extensión de WHI
Ver. 9
9.6. Segunda estadía en el hospital de dos o más noches.
Nombre del hospital:
Dirección:
Para Uso Exlusivo
de la Oficina
Provider ID
Ciudad
Número de teléfono: (
)
9.7. Fecha en la que ingresó en el
Estado
hospital:
Código postal
mes
9.8. Fecha en la que salió del hospital:
día
mes
año
-
día
año
9.9. Razón de esta estadía en el hospital: (Marque todas las opciones que correspondan).
1
2
3
4
88
9.10.
5
Cirugías ginecológicas que no sean por cáncer: p. ej., suspensión de la vejiga, prolapso
vaginal/uterino/rectal, incontinencia por estrés
Ataque de la vesícula biliar o cirugía de la vesícula biliar
Cirugía de cataratas
Reparación o reemplazo articular
Otras razones: (Especifique) ______________________________________________
For Office Use Only
9.11. Tercera estadía en el hospital de dos o más noches.
Nombre del hospital:
Dirección:
Para Uso Exlusivo
de la Oficina
Provider ID
Ciudad
Número de teléfono: (
)
Estado
9.12. Fecha en la que ingresó en el hospital:
Código postal
mes
9.13. Fecha en la que salió del hospital:
día
mes
año
-
día
año
9.14. Razón de esta estadía en el hospital: (Marque todas las opciones que correspondan).
1 Cirugías ginecológicas que no sean por cáncer: p. ej., suspensión de la vejiga, prolapso
vaginal/uterino/rectal, incontinencia por estrés
2 Ataque de la vesícula biliar o cirugía de la vesícula biliar
3
4
88
9.15.
5
Cirugía de cataratas
Reparación o reemplazo articular
Otras razones: (Especifique) ______________________________________________
For Office Use Only
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Página 11 de 12
WHI
10.
Formulario 33DS - Actualización del Historial Clínico (Detalles)
Extensión de WHI
¿En qué fecha terminó de responder este formulario?
mes
Ver. 9
día
año
Incluya comentarios e información adicional sobre el proveedor a continuación.
__________________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
Muchas gracias. Tómese unos minutos para verificar que no haya saltado ninguna pregunta.
No dude en incluir cualquier comentario en el espacio proporcionado más arriba.
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Página 12 de 12
WHI
Form 153 – Medication and Supplement Inventory
WHI Extension Study
Ver. 1
OMB #___ Exp: x/xx
To help us learn about the health of WHI participants, we would like to know about the medications and
supplements you take.
This form asks about all of the prescription medications you are currently taking, and some of the overthe-counter medications and dietary supplements you may be taking.
If you would like to have a WHI staff member at the Clinical Coordinating Center complete this
form with you over the phone, please feel free to call 1-800-218-8415.
Public reporting burden for this collection of information is estimated to average 20 minutes per response, including the time for reviewing instructions, searching
existing data sources, gathering and maintaining the data needed, and completing and reviewing the collection of information. An agency may not conduct or
sponsor, and a person is not required to respond to, a collection of information unless it displays a currently valid OMB control number. Send comments
regarding this burden estimate or any other aspect of this collection of information, including suggestions for reducing this burden, to: NIH, Project Clearance
Branch, 6705 Rockledge Drive, MSC 7974, Bethesda, MD 20892-7974, ATTN: PRA (0925-0414). Do not return the completed form to this address.
OFFICE USE ONLY
1. Date Received:
-
2. Reviewed By:
-
3. Contact Type:
¤ 1 Phone
¤ 2 Mail
¤ 8 Other
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120508
4. Language:
¤
FCA
Page 1 of 9
¤
OU1
¤
¤ 1 English ¤ 2 Spanish
OU2
WHI
Form 153 – Medication and Supplement Inventory
WHI Extension Study
Ver. 1
OMB #___ Exp: x/xx
Section A. Prescription Medications
This first section asks about prescription medications you are currently taking. This includes
medications that you only take as needed, such as nitroglycerin. A prescription medication is one that is
written (or phoned in) by your health care provider and must be filled at a pharmacy or drug store.
1. Are you currently taking any medications that require a prescription from a doctor or health
care provider?
¤ 1 No
¤ 2 Yes
Go to Section B on Page 6
Continue below
For this section, you will need information from the labels on bottles or packaging that your prescription
medications came in. To get started, please gather together all of your prescription medications, so that
this information is readily available as you complete the form. These medications may be in your
medicine cabinet, refrigerator, or purse. It is important to include all of your prescriptions.
For each prescription medication, please answer the questions on the next page, including the
medication’s name and strength. You will find this information on the label of the pill bottle or
container. An example of a prescription label and a completed medication question is shown below.
Example of a Prescription Label:
Walgreens, Seattle, WA 98028
(DD/) Ph: 866-254-1669
RX#4599773 Sept. 6, 2005 Fill 1 of 1
DOE, JANE 206-566-0442
Take one capsule by mouth as directed in morning
and at bedtime
Discard after Sept. 6, 2006 Mfr________
Qty: 60 CAP Kroll, Phil MD
Phenytoin NA (Dilantin) 100MG CAP
On this label, the medication name Phenytoin
NA (Dilantin), strength 100 MG, and type CAP are
all on one line.
Example of a Completed Question (using the label example above):
Prescription Medication
a. Name of the medication
(as written on label):
b. Strength of the medication
(as written on label):
c. Medication type (examples: capsule, tablet,
cream, liquid, suppository, inhaler, injection):
d. About how long have you been taking this
medication? (if you’re not sure, please use
your best guess)
Record Information Below:
PHENYTOIN NA (DILANTIN)
(DILANTIN)
100 MG
CAPSULE
¤ 1 Less than a month
¤ 2 1 to12 months
3
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120508
Page 2 of 9
More than 1 year
How many years?
3
WHI
Form 153 – Medication and Supplement Inventory
WHI Extension Study
Ver. 1
OMB #___ Exp: x/xx
2. For each of the prescription medications you are currently taking, please answer the questions
below using the label on the prescription bottle. Please print clearly. You can use your best
estimate about how long you have been taking the medication.
Complete all of the information in the box (a through d) for each medication you take. There are
enough boxes for 10 different medications. When you have filled out the information for all of your
prescription medications, please go to Section B of the questionnaire on page 6.
Prescription Medication #1
a. Name of the medication
(as written on label):
b. Strength of the medication
(as written on label):
c. Medication type (examples: capsule, tablet,
cream, liquid, suppository, inhaler, injection):
d. About how long have you been taking this
medication? (if you’re not sure, please use
your best guess)
Prescription Medication #2
a. Name of the medication
(as written on label):
b. Strength of the medication
(as written on label):
c. Medication type (examples: capsule, tablet,
cream, liquid, suppository, inhaler, injection):
d. About how long have you been taking this
medication? (if you’re not sure, please use
your best guess)
Prescription Medication #3
a. Name of the medication
(as written on label):
b. Strength of the medication
(as written on label):
c. Medication type (examples: capsule, tablet,
cream, liquid, suppository, inhaler, injection):
d. About how long have you been taking this
medication? (if you’re not sure, please use
your best guess)
Write in Information Below:
¤ 1 Less than a month
¤ 2 1 to12 months
¤ 3 More than 1 year
How many years?
Write in Information Below:
¤ 1 Less than a month
¤ 2 1 to12 months
¤ 3 More than 1 year
How many years?
Write in Information Below:
¤ 1 Less than a month
¤ 2 1 to12 months
¤ 3 More than 1 year
How many years?
Continue on the next page, or go to Page 6 if you have listed all your medications
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Page 3 of 9
WHI
Form 153 – Medication and Supplement Inventory
WHI Extension Study
Prescription Medication #4
a. Name of the medication
(as written on label):
b. Strength of the medication
(as written on label):
c. Medication type (examples: capsule, tablet,
cream, liquid, suppository, inhaler, injection):
d. About how long have you been taking this
medication? (if you’re not sure, please use
your best guess)
Prescription Medication #5
a. Name of the medication
(as written on label):
b. Strength of the medication
(as written on label):
c. Medication type (examples: capsule, tablet,
cream, liquid, suppository, inhaler, injection):
d. About how long have you been taking this
medication? (if you’re not sure, please use
your best guess)
Prescription Medication #6
a. Name of the medication
(as written on label):
b. Strength of the medication
(as written on label):
c. Medication type (examples: capsule, tablet,
cream, liquid, suppository, inhaler, injection):
d. About how long have you been taking this
medication? (if you’re not sure, please use
your best guess)
Prescription Medication #7
a. Name of the medication
(as written on label):
b. Strength of the medication
(as written on label):
c. Medication type (examples: capsule, tablet,
cream, liquid, suppository, inhaler, injection):
d. About how long have you been taking this
medication? (if you’re not sure, please use
your best guess)
Ver. 1
OMB #___ Exp: x/xx
Write in Information Below:
¤ 1 Less than a month
¤ 2 1 to12 months
¤ 3 More than 1 year
How many years?
Write in Information Below:
¤ 1 Less than a month
¤ 2 1 to12 months
¤ 3 More than 1 year
How many years?
Write in Information Below:
¤ 1 Less than a month
¤ 2 1 to12 months
¤ 3 More than 1 year
How many years?
Write in Information Below:
¤ 1 Less than a month
¤ 2 1 to12 months
¤ 3 More than 1 year
How many years?
Continue on the next page, or go to Page 6 if you have listed all your medications
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Page 4 of 9
WHI
Form 153 – Medication and Supplement Inventory
WHI Extension Study
Prescription Medication #8
a. Name of the medication
(as written on label):
b. Strength of the medication
(as written on label):
c. Medication type (examples: capsule, tablet,
cream, liquid, suppository, inhaler, injection):
d. About how long have you been taking this
medication? (if you’re not sure, please use
your best guess)
Prescription Medication #9
a. Name of the medication
(as written on label):
b. Strength of the medication
(as written on label):
c. Medication type (examples: capsule, tablet,
cream, liquid, suppository, inhaler, injection):
d. About how long have you been taking this
medication? (if you’re not sure, please use
your best guess)
Prescription Medication #10
a. Name of the medication
(as written on label):
b. Strength of the medication
(as written on label):
c. Medication type (examples: capsule, tablet,
cream, liquid, suppository, inhaler, injection):
d. About how long have you been taking this
medication? (if you’re not sure, please use
your best guess)
Ver. 1
OMB #___ Exp: x/xx
Write in Information Below:
¤ 1 Less than a month
¤ 2 1 to12 months
¤ 3 More than 1 year
How many years?
Write in Information Below:
¤ 1 Less than a month
¤ 2 1 to12 months
¤ 3 More than 1 year
How many years?
Write in Information Below:
¤ 1 Less than a month
¤ 2 1 to12 months
¤ 3 More than 1 year
How many years?
3. In the question above, there is room to list up to 10 prescription medications. If you take more than
10, please list the names of those medications below. List only their names, and do not include any
medications you already told us about in the boxes above. You may receive a call from the WHI
Clinical Coordinating Center to gather more detailed information on these medications.
a._______________________________________ f.___________________________________
b._______________________________________ g.___________________________________
c._______________________________________ h.___________________________________
d._______________________________________ i.__________________________ _________
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Page 5 of 9
WHI
Form 153 – Medication and Supplement Inventory
WHI Extension Study
Ver. 1
OMB #___ Exp: x/xx
Section B. Barriers to Prescription Medications
4. Have any of the following barriers prevented you from obtaining or taking any medications that have
been prescribed for you? (Please check all that apply.)
¤ 1 My health insurance would not cover the medication.
¤ 2 The medication or copayment cost too much.
¤ 3 It is a problem for me to get to the medical facility/physician.
¤ 4 Taking the medication would be inconvenient.
¤ 5 I was concerned about possible side effects or complications from the medication.
¤ 6 I was concerned about missing work due to taking the medication.
¤ 7 My family discouraged me from taking the medication.
¤ 8 My friends discouraged me from taking the medication.
¤ 9 I am taking too many medications.
¤ 10 I don’t like taking medications.
¤ 0 I have not experienced any barriers to taking prescription medications.
Section C. Non-Prescription Medications
This section asks about certain non-prescription medicines you have taken at least once a week in the
past two weeks. These are medicines that you can buy over-the-counter without a prescription from
your health care provider.
5. Please answer the following questions about the non-prescription medicines listed below. For
each type of medicine that you are taking, please write in the name and strength from the product
label, how often you take it, and how long you have taken it. For each type of medicine, there are
spaces to write in two products. If you are taking more than two of the medicines in any group listed
below, please write in just the two that you take most often. Note that the brand names provided
below are just examples; you may be taking another brand of the medicine.
Product Information
(listed on the bottle or package)
Are you taking:
Aspirin, for example,
¤
Bayer, St. Josephs,
Bufferin, Anacin,
Excedrin, BC powder,
baby aspirin, Doan’s
(This does not include
aspirin-free drugs such
as Tylenol or Advil.) ¤
Name of the product:
1
Yes
No
Please go to next page
120508
month
¤ 2 4-6 days a week ¤ 2 1 to12 months
¤ 3 2-3 days a week ¤ 3 More than
1 year
¤ 4 Once a week
many
¤ 5 1-3 days a month How
years?
Strength:
R:\doc\Forms\English\Current\F1-199\F253V1.doc
How long have
you been
taking it?
¤ 1 Once a day or ¤ 1 Less than a
more
Strength:
0
How often do you
take it?
Page 6 of 9
WHI
Form 153 – Medication and Supplement Inventory
WHI Extension Study
Product Information
(listed on the bottle or package)
Are you taking:
Anti-Inflammatory
pain medicines, such
as Advil, Aleve,
Ibuprofen, Motrin,
Naprosyn, Naproxen,
Nuprin, Anaprox, or
Orudis KT
Name of the product:
¤ 1 Yes
Are you taking a
¤
second type of
Antacid or heartburn
medicine?
No
1
Yes
month
Name of the product:
¤ 1 Once a day or ¤ 1 Less than a
more
month
Strength:
¤ 2 4-6 days a week ¤ 2 1 to12 months
¤ 3 2-3 days a week ¤ 3 More than
1 year
¤ 4 Once a week
many
¤ 5 1-3 days a month How
years?
Name of the product:
¤ 1 Once a day or ¤ 1 Less than
Yes
0
¤ 1 Once a day or ¤ 1 Less than a
Strength:
¤ 0 No
1
How long have
you been
taking it?
¤ 2 4-6 days a week ¤ 2 1 to12 months
¤ 3 2-3 days a week ¤ 3 More than
1 year
¤ 4 Once a week
many
¤ 5 1-3 days a month How
years?
¤ 1 Yes
Antacid or heartburn
¤
medicines, such as
Axid, Pepcid AC,
Prilosec, Tagamet,
Zantac, Cimetidine,
Famotidine,
Omeprazole, or
¤
Ranitidine
OMB #___ Exp: x/xx
How often do you
take it?
more
¤ 0 No
Are you taking a
second type of AntiInflammatory pain
medicine?
Ver. 1
more
a month
Strength:
¤ 2 4-6 days a week ¤ 2 1 to12 months
¤ 3 2-3 days a week ¤ 3 More than
1 year
¤ 4 Once a week
many
¤ 5 1-3 days a month How
years?
Name of the product:
¤ 1 Once a day or ¤ 1 Less than
more
¤ 2 4-6 days a week ¤ 2 1 to12 months
¤ 3 2-3 days a week ¤ 3 More than
1 year
¤ 4 Once a week
many
¤ 5 1-3 days a month How
years?
Strength:
¤ 0 No
Please go to next page
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120508
a month
Page 7 of 9
WHI
Form 153 – Medication and Supplement Inventory
WHI Extension Study
Product Information
(listed on the bottle or package)
Are you taking:
Natural female
hormones, herbal
estrogens, or
phytoestrogens, such
as Remifemin, DHEA
pills, wild yam, soy or
flax products, dong
quai, or black cohosh
Name of the product:
¤ 1 Yes
1
OMB #___ Exp: x/xx
How often do you
take it?
How long have
you been
taking it?
¤ 1 Once a day or ¤ 1 Less than a
more
month
Strength:
¤ 2 4-6 days a week ¤ 2 1 to12 months
¤ 3 2-3 days a week ¤ 3 More than
1 year
¤ 4 Once a week
many
¤ 5 1-3 days a month How
years?
Name of the product:
¤ 1 Once a day or ¤ 1 Less than a
¤ 0 No
Are you taking a
second type of natural ¤
female hormones,
herbal estrogens, or
phytoestrogens?
Ver. 1
Yes
more
month
¤ 2 4-6 days a week ¤ 2 1 to12 months
¤ 3 2-3 days a week ¤ 3 More than
1 year
¤ 4 Once a week
many
¤ 5 1-3 days a month How
years?
Strength:
¤ 0 No
6. In most states, some types of insulin can be purchased over-the-counter without a prescription. If you
are currently taking insulin and you haven’t included it on the list of your prescription medicines in
Section A, please write it in here.
Product Information
(listed on the bottle or package)
Are you taking:
Are you taking overthe-counter insulin?
(if you listed insulin as
a prescription
medication in Section
A, do not include
here)
Name of the product:
¤ 1 Yes
¤1
Once a day or
more
How long have
you been
taking it?
¤ 1 Less than a
month
¤ 2 Less than once ¤ 2 1 to12 months
a day
¤ 3 More than
Strength:
1 year
¤ 0 No
How many
years?
Please go to next page
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How often do you
take it?
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Page 8 of 9
WHI
Form 153 – Medication and Supplement Inventory
WHI Extension Study
Ver. 1
OMB #___ Exp: x/xx
Section D. Dietary Supplements
In this final section, we ask about certain vitamin or mineral supplements you have taken at least once a
week in the past two weeks.
7. Please answer the following questions below about the vitamin or mineral supplements listed below.
For each vitamin supplement that you are taking, please write in the name from the bottle/package, how
often, and how long you have been taking it. Although you may be taking other supplements at this
time, we are asking only for information on the supplements listed.
Information about the
Vitamin Supplement
(on the bottle)
Daily Multi-Vitamin
Supplement
A multi-vitamin
supplement that has 10
or more vitamins
and/or minerals in one
pill. Examples are
One-A-Day, Centrum,
Theragran, Geritol.
Calcium / Vitamin D
supplement mixture
A pill that contains
both Calcium and
Vitamin D, but not in a
multi-vitamin with
several vitamins and
minerals.
Calcium as a single
mineral supplement
containing no other
vitamins or minerals
¤ 1 Yes
¤ 1 Once a day or ¤ 1 Less than a month
more
¤ 2 1 to12 months
¤ 2 4-6 days a week ¤ 3 More than 1 year
¤ 3 2-3 days a week How many
¤ 4 Once a week
years?
Name of the product:
¤1
Once a day or
more
¤1
Once a day or
more
¤1
Once a day or
more
¤ 1 Yes
Calcium
Strength:
Vitamin D
Strength:
Name of the product:
¤ 1 Yes
Strength:
¤ 0 No
Vitamin D (Calciferol)
¤
as a single vitamin
supplement containing
no other vitamin or
mineral.
Name of the product:
1
How long have you
been taking it?
Product name and/or
brand:
¤ 0 No
¤ 0 No
How often do you
take it?
Yes
Strength:
¤ 0 No
¤ 1 Less than a month
¤ 2 1 to12 months
¤ 2 4-6 days a week ¤ 3 More than 1 year
¤ 3 2-3 days a week How many
¤ 4 Once a week
years?
¤ 1 Less than a month
¤ 2 1 to12 months
¤ 2 4-6 days a week ¤ 3 More than 1 year
¤ 3 2-3 days a week How many
¤ 4 Once a week
years?
¤ 1 Less than a month
¤ 2 1 to12 months
¤ 2 4-6 days a week ¤ 3 More than 1 year
¤ 3 2-3 days a week How many
¤ 4 Once a week
years?
8. What is the date that you finished answering this form?
Month
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Day
Year
WHI
Form 154 – Breast Cancer Prevention and Treatment Medications
Ver. 1
WHI Extension Study
OMB #____ Exp: x/xx
To help us learn about the health of WHI participants, we would
like to know more about some of the medications you may take.
As part of your participation in the Women’s Health Initiative,
you previously reported a breast biopsy or a diagnosis of breast
cancer (including breast cancer in situ). This form asks about
medications that you may have used to prevent or treat breast
cancer.
If you would like to have a WHI staff member at the Clinical
Coordinating Center complete this form with you over the phone,
please feel free to call 1-800-218-8415.
Public reporting burden for this collection of information is estimated to average 5 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:
-
2. Reviewed By:
-
3. Contact Type:
¤ 1 Phone
¤ 2 Mail
¤ 8 Other
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120508
4. Language:
¤
FCA
Page 1 of 4
¤
OU1
¤
¤ 1 English ¤ 2 Spanish
OU2
WHI
Form 154 – Breast Cancer Prevention and Treatment Medications
Ver. 1
WHI Extension Study
OMB #____ Exp: x/xx
The first set of questions asks about medications known as SERMS (selective estrogen receptor modulators).
These medications include tamoxifen (Nolvadex®), raloxifene (Evista®), and toremifene (Fareston®).
Since your breast biopsy or breast cancer diagnosis:
1. Have you ever taken tamoxifen (Nolvadex®)?
¤ 0 No
1.1 How long did you take or have you taken
tamoxifen? (use your best estimate; mark only one)
¤ 1 Less than 1 month ¤ 4 1-2 years
¤ 1 Yes
¤ 9 Don’t know
¤ 2 1-5 months
¤ 3 6-11 months
¤ 5 3-4 years
¤ 6 5 or more years
2. Have you ever taken raloxifene (Evista®)?
¤ No
0
2.1 How long did you take or have you taken
raloxifene? (use your best estimate; mark only one)
¤ 1 Less than 1 month
¤ 4 1-2 years
¤ 1 Yes
¤ 9 Don’t know
¤ 2 1-5 months
¤ 3 6-11 months
¤ 5 3-4 years
¤ 6 5 or more years
3. Have you ever taken toremifene (Fareston®)?
¤ 0 No
3.1 How long did you take or have you taken
toremifene? (use your best estimate; mark only one)
¤ 1 Less than 1 month
¤ 4 1-2 years
¤ 1 Yes
¤ 9 Don’t know
¤ 2 1-5 months
¤ 3 6-11 months
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120508
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¤ 5 3-4 years
¤ 6 5 or more years
WHI
Form 154 – Breast Cancer Prevention and Treatment Medications
Ver. 1
WHI Extension Study
OMB #____ Exp: x/xx
These next questions ask about medications known as anti-estrogen therapies or aromatase inhibitors. These
medications include anastrozole (Arimidex®), exemestane (Aromasin®), and letrozole (Femara®).
Since your breast biopsy or breast cancer diagnosis:
4. Have you ever taken anastrozole (Arimidex®)?
¤ No
0
5.1 How long did you take or have you taken
anastrozole? (use your best estimate; mark only one)
¤ 1 Less than 1 month ¤ 4 1-2 years
¤ 1 Yes
¤ 9 Don’t know
¤ 2 1-5 months
¤ 3 6-11 months
¤ 5 3-4 years
¤ 6 5 or more years
5. Have you ever taken exemestane (Aromasin®)?
¤ 0 No
6.1 How long did you take or have you taken
exemestane? (use your best estimate; mark only
one)
¤ 1 Less than 1 month ¤ 4 1-2 years
¤ 1 Yes
¤ 9 Don’t know
¤ 2 1-5 months
¤ 3 6-11 months
¤ 5 3-4 years
¤ 6 5 or more years
6. Have you ever taken letrozole (Femara®)?
¤ 0 No
7.1 How long did you take or have you taken letrozole?
(use your best estimate; mark only one)
¤ 1 Less than 1 month ¤ 4 1-2 years
¤ 1 Yes
¤ 9 Don’t know
¤ 2 1-5 months
¤ 3 6-11 months
¤ 5 3-4 years
¤ 6 5 or more years
7. Have you ever taken any SERM or aromatase inhibitor that is not listed above, or that you may not recall
the name of?
¤ 0 No
8.1 How long did you take or have you taken this
medication? (use your best estimate; mark only one)
¤ 1 Less than 1 month ¤ 4 1-2 years
¤ 1 Yes
¤ 9 Don’t know
¤ 2 1-5 months
¤ 3 6-11 months
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¤ 5 3-4 years
¤ 6 5 or more years
WHI
Form 154 – Breast Cancer Prevention and Treatment Medications
Ver. 1
WHI Extension Study
OMB #____ Exp: x/xx
8. Have any of the following barriers prevented you from obtaining or taking the prescribed breast cancer
medications previously asked about (i.e., tamoxifen, raloxifene, toremifene, anastrazole, exemestane, and
letrozole)? (Please check all that apply)
¤ 0 I did not experience any barriers to taking these medications.
¤ 2 I have never heard of these medications.
¤ 3 My health insurance would not cover these medications.
¤ 4 These medications or copayments cost too much.
¤ 5 It is a problem for me to get to my medical facility/physician.
¤ 6 Taking these medications would be inconvenient.
¤ 7 I was concerned about possible side effects or complications from these medications.
¤ 8 I was concerned about missing work due to taking these medications.
¤ 9 My family discouraged me from taking these medications.
¤ 10 My friends discouraged me from taking these medications.
¤ 11 I am taking too many medications.
¤ 12 I don’t like taking medications.
¤ 13 My physician did not recommend these medications for my particular type of breast disease.
¤ 14 Other:_____________________________________________________________________
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| File Type | application/pdf |
| Author | Administrator |
| File Modified | 2008-12-09 |
| File Created | 2008-12-09 |