Form 2 Main Questionnaire

I.D. # __ - __ - __ __ __ __ __ __

__________________________________________________________________________

OMB# 0925-XXXX

Expiration Date: XX / XX / XXXX

Attachment #6

Name: Main Case-Control Questionnaire

BURDEN STATEMENT:

Public reporting burden for this collection of information is estimated to average 1 hour per response, including the time for reviewing instructions, searching existing data sources, gathering and maintaining the data needed, and completing and reviewing the collection of information. An agency may not conduct or sponsor, and a person is not required to respond to, a collection of information unless it displays a currently valid OMB control number. Send comments regarding this burden estimate or any other aspect of this collection of information, including suggestions for reducing this burden, to: NIH, Project Clearance Branch, 6705 Rockledge Drive, MSC 7974, Bethesda, MD 20892-7974, ATTN: PRA (0925-XXXX). Do not return the completed form to this address.

PRIVACY STATEMENT:

Statement Of Privacy Act Applicability

You will be asked to participate in the research study “Resource Collection and Evaluation of Human Tissues from Donors with an Epidemiological Profile for NCI Contract # NO2-RC57700”. The study will collect and use health information that can identify you. The authority to collect this information is under 42 USC 285 for the National Cancer Institute, National Institutes of Health. The Privacy Act from 1974 applies to the information collection.

Federal laws require researchers to protect the privacy of your health information. The collection of health information by this study “Resource Collection and Evaluation of Human Tissues from Donors with an Epidemiological Profile for NCI Contract # NO2-RC57700” is covered by the Privacy Act and is in compliance with the Privacy Act System of Records Notice (SORN) # 09-25-0200 http://oma.od.nih.gov/ms/privacy/pa-files /0200, which covers clinical, basic, and population-based research studies of the National Cancer Institute and the National Institutes of Health.

MARYLAND LUNG AND PROSTATE

CANCER STUDY AND

MULTI-ORGAN STUDIES

QUESTIONNAIRE

National Cancer Institute

Building 37, Third Floor

Bethesda, Maryland 20892

Phone (301) 496-2048 Fax (301) 402-0497

University of Maryland School of Medicine

Howard Hall, Third Floor, Suite 322

660 West Redwood Street

Baltimore, Maryland 21201-1596

Phone (410) 706-5129 Fax (410) 706-5173

TABLE OF CONTENTS

A. IDENTIFIER SHEET 4

B. SOCIO-ECONOMIC INFORMATION 6

C. NUTRITIONAL SUPPLEMENTS 7

D. TOBACCO HISTORY 10

E. ALCOHOL HISTORY 19

F. MEDICAL HISTORY 21

G. FAMILY HISTORY 24

H. REPRODUCTIVE HISTORY 29

I. OCCUPATIONAL HISTORY 34

J. RESIDENTIAL HISTORY 36

K. EXERCISE 38

L. GENERAL INFORMATION 40

M. ADMINISTRATIVE INFORMATION 42

N. INTERVIEWER REMARKS 42

O. NUTRITION SUPPLEMENT 44

1. Date: __ __ / __ __ / __ __ __ __

2. Interviewer’s name:________________ Interviewer’s ID __ __

3. Hospital:_____________________________________ 

4. Doctor’s Name:___________________________ 

5. Patient’s Medical Record # ______________________

6. Patient’s Ethnicity ( )₁ Hispanic/Latino ( )₂ Non Hispanic/Latino

7. Patient’s Race ( )₁ White

( )₂ Black/African American

( )₃ Asian

( )₄ Native Hawaiian/Other Pacific Islander

( )₅ American Indian/Alaska Native

8. Gender ( )₁ Male

( )₂ Female

9. Time started: __ __:__ __ ( )₁ AM

( )₂ PM

OFFICE USE ONLY

Review

Reviewer’s initials: ___ ___ ___ Date reviewed: __ __ / __ __ / __ __ __ __

Coding and Editing

Coder’s Initials: ___ ___ ___ Date coded: __ __ / __ __ / __ __ __ __

Data Entry

First Entry  Initials: ___ ___ ___ Date Entered: __ __ / __ __ / __ __ __ __

Second Entry  Initials: ___ ___ ___ Date Entered: __ __ / __ __ / __ __ __ __

1. IDENTIFIER SHEET

1. What is your name?________________/______________/_________________

First Middle Last

2. What is your date of birth? __ __ / __ __ / __ __ __ __

3. What is your address?

____________________________________________________________

Street Apt. No.

_______________________ ___ ___ __ __ __ __ __- __ __ __ __

City State Zip code

4. What is your telephone number? Home:( __ __ __) __ __ __ - __ __ __ __

Work: ( __ __ __) __ __ __ - __ __ __ __

Ext. __ __ __ __

5. Who is interviewed: ( )₀ Patient (skip to A.8)

( )₁ Other

( )₂ No interview is possible

6. Name of person interviewed if other than the patient

______________________________________________________________

Last First Middle

6. Relationship to patient: ( )₀ Spouse

( )₁ Parent

( )₂ Child

( )₃ Brother or sister

( )₄ Friend

( )₅ Other -Specify________________________

8. What is the name, address and telephone number of a person who can help us contact you in the future, or your next-of-kin (or person who was interviewed if other than patient)?

____________________________________ __________________________

Name Relationship to patient

_______________________________________________ __________

Street Apt. No.

____________________________ ___ ___ __ __ __ __ __- __ __ __ __

City State Zip Code

Home telephone number # ( __ __ __) __ __ __ - __ __ __ __

TYPE OF STUDY PARTICIPANT ( )₁ Lung Cancer Case

( )₂ Prostate Cancer Case

( )₃ Hospital Control

( )₄ Population Control

( )₅ Multi-organ patient

2. SOCIO-ECONOMIC INFORMATION

Now I would like to ask you some general information about you.

1. What is your marital status? ( )₁ Single, never married

( )₂ Married

( )₃ Divorced

( )₄ Separated

( )₅ Has a partner, living as married

( )₆ Widowed

2. Do you consider yourself Hispanic/Latino or Not Hispanic/Latino? ( )₁ Hispanic/Latino

( )₂ Not Hispanic/Latino

2. Do you consider yourself to be:

( )₁ Black or African American

( )₂ White

( )₃ Asian

( )₄ Native Hawaiian or Other Pacific Islander

( )₅ American Indian/Alaska Native

2. Most people in the United States have ancestors who came from other parts of the world. Please tell me what country or countries your ancestors came from.









5. In what religion were you raised?



SOCIO-ECONOMIC INFO. ( )₁ Very good ( )₂ Good ( )₃ Fair ( )₄ Poor

3. NUTRITIONAL SUPPLEMENTS

Now I would like to learn more about your typical eating and drinking habits.

1. During the last 7 days, have you taken any vitamins or calcium?

( )₀ No (Skip to C. 3) ( )₁ Yes

2.	Did you take:	How many tablets in the past 7 days?
a.	Multivitamins, one-a-day type, such as Centrum ( )0 No (Skip to 2b) ( )1 Yes	___ ___ ___
b.	Multivitamins, stress tabs ( )0 No (Skip to 2c) ( )1 Yes	___ ___ ___
c.	Multivitamins, therapeutic type such as Theragram ( )0 No (Skip to 2d) ( )1 Yes	___ ___ ___
d.	Multivitamins, other ( )0 No (Skip to 2e) ( )1 Yes If yes, (specify)  If yes, (specify) 	___ ___ ___ ___ ___ ___
e.	Vitamin A ( )0 No (Skip to 2f) ( )1 Yes	___ ___ ___
f.	Vitamin E ( )0 No (Skip to 2g) ( )1 Yes	___ ___ ___
g.	Vitamin C ( )0 No (Skip to 2h) ( )1 Yes	___ ___ ___
h.	Beta Carotene ( )0 No (Skip to 2i) ( )1 Yes	___ ___ ___
i.	Calcium ( )0 No (Skip to 2j) ( )1 Yes	___ ___ ___

j.	Other vitamins ( )0 No (Skip to 3) ( )1 Yes If yes, (specify)  If yes, (specify) 	___ ___ ___ ___ ___ ___
k.	Other vitamins ( )0 No (Skip to 3) ( )1 Yes If yes, (specify)  If yes, (specify) 	___ ___ ___ ___ ___ ___
l.	Other vitamins ( )0 No (Skip to 3) ( )1 Yes If yes, (specify)  If yes, (specify) 	___ ___ ___ ___ ___ ___

3. During the past seven days, have you eaten any special foods, food supplements such as those purchased through a natural food store or health food store?

( )₀ No (Skip to C.5) ( )₁ Yes

3. Please tell me what those foods, food supplements or vitamins were:

_____________________________________________ 

_____________________________________________ 

5. Please answer the following questions about supplements that you may have taken regularly during the past 5 years, at least 1 pill/week for 2 months.

Have you taken the following regularly - at least 1/week for 2 months during the past 5 years?	How many pills per day or week did you take regularly, during the past 5 years?	How long did you take regularly, during the past 5 years?	Did you take regularly one year prior to interview?
a. Aspirin or aspirin containing compounds (such as Bufferin, Anacin, Ascriptin, Excedrin) ( )0 no ( )1 yes ( )8 Don’t know	___ # pills per: ( )1 day ( )2 week ( )8 Don’t know	__ __ ( )1 weeks ( )2 months ( )3 years ( )8 Don’t know	( )0 no ( )1 yes ( )8 Don’t know
b. Tylenol and acetaminophen compounds (such as Tylenol or Aspirin-free Anacin, or Excedrin-PM) ( )0 no ( )1 yes ( )8 Don’t know	___ # pills per: ( )1 day ( )2 week ( )8 Don’t know	__ __ ( )1 weeks ( )2 months ( )3 years ( )8 Don’t know	( )0 no ( )1 yes ( )8 Don’t know
c. Pain relievers not containing aspirin or Tylenol (such as Aleve, Ibuprofen, Motrin, Advil, Nuprin, Naprosyn, Feldene, Indocin, Clinoril) ( )0 no ( )1 yes ( )8 Don’t know	___ # pills per: ( )1 day ( )2 week ( )8 Don’t know	__ __ ( )1 weeks ( )2 months ( )3 years ( )8 Don’t know	( )0 no ( )1 yes ( )8 Don’t know

SUPPLEMENT INFO. ( )₁ Very good ( )₂ Good ( )₃ Fair ( )₄ Poor

4. TOBACCO HISTORY

Next, I would like to ask you some questions about any smoking history you may have.

1. Have you ever smoked more than 100 cigarettes, which is equivalent to five packs, in your life? ( )₀ No (Skip to D. 18)

( )₁ Yes

2. Please tell me about your smoking history. I will be asking you questions about any times you may have stopped or changed your patterns.

Period

1

2

3

4

5

6

a. In what year did you start smoking cigarettes or change your patterns?

__ __ __ __

__ __ __ __

__ __ __ __

__ __ __ __

__ __ __ __

__ __ __ __

b. What was the average number of cigarettes or packs per day you smoked during this time?

__ __ __ __ ( )1cigarettes ( )2 packs

__ __ __ __ ( )1cigarettes ( )2 packs

__ __ __ __ ( )1cigarettes ( )2 packs

__ __ __ __ ( )1cigarettes ( )2 packs

__ __ __ __ ( )1cigarettes ( )2 packs

__ __ __ __ ( )1cigarettes ( )2 packs

c. After starting, did you change your patterns or stop smoking for more than 6 months?

( )0 No (D3) ( )1 Stopped smoking ( )2 changed pattern

( )0 No (D3) ( )1 Stopped smoking ( )2 changed pattern

( )0 No (D3) ( )1 Stopped smoking ( )2 changed pattern

( )0 No (D3) ( )1 Stopped smoking ( )2 changed pattern

( )0 No (D3) ( )1 Stopped smoking ( )2 changed pattern

( )0 No (D3) ( )1 Stopped smoking ( )2 changed pattern

d. In what year did you stop smoking or change your patterns for more than six months?

__ __ __ __ If this is a change of pattern, skip to D2a

__ __ __ __ If this is a change of pattern, skip to D2a

__ __ __ __ If this is a change of pattern, skip to D2a

__ __ __ __ If this is a change of pattern, skip to D2a

__ __ __ __ If this is a change of pattern, skip to D2a

__ __ __ __

e. Did you start smoking again?

( )0 No (D3) ( )1Yes (D2a)

( )0 No (D3) ( )1Yes (D2a)

( )0 No (D3) ( )1Yes (D2a)

( )0 No (D3) ( )1Yes (D2a)

( )0 No (D3) ( )1Yes (D2a)

( )0 No (D3) ( )1Yes (D2a)

If R stopped smoking more than 6 months ago, Skip to D. 6

3. Have you increased or decreased your amount of cigarette smoking in the last 6 months? ( )₀ No (Skip to D6)

( )₁ Yes

Period		1	2	3
4.	How long ago did you change your level of smoking?	__ __ ( )1 weeks ( )2 months	__ __ ( )1 weeks ( )2 months	__ __ ( )1 weeks ( )2 months
5a.	Since then, what is the average amount of cigarettes you smoked per day?	__ __ ( )1 cigarettes ( )2 packs	__ __ ( )1 cigarettes ( )2 packs	__ __ ( )1 cigarettes ( )2 packs
5b.	Did you change your level of smoking again?	( )0 No (D6) ( )1 Yes (D4)	( )0 No (D6) ( )1 Yes (D4)	( )0 No (D6) ( )1 Yes (D6)

For Case-Control Patients ONLY, Multi-organ patients skip to question #18.

6. How many cigarettes have you smoked in the last 48 hours?

__ __ __

6. Can you tell me the brand name of the cigarettes that you smoked the longest?

_______________________ 

6. What is the most recent brand that you smoked?

_______________________ 

6. When you were last smoking regularly, can you tell me, how soon after you (wake/woke) up (do/did) you smoke your first cigarette? (Read Responses)

( )₁ Within 5 minutes

( )₂ 6 - 30 minutes

( )₃ 31 - 60 minutes

( )₄ After 60 minutes

6. (Do/Did) you find it difficult not to smoke in places where it is forbidden, such as a church, library, or public building?

( )₀ No ( )₁ Yes

6. Which cigarette would you (hate/have hated) most to give up?

( )₀ None/can’t decide

( )₁ The first one in the morning

( )₂ All others

( )₃ After Meals

6. (Do /Did) you smoke more frequently during the first hours after waking than during the rest of the day? ( )₀ No

( )₁ Yes

6. (Do\did) you smoke if you (are/were) so ill that you (are/were) in bed most of the day?

( )₀ No

( )₁ Yes

6. During periods when you smoke(d), (do/did) you usually smoke filter or non-filter cigarettes?

( )₁ Filter

( )₂ Non-Filter

( )₃ Both

6. During periods when you smoke(d), (do/did) you usually smoke menthol or non-menthol cigarettes?

( )₁ Menthol

( )₂ Non-Menthol

( )₃ Both

6. When smoking cigarettes, do/did you usually inhale?

( )₀ No (Skip to D. 18)

( )₁ Yes

6. Did you inhale slightly, moderately, or deeply?

( )₁ Slightly

( )₂ Moderately

( )₃ Deeply

6. Have you ever smoked at least one cigar a month for more than 6 months?

( )₀ No

( )₁ Yes

19. Have you ever smoked a pipe on a daily basis for more than 6 months?

( )₀ No

( )₁ Yes

20. During your childhood, until you moved out of your childhood home, did anyone in your home smoke cigarettes?

( )₀ No ( Skip to D. 23)

( )₁ Yes

21. How many people smoked in your home?

__ __

22. Who smoked in your home during childhood? (For Case-Control Participants Only. Multi-organ patients skip to question 23)

		1	2	3	4
Please tell me their first names.
a.	What is their relationship to you?				
b.	Would you say they smoked lightly, moderately, heavy or you do not know?	( )1 light ( )2 moderate ( )3 heavy ( )8 DK	( )1 light ( )2 moderate ( )3 heavy ( )8 DK	( )1 light ( )2 moderate ( )3 heavy ( )8 DK	( )1 light ( )2 moderate ( )3 heavy ( )8 DK
c.	On the average, how many cigars, pipes, cigarettes or packs per day (does/did) (he/she) smoke at home?	__ __ __ ( )1 cigarettes ( )2 packs ( )3 cigars ( )4 pipes	__ __ __ ( )1 cigarettes ( )2 packs ( )3 cigars ( )4 pipes	__ __ __ ( )1 cigarettes ( )2 packs ( )3 cigars ( )4 pipes	__ __ __ ( )1 cigarettes ( )2 packs ( )3 cigars ( )4 pipes
d.	For how many years did (he/she) smoke while you were in the home?	__ __ < 1 year = 1 year	__ __ < 1 year = 1 yr	__ __ < 1 year = 1 yr	__ __ < 1 year = 1 yr

		5	6	7	8
22. Con’t: Please tell me their first names.
e.	What is their relationship to you?				
f.	Would you say they smoked lightly, moderately, heavy or you do not know?	( )1 light ( )2 moderate ( )3 heavy ( )8 DK	( )1 light ( )2 moderate ( )3 heavy ( )8 DK	( )1 light ( )2 moderate ( )3 heavy ( )8 DK	( )1 light ( )2 moderate ( )3 heavy ( )8 DK
g.	On the average, how many cigars, pipes, cigarettes or packs per day (does/did) (he/she) smoke at home?	__ __ __ ( )1 cigarettes ( )2 packs ( )3 cigars ( )4 pipes	__ __ __ ( )1 cigarettes ( )2 packs ( )3 cigars ( )4 pipes	__ __ __ ( )1 cigarettes ( )2 packs ( )3 cigars ( )4 pipes	__ __ __ ( )1 cigarettes ( )2 packs ( )3 cigars ( )4 pipes
h.	For how many years did (he/she) smoke while you were in the home?	__ __ < 1 year = 1 yr	__ __ < 1 year = 1 yr	__ __ < 1 year = 1 yr	__ __ < 1 year = 1 yr

23. As an adult, does or did your (wife/husband/partner) or anyone else smoke or smoked cigarettes in your home? (If smoking is done only outside the home, then do not include.)

( )₀ No (Skip to D.26)

( )₁ Yes

24. How many people smoke or smoked in your home?

__ __

25. Who smoked in your home as an adult? (For Case-Control Participants Only. Multi-organ patients skip to question 26)

		1	2	3	4
Please tell me their first names.
a.	What is their relationship to you?				
b.	Would you say they smoked lightly, moderately, heavy or you do not know?	( )1 light ( )2 moderate ( )3 heavy ( )8 DK	( )1 light ( )2 moderate ( )3 heavy ( )8 DK	( )1 light ( )2 moderate ( )3 heavy ( )8 DK	( )1 light ( )2 moderate ( )3 heavy ( )8 DK
c.	On the average, how many cigars, pipes, cigarettes or packs per day (does/did) (he/she) smoke at home?	__ __ __ ( )1 cigarettes ( )2 packs ( )3 cigars ( )4 pipes	__ __ __ ( )1 cigarettes ( )2 packs ( )3 cigars ( )4 pipes	__ __ __ ( )1 cigarettes ( )2 packs ( )3 cigars ( )4 pipes	__ __ __ ( )1 cigarettes ( )2 packs ( )3 cigars ( )4 pipes
d.	For how many years did (he/she) smoke while you were in the home?	__ __ < 1 year = 1 yr	__ __ < 1 year = 1 yr	__ __ < 1 year = 1 yr	__ __ < 1 year = 1 yr
e.	Did (he/she) stop smoking while you were in the house?	( )0 No (25g) ( )1 Yes	( )0 No (25g) ( )1 Yes	( )0 No (25g) ( )1 Yes	( )0 No (25g) ( )1 Yes
f.	How long ago did (he/she) stop smoking?	__ __ ( )1 months ( )2 years ( )3 weeks	__ __ ( )1 months ( )2 years ( )3 weeks	__ __ ( )1 months ( )2 years ( )3 weeks	__ __ ( )1 months ( )2 years ( )3 weeks
g.	During the last thirty days, how many cigars, pipes, or cigarettes per day did (he/she) smoke at home?	__ __ 66= Deceased 77=Not living in the house	__ __ 66= Deceased 77=Not living in the house	__ __ 66= Deceased 77=Not living in the house	__ __ 66= Deceased 77=Not living in the house

25. Smoked in your home as an adult (continued)

		5	6	7	8
Please tell me their first names.
h.	What is their relationship to you?				
i.	Would you say they smoked lightly, moderately, heavy or you do not know?	( )1 light ( )2 moderate ( )3 heavy ( )8 DK	( )1 light ( )2 moderate ( )3 heavy ( )8 DK	( )1 light ( )2 moderate ( )3 heavy ( )8 DK	( )1 light ( )2 moderate ( )3 heavy ( )8 DK
j.	On the average, how many cigars, pipes, cigarettes or packs per day (does/did) (he/she) smoke at home?	__ __ __ ( )1 cigarettes ( )2 packs ( )3 cigars ( )4 pipes	__ __ __ ( )1 cigarettes ( )2 packs ( )3 cigars ( )4 pipes	__ __ __ ( )1 cigarettes ( )2 packs ( )3 cigars ( )4 pipes	__ __ __ ( )1 cigarettes ( )2 packs ( )3 cigars ( )4 pipes
k.	For how many years did (he/she) smoke while you were in the home?	__ __ < 1 year = 1 yr	__ __ < 1 year = 1 yr	__ __ < 1 year = 1 yr	__ __ < 1 year = 1 yr
l.	Did (he/she) stop smoking while you were in the house?	( )0 No (25n) ( )1 Yes	( )0 No (25n) ( )1 Yes	( )0 No (25n) ( )1 Yes	( )0 No (25n) ( )1 Yes
m.	How long ago did (he/she) stop smoking?	__ __ ( )1 months ( )2 years ( )3 weeks	__ __ ( )1 months ( )2 years ( )3 weeks	__ __ ( )1 months ( )2 years ( )3 weeks	__ __ ( )1 months ( )2 years ( )3 weeks
n.	During the last thirty days, how many cigars, pipes, or cigarettes per day did (he/she) smoke at home?	__ __ 66= Deceased 77=Not living in the house	__ __ 66= Deceased 77=Not living in the house	__ __ 66= Deceased 77=Not living in the house	__ __ 66= Deceased 77=Not living in the house

26. Were you exposed to cigarette smoke in your work place during the last 48 hours? ( )₀ No

( )₁ Yes

( )₂ Not at work in the last 48 hours

( )₃ Not currently working (or retired)

27. In your workplace, were you employed at a job or jobs for more than five years where co-workers smoked cigarettes in your immediate area?

( )₀ No

( )₁ Yes

28. For how many years were you working a job where people smoked regularly in your immediate work area?

___ ___ ( If 00, skip to Section E)

29. How long ago has it been since you were working at a job where people smoked regularly in your immediate work area?

( )₁ Today

( )₂ __ __ Day(s)

( )₃ __ __ Month(s)

( )₄ __ __ Year(s)

30. Would you say you were exposed at work to cigarette smoke lightly, moderately, heavy or you do not know?

( )₁ Lightly

( )₂ Moderately

( )₃ Heavy

( )₄ Do not know

TOBACCO HISTORY ( )₁ Very good ( )₂ Good ( )₃ Fair ( )₄ Poor

E. ALCOHOL HISTORY

Now, I would like to ask you some questions about any alcoholic beverages you may drink on a regular basis.

1. In your entire life, have you ever consumed more than 12 alcoholic beverages per year, such as beer, wine, wine coolers or liquor? ( )₀ No (Skip to E.3)

( )₁ Yes

2. Tell me about the types of alcohol and when you were drinking them.

Period	1	2	3	4	5	6	7
a. At what age did you first start to drink/when you next began to drink?	___ ___	___ ___	___ ___	___ ___	___ ___	___ ___	___ ___
b. How many cans, bottles or 12 oz of beer did/do you drink?	___ ___ ( )1 Per day ( )2 Per wk. ( )3 Per mo. ( )4 Per yr.	___ ___ ( )1 Per day ( )2 Per wk. ( )3 Per mo. ( )4 Per yr.	___ ___ ( )1 Per day ( )2 Per wk. ( )3 Per mo. ( )4 Per yr.	___ ___ ( )1 Per day ( )2 Per wk. ( )3 Per mo. ( )4 Per yr.	___ ___ ( )1 Per day ( )2 Per wk. ( )3 Per mo. ( )4 Per yr.	___ ___ ( )1 Per day ( )2 Per wk. ( )3 Per mo. ( )4 Per yr.	___ ___ ( )1 Per day ( )2 Per wk. ( )3 Per mo. ( )4 Per yr.
c. How many 4 oz glasses of wine did/do you drink?	___ ___ ( )1 Per day ( )2 Per wk. ( )3 Per mo. ( )4 Per yr.	___ ___ ( )1 Per day ( )2 Per wk. ( )3 Per mo. ( )4 Per yr.	___ ___ ( )1 Per day ( )2 Per wk. ( )3 Per mo. ( )4 Per yr.	___ ___ ( )1 Per day ( )2 Per wk. ( )3 Per mo. ( )4 Per yr.	___ ___ ( )1 Per day ( )2 Per wk. ( )3 Per mo. ( )4 Per yr.	___ ___ ( )1 Per day ( )2 Per wk. ( )3 Per mo. ( )4 Per yr.	___ ___ ( )1 Per day ( )2 Per wk. ( )3 Per mo. ( )4 Per yr.
d. How many 1 ½ oz. shots of liquor, by itself or in a drink did/do you drink?	___ ___ ( )1 Per day ( )2 Per wk. ( )3 Per mo. ( )4 Per yr.	___ ___ ( )1 Per day ( )2 Per wk. ( )3 Per mo. ( )4 Per yr.	___ ___ ( )1 Per day ( )2 Per wk. ( )3 Per mo. ( )4 Per yr.	___ ___ ( )1 Per day ( )2 Per wk. ( )3 Per mo. ( )4 Per yr.	___ ___ ( )1 Per day ( )2 Per wk. ( )3 Per mo. ( )4 Per yr.	___ ___ ( )1 Per day ( )2 Per wk. ( )3 Per mo. ( )4 Per yr.	___ ___ ( )1 Per day ( )2 Per wk. ( )3 Per mo. ( )4 Per yr.
e. Have you ever stopped drinking or changed your patterns for more than 12 months?	( )0 No (E3) ( )1 Stopped ( )2 Changed pattern	( )0 No (E3) ( )1 Stopped ( )2 Changed pattern	( )0 No (E3) ( )1 Stopped ( )2 Changed pattern	( )0 No (E3) ( )1 Stopped ( )2 Changed pattern	( )0 No (E3) ( )1 Stopped ( )2 Changed pattern	( )0 No (E3) ( )1 Stopped ( )2 Changed pattern	( )0 No (E3) ( )1 Stopped ( )2 Changed pattern
f. What age did you stop drinking or change your patterns for more than 12 months?	___ ___	___ ___	___ ___	___ ___	___ ___	___ ___	___ ___

3. Have you had any alcoholic beverages such as beer, wine or liquor in the last 7 days?

( )₀ No (Skip to Section F)

( )₁ Yes

In the last seven days, how much did you drink of the following?:

Number:

a. Cans, bottles or 12 oz. glass of beer	__ __ __
b. 4 oz. glasses of wine	__ __ __
c. 1 ½ oz. shots of hard liquor or drinks containing a shot of hard liquor	__ __ __

ALCOHOL HISTORY ( )₁ Very good ( )₂ Good ( )₃ Fair ( )₄ Poor

F. MEDICAL HISTORY

Now I would like to ask you some questions about your medical history and your health.

1.	Did a doctor ever tell you that you had?:	Yes/No	How old were you when you were first diagnosed? DK = 888, condition at birth =000
a.	Chronic bronchitis	( )0 No (Skip to 1b) ( )1 Yes	___ ___ ___
b.	Emphysema	( )0 No (Skip to 1c) ( )1 Yes	___ ___ ___
c.	Asthma during adult years	( )0 No (Skip to 1d) ( )1 Yes	___ ___ ___
d.	Tuberculosis	( )0 No (Skip to 1e) ( )1 Yes	___ ___ ___
e.	Asbestosis	( )0 No (Skip to 1f) ( )1 Yes	___ ___ ___
1.	(Cont.) Did a doctor ever tell you that you had:	Yes/No	How old were you when you were first diagnosed? DK = 888, condition at birth =000
f.	Lung disease, other than cancer (specify) *do not include current lung cancer 	( )0 No (Skip to 1g) ( )1 Yes	___ ___ ___
g.	Liver disease, such as chronic hepatitis or cirrhosis	( )0 No (Skip to 1h) ( )1 Yes	___ ___ ___
h.	Kidney disease	( )0 No (Skip to 1i) ( )1 Yes	___ ___ ___
i.	Heart disease	( )0 No (Skip to 1j) ( )1 Yes	___ ___ ___
j.	Diabetes	( )0 No (Skip to 1k) ( )1 Yes	___ ___ ___
k.	Lupus	( )0 No (Skip to 1l) ( )1 Yes	___ ___ ___
l.	Rheumatoid arthritis	( )0 No (Skip to 1m) ( )1 Yes	___ ___ ___
m	Thyroid condition (specify) 	( )0 No (Skip to 1n) ( )1 Yes	___ ___ ___
n.	Anemia (chronic anemia, not one episode)	( )0 No (Skip to 1o) ( )1 Yes	___ ___ ___
o.	Stroke	( )0 No (Skip to 2) ( )1 Yes	___ ___ ___

2. Have you taken any prescription or non prescription medicines in the last 3 months?

( )₀ No (Skip to F.3)

( )₁ Yes

What is the name of the medicine?	Medication code  (office use)	When was the last time you took it?	What is it for?	Indication code  (office use)
a.		__ __ / __ __ / __ __ __ __
b.		__ __ / __ __ / __ __ __ __
c.		__ __ / __ __ / __ __ __ __
d.		__ __ / __ __ / __ __ __ __
e.		__ __ / __ __ / __ __ __ __
f.		__ __ / __ __ / __ __ __ __
g.		__ __ / __ __ / __ __ __ __
h.		__ __ / __ __ / __ __ __ __
i.		__ __ / __ __ / __ __ __ __
j.		__ __ / __ __ / __ __ __ __
k.		__ __ / __ __ / __ __ __ __
l.		__ __ / __ __ / __ __ __ __

m.

__ __ / __ __ / __ __ __ __

3. What is your current weight?

___ ___ ___ lbs

4. What was your weight 10 years ago?

___ ___ ___ lbs

5. What was your weight 2 years ago?

___ ___ ___ lbs

6. How tall are you?

______feet ___ ___ inches

MEDICAL HISTORY ( )₁ Very good ( )₂ Good ( )₃ Fair ( )₄ Poor

G. FAMILY HISTORY

Now, I would like to learn more about the members of your family. First, I need to get some background about the structure of your family.

1. I would like to ask how many children you have had. Please include only those children related to you by blood.

____ ____

# Children

2. Were you adopted?

( )₀ No

( )₁ Yes

3. Counting only the brothers and sisters related to you by blood, how many brothers and sisters have you had? Please include half brothers and sisters.

___ ___ ___ ___

# Brothers # Sisters

4. Counting only the aunts and uncles related to you by blood, how many aunts and uncles have you had?

___ ___ ___ ___

# Uncles # Aunts

4. Has anyone in your family that is related to you by blood, ever been told they have cancer, include children, parents, grandparents, brothers, sisters, great grand parents, cousins or immediate aunts or uncles? (Include description of maternal or paternal relative) ( )₀ No (Skip to G.7) ( )₁ Yes

6. Which relative?	First name	Where did the cancer start? DK = 888	How old were they when they were diagnosed?
a. 			( )1 <20 ( )5 50-59 ( )2 20-29 ( )6 60-69 ( )3 30-39 ( )7 > 70 ( )4 40-49 ( )8 Don’t know
b. 			( )1 <20 ( )5 50-59 ( )2 20-29 ( )6 60-69 ( )3 30-39 ( )7 > 70 ( )4 40-49 ( )8 Don’t know
c. 			( )1 <20 ( )5 50-59 ( )2 20-29 ( )6 60-69 ( )3 30-39 ( )7 > 70 ( )4 40-49 ( )8 Don’t know
d. 			( )1 <20 ( )5 50-59 ( )2 20-29 ( )6 60-69 ( )3 30-39 ( )7 > 70 ( )4 40-49 ( )8 Don’t know
e. 			( )1 <20 ( )5 50-59 ( )2 20-29 ( )6 60-69 ( )3 30-39 ( )7 > 70 ( )4 40-49 ( )8 Don’t know
f. 			( )1 <20 ( )5 50-59 ( )2 20-29 ( )6 60-69 ( )3 30-39 ( )7 > 70 ( )4 40-49 ( )8 Don’t know
g. 			( )1 <20 ( )5 50-59 ( )2 20-29 ( )6 60-69 ( )3 30-39 ( )7 > 70 ( )4 40-49 ( )8 Don’t know
h. 			( )1 <20 ( )5 50-59 ( )2 20-29 ( )6 60-69 ( )3 30-39 ( )7 > 70 ( )4 40-49 ( )8 Don’t know
i. 			( )1 <20 ( )5 50-59 ( )2 20-29 ( )6 60-69 ( )3 30-39 ( )7 > 70 ( )4 40-49 ( )8 Don’t know
j. 			( )1 <20 ( )5 50-59 ( )2 20-29 ( )6 60-69 ( )3 30-39 ( )7 > 70 ( )4 40-49 ( )8 Don’t know
k. 			( )1 <20 ( )5 50-59 ( )2 20-29 ( )6 60-69 ( )3 30-39 ( )7 > 70 ( )4 40-49 ( )8 Don’t know

7. For the next questions, I’d like you to think about all those members of your family, who have medical problems other than cancer. (Include spouse, children, siblings, or parents.)

	Did a doctor ever tell any member of your family that he or she had . . .	Which relatives had the problem?	First name	How old were they when they were diagnosed? DK=888
a.	Chronic bronchitis? ( )0 No (Skip to 7b) ( )1 Yes			__ __ __
				__ __ __
				__ __ __
b.	Emphysema ( )0 No (Skip to 7c) ( )1 Yes			__ __ __
				__ __ __
				__ __ __
				__ __ __
c.	Asthma during adult years ( )0 No (Skip to 7d) ( )1 Yes			__ __ __
				__ __ __
				__ __ __
				__ __ __
d.	Tuberculosis ( )0 No (Skip to 7e) ( )1 Yes			__ __ __
				__ __ __
e.	Asbestosis ( )0 No (Skip to 7f) ( )1 Yes			__ __ __
				__ __ __
f.	Other lung disease specify:__________  ( )0 No (Skip to H ) ( )1 Yes			__ __ __
				__ __ __
g.	Other lung disease specify:_________  ( )0 No (Skip to H ) ( )1 Yes			__ __ __
				__ __ __

FAMILY HISTORY ( )₁ Very good ( )₂ Good ( )₃ Fair ( )₄ Poor

H. REPRODUCTIVE HISTORY (IF MALE, SKIP TO SECTION I, P.35)

This next set of questions may seem personal, but remember that your answers are very important to us.

1. Have you ever been pregnant? ( )₀ No (Skip to H. 7)

( )₁ Yes

2. How many times have you been pregnant? ___ ___

	1	2	3	4	5	6	7	8	9	10	11	12
3. How old were when you became pregnant? (Should be chronological)
4. What was the outcome of this pregnancy? (Check one for each pregnancy)
01 Single live birth
02 Multiple live birth, any living
03 Multiple birth, none living
04 Stillbirth
05 Miscarriage
06 Induced Abortion
07 Ectopic or tubal
08 Currently pregnant
09 Other (specify)________
If R had no live births, Skip to H.7
	1	2	3	4	5	6	7	8	9	10	11	12
5. Did you breast feed any of these babies for at least two weeks or longer? ( )0 No (Skip to H.7) ( )1 Yes
6. For how many weeks did you breast feed these babies, until you stopped all together?

7. At what age did you have your first menstrual period? ___ ___

8. At what age did your menstrual periods become regular? ___ ___

(77 = period never became regular)

9. Have you used birth control, or family planning during your life?

( )₀ No (Skip to H.11) ( )₁ Yes

For Case-Control Participants ONLY, MULTI-ORGAN patients answer only 10a and then skip to question #11

10. What type of birth control or family planning, if any, have you used during your life?	At what age did you start?	At what age did you stop? 77= still using
a. Birth control pills ( )0 No (Skip to 11b) ( )1 Yes	__ __	__ __
	__ __	__ __
	__ __	__ __
b. Birth control shots or injections ( )0 No (Skip to 11c) ( )1 Yes	__ __	__ __
	__ __	__ __
	__ __	__ __
c. Implants, such as Norplant ( )0 No (Skip to 11d) ( )1 Yes	__ __	__ __
	__ __	__ __
	__ __	__ __
d. Condoms or rubbers ( )0 No (Skip to 11e) ( )1 Yes	__ __	__ __
	__ __	__ __
	__ __	__ __
e. Diaphragm, cap or sponge ( )0 No (Skip to 11f) ( )1 Yes	__ __	__ __
	__ __	__ __
	__ __	__ __
f. Foam, jelly, cream or suppositories ( )0 No (Skip to 11g) ( )1 Yes	__ __	__ __
	__ __	__ __
	__ __	__ __
g. Rhythm, calendar, ovulation or withdrawal ( )0 No (Skip to 11h) ( )1 Yes	__ __	__ __
	__ __	__ __
	__ __	__ __
h. IUD, intrauterine devise, such as a loop or coil ( )0 No (Skip to H.12) ( )1 Yes	__ __	__ __
	__ __	__ __

11. Did you ever have your tubes tied, sterilization?

( )₀ No (Skip to H.13)

( )₁ Yes

12. When did the surgery take place?

__ __ / __ __ /__ __ __ __

13. Did your partner ever have a vasectomy, male sterilization or surgery?

( )₀ No (Skip to H.15)

( )₁ Yes

14. When did the surgery take place?

__ __ / __ __ /__ __ __ __

15. Did you ever use birth control pills, shots or implants for any reason other than birth control?

( )₀ No (Skip to H.17)

( )₁ Yes

16. What was the reason? Please answer yes or no to the following.

a. Regulate periods ( )₀ No ( )₁ Yes

b. Acne ( )₀ No ( )₁ Yes

c. Cramps or painful ovulation ( )₀ No ( )₁ Yes

d. Menopausal symptoms ( )₀ No ( )₁ Yes

e. Other ( )₀ No ( )₁ Yes

(specify) 

17. Have you had a menstrual period in the last 6 weeks?

( )₀ No

( )₁ Yes

18. Are you still menstruating?

( )₀ No

( )₁ Yes (Skip to H. 22)

19. At what age was your last menstrual period?

___ ___

20. What was the reason that your menstrual periods stopped?

( )₁ Change of life or natural Menopause

( )₂ Hysterectomy, still has ovaries

( )₃ Hysterectomy, ovaries removed

( )₄ Hysterectomy, don’t know whether ovaries removed

( )₅ Currently pregnant

( )₆ Other reason (specify why): _______________________________________________

21. Has a doctor or other health professional ever told you that you had completed menopause or the change in life?

( )₀ No

( )₁ Yes

22. Have you ever used hormonal medications just before, during or after menopause, such as pills, vaginal creams, shots, suppositories or skin patches?

( )₀ No (Skip to Section I)

( )₁ Yes

		At what age did you start to use them?	Total number of years used? 77= still using
a. Estrogen pills (Premarin, Estrace, Estratab, Ogen)	( )0 No ( )1 Yes	__ __	__ __
b. Progresterone pills (Progestins, Provera, Megace)	( )0 No ( )1 Yes	__ __	__ __
c. Estrogen and progesterone pills (Prempo)	( )0 No ( )1 Yes	__ __	__ __
d. Estrogen and testerone (Estratest)	( )0 No ( )1 Yes	__ __	__ __
e. Estrogen vaginal cream	( )0 No ( )1 Yes	__ __	__ __
f. Estrogen shots	( )0 No ( )1 Yes	__ __	__ __
g. Estrogen skin patches (Estraderm)	( )0 No ( )1 Yes	__ __	__ __

h. Estrogen patch and progesterone pills	( )0 No ( )1 Yes	__ __	__ __
i. Suppository	( )0 No ( )1 Yes	__ __	__ __
j. Other __________________ 	( )0 No ( )1 Yes	__ __	__ __

REPRODUCTIVE HISTORY ( )₁ Very good ( )₂ Good ( )₃ Fair ( )₄ Poor

I. OCCUPATIONAL HISTORY

Next, I would like to ask you some questions about your current and past jobs.

1. Are you currently employed?

   1. ( )₀ No (Skip to I. 3)

   2. ( )₁ Yes

2. What is your current job title?

___________________________________________________ 

3. What is or was your usual occupation for your adult life? That is, what occupation did you work at the longest during your adult life? (If R never worked, Skip to J)

G Never worked

___________________________________________________ 

4. What is or was your usual activities in this job? (Relates to Question 3)

________________________________________________________

5. In what kind of business or industry did you work the longest in your life?

____________________________________________________ 

6. Have you ever had a job in the following industries?	Fill in Yes or No	What was your job title? (Code )	In what year did you start working there?	What year were you last employed there? Still employed=7777
a. Shipbuilding	( )0 No ( )1 Yes		__ __ __ __	__ __ __ __
b. Construction	( )0 No ( )1 Yes		__ __ __ __	__ __ __ __
c. Fishing	( )0 No ( )1 Yes		__ __ __ __	__ __ __ __

d. Lumber, wood, furniture, manufacturing or paper	( )0 No ( )1 Yes		__ __ __ __	__ __ __ __
e. Petrochemical	( )0 No ( )1 Yes		__ __ __ __	__ __ __ __

f. Metal refining, manufacturing, polishing or plating	( )0 No ( )1 Yes		__ __ __ __	__ __ __ __
g. Chemical manufacturing	( )0 No ( )1 Yes		__ __ __ __	__ __ __ __

h. Cement manufacture

( )0 No ( )1 Yes

__ __ __ __

__ __ __ __

i. Demolition

( )0 No ( )1 Yes

__ __ __ __

__ __ __ __

j. Steel mill or foundry	( )0 No ( )1 Yes		__ __ __ __	__ __ __ __
k. Dye industry	( )0 No ( )1 Yes		__ __ __ __	__ __ __ __
l. Hazardous waste removal	( )0 No ( )1 Yes		__ __ __ __	__ __ __ __

OCCUPATIONAL HISTORY ( )₁ Very good ( )₂ Good ( )₃ Fair ( )₄ Poor

J. RESIDENTIAL HISTORY

1. Where were you born?______________________ ___ ___

City State

2. How many months or years did you live in the city or town where you were born?

____ ____ ( )₁ months

( )₂ years

If R lived here all his/her life, Skip to Section K

(R needs to live in location 6 months to constitute residence.)

3. Please tell me about each of the cities or town that you have lived in during your life. ( ) Military (check box)

Period		1.	2.	3.	4.
a. Where did you live next? Code country 	City/town
	State	___ ___	___ ___	___ ___	___ ___
	Country

Did you move from here?	Fill in Yes or No	( )0 No (K) ( )1 Yes	( )0 No (K) ( )1 Yes	( )0 No (K) ( )1 Yes	( )0 No (K) ( )1 Yes
At what age did you move from here?		___ ___	___ ___	___ ___	___ ___

Period		5.	6.	7.	8.
a. Where did you live next? Code country 	City/town
	State	___ ___	___ ___	___ ___	___ ___
	Country

Did you move from here?	Fill in Yes or No	( )0 No (K) ( )1 Yes	( )0 No (K) ( )1 Yes	( )0 No (K) ( )1 Yes	( )0 No (K) ( )1 Yes
At what age did you move from here?		___ ___	___ ___	___ ___	___ ___

Period		9.	10.	11.	12.
a. Where did you live next? Code country 	City/town
	State	___ ___	___ ___	___ ___	___ ___
	Country

Did you move from here?	Fill in Yes or No	( )0 No (K) ( )1 Yes	( )0 No (K) ( )1 Yes	( )0 No (K) ( )1 Yes	( )0 No (K) ( )1 Yes
At what age did you move from here?		___ ___	___ ___	___ ___	___ ___

RESIDENTIAL HISTORY ( )₁ Very good ( )₂ Good ( )₃ Fair ( )₄ Poor

K. EXERCISE

For Case-Control Participants ONLY. Multi-organ patients skip to section L

Please tell me about the kinds of activities you do during the week.

1. How would you describe your usual activity during your work in the past year?

( )₀ Hard physical effort (ex. heavy lifting, digging).

Activities that make you breathe much harder than normal.

( )₁ Moderate physical effort (ex. carrying light loads).

Activities that make you breathe somewhat harder than normal.

( )₂ Less physical effort (ex. sitting at a desk, reading, working at a

computer.)

( )₃ Not working.

( )₈ Don’t Know

1. How would you describe your usual leisure time activity in the past year?

( )₀ Hard physical effort (ex. heavy lifting, aerobics, or fast

bicycling).

Activities that make you breathe much harder than normal.

( )₁ Moderate physical effort (ex. carrying light loads, bicycling at a

regular pace, gardening, or taking walks).

Activities that make you breather somewhat harder than normal.

( )₂ Less physical effort (ex. sitting at a desk, reading, visiting friends,

or watching television.)

( )₈ Don’t Know

2. How would you describe your usual activity during your work 20 years ago?

( )₀ Hard physical effort (ex. heavy lifting, digging).

Activities that make you breathe much harder than normal.

( )₁ Moderate ph ysical effort (ex. carrying light loads).

Activities that make you breathe somewhat harder than normal.

( )₂ Less physical effort (ex. sitting at a desk, reading, working at a computer.)

( )₃ Not working.

( )₈ Don’t Know

3. How would you describe your usual leisure time activity 20 years ago?

( )₀ Hard physical effort (ex. heavy lifting, aerobics, or fast

bicycling).

Activities that make you breathe much harder than normal.

( )₁ Moderate physical effort (ex. carrying light loads, bicycling at a

regular pace, gardening, or taking walks).

Activities that make you breather somewhat harder than normal.

( )₂ Less physical effort (ex. sitting at a desk, reading, visiting friends,

or watching television.)

( )₈ Don’t Know

EXERCISE ( )₁ Very good ( )₂ Good ( )₃ Fair ( )₄ Poor

L. GENERAL INFORMATION:

1. What was the highest level of education that you completed:

( )₁ Elementary School (5^th or 6^th grade)

( )₂ Middle or Junior High School (7^th, 8^th or 9^th grade)

( )₃ 10^th or 11^th grade

( )₄ High School or GED (12th grade)

( )₅ Some College (includes AA degree)

( )₆ Technical School

( )₇ College

( )₈ Professional School (includes MS, PhD, MD, etc)

2. We need your social security number for the purposes of using it as a unique identifier. May I please have your social security number?

___ ___ ___ - ___ ___ - ___ ___ ___ ___

Fill in with 8s for Don’t Know/Refused.

3. What is your current level of household income per year?

( )₁ Less than $10,000

( )₂ $10,000-29,999

( )₃ $30,000-59,999

( )₄ $60,000-90,000

( )₅ Greater than $90,000

( )₈ Don’t Know/Refused

4. How many people are currently supported in your household?

___ ___

Fill in with 8s for Don’t Know/Refused.

5. What was the current level of household income in your home twenty years ago?

( )₁ Less than $10,000

( )₂ $10,000-29,999

( )₃ $30,000-59,999

( )₄ $60,000-90,000

( )₅ Greater than $90,000

( )₈ Don’t Know/Refused

6. Twenty years ago, how many people were supported in your household?

___ ___

ASK LUNG AND PROSTATE CANCER CASE PATIENTS ONLY (Questions 7-9)

7. Are you having any surgery in the near future?

( )₀ No (Skip to Ending)

( )₁ Yes

8. What kind of surgery are you having?

___________________________________________.

9. When are you having this surgery?

___ ___ / ___ ___ /___ ___ ___ ___

FOR ALL PARTICIPANTS

10. May we contact you again later if we need to clarify any of the information you have provided. ( )₀ No

( )₁ Yes

11. Time ended: __ __ : __ ___ ( )₁ AM

( )₂ PM

For Case-Control Participants ONLY – First get specimen samples and then provide reimbursement of $50.00.

Blood Specimen Collected

Urine Specimen Collected

M. ADMINISTRATIVE INFORMATION

1. Date form completed: __ __ / __ __ / __ __ __ __

2. Name of Interviewer _______________/___________/_____________

3. Interviewer ID number: __ __

4. Interviewer’s Signature: _______________________________

N. INTERVIEWER REMARKS

1. Interview was conducted:

( )₁ Home

( )₂ Hospital - inpatient (specify)________________ 

( )₃ Hospital - outpatient (specify)_______________ 

( )₄ Non-residential, non-hospital location

(specify) _____________________________ 

( )₅ One of the Study Offices

( )₆ Other (specify) ________________________ 

2. Respondent’s cooperation was: ( )₁ Very good

( )₂ Good

( )₃ Fair

( )₄ Poor

3. The overall quality of the interview was: ( )₁ Very good

( )₂ Good

( )₃ Fair

( )₄ Poor

4. Did any of the following occur during the interview?

a. R did not know enough information regarding the topics ( )₀ No ( )₁ Yes

b. R did not want to be more specific ( )₀ No ( )₁ Yes

c. R did not understand or speak English well ( )₀ No ( )₁ Yes

d. R was upset or depressed ( )₀ No ( )₁ Yes

e. R had poor hearing or speech ( )₀ No ( )₁ Yes

f. R was confused by frequent interruptions ( )₀ No ( )₁ Yes

g. R was emotionally unstable ( )₀ No ( )₁ Yes

h. Others helped with the answers ( )₀ No ( )₁ Yes

i. R required a lot of probing ( )₀ No ( )₁ Yes

j. Patient was reserved ( )₀ No ( )₁ Yes

k. R was physically ill ( )₀ No ( )₁ Yes

l. Other, specify ________________________________ ( )₀ No ( )₁ Yes

5. Comments/Remarks:

______________________________________________________________

______________________________________________________________

______________________________________________________________

______________________________________________________________

O. Supplemental Nutrition Section

Now I would like to learn more about your typical eating and drinking habits.

Time began: __ __ : __ ___ ( )₁ AM

( )₂ PM

1. During the past 6 months, how often have you eaten meat? (Includes chicken, beef, pork and lamb but not fish)

( )₀ daily

( )₁ 4-6 per week

( )₂ 2-3 per week

( )₃ once per week

( )₄ 1-3 per month

( )₅ never or less than once a month

2. Two years ago, how often did you eat meat? (Includes chicken, beef, pork and lamb but not fish)

( )₀ as frequently as it has been in the past 6 months

( )₁ daily

( )₂ 4-6 per week

( )₃ 2-3 per week

( )₄ once per week

( )₅ 1-3 per month

( )₆ never or less than once a month

3. How much meat do you usually eat per serving?(Includes chicken, beef, pork and lamb but not fish)

For help: three ounces of meat is about the size of a cassette tape or a deck of

cards.

( )₀ more than 12 ounces

( )₁ 7-12 ounces

( )₂ 3-6 ounces

( )₃ less than 3 ounces, but still eats meat

( )₄ never eats meat

4. During the past 6 months, how often have you eaten beef or lamb (includes steaks, stew, hamburger, roast, or hotdog)?

( )₀ daily

( )₁ 4-6 per week

( )₂ 2-3 per week

( )₃ once per week

( )₄ 1-3 per month

( )₅ never or less than once a month

5. During the past 6 months, how often have you eaten pork (includes bacon, chops, roast, or sausage)?

( )₀ daily

( )₁ 4-6 per week

( )₂ 2-3 per week

( )₃ once per week

( )₄ 1-3 per month

( )₅ never or less than once a month

6. During the past 6 months, how often have you eaten poultry (includes chicken, turkey, or duck)?

( )₀ daily

( )₁ 4-6 per week

( )₂ 2-3 per week

( )₃ once per week

( )₄ 1-3 per month

( )₅ never or less than once a month

7. How is your meat usually cooked? (Includes chicken, beef, pork and lamb but not fish) (Code all that apply)

( )₀ never eats meat (skip to question 8)

( )₁ eats meat (skip to question 7a)

	How is your meat usually cooked?
a.	baked	( )0 no ( )1 yes
b.	boiled	( )0 no ( )1 yes
c.	fried	( )0 no ( )1 yes
d.	grilled	( )0 no ( )1 yes
e.	steamed	( )0 no ( )1 yes
f.	microwaved	( )0 no ( )1 yes
e.	broiled	( )0 no ( )1 yes

8. Which method do you use most often? (Includes chicken, beef, pork and lamb but not fish)

( )₀ baked

( )₁ boiled

( )₂ fried

( )₃ grilled

( )₄ steamed

( )₅ microwaved

( )₆ broiled

( )₇ never eats meat

9. The red meat you eat is usually (Includes beef and pork)

( )₀ well done

( )₁ medium

( )₂ rare

( )₃ never eats meat

10. How often do you eat fish? (Fresh fish, not canned fish)

( )₀ daily

( )₁ 4-6 per week

( )₂ 2-3 per week

( )₃ once per week

( )₄ 1-3 per month

( )₅ never or less than once a month

11. How much fish do you usually eat per serving?

For help: three ounces of grilled fish is the size of a typical checkbook.

( )₀ more than 12 ounces

( )₁ 7-12 ounces

( )₂ 3-6 ounces

( )₃ less than 3 ounces

12. What kinds of fat is used in the foods you eat? (Code all that apply)

( )₀ none (skip to question 13)

( )₁ eats fat (skip to question 12a)

	What kinds of fat used in the foods you eat?
a.	butter	( )0 no ( )1 yes
b.	bacon-fat	( )0 no ( )1 yes
c.	margarine	( )0 no ( )1 yes
d.	olive oil	( )0 no ( )1 yes
e.	canola oil	( )0 no ( )1 yes
f.	other oils	( )0 no ( )1 yes

13. During the past 6 months, how often did you have bacon-fat or drippings in your meals (includes breakfast, lunch, dinner)?

( )₀ two-times or more per day

( )₁ once per day

( )₂ 4-6 per week

( )₃ 2-3 per week

( )₄ once per week

( )₅ less than once per week

( )₆ none or less than once per month

14. Two years ago, how often did you have bacon-fat or drippings in your meals?

( )₀ as frequently as it has been in the past 6 months

( )₁ twice per day

( )₂ once per day

( )₃ 4-6 per week

( )₄ 2-3 per week

( )₅ once per week

( )₆ less than once per week

( )₇ none or less than once per month

15. During the past 6 months, how much butter have you eaten per week?

For help: eight tablespoons of butter are equal to a stick of butter

( )₀ more than 24 tablespoons (or more than 3 sticks)

( )₁ 17-24 tablespoons (or 2-3 sticks)

( )₂ 9-16 tablespoons (or 1-2 sticks)

( )₃ 8 tablespoons or less (or less than a stick)

( )₄ none

16. Two years ago, how much butter did you eat per week?

( )₀ more than 24 tablespoons (or more than 3 sticks)

( )₁ 17-24 tablespoons (or 2-3 sticks)

( )₂ 9-16 tablespoons (or 1-2 sticks)

( )₃ 8 tablespoons or less (or less than 1 stick)

( )₄ none

17. During the past 6 months, how often have you eaten vegetables (includes garlic, onions)?

( )₀ daily

( )₁ 4-6 per week

( )₂ 2-3 per week

( )₃ once per week

( )₄ 1-3 per month

( )₅ never or less than once a month

18. Two years ago, how often did you eat vegetables (includes garlic, onions)?

( )₀ as frequently as it has been in the past 6 months

( )₁ daily

( )₂ 4-6 per week

( )₃ 2-3 per week

( )₄ once per week

( )₅ 1-3 per month

( )₆ never or less than once a month

19. How many vegetables do you usually eat per serving?

For help: Your fist is approximately one cup.

( )₀ 2 cups or more

( )₁ between 1 and 2 cups

( )₂ ½ cup to 1 cup

( )₃ less than ½ a cup

( )₄ none

20. How are your vegetables usually cooked?

( )₀ steamed

( )₁ sauteed

( )₂ boiled

( )₃ fried

( )₄ microwaved

( )₅ fresh/uncooked

( )₆ never eats vegetables

21. Over the past 6 months, how often did you eat broccoli (fresh or frozen)?

( )₀ never (Skip to question O.23)

( )₁ less than once per month

( )₂ 2-3 times per month

( )₃ 1 time per week

( )₄ 2 times per week

( )₅ 3-4 times per week

( )₆ 5-6 times per week

( )₇ 1 time per day

( )₈ 2 or more times per day

22. Each time you ate broccoli, how much did you usually eat?

For help: Your fist is approximately one cup.

( )₀ Less than 1/4 cup

( )₁ 1/4 to 1 cup

( )₂ More than 1 cup

23. During the past 6 months, how often have you eaten garlic?

( )₀ daily

( )₁ 4-6 per week

( )₂ 2-3 per week

( )₃ once per week

( )₄ 1-3 per month

( )₅ never or less than once a month

24. Two years ago, how often did you eat garlic?

( )₀ as frequently as it has been in the past 6 months

( )₁ daily

( )₂ 4-6 per week

( )₃ 2-3 per week

( )₄ once per week

( )₅ 1-3 per month

( )₆ never or less than once a month

25. How much fresh garlic do you have in your food per week?

( )₀ more than 2 heads

( )₁ 2 heads

( )₂ 1 head

( )₃ half a head

( )₄ a clove

( )₅ none

26. During the past 6 months, how often have you eaten onions?

( )₀ daily

( )₁ 4-6 per week

( )₂ 2-3 per week

( )₃ once per week

( )₄ 1-3 per month

( )₅ never or less than once a month

27. Two years ago, how often did you eat onions?

( )₀ as frequently as it has been in the past 6 months

( )₁ daily

( )₂ 4-6 per week

( )₃ 2-3 per week

( )₄ once per week

( )₅ 1-3 per month

( )₆ never or less than once a month

28. How many onions do you eat with your food per week?

( )₀ more than 4 onions

( )₁ 3-4 onions

( )₂ 2 onions

( )₃ 1 onion

( )₄ half an onion or less

( )₅ none

29. How often do you eat other types of allium vegetables such as leek, chives or scallions?

( )₀ daily

( )₁ 4-6 per week

( )₂ 2-3 per week

( )₃ once per week

( )₄ 1-3 per month

( )₅ never or less than once a month

30. During the past 6 months, how often have you eaten fresh tomatoes?

( )₀ daily

( )₁ 4-6 per week

( )₂ 2-3 per week

( )₃ once per week

( )₄ 1-3 per month

( )₅ never or less than once a month

31. Two years ago, how often did you eat fresh tomatoes?

( )₀ as frequently as it has been in the past 6 months

( )₁ daily

( )₂ 4-6 per week

( )₃ 2-3 per week

( )₄ once per week

( )₅ 1-3 per month

( )₆ never or less than once a month

32. How many fresh tomatoes do you eat per week?

( )₀ more than 10

( )₁ 6-10

( )₂ 3-5

( )₃ 1-2

( )₄ less than one

33. How often do you eat food with processed tomatoes (puree, sauce)?

Examples are: spaghetti or pizza with tomato sauce.

( )₀ daily

( )₁ 4-6 per week

( )₂ 2-3 per week

( )₃ once per week

( )₄ 1-3 per month

( )₅ never or less than once a month

34. How often do you have ketchup with your food?

( )₀ daily

( )₁ 4-6 per week

( )₂ 2-3 per week

( )₃ once per week

( )₄ 1-3 per month

( )₅ never or less than once a month (Skip to end)

35. How much ketchup do you usually eat per meal?

( )₀ more than 6 tablespoons

( )₁ 4-6 tablespoons

( )₂ 1-3 tablespoons

( )₃ less than 1 tablespoon

This completes this portion of the interview.

Time ended __ __ : __ ___ ( )₁ AM

( )₂ PM

NUTRITION ( )₁ Very good ( )₂ Good ( )₃ Fair ( )₄ Poor

This completes our interview. I would like to now take the blood and urine sample. I want to thank you very much for the time you have spent in answering my questions today.

MLCS-MD 1.9 May 6, 2010 Page 3 of 53