Form 3 Prostate Supplemental Questionnaire

Resource for the Collection and Evaluation of Human Tissues and Cells from Donors with an Epidemiology Profile (NCI)

Attach 7 - Supp Questionnaire for Prostate-No.2

Prostate Supplemental Questionnaire

OMB: 0925-0623

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ID # ___ - ___ - ___ ___ ___ ___ ___ ___

Supplemental Questionnaire for Prostate Study Participants




__________________________________________________________________________


OMB# 0925-XXXX

Expiration Date: XX / XX / XXXX

Attachment # 7

Name: Supplemental Case-Control Questionnaire

BURDEN STATEMENT:

Public reporting burden for this collection of information is estimated to average 30 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-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







Table of Contents



Topic Page


A. Anthropometry 4


B. Medical History and Family Medical History 7


C. Sexual History 14




Identifier Sheet:


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


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


  1. Hospital:________________________________ 

  2. Doctor’s Name:___________________________ 


  1. Patient’s Medical Record # ______________________


  1. Patient’s Ethnicity ( )1 Hispanic/Latino ( )2 Not Hispanic/Latino


  1. Patient’s Race ( )1 White

( )2 Black/African American


  1. Time started: __ __:__ __ ( )1 AM

( )2 PM


  1. Time ended: __ __:__ __ ( )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: __ __ / __ __ / __ __ __ __



The interviewer will give a copy of this questionnaire to the person before the interview starts. The person should have the opportunity to read the questions while being interviewed. Section C is self-administered, and the person will be given 20 min to complete this section.



A. Anthropometry


1. When you were (AGE), how did your height compare with other boys/men your age? Were you much shorter, shorter, about the same, taller, or much taller than the average boy or man?



Age

1.

Much shorter (more than a foot)

2.

Shorter (a foot or less)

3.

About the same

4.

Taller (a foot or less)

5.

Much taller (more than a foot)

a.

9 or 10






b.

20-25








2. At what age did you reach your adult height?


__ __ __ years


3. When you were (AGE), how did your weight compare with other boys/men your age? Were you much thinner, thinner, about the same, heavier, or much heavier than the average boy or man?



Age

1.

Much thinner

2.

Thinner

3.

About the same

4.

Heavier

5.

Much heavier

a.

9 or 10






b.

20-25






c.

40-45






d.

Now, current age










4. When you were about 25 years old, about how much did you weigh?


__ __ __ lbs


5. Since you were 25 years old, what was the most you have ever weighed?


__ __ __ lbs


6. When you gain weight, where on your body do you mainly tend to add the weight?

( )0 don’t gain weight

( )1 around the waist and stomach

( )2 around the hips and thighs

( )3 around the chest and shoulders

( )4 equally all over

( )5 other (specify) ______________________________ 


7. During the past 6 months, have you lost 10 or more pounds?

( )0 No (Skip to A. 10)

( )1 Yes



8. If yes, how much weight did you lose?

( )0 more than 40 pounds

( )1 21-40 pounds

( )2 10-20 pounds


9. Was your weight loss on purpose?

( )0 No

( )1 Yes

10. Interviewer: will ask.. I would now like to measure your waist circumference.


Waist circumference (cm)


First Second Difference Tolerance Third

|__|__|__|.|__| |__|__|__|.|__| |__|__|__|.|__| 2.0 |__|__|__|.|__|


11. Interviewer: will ask.. I would now like to measure your hip circumference.


Hip circumference (cm)


First Second Difference Tolerance Third

|__|__|__|.|__| |__|__|__|.|__| |__|__|__|.|__| 2.0 |__|__|__|.|__|




12. How would you describe your chest hair density?

( )0 thick

( )1 medium

( )2 thin

( )3 no hairs


13. Have you experienced any permanent hair loss from your scalp since you were

twenty years old?


( )0 No (Skip to A. 15)

( )1 Yes

14. If yes, at what age did the hair loss begin?


__ __ years

15. Interviewer: Please indicate hair thickness

( )0 thick

( )1 medium

( )2 thin

( )3 no hairs

16. Interviewer: Please indicate hair pattern on dome

( )0 no evident loss

( )1 some loss

( )2 patterned baldness

( )3 few hairs

( )4 no hairs


Some loss Patterned baldness


17. Have you ever used any hair growth products?

( )0 No

( )1 Yes


18. Are you using a wig or toupee?

( )0 No

( )1 Yes

B. Medical History and Family Medical History


1. Are you now taking insulin?


( )0 No (Skip to B. 4)

( )1 Yes

2. At what age did you begin to take insulin? __ __ years


3. For what reason do you take insulin? ________________________ 


4. Are you now taking pills to lower you blood sugar? These are sometimes called oral agents or oral hypoglycemic agents?


( )0 No (Skip to B. 7)

( )1 Yes


5. At what age did you begin to take hypoglycemic agents? __ __ years


6. For what reason do you take hypoglycemic agents? ___________________ 




7.

Have you ever taken the following medication?

Yes/No

When did you start taking the medicine or drug? (Year)

If you stopped taking the medication or drug, when did you stop? (Year)

For how many years in total have you been taking the medication or drug?

a.

Proscar

( )0 No

( )1 Yes

( )2 Don’t know


__ __ __ __


__ __ __ __


___ ___

b.

Propecia

( )0 No

( )1 Yes

( )2 Don’t know


__ __ __ __


__ __ __ __


___ ___

c.

Viagra

( )0 No

( )1 Yes

( )2 Don’t know


__ __ __ __


__ __ __ __


___ ___

d.

Androgen supplements

(such as DHEA, Androstenedione, Norandrostenedione)

( )0 No

( )1 Yes

( )2 Don’t know


__ __ __ __


__ __ __ __


___ ___

e.

Body-building or performance enhancing agents

( )0 No

( )1 Yes

( )2 Don’t know


__ __ __ __


__ __ __ __


___ ___

f.

Non-steroidal anti-inflammatory drugs (Advil, Aspirin, Motrin, Aleve, Piroxicam, Naproxen, Sulindac)

( )0 No

( )1 Yes

( )2 Don’t know


__ __ __ __ __ __ __ __ __



__ __ __ __


___ ___



8. During a typical night, how many times do you wake up to urinate?

( )0 never (Skip to B. 10)

( )1 once (Skip to B. 10)

( )2 twice

( )3 three times

( )4 more than three times


9. How old were you when you first began waking to urinate more than once a night on

a regular basis?


___ ___ years




10. Were you ever treated by a doctor for a urinary tract infection since the age of 25?

( )0 No (Skip to B. 12)

( )1 Yes


11. How old were you when your doctor first told you that you had a urinary tract infection?

__ __ years


12. Have you had a vasectomy that is a sterilization operation for men?

( )0 No (Skip to B. 14)

( )1 Yes


13. How old were you when you had a vasectomy?

__ __ years


14. Are you circumcised?

( )0 No (Skip to B. 16)

( )1 Yes


15. At what age were you circumcised?

( )1 newborn

( )2 other (specify in years) _______

16. Did a doctor ever tell you that you had a problem with your prostate or a disorder of the prostate?

( )0 No (Skip to B. 18)

( )1 Yes











17.

Did a doctor ever tell you that you had:

Yes/No

How old were you when you were diagnosed?

a.

an enlarged prostate or benign prostatic hypertrophy

( )0 No

( )1 Yes

( )2 Don’t know


__ __

b.

an inflamed prostate or prostatitis


( )0 No

( )1 Yes

( )2 Don’t know


__ __

c.

some other problem or disorder related to the urinary tract (specify) ____________________ 

( )0 No

( )1 Yes

( )2 Don’t know


__ __



18. Have you ever had any prostate surgery?

( )0 No (Skip to B. 21)

( )1 Yes




19. How many prostate surgeries have you had? __________





20.

Year of last surgery

Hospital name

City

State

a.





b.





c.










21.

Did a doctor ever tell you that you had:

Yes/No

How old were you when you were first diagnosed?

How many times altogether have you had (disease)?

a.

Gonorrhea

( )0 No

( )1 Yes


__ __ __


__ __

b.

Syphilis

( )0 No ( )1 Yes


__ __ __


__ __

c.

Other venereal or sexually transmitted disease (Specify)___________

( )0 No ( )1 Yes


__ __ __


__ __

d.

Other venereal or sexually transmitted disease (Specify)___________

( )0 No ( )1 Yes


__ __ __


__ __

e.

Other venereal or sexually transmitted disease (Specify)___________

( )0 No ( )1 Yes


__ __ __


__ __

f.

Other venereal or sexually transmitted disease (Specify)___________

( )0 No ( )1 Yes


__ __ __


__ __



Family Medical History


22. Has anyone in your family that is related to you by blood, ever been told he had benign prostatic hypertrophy or an enlarged prostate? Include your sons, grandsons, father, paternal grandfather, maternal grandfather, great grandfathers, brothers, male cousins, and immediate uncles.


( )0 No (Skip to B. 24)

( )1 Yes


23. Which

relative?

First name

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



24. Has anyone in your family that is related to you by blood, ever been told he had an inflamed prostate or prostatitis? Include your sons, grandsons, father, paternal grandfather, maternal grandfather, great grandfathers, brothers, male cousins, and immediate uncles.


( )0 No (Go to Sexual History Section C)

( )1 Yes



25. Which

relative?

First name

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


C. Sexual History


Section C is self-administered, and the person will be given 20 min to complete this section.




  1. At what age did you experience puberty (voice change, growth of pubic hair)?

__ __ years



  1. How many live-born children have you fathered? Do not include any stepchildren, foster children, or adopted children.

__ __ __ (If zero, skip to C. 4)


  1. How old were you when your first child was born?


__ __ years


  1. How old were you when you first had sexual intercourse?


__ __ years



  1. Throughout your life, what is the total number of partners with whom you have had sexual intercourse?


( )1 less than 5

( )2 5 to 9

( )3 10 to 19

( )4 20 to 39

( )5 40 or more


  1. Have you ever tried to conceive a child for one year or more without success?


( )0 No (Skip to C. 8)

( )1 Yes

  1. Did a doctor ever say that you had a problem that might be related to your difficulty in conceiving a child? If so, what was the problem? ____________________ 




9. If you think back to when you were (age group), and you think about the period of time in that decade when you had sexual intercourse, how often would you say you had sexual intercourse per year?

8. When you were (age group) with how many different partners did you have intercourse?




_ _

times per


( ) month


( ) year


( )0 0

( )1 1

( )2 2

( )3 3-4

( )4 5-9

( )5 10-19

( )6 20-39

( )7 40 or

more

In your

teens

_ _

times per


( ) month


( ) year


( )0 0

( )1 1

( )2 2

( )3 3-4

( )4 5-9

( )5 10-19

( )6 20-39

( )7 40 or

more


In your 20s


_ _

times per


( ) month


( ) year


( )0 0

( )1 1

( )2 2

( )3 3-4

( )4 5-9

( )5 10-19

( )6 20-39

( )7 40 or

more


In your 30s


_ _

times per


( ) month


( ) year


( )0 0

( )1 1

( )2 2

( )3 3-4

( )4 5-9

( )5 10-19

( )6 20-39

( )7 40 or

more


In your 40s

_ _

times per


( ) month


( ) year


( )0 0

( )1 1

( )2 2

( )3 3-4

( )4 5-9

( )5 10-19

( )6 20-39

( )7 40 or

more


In your 50s


_ _

times per


( ) month


( ) year


( )0 0

( )1 1

( )2 2

( )3 3-4

( )4 5-9

( )5 10-19

( )6 20-39

( )7 40 or

more


In your 60s


_ _

times per


( ) month


( ) year









( )0 0

( )1 1

( )2 2

( )3 3-4

( )4 5-9

( )5 10-19

( )6 20-39

( )7 40 or

more


In your 70s



10. Do you usually use condoms (rubbers)?

( )0 No

( )1 Yes


11. Before one year ago, did you usually use condoms (rubbers)?

( )0 No

( )1 Yes


12. Not counting the past year, for how many years did you use condoms (rubbers)?

______________

YEARS





Thank you for your time! We greatly appreciate your participation in the study.

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