Health Survey

Survey ID# _ _ _ _ _ _ _ _

Attachment C. Health survey.

Form Approved

OMB No. 0923-xxxx

Exp. Date xx/xx/20xx

Health survey of former Marines, dependents, and employees at USMC Base Camp Lejeune and USMC Base Camp Pendleton

Contact and demographic information

Participant Name: First: ___________ Middle Name: _______ Last: ______________

Suffix (Jr., Sr., etc.): _____

Date of Birth (Please enter 2 digit month/2 digit day/4 digit year): _ _ /_ _ /_ _ _ _

Gender: ○ Male ○ Female

Public reporting burden of this collection of information is estimated to average 45 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 the burden estimate or any other aspect of this collection of information, including suggestions for reducing this burden, to: CDC/ATSDR Information Collection Review Office, 1600 Clifton Road, MS D-74, Atlanta, GA 30333; ATTN: PRA (0923-xxxx).

Are you completing this survey for yourself?

• Yes - GO TO RESIDENTIAL HISTORY

• No

Is the person listed above unable to complete the survey or is the person deceased?

• Unable - GO TO RESIDENTIAL HISTORY

• Deceased - COMPLETE NEXT OF KIN INFORMATIOn

If you are filling out the survey as next of kin on behalf of a deceased participant please provide:

Next-of-kin Name: First: ___________ Middle Name: _______ Last: ______________

Suffix (Jr., Sr., etc.): _____

Relationship to deceased participant:

• Spouse

Were you married to the participant when he/she was living or working at Camp Lejeune or Camp Pendleton?

O No

O Yes

• Sibling

• Parent

• Child

• Cousin

• Other: _____________________

Residential history

4. Were you active duty at Camp Lejeune or Camp Pendleton?

○ No – GO TO QUESTION 5

○ Yes

Please use the table below to fill in what unit(s) you were assigned to while you were at Camp Lejeune or Camp Pendleton and where you resided (location of barracks or family housing area). When you have finished filling in the table, go to question 6.

Name of unit	Start month and year	End month and year	Where resided	Base (please circle)
				Lejeune Pendleton
				Lejeune Pendleton
				Lejeune Pendleton
				Lejeune Pendleton
				Lejeune Pendleton

4. Were you the spouse or a dependent of an active duty Marine or Navy sailor/officer at Camp Lejeune or Camp Pendleton?

   1. No – GO TO QUESTION 6

   2. Yes - please give us the full name of your sponsor. __________________________________

5a. Please use the table below to fill in where you lived and when during the time you were living at Camp Lejeune or Camp Pendleton.

Start Month	Start Year	End Month	End Year	Address (street number, street name or housing area)	Base (please circle)
					Lejeune Pendleton
					Lejeune Pendleton
					Lejeune Pendleton
					Lejeune Pendleton

Medical history

We are interested in finding out more about diseases, medical conditions, and illnesses you may have had since you first were stationed, employed, or living at Camp Lejeune or Camp Pendleton.

What is the name and contact information (address and phone number) of your current doctor(s) or other health care provider(s)?

________________________________________________________________________

________________________________________________________________________

6. Since you first were stationed, employed, or living at Camp Lejeune or Camp Pendleton, were you told by a doctor or other health professional that you had cancer or a malignancy of any kind?

• No – GO TO QUESTION 7

• Yes

6a. What kind of cancer was it?

First kind of cancer (select one):

• Appendix

• Bladder

• Blood

• Bone

• Brain

• Breast

• Carcinoid

• Cervix

• Colon

• Esophagus

• Gallbladder

• Kidney

• Larynx-windpipe

• Leukemia

• Liver

• Lung

• Lymphoma

• Melanoma

• Mouth/tongue/lip

• Ovary

• Pancreas

• Prostate

• Rectum

• Skin (non-melanoma)

• Skin (don’t know what kind)

• Small intestine

• Soft tissue (muscle or fat)

• Stomach

• Testis

• Throat - pharynx

• Thyroid

• Uterus

• Other: __________________

• Don't know

6b. How old were you when the first cancer was first diagnosed? ________ years old

6c. Was this a primary cancer (not a cancer that spread or metastasized from somewhere else in the body)?

• No

• Yes

6d. What state were you living in when your cancer was diagnosed? ________

6e. What is the name and contact information (address and phone number) of the doctor or other health professional who diagnosed your cancer?

________________________________________________________________________

6f. Were you hospitalized for treatment of your cancer?

• No

• Yes (specify where) ___________________________________

6g. Second kind of cancer (select one):

• No more – GO TO QUESTION 7

• Appendix

• Bladder

• Blood

• Bone

• Brain

• Breast

• Carcinoid

• Cervix

• Colon

• Esophagus

• Gallbladder

• Kidney

• Larynx-windpipe

• Leukemia

• Liver

• Lung

• Lymphoma

• Melanoma

• Mouth/tongue/lip

• Ovary

• Pancreas

• Prostate

• Rectum

• Skin (non-melanoma)

• Skin (don’t know what kind)

• Small intestine

• Soft tissue (muscle or fat)

• Stomach

• Testis

• Throat - pharynx

• Thyroid

• Uterus

• Other: __________________

• Don't know

6h. How old were you when the second cancer was first diagnosed? ________ years old

6i. Was this a primary cancer (not a cancer that spread or metastasized from somewhere else in the body)?

• No

• Yes

6j. What state were you living in when your second cancer was diagnosed? ________

6k. What is the name and contact information (address and phone number) of the doctor or other health professional who diagnosed your second cancer?

________________________________________________________________________

6l. Were you hospitalized for treatment of your second cancer?

• No

• Yes (specify where) ___________________________________

6m. More than 2 kinds of cancer (select all that apply):

• No more

• Appendix

• Bladder

• Blood

• Bone

• Brain

• Breast

• Carcinoid

• Cervix

• Colon

• Esophagus

• Gallbladder

• Kidney

• Larynx-windpipe

• Leukemia

• Liver

• Lung

• Lymphoma

• Melanoma

• Mouth/tongue/lip

• Ovary

• Pancreas

• Prostate

• Rectum

• Skin (non-melanoma)

• Skin (don’t know what kind)

• Small intestine

• Soft tissue (muscle or fat)

• Stomach

• Testis

• Throat - pharynx

• Thyroid

• Uterus

• Other: __________________

• Don't know

7. Since you first were stationed, employed, or living at Camp Lejeune or Camp Pendleton, were you told by a doctor or other health professional that you had kidney disease or kidney failure? Do not include kidney stones, bladder infections or incontinence.

• No – GO TO QUESTION 8

• Yes

7a. What was the name of the kidney disease?

7b. How old were you when you were told this? ________ years old

7c. What is the name and contact information (address and phone number) of the doctor or other health professional who diagnosed your kidney disease or kidney failure? ______________________________________________________________________________

7d. Were you hospitalized for treatment of your kidney disease or kidney failure?

○ No

○ Yes (specify where) ___________________________________

7. Since you first were stationed, employed, or living at Camp Lejeune or Camp Pendleton, were you told by a doctor or other health professional that you had a liver disease?

• No – GO TO QUESTION 9

• Yes

8a. What was the name of the liver disease? ___________________________

8b. How old were you when you were told this? ________ years old

8c. What is the name and contact information (address and phone number) of the doctor or other health professional who diagnosed your liver disease? ______________________________________________________________________________

8d. Were you hospitalized for treatment of your liver disease?

• No

• Yes (specify where) ___________________________________

7. Since you first were stationed, employed, or living at Camp Lejeune or Camp Pendleton, were you told by a doctor or other health professional that you have lupus?

• No – GO TO QUESTION 10

• Yes

9a. How old were you when you were told this? ________ years old

9b. What is the name and contact information (address and phone number) of the doctor or other health professional who diagnosed your lupus?

______________________________________________________________________________

9c. Were you hospitalized for treatment of your lupus?

• No

• Yes (specify where) ___________________________________

10. Since you first were stationed, employed, or living at Camp Lejeune or Camp Pendleton, were you told by a doctor or other health professional that you have scleroderma?

• No – GO TO QUESTION 11

• Yes

10a. How old were you when you were told this? ________ years old

10b. What is the name and contact information (address and phone number) of the doctor or other health professional who diagnosed your scleroderma?

______________________________________________________________________________

10c. Were you hospitalized for treatment of your scleroderma?

• No

• Yes (specify where) ___________________________________

11. Since you first were stationed, employed, or living at Camp Lejeune or Camp Pendleton, were you told by a doctor or other health professional that you have Parkinson’s disease?

• No – GO TO QUESTION 12

• Yes

11a. How old were you when you were told this? ________ years old

11b. What is the name and contact information (address and phone number) of the doctor or other health professional who diagnosed your Parkinson’s disease?

______________________________________________________________________________

11c. Were you hospitalized for treatment of your Parkinson’s disease?

• No

• Yes (specify where) ___________________________________

12. Since you first were stationed, employed, or living at Camp Lejeune or Camp Pendleton, were you told by a doctor or other health professional that you have multiple sclerosis (MS)?

• No – GO TO QUESTION 13

• Yes

12a. How old were you when you were told this? ________ years old

12b. What is the name and contact information (address and phone number) of the doctor or other health professional who diagnosed your multiple sclerosis (MS)?

______________________________________________________________________________

12c. Were you hospitalized for treatment of your multiple sclerosis (MS)?

• No

• Yes (specify where) ___________________________________

13. Since you first were stationed, employed, or living at Camp Lejeune or Camp Pendleton, were you told by a doctor or other health professional that you have amyotrophic lateral sclerosis (ALS), often referred to as "Lou Gehrig's Disease” or motor neuron disease?

• No – GO TO QUESTION 14

• Yes

13a. How old were you when you were told this? ________ years old

13b. What is the name and contact information (address and phone number) of the doctor or other health professional who diagnosed your amyotrophic lateral sclerosis (ALS)/"Lou Gehrig's Disease”/motor neuron disease?

______________________________________________________________________________

13c. Were you hospitalized for treatment of your amyotrophic lateral sclerosis (ALS)/"Lou Gehrig's Disease”/motor neuron disease?

• No

• Yes (specify where) ___________________________________

14. Since you first were stationed, employed, or living at Camp Lejeune or Camp Pendleton, were you told by a doctor or other health professional that you had a persistent skin rash or dermatitis?

• No – GO TO QUESTION 15

• Yes

14a. What was the name of the skin rash or dermatitis?

14b. How old were you when you were told this? ________ years old

14c. What is the name and contact information (address and phone number) of the doctor or other health professional who diagnosed your skin rash or dermatitis? ______________________________________________________________________________

14d. Were you hospitalized for treatment of your skin rash or dermatitis?

• No

• Yes (specify where) ___________________________________

14e. How long did the skin rash last? _________________________________________

14f. Where on your body did the skin rash occur? ___________________________

14g. What were the symptoms of the skin rash? (check all that apply)

O redness

O swelling

O itching

O dry skin with scaling/flaking

O crusts

O blisters

O fissures or cracks

O oozing

O bleeding

14. Since you first were stationed, employed, or living at Camp Lejeune or Camp Pendleton, were you told by a doctor or other health professional that you have aplastic anemia?

• No – GO TO QUESTION 16

• Yes

15a. How old were you when you were told this? ________ years old

15b. What is the name and contact information (address and phone number) of the doctor or other health professional who diagnosed your aplastic anemia?

______________________________________________________________________________

15c. Were you hospitalized for treatment of your aplastic anemia?

• No

• Yes (specify where) ___________________________________

14. Since you first were stationed, employed, or living at Camp Lejeune or Camp Pendleton, were you told by a doctor or other health professional that you have infertility?

• No – GO TO QUESTION 17

• Yes

16a. What did your doctor or other health professional tell you was the reason for your infertility? _____________________________________________________________________

16b. How old were you when you were told this? ________ years old

16c. What is the name and contact information (address and phone number) of the doctor or other health professional who diagnosed your infertility?

______________________________________________________________________________

16d. Were you hospitalized for treatment of your infertility?

• No

• Yes (specify where) ___________________________________

Other health conditions

14. Please use the following space to add any comments regarding any serious health issues that you experienced since you first were stationed, employed, or living at Camp Lejeune or Camp Pendleton that were not covered by the survey.

______________________________________________________________________________

____________________________________________________________________________________________________________________________________________________________

MALE RESPONDENTS – GO TO OCCUPATIONAL HISTORY SECTION

Reproductive history (women only)

14. Since you first were stationed, employed, or living at Camp Lejeune or Camp Pendleton, were you told by a doctor or other health professional that you have endometriosis?

• No – GO TO QUESTION 19

• Yes

18a. How old were you when you were told this? ________ years old

18b. What is the name and contact information (address and phone number) of the doctor or other health professional who diagnosed your endometriosis?

______________________________________________________________________________

18c. Were you hospitalized for treatment of your endometriosis?

• No

• Yes (specify where) ___________________________________

19. Have you ever been pregnant?

• No – GO TO OCCUPATIONAL HISTORY SECTION

• Yes

19a. Have you ever had a pregnancy that resulted in a live birth?

• No

• Yes

19b. During the time when you lived or worked at Camp Lejeune or Camp Pendleton, were you pregnant?

• No – GO TO OCCUPATIONAL HISTORY SECTION

• Yes

The next set of questions ask about each pregnancy that occurred during the time that you lived or worked at Camp Lejeune or Camp Pendleton. Please fill in the answers on the table.

19c. What month and year did your pregnancy end? (Please enter 2 digit month/4 digit year)

19d. What was the outcome of the pregnancy? (check one)

○ Live birth of single child

○ Live birth of multiple children

○ Tubal pregnancy

○ Elective abortion

○ Miscarriage or stillbirth, ________ week the pregnancy ended

Did you have a positive pregnancy test before the miscarriage occurred?

O No

O Yes

Was the miscarriage confirmed by a physician or other health provider?

O No

O Yes

19e. Did this pregnancy involve a birth defect?

O No

O Yes (specify name of the birth defect) ________________________

Repeat Question 19 for every pregnancy that occurred during the time that you lived or worked at Camp Lejeune or Camp Pendleton.

	c. Month and year pregnancy ended	d. Outcome of the pregnancy	e. Birth defect
Pregnancy #1		○ Live birth of single child ○ Live birth of multiple children ○ Tubal pregnancy ○ Elective abortion ○ Miscarriage or stillbirth, ________ weeks Positive pregnancy test before? O yes O no Miscarriage confirmed? O yes O no	No Yes If yes, name of birth defect: _____________________
Pregnancy #2		○ Live birth of single child ○ Live birth of multiple children ○ Tubal pregnancy ○ Elective abortion ○ Miscarriage or stillbirth, ________ weeks Positive pregnancy test before? O yes O no Miscarriage confirmed? O yes O no	No Yes If yes, name of birth defect: _____________________
Pregnancy #3		○ Live birth of single child ○ Live birth of multiple children ○ Tubal pregnancy ○ Elective abortion ○ Miscarriage or stillbirth, ________ weeks Positive pregnancy test before? O yes O no Miscarriage confirmed? O yes O no	No Yes If yes, name of birth defect: _____________________
Pregnancy #4		○ Live birth of single child ○ Live birth of multiple children ○ Tubal pregnancy ○ Elective abortion ○ Miscarriage or stillbirth, ________ weeks Positive pregnancy test before? O yes O no Miscarriage confirmed? O yes O no	No Yes If yes, name of birth defect: _____________________

Occupational history

The next set of questions ask about your work experiences – paid, volunteer, or military – starting with the time you were first stationed, employed or living at Camp Lejeune or Camp Pendleton to the present. This includes part-time and full-time jobs, jobs at home, jobs on base, and jobs on a farm that lasted one month or more. Please fill in the answers on the table.

20. Starting with the time you were first stationed, employed or living at Camp Lejeune Camp or Pendleton, what was the name and location (city, state) of the first company or organization you worked for? If you never worked, go to question 24.

20a. If the job was on base at Camp Lejeune or Camp Pendleton, please specify the area on base where you worked (e.g., address or building number).

20b. What month and year did you start that job? (Please enter 2 digit month/4 digit year)

20c. What month and year did you end that job? (Please enter 2 digit month/4 digit year)

20d. What was your job title there?

20e. What did that company or organization do or make?

20f. Describe what you did and how you did it. What were your main activities and duties?

20g. Did you work part-time or full-time? Part-time is less than 35 hours per week.

20h. Did you work with or make

i. pesticides, herbicides, fungicides, insecticides, or rat poison?

if yes:

what is the name of the chemical you worked with or used?

how many hours per week were you around these products?

2. ionizing radiation such as x-rays?

if yes:

what kind of radiation did you work with or use?

how many hours per week were you around these products?

2. heavy metals such as lead, mercury, or nickel?

if yes:

what is the name of the metal you worked with or used?

how many hours per week were you around these products?

2. solvents like paint thinners, paints, glues, metal degreasing agents, auto fluids, dry cleaning agents, toluene, carbon disulfide, trichloroethylene, or carbon tetrachloride?

if yes:

what is the name of the chemical you worked with or used?

how many hours per week were you around these products?

Repeat Question 20 for every job held until present or retirement.

Occupational history

Name and location of company	a. If on base, specify area	b. Start month and year	c. End month and year	d. Job title	e. What does company do/make	f. Describe what you did	g. Part or full time	h.i. Work with pesticides	h. ii. Work with ionizing radiation	h. iii. Work with heavy metals	h. iv. Work with solvents
								No Yes If yes, name of chemical hours per week	No Yes If yes, what kind hours per week	No Yes If yes, name of metal hours per week	No Yes If yes, name of chemical hours per week
								No Yes If yes, name of chemical hours per week	No Yes If yes, what kind hours per week	No Yes If yes, name of metal hours per week	No Yes If yes, name of chemical hours per week
								No Yes If yes, name of chemical hours per week	No Yes If yes, what kind hours per week	No Yes If yes, name of metal hours per week	No Yes If yes, name of chemical hours per week

Name and location of company	a. If on base, specify area	b. Start month and year	c. End month and year	d. Job title	e. What does company do/make	f. Describe what you did	g. Part or full time	h.i. Work with pesticides	h. ii. Work with ionizing radiation	h. iii. Work with heavy metals	h. iv. Work with solvents
								No Yes If yes, name of chemical hours per week	No Yes If yes, what kind hours per week	No Yes If yes, name of metal hours per week	No Yes If yes, name of chemical hours per week
								No Yes If yes, name of chemical hours per week	No Yes If yes, what kind hours per week	No Yes If yes, name of metal hours per week	No Yes If yes, name of chemical hours per week
								No Yes If yes, name of chemical hours per week	No Yes If yes, what kind hours per week	No Yes If yes, name of metal hours per week	No Yes If yes, name of chemical hours per week

21. Were you stationed in Vietnam?

• No – GO TO QUESTION 24

• Yes

22a. What month and year did your tour of duty in Vietnam start? (Please enter 2 digit month/4 digit year) _ _/_ _ _ _

22b. What month and year did your tour of duty in Vietnam end? (Please enter 2 digit month/4 digit year) _ _/_ _ _ _

23. Did you ever come into contact with herbicides while in Vietnam? (For example, did you inhale herbicides or get herbicides on your skin or clothing?)

• No – GO TO QUESTION 24

• Yes (describe how you were exposed) ____________________________________

Smoking history

24. Have you ever smoked cigarettes regularly?

• No – GO TO QUESTION 31

• Yes

24. Do you smoke cigarettes now?

• No – GO TO QUESTION 28

• Yes

24. On average, over all the years you have smoked, how many cigarettes a day did you smoke? ________ cigarettes

24. How many years have you smoked, excluding any times you may have quit? ________ years – GO TO QUESTION 31

24. How old were you the last time you quit smoking cigarettes? ________ years old

24. On average, when you were smoking, about how many cigarettes a day did you smoke? ________ cigarettes

24. How many years did you smoke, excluding any times you may have quit? ________ years

24. Have you ever used any other tobacco products regularly (such as chewing tobacco, smokeless tobacco, a pipe, etc.)?

• No – GO TO QUESTION 34

• Yes

32. Do you currently use other tobacco products regularly?

• No

• Yes

33. What other tobacco products have you used or do you currently use?

○ Chewing tobacco

○ Smokeless tobacco

○ Pipe

○ Other (specify): _________________________

33. Whether or not you smoke, have you ever lived for more than 1 year with someone who smoked on a daily basis?

• No – GO TO QUESTION 35

• Yes

34a. If yes, for how many years?

• 1-3 years ○ 7-9 years ○ 13-15 years

• 4-6 years ○ 10-12 years ○ 16 or more years

34b. If yes, was this usually……

• One person

• Two persons

• More than two persons

Alcohol history

The following questions relate to your consumption of alcohol.

A serving of alcohol is 1 can of beer, 1 glass of wine, 1 can or bottle of wine cooler, 1 shot of liquor.

33. Have you ever consumed alcohol?

• No – GO TO CONCLUSION

• Yes

33. At what age did you start drinking alcohol? ________ years old

33. Do you drink alcoholic beverages now?

• No – GO TO QUESTION 41

• Yes

33. On average, how often do you drink alcoholic beverages? (check one)

• Almost every day

• 2 to 4 times a week

• 1 time a week

• 1 to 3 times a month

• Less than once a month

33. When you drink, about how many drinks do you usually have? ________ drinks per ○day ○week ○month ○year

33. Is there a time in the past that you drank significantly more on average than you usually drink now?

• No

• Yes

GO TO DEMOGRAPHICS

33. How old were you when you stopped drinking alcoholic beverages? _______ years old

33. On average, how often did you drink alcoholic beverages?

• Almost every day

• 2 to 4 times a week

• 1 time a week

• 1 to 3 times a month

• Less than once a month

33. When you drank, about how many drinks did you usually have? ________ drinks per

○day ○week ○month ○year

Demographics

1. What race do you consider yourself to be? (Check one or more)

   • American Indian or Alaska Native

   • Asian

   • Native Hawaiian or Other Pacific Islander

   • Black or African American

   • White

2. Do you consider yourself to be Hispanic or Latino?

   • Hispanic or Latino

   • Not Hispanic or Latino

3. What is the highest level of education you have completed? (check one)

   • Less than a high school diploma

   • High school diploma or GED

   • Some college, Associates Degree or other post-secondary education

   • Bachelor’s degree (4 years of college) or higher

Social Security Number (SSN) _ _ _ - _ _ - _ _ _ _ (The authority for collecting your SSN is the National Defense Authorization Act for Fiscal Year 2008. Your SSN will be kept private. We do not plan to share this information with anyone other than ATSDR staff. We will use your SSN for identity verification purposes and to link with your medical data.)

Please provide your:

Street Address: __________________________________ Apartment Number: _____

City: ________________State: _ _ ZIP code: _ _ _ _ _ - _ _ _ _ Country: __________

Telephone Number: Home Phone: _ _ _ - _ _ _ - _ _ _ _ Cell Phone: _ _ _ - _ _ _ - _ _ _ _

E-Mail address: _____________________________________________________

Please provide the contact information of a friend or family member who will always know your whereabouts in case we need to contact you in the future.

First Name: _________________________ Last Name: _________________________

Street Address: ___________________________________ Apartment Number: _____

City: ________________State: _ _ ZIP code: _ _ _ _ _ - _ _ _ _ Country: __________

Telephone Number: Home Phone: _ _ _ - _ _ _ - _ _ _ _

Cell Phone: _ _ _ - _ _ _ - _ _ _ _

Relationship to you (sibling, child, friend, etc.)__________________________________

Conclusion

The Agency for Toxic Substances and Disease Registry (ATSDR) would like to sincerely thank you for your time and efforts. Your contributions to this important health survey will help us to learn more about ways to improve health and prevent disease in the future.

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