Form 3 Supplemental Questionnaire (SQX).
Prostate, Lung, Colorectal and Ovarian Cancer Screening Trial (PLCO) (NCI)
Attach_05_SQX
Supplemental Questionnaire (SQX) for PLCO
OMB: 0925-0407
Version Date: 1/06 Expiration Date: xx/xx/xxxx Form Approved OMB No.: 0925-0407
Prostate, Lung, Colorectal and Ovarian
Cancer Screening Trial
SUPPLEMENTAL QUESTIONNAIRE
Participant
ID Number
PLEASE COMPLETE: Today’s Date: |___||___|/|___||___|/|___||___||___||___|
Participant Date of Birth: |___||___|/|___||___|/|___||___||___||___|
STATEMENT OF CONFIDENTIALITY
Collection of this information is authorized by The Public Health Service Act, Section 412 (42 USC 285 a-1). Rights of study participants are protected by The Privacy Act of 1974. Participation is voluntary, and there are no penalties for not participating or withdrawing from the study at any time. Refusal to participate will not affect your benefits in any way. The information collected in this study will be held in professional confidence. Names and other identifiers will be separated from information provided and will not appear in any report of the study. Information provided will be combined for all study participants and report as statistical summaries.
Public reporting burden for this collection of information is estimated to average 30 minutes per response, including 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 (0925-0407). Do not return the completed form to this address.
WHEN FILLING OUT THE QUESTIONNAIRE, PLEASE FOLLOW THESE INSTRUCTIONS
Use a blue or black ball-point pen or a Number 2 pencil. Do not use red ink or a felt tip pen. Do not fold, staple, or tear the forms.
Circles: Please fill in the circles completely. Try not to go outside the lines.
Correct mark ● Incorrect marks
GENERAL INFORMATION
1. What is your current marital status?
Married/living as married
Widowed Separated
Divorced Never married
2. Are you currently…
Homemaker Unemployed
Employed full-time Retired
Employed part-time Disabled
Extended sick leave
Other (specify) ______________
3. Into what religion were you born?
Catholic
Christian Scientist
Greek Orthodox
Jewish
LDS or Mormon
Protestant
Seventh Day Adventist
Other (specify) ______________
None
Family Background and Body Type
4. Are you Hispanic or Latino?
Yes, Hispanic or Latino
No, not Hispanic or Latino
5. What is your race?
American Indian or Alaska Native
Asian
Black or African American
Native Hawaiian or Other Pacific Islander
White
6. What is your current family income?
Less than $20,000
$20,000 to 49,999
$50,000 to 99,999
$100,000 to 200,000
More than $200,000
Prefer not to answer
7. What is your current height?
|___| |____|____|
FEET INCHES
8. Please estimate your weight when you were the following ages. (exclude any periods when you were pregnant)
-
Age
Weight
30s
|____|____|____| Pounds
40s
|____|____|____| Pounds
50s
|____|____|____| Pounds
60s
|____|____|____| Pounds
70s
|____|____|____| Pounds
9. What is your current weight?
|____|____|____|
POUNDS
10. When you gain weight, where do you MAINLY tend to add the weight?
Don’t gain weight
Around the chest and shoulders
Around the waist and stomach
Around the hips and thighs
Equally all over
Other (specify) ______________
11. When you are trying to slim down, where is it most difficult to lose the weight?
Don’t try to lose weight
Can’t lose weight
Around the chest and shoulders
Around the waist and stomach
Around the hips and thighs
Equally all over
Other (specify) ______________
12. Compared to other people of the same sex and height, when sitting, are you…
Especially tall
Somewhat tall
Typical
Somewhat short
Especially short
13. How would you describe your waist in comparison to your hips (waist-to-hip ratio)?
Waist much smaller than hips
Waist somewhat smaller than hips
Waist similar to hips
Waist somewhat larger than hips
Waist much larger than hips
14. What was your father’s age when you were born?
Less than 20 50 to 59
20 to 29 60 to 69
30 to 39 70 or older
40 to 49 Unknown
15. What was your mother’s age when you were born?
Less than 20 35 to 39
20 to 24 40 to 44
25 to 29 45 or older
30 to 34 Unknown
16. How many of each of the following blood relatives (do not count half sisters or half brothers) do/did you have? (Please include any deceased)
-
a. Sisters
0
1
2
3
4
5 or more
b. Brothers
0
1
2
3
4
5 or more
c. Daughters
0
1
2
3
4
5 or more
d. Sons
0
1
2
3
4
5 or more
17. Were any of your blood relatives ever diagnosed with cancer?
(BLOOD RELATIVES INCLUDE MOTHER, FATHER, SISTERS, BROTHERS, CHILDREN.
DO NOT INCLUDE SKIN CANCER UNLESS IT WAS MELANOMA.)
No relatives diagnosed with cancer GO TO QUESTION 18
Yes, at least one relative diagnosed with cancer (COMPLETE THE TABLE BELOW. IF YOU HAVE MORE THAN FIVE RELATIVES DIAGNOSED WITH CANCER, PLEASE INCLUDE A SEPARATE PAGE WITH THIS INFORMATION.)
FOR each row, mark one relative who had cancer |
What type(s) of cancer did he/she have? (MARK ALL THAT APPLY) |
At what age was he/she diagnosed with first cancer? |
|||
Mother Father Sister/Brother Daughter/Son |
Breast Prostate Lung Ovarian |
Lymphoma Colorectal Endometrial Bladder |
Leukemia Other ________ Don’t know |
Less than 40 40 to 49 50 to 59 60 to 69 |
70 to 79 Age 80 or greater Don’t know |
Mother Father Sister/Brother Daughter/Son |
Breast Prostate Lung Ovarian |
Lymphoma Colorectal Endometrial Bladder |
Leukemia Other ________ Don’t know |
Less than 40 40 to 49 50 to 59 60 to 69 |
70 to 79 Age 80 or greater Don’t know |
Mother Father Sister/Brother Daughter/Son |
Breast Prostate Lung Ovarian |
Lymphoma Colorectal Endometrial Bladder |
Leukemia Other ________ Don’t know |
Less than 40 40 to 49 50 to 59 60 to 69 |
70 to 79 Age 80 or greater Don’t know |
Mother Father Sister/Brother Daughter/Son |
Breast Prostate Lung Ovarian |
Lymphoma Colorectal Endometrial Bladder |
Leukemia Other ________ Don’t know |
Less than 40 40 to 49 50 to 59 60 to 69 |
70 to 79 Age 80 or greater Don’t know |
Mother Father Sister/Brother Daughter/Son |
Breast Prostate Lung Ovarian |
Lymphoma Colorectal Endometrial Bladder |
Leukemia Other ________ Don’t know |
Less than 40 40 to 49 50 to 59 60 to 69 |
70 to 79 Age 80 or greater Don’t know |
HEALTH History
-
18. Were you ever diagnosed with:
[IF YES:] At what age were you
first diagnosed?
a. A stroke?
Yes →
No
Less than 50 60 to 69
50 to 59 70 or older
b. A heart attack?
Yes →
No
Less than 50 60 to 69
50 to 59 70 or older
c. High cholesterol?
Yes →
No
Less than 50 60 to 69
50 to 59 70 or older
d. High blood pressure?
Yes →
No
Less than 50 60 to 69
50 to 59 70 or older
e. Diabetes?
Yes →
No
Less than 50 60 to 69
50 to 59 70 or older
f. Osteoporosis?
Yes →
No
Less than 50 60 to 69
50 to 59 70 or older
g. Asthma?
Yes →
No
Less than 10 30 to 39
10 to 19 40 to 49
20 to 29 50 or older
h. Emphysema?
Yes →
No
Less than 50 60 to 69
50 to 59 70 or older
-
19. Were you ever diagnosed with:
[IF YES:] What type of arthritis?
[IF YES:] At what age were you first diagnosed with arthritis?
Arthritis?
Yes →
No
Rheumatoid Arthritis
Osteoarthritis
Not sure which type
Less than 30 50 to 59
30 to 39 60 to 69
40 to 49 70 or older
20. After you were 40 years old, did you ever have a bone fracture or broken bone in any of the following parts of your body? (MARK ALL THAT APPLY)
Hip
Forearm or wrist
Vertebra
Any other bone
No bones fractured or broken
Questions 21 to 28 concern medications (either prescription or over-the-counter) that are anti-inflammatory or pain relievers.
21. During the last 12 months, about how often did you usually take aspirin (examples of aspirin include Bayer, Bufferin, Anacin, and baby aspirin)?
None or less than 1 time per month
1 to 3 times per month
1 to 2 times per week
3 to 6 times per week
7 or more times per week
22. When you took aspirin, what strength or dose did you usually take?
None
Adult strength (usually 325mg)
Baby strength (usually 81mg)
Some other strength
don’t know the strength
23. For how many years have you taken aspirin at least once per week?
None
Less than 10 years
10 to 19 years
20 to 39 years
40 or more years
24. During the last 12 months, about how often did you usually take acetaminophen (examples of acetaminophen include Tylenol and Panedol)?
None or less than 1 time per month
1 to 3 times per month
1 to 2 times per week
3 to 6 times per week
7 or more times per week
25. For how many years have you taken acetaminophen at least once per week?
None
Less than 10 years
10 to 19 years
20 to 39 years
40 or more years
26. Not including aspirin, during the last 12 months, did you take any of the following nonsteroidal anti-inflammatory drugs (NSAIDs) at least once a week?
(MARK ALL THAT APPLY)
Aleve
Advil
Bextra
Celebrex
Indocin
Medipren
Motrin
Naprosyn
Nuprin
Vioxx
Other _______________
None of the NSAIDs
27. During the last 12 months, about how often did you usually take nonsteroidal anti-inflammatory drugs (NSAIDs)?
None or less than 1 time per month
1 to 3 times per month
1 to 2 times per week
3 to 6 times per week
7 or more times per week
28. For how many years have you taken NSAIDs at least once per week?
None
Less than 10 years
10 to 19 years
20 to 39 years
40 or more years
PHYSICAL ACTIVITY
The next few questions refer to your usual physical activities over the last 12 months. Work includes paid employment or volunteer work.
29. Think about your activities at work over the past 12 months. Which of the following choices best describes your usual activities at work?
Did not work during past 12 months
Mostly sitting with little walking
Mostly walking with some sitting
Mostly walking with some manual labor or exercise
Mostly manual labor or exercise
30. Not including any time at work, think about your activities over the past 12 months. How often did you walk a mile or more at a time without stopping?
None or less than 1 time per month
1 to 3 times per month
1 to 2 times per week
3 to 6 times per week
7 or more times per week
31. In the past 12 months did you: |
[IF YES:] In the past 12 months, how often did you do this activity? |
|
a. Jog or run outside or on a treadmill? |
Yes → No |
Less than 1 time/month 1-3 times/month 3-6 times/week 1-2 times/week 7+ times/week |
b. Ride a bicycle or an exercise bicycle? |
Yes → No |
Less than 1 time/month 1-3 times/month 3-6 times/week 1-2 times/week 7+ times/week |
c. Swim? |
Yes → No |
Less than 1 time/month 1-3 times/month 3-6 times/week 1-2 times/week 7+ times/week |
d. Do aerobics, water aerobics or aerobic dancing? |
Yes → No |
Less than 1 time/month 1-3 times/month 3-6 times/week 1-2 times/week 7+ times/week |
e. Do other dancing? |
Yes → No |
Less than 1 time/month 1-3 times/month 3-6 times/week 1-2 times/week 7+ times/week |
f. Do calisthenics or exercise? |
Yes → No |
Less than 1 time/month 1-3 times/month 3-6 times/week 1-2 times/week 7+ times/week |
g. Garden or do yard work? |
Yes → No |
Less than 1 time/month 1-3 times/month 3-6 times/week 1-2 times/week 7+ times/week |
h. Lift weights? |
Yes → No |
Less than 1 time/month 1-3 times/month 3-6 times/week 1-2 times/week 7+ times/week |
32. Over the last 12 months, on average, how many days per week did you spend in any physical activity strenuous enough to work up a sweat or to increase your breathing and heart rate to very high levels?
None or less than 1 day per week
2 to 3 days per week
4 to 5 days per week
6 to 7 days per week
33. Over the last 12 months, on average, how long was each session of strenuous activity?
None or less than 15 minutes
16 to 19 minutes
20 to 29 minutes
30 to 39 minutes
40 minutes or more
34. Over the last 12 months, on average, how many days per week did you spend in any moderate physical activity where you worked up a light sweat or increased your breathing and heart rate to moderately higher levels?
None or less than 1 day per week
2 to 3 days per week
4 to 5 days per week
6 to 7 days per week
35. Over the last 12 months, on average, how long was each session of moderate activity?
None or less than 15 minutes
16 to 19 minutes
20 to 29 minutes
30 to 39 minutes
40 minutes or more
36. Over the past 12 months, on average, how many hours per week did you spend doing light work around the house including preparing meals, cleaning, doing small repairs, washing dishes, etc.?
None or less than 1 hour per week
Around 1 hour per week
2 to 3 hours per week
4 to 5 hours per week
6 to 7 hours per week
More than 7 hours per week
37. What is your usual walking pace?
Easy (less than 2 mph)
Normal, average (2 to 2.9 mph)
Brisk pace (3 to 3.9 mph)
Very brisk, striding (4 mph or faster)
Unable to walk
38. How many flights of stairs do you usually climb daily?
No flights
1 to 2 flights
3 to 4 flights
5 to 9 flights
10 flights or more
39. How often do you leave your home for shopping or other activities?
None or less than 1 time per week
1 time per week
2 to 4 times per week
5 to 6 times per week
7 or more times per week
40. Compared with yourself 10 years ago, are you now more active, less active, or about the same?
More active
Less active
About the same
Tobacco Section
Now think about your smoking history.
41. Have you smoked at least 100 cigarettes in your entire life?
Yes CONTINUE WITH QUESTION 42
No GO TO QUESTION 55
42. How old were you when you first started smoking cigarettes fairly regularly?
(Enter age OR fill circle () IF NEVER SMOKED REGULARLY)
|____|____| OR NEVER
AGE STARTED SMOKED
SMOKING REGULARLY
43. Over your lifetime, did you mainly smoke Ultra-light, Light, or Regular cigarettes?
Ultra-Light
Light or mild
Regular or full-flavor
No usual type of cigarettes
44. Over your lifetime, did you mainly smoke menthol or non-menthol cigarettes?
Menthol
Non-menthol
No usual type of cigarettes
45. In the past 30 days, did you smoke cigarettes every day, some days, or not at all?
Every day CONTINUE WITH QUESTION 46
Some days CONTINUE WITH QUESTION 46
Not at all GO TO QUESTION 52
46. In the past 30 days, on days that you smoked, about how many cigarettes did you usually smoke each day?
1 to 5 each day
6 to under 1 pack each day
About 1 pack each day
About 1½ packs each day
About 2 packs each day
More than 2 packs each day
47. How soon after you wake up do you usually smoke your first cigarette of the day?
Within 5 minutes
6 to 30 minutes
31 to 60 minutes
More than 60 minutes
48. For each of the following statements mark if it is true for you.
True “I have trouble going more
False than a few hours without
smoking.”
True “Even in a bad rainstorm,
False if I ran out of cigarettes, I
would probably go to the
store to get some more.”
True “When I go without
False smoking for a few hours,
I experience craving.”
True “If I were in a public place
False where smoking was not
allowed, I would probably go
outside to smoke a cigarette,
even in cold or rainy weather.”
49. Are you considering quitting smoking during the next 6 months?
Yes, plan to stop within next 30 days
Yes, plan to stop within next 6 months, but not within next 30 days
No, not thinking of quitting in next 6 months
50. In the past, have you ever made a serious attempt to quit smoking? That is, have you stopped smoking for at least one day or longer because you were trying to quit?
Yes CONTINUE WITH QUESTION 51
No GO TO QUESTION 54
51. What was the longest length of time you stopped smoking because you were trying to quit?
Less than 1 week
1 to 3 weeks
1 to 2 months
3 to 11 months
1 to 4 years
5 to 9 years
10 years or more
52. How old were you when you most recently quit smoking?
|____|____|
AGE STOPPED SMOKING
53. Thinking of the most recent time you quit smoking, did you use any of the following products? (MARK EACH ONE THAT YOU USED)
Nicotine gum
Nicotine patch
Nicotine nasal spray, inhaler, lozenge, or tablet
Prescription pill such as Zyban, Buproprion, or Wellbutrin
None of these
54. During the past 12 months did any doctor, dentist, nurse, or any other health professional advise you to quit smoking?
Yes
No, was not advised to quit
No, did not see a health professional in past 12 months
No, did not smoke in past 12 months
Now think about your exposure to other peoples’ smoke.
55. Before you were 18, did you ever live with someone who smoked cigarettes in the home on a regular basis?
Yes, during most of your childhood
Yes, during some of your childhood
No, not at all
56. As an adult (AFTER you turned 18), did you ever live with someone who smoked cigarettes in the home on a regular basis?
Yes, during most of your adult life
Yes, during some of your adult life
No, not at all
57. As an adult (AFTER you turned 18), did you ever work indoors with someone who smoked cigarettes in your work area on a regular basis?
Yes, during most of your work experience
Yes, during some of your work experience
No, not at all
58. How often do you worry about getting lung cancer? Would you say:
Rarely or never
Sometimes
Often
All of the time
59. Compared to others your age who currently smoke, what do you think are your chances of being diagnosed with lung cancer during your lifetime?
Are you:
at much less risk
at less risk
at the same risk
at higher risk
at much higher risk
Questions 60 to 73 are for women only. Men please go to Question 74.
WOMEN ONLY
60. During any of your pregnancies, were you carrying more than one baby (twins, triplets, etc.)?
Yes
No
Never pregnant
61. In your lifetime, how many total months have you breast-fed?
None or never pregnant
Less 6 months
6 to 11 months
12 to 35 months
36 months or more
62. When did you have your last Pap smear?
Never
Less than 1 year ago
1 year ago
2 to 3 years ago
4 or more years ago
63. When did you have your last mammogram?
Never
Less than 1 year ago
1 year ago
2 to 3 years ago
4 or more years ago
64.. Did you ever take any of the following medications to strengthen your bones or for any other reason? Did you ever take: |
[IF EVER TOOK:] Are you taking this medication now? |
|
a. Nolvadex (Tamoxifen)? |
Yes → No |
Yes No |
b. Evista (Raloxifene)? |
Yes → No |
Yes No |
c. Fosamax (Alendronate)? |
Yes → No |
Yes No |
d. Actonel (Risendronate)? |
Yes → No |
Yes No |
e. Miacalcin (Calcitonin)? |
Yes → No |
Yes No |
f. Didronel (Etidronate)? |
Yes → No |
Yes No |
g. Forteo (Teriparatide)? |
Yes → No |
Yes No |
h. Boniva (Ibandronate)? |
Yes → No |
Yes No |
-
65. Did you ever have a breast biopsy?
[IF YES:] How many have you had?
[IF YES:] At what age was your most recent one?
Yes →
No
1
2
3 or more
Less than 30 50 to 59
30 to 39 60 to 69
40 to 49 70 or older
-
66. Have you ever had an ovary removed?
[IF YES:] How many ovaries have been removed?
[IF YES:] At what age was your most recent ovary removal?
Yes →
No
Both ovaries
One ovary
Partial removal of an ovary
Not sure
Less than 40 55 to 59
40 to 44 60 to 69
45 to 49 70 to 79
50 to 54 80 or older
-
67. Have you ever had a hysterectomy, that is, have you had your uterus or womb removed?
[IF YES:] At what age was your hysterectomy?
Yes →
No
Less than 40 55 to 59
40 to 44 60 to 69
45 to 49 70 to 79
50 to 54 80 or older
Sometimes women take female hormones, such as estrogen or progestin during or after menopause. The next few questions ask about your use of such hormones, often called hormone replacement therapy or HRT.
68. Have you ever taken HRT?
Yes CONTINUE WITH QUESTION 69
No END. THANK YOU FOR
COMPLETING THE QUESTIONNAIRE
69. At about what age did you first begin taking HRT?
|____|____|
AGE FIRST TOOK HRT
70. What type of HRT did you take when you first began HRT?
Estrogen pills only (such as Premarin, Estrace, Estratab, Menest, Orthoest, Ogen, Gynodiol, Cenestin, or Alora)
Progesterone/progestin pills only (such as Provera, Amen, Cycrin, Megace, Curretab, Prometrium, or Aygestin)
Estrogen and progesterone/progestin in the same pill (such as Prempro or Premphase) or in different pills
Estrogen creams, shots, or patches
Progesterone/progestin creams, shots, or patches
Estrogen and progesterone/progestin creams, shots, or patches
Not sure
71. Are you still taking this type of HRT, or did you stop, or switch types?
Still taking this type of HRT END. THANK YOU FOR COMPLETING THE QUESTIONNAIRE
Stopped taking this type of HRT At what Age did you Stop |____|____|
END. THANK YOU FOR COMPLETING THE QUESTIONNAIRE
Switched taking this type of HRT At what Age did you Switch |____|____|
72. When you switched, what type of HRT did you switch to?
Estrogen pills only
Progesterone/progestin pills only
Estrogen and progesterone/progestin in the same pill or in different pills
Estrogen creams, shots, or patches
Progesterone/progestin creams, shots, or patches
Estrogen and progesterone/progestin creams, shots, or patches
Not sure
73. Are you still taking this type of HRT?
Yes
No
WOMEN END. THANK YOU FOR COMPLETING THE QUESTIONNAIRE
MEN ONLY
74. What was your hair pattern at age 45?
75. During a typical night in the last 12 months, how many times did you wake up to urinate?
Never 3 times
Once 4 or more times
2 times
76. How old were you when you first began waking up to urinate more than once a night on a regular basis?
Never woke up to urinate more than once a night
Less than 30 50 to 59
30 to 39 60 to 69
40 to 49 70 or older
77. Has a doctor ever told you that you had an enlarged prostate or benign prostatic hypertrophy (BPH)?
Yes CONTINUE WITH QUESTION 78
No END. THANK YOU FOR COMPLETING THE QUESTIONNAIRE
78. How old were you when a doctor first told you that you had this problem?
Less than 30 50 to 59
30 to 39 60 to 69
40 to 49 70 or older
MEN END. THANK YOU FOR
COMPLETING THE QUESTIONNAIRE
| File Type | application/msword |
| Author | Thea Zimmerman |
| Last Modified By | merrill_l |
| File Modified | 2011-06-09 |
| File Created | 2011-06-09 |
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