1 SIS_Annual_Forms_20121018_Att 1A

FORM: 41

VERS: 04

OMB No. 0925-0522

Sister Study Health Update: Year 3
* Please return this form even if there are no changes to report. *
It is important to the Sister Study that we stay updated on your health. Please take a few minutes
to fill out this form and let us know if you have been diagnosed with any of the following conditions
since August 2010.

/

Today’s date
month

/
day

ID #
year

*«StudyID»-hlth*
«StudyID»

Since August 2010, has a doctor or other health professional told you that you had any of the following conditions?
If YES, give the month and year of diagnosis.
NO

YES

MONTH / YEAR

a

Breast cancer

aNa

aYa

aa aa / a2a a0a aa aa

b

DCIS (ductal [breast] carcinoma in situ)

aNa

aYa

aa aa / a2a a0a aa aa

c

LCIS (lobular [breast] carcinoma in situ)

aNa

aYa

aa aa / a2a a0a aa aa

d

Lung cancer

aNa

aYa

aa aa / a2a a0a aa aa

e

Ovarian cancer

aNa

aYa

aa aa / a2a a0a aa aa

f

Cancer of the uterus or endometrium

aNa

aYa

aa aa / a2a a0a aa aa

g

Cancer of the colon or rectum

aNa

aYa

aa aa / a2a a0a aa aa

h

Malignant melanoma

aNa

aYa

aa aa / a2a a0a aa aa

i

Any other type of cancer except non-melanoma
skin cancer

aNa

aYa

aa aa / a2a a0a aa aa

j

Heart attack (myocardial infarction – MI)

aNa

What kind?
aYa

_______________________________
aa aa / a2a a0a aa aa

Were you a patient in a hospital overnight?
aYa

Other heart disease (e.g. angina, congestive
heart failure, arrhythmias)

aNa

l

Stroke, mini-stroke, TIA

aNa

aYa

aa aa / a2a a0a aa aa

m

Thyroid disease

aNa

aYa

aa aa / a2a a0a aa aa

n

Autoimmune disease (e.g., rheumatoid arthritis,
lupus, scleroderma, multiple sclerosis, or other)

aNa

aYa

aa aa / a2a a0a aa aa

o

Asthma

aNa

aYa

aa aa / a2a a0a aa aa

p

Hypertension (high blood pressure)

aNa

aYa

aa aa / a2a a0a aa aa

q

Diabetes

aNa

aYa

aa aa / a2a a0a aa aa

r

Hip, wrist or other fracture

aYa

aa aa / a2a a0a aa aa

aNa

s

Any other major illness

aNa

What kind?

What kind?
aYa

What kind?

aYa

aa aa / a2a a0a aa aa

k

What kind?

aNa

_______________________________

_______________________________

_______________________________
aa aa / a2a a0a aa aa
_______________________________

Thank you for your continued participation in the Sister Study. Please mail this form to:
The Sister Study, 1009 Slater Road, Suite 120, Durham, NC 27703. A postage-paid envelope is provided.
Phone: 1-877-4SISTER (1-877-474-7837); email: [email protected]
U.S. Department of Health and Human Services / National Institutes of Health / National Institute of Environmental Health Sciences

SIS «StudyID»

FORM: 23

VERS: 01

OMB No. 0925-0522

Contact Information Update Form
Please return this form even if there are no changes to report.

Help us keep in touch with you by reporting changes to your contact information. If you’ve moved, are about to
move, or changed your phone number or email address, please provide your updated information.
Today’s date:

/ 2 0

/
(month)

(day)

(year)

There have been no changes to any of my contact information. (Check box and go to next page.)
Name and Primary Address

Update or Correction

Name: «FirstName»
«MiddleInitial»
«LastName»
If you have more than one residence, provide information for your primary address, where you live most of the year.

Street Address: «Address1»
«Address2»
,

«City», «State»
-

«Zip»
If you have moved, what was the date of your move? OR,
If you are moving in 2-3 months, what date will you move?

(month)

Mailing Address:

Same as street address

/

(day)

/

2 0
(year)

«Address1»
«Address2»
,

«City», «State»
-

«Zip»
Telephone Numbers We Can Use to Reach You:
Home phone: «HomePhoneNumber»

(

)

-

Work phone: «WorkPhoneNumber» «WorkPhoneExt»

(

)

-

Cell phone: «OtherPhoneNumber»

(

)

-

ext.

Email Address We Can Use to Reach You:
Email: «Email1»

@

.

PAGE ONE - PLEASE CONTINUE TO NEXT PAGE
ID#: SIS

*«StudyID»-spec*

National Institute of Environmental Health Sciences / National Institutes of Health / U.S. Department of Health and Human Services

Please return this form even if there are no changes to report.

We request the names of two people who do not live with you, but who will always know
how to reach you. Please be sure their information is up to date. You may replace a contact
person with someone else by filling in the new information. If we do not have two contacts
for you, please provide the information below.
There have been no changes to any of the information for my contact people. (Check box and return form.)
First Contact

Update/Correction/New Contact

Name: «FirstName»
«LastName»
Relationship to you: «Relationship»
Address: «StreetNumber» «StreetName»
«ApartmentNumber»
,

«City», «State»
-

«Zip»
Phone Number: «PhoneNumber»

(

What is the reason for the changes you made?

-

)

updating old or outdated information
correcting errors in current information
replacing old contact with a new contact person

Second Contact

Update/Correction/New Contact

Name: «FirstName»
«LastName»
Relationship to you: «Relationship»
Address: «StreetNumber» «StreetName»
«ApartmentNumber»
,

«City», «State»
-

«Zip»
Phone Number: «PhoneNumber»
What is the reason for the changes you made?

(

)

-

updating old or outdated information
correcting errors in current information
replacing old contact with a new contact person

After completing both pages of this form, please mail it to the address below. A postage-paid envelope is
provided. Thank you!

The Sister Study, 1009 Slater Road, Suite 120, Durham, NC 27703
phone: 1-877-4SISTER (1-877-474-7837); email: [email protected]

National Institute of Environmental Health Sciences / National Institutes of Health / U.S. Department of Health and Human Services