Form 1 SIS_Triennial_Forms_20121018_Att 2A

The Sister Study: Environmental and Generic Risk Factors for Breast Cancer

SIS_Triennial_Forms_20121018_Att 2A

Bi/Trienniel Follow-Up

OMB: 0925-0522

⚠️ Notice: This form may be outdated. More recent filings and information on OMB 0925-0522 can be found here:

2016-02-29 - Revision of a currently approved collection

Document [pdf]

Download: pdf | pdf

ATTACHMENT 2A
Form: 49

Vers:

ID#: SIS

OMB No. 0925-0522

The Sister Study
Health and Medical History
Version 2

Instructions:
Please use DARK BLUE OR BLACK BALLPOINT PEN.
Mark only one answer for each question unless otherwise indicated.
Follow the arrow from your response to find the next question.
Only write comments in the spaces provided.
Please keep this questionnaire clean, flat, and dry.
Do not fold or tear any of the pages.
Fill in the bubbles COMPLETELY for each of the questions in this form.

Like this:

Not like this:

 

If you must change an answer, please mark a single horizontal line through the incorrect answer
and bubble in the correct answer completely.

Like this:

YES

Not like this:



YES

Please write responses in all capital letters and numbers without touching the sides of the boxes.

A B C D E F G H I J K L M N O P Q R S T U V W X Y Z

1 2 3 4 5 6 7 8 9 0
When writing dates, please
follow this example.

EXAMPLE: June 7, 2011 =

0 6 / 0 7 / 2 0 1 1
(month)

(day)

(year)

Public reporting burden for this collection of information is estimated to average 20 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 (0925-0522). Do not return the completed form to this address.

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

Draft

Your continued participation in the Sister Study is completely voluntary and greatly appreciated. If you
are not comfortable answering a question, just skip it and go to the next one. All information you share
will be kept confidential.

Today's Date:
MONTH

DAY

0
YEAR

GENERAL HEALTH
1.

In the past 24 months, would you say your health has generally been…
excellent,
very good,
good,
fair, or
poor?

In the past 24 months, have you...
No

Yes

a. had a routine physical exam?
b. been to a dentist for a routine check-up or cleaning?
c. had a Pap smear?
d. had a breast exam by a doctor or other health professional?
e. had a screening mammogram?
f. had a screening ultrasound of the breast?
g. had a screening MRI of the breast?
h. had a bone density scan or osteoporosis screening?
i. had a screening colonoscopy or sigmoidoscopy exam?
j. had an ultrasound of the uterus?

Draft

Do you have any form of general health care coverage, including health insurance, prepaid plans
such as HMOs, or government plans such as Medicare or Medicaid?
No
Yes

No
Yes

Since January 1, 2009, have you ever been unable to get screening mammography because your
insurance doesn't cover it or you don't have access to screening through your work or other
sources?
No
Yes

What is your current weight (in pounds)?

POUNDS

What is your current height?

FEET

INCHES

Since January 1, 2009, how many times have you lost 20 pounds (9 kilograms) or more and then
later gained all the weight back? (If none, please enter "00".)

# TIMES
Draft

Please use a ballpoint pen for this form

Was there a time in the past 12 months when you needed to see a doctor but did not because
of the cost?

Have you ever been vaccinated for shingles (herpes zoster)?
No

GO TO QUESTION 10

9a.

Yes

10.

/
MONTH

YEAR

In the past 12 months, did you get vaccinated for the flu (either a flu shot or nasal spray)?
No

GO TO QUESTION 11

10a.

Yes

11.

In what month and year did
you have a shingles vaccination?

In what month and year did
you receive the flu vaccine?

MONTH

YEAR

During the past 12 months, did you have any cold sores?
No
Yes, 1-2 times
Yes, 3 or more times

12.

During the past 12 months, did you have any colds?
No

Yes

13.

GO TO QUESTION 13

12a.

How many colds did you have?

1-2
3-4
5 or more

During the past 12 months, did you have the flu or influenza? The flu is a respiratory illness with
fever. Other symptoms include weakness, fatigue, and muscle aches.
No
Yes
Draft

FAMILY MEDICAL HISTORY

14.

Since January 1, 2009, were any of your sisters diagnosed with breast cancer for the first time?
No
Yes

Since January 1, 2009, have any other close blood relatives of yours been diagnosed with breast
cancer for the first time?
No

Yes

GO TO QUESTION 16
15a.

What is/are the relative(s)’
relationship to you?
(Please mark all that apply.)

Mother
Father
Brother
Daughter
Son
Grandmother
Grandfather
Other relative related
to you by blood

16.

Since January 1, 2009, have any close blood relatives of yours been diagnosed with ovarian
cancer for the first time?
No

Yes

GO TO THE NEXT PAGE, QUESTION 17
16a.

What is/are the relative(s)’
relationship to you?
(Please mark all that apply.)

Sister
Mother
Daughter
Grandmother
Other relative related
to you by blood

Draft

Please use a ballpoint pen for this form

15.

17.

Have any close blood relatives of yours ever been diagnosed with Parkinson's disease?
No

Yes

GO TO QUESTION 18
17a.

What is/are the relative(s)’
relationship to you?
(Please mark all that apply.)

Mother
Father
Sister
Brother
Daughter
Son
Other relative related
to you by blood

18.

Have any close blood relatives of yours ever been diagnosed with Alzheimer's disease?
No

Yes

GO TO QUESTION 19
18a.

What is/are the relative(s)’
relationship to you?
(Please mark all that apply.)

Mother
Father
Sister
Brother
Daughter
Son
Other relative related
to you by blood

19.

Have any close blood relatives of yours ever been diagnosed with diabetes?
No

Yes

GO TO THE NEXT PAGE, QUESTION 20
19a.

What is/are the relative(s)’
relationship to you?
(Please mark all that apply.)

Mother
Father
Sister
Brother
Daughter
Son
Other relative related
to you by blood
Draft

20.

Have any close blood relatives of yours ever been diagnosed with heart disease?
No

Yes

GO TO QUESTION 21
20a.

What is/are the relative(s)’
relationship to you?
(Please mark all that apply.)

Mother
Father
Sister
Brother

21.

Have any close blood relatives of yours ever had a stroke?
No

Yes

GO TO THE NEXT PAGE, QUESTION 22
21a.

What is/are the relative(s)’
relationship to you?
(Please mark all that apply.)

Mother
Father
Sister
Brother
Daughter
Son
Other relative related
to you by blood

Draft

Please use a ballpoint pen for this form

Daughter
Son
Other relative related
to you by blood

PERSONAL MEDICAL HISTORY
We are interested in changes to your health in the past few years. Please think about your medical
history since January 1, 2009.
Has a doctor or other health
professional told you that you
had...

NEVER OR
BEFORE1/1/2009

DIAGNOSED
1/1/2009 OR LATER

22. breast cancer? Please
do not include in situ
cancer.

Never diagnosed
Diagnosed before
January 1, 2009

Diagnosed January 1,
2009 or later

23. ductal (breast)
carcinoma in situ (DCIS)?

Never diagnosed
Diagnosed before
January 1, 2009

Diagnosed January 1,
2009 or later

24. lobular (breast)
carcinoma in situ (LCIS)?

Never diagnosed
Diagnosed before
January 1, 2009

Diagnosed January 1,
2009 or later

25. lung cancer?

Never diagnosed
Diagnosed before
January 1, 2009

Diagnosed January 1,
2009 or later

Never diagnosed
Diagnosed before
January 1, 2009

Diagnosed January 1,
2009 or later

27. cancer of the uterus or
endometrium?

Never diagnosed
Diagnosed before
January 1, 2009

Diagnosed January 1,
2009 or later

28. cancer of the colon or
rectum?

Never diagnosed
Diagnosed before
January 1, 2009

Diagnosed January 1,
2009 or later

29. Hodgkin's disease or
Hodgkin's lymphoma?

Never diagnosed
Diagnosed before
January 1, 2009

Diagnosed January 1,
2009 or later

30. non-Hodgkin’s
lymphoma?

Never diagnosed
Diagnosed before
January 1, 2009

Diagnosed January 1,
2009 or later

31. leukemia?

Never diagnosed
Diagnosed before
January 1, 2009

Diagnosed January 1,
2009 or later

26. ovarian cancer?

a.
If diagnosed January 1, 2009
or later, what month and
year were you diagnosed?

MONTH

YEAR

MONTH

0
YEAR

MONTH

0
YEAR

MONTH

0
YEAR

MONTH

0
YEAR

MONTH

0
YEAR

MONTH

0
YEAR

MONTH

0
YEAR

MONTH

0
YEAR

/
MONTH

0
YEAR
Draft

Has a doctor or other health
professional told you that
you had...

32. malignant melanoma?

DIAGNOSED
1/1/2009 OR LATER

Never diagnosed
Diagnosed before
January 1, 2009

Diagnosed January 1,
2009 or later

Never diagnosed
Diagnosed before
January 1, 2009

Diagnosed January 1,
2009 or later

MONTH

0
YEAR

a. MONTH/YEAR DIAGNOSED

MONTH

0
YEAR

b. Was it...
(Please mark all
that apply.)
basal cell?
squamous cell?
other?

34. any other type of
cancer not already
listed?

Never diagnosed
Diagnosed before
January 1, 2009

Diagnosed January 1,
2009 or later

a. MONTH/YEAR DIAGNOSED

MONTH

0
YEAR

b. Please specify what
type of cancer:

c. If you were diagnosed
with a second other
type of cancer January
1, 2009 or later, what
month and year were
you diagnosed?

/
MONTH

0
YEAR

d. Please specify what
type of cancer:

Draft

Please use a ballpoint pen for this form

33. skin cancer
(not malignant
melanoma)?

NEVER OR
BEFORE1/1/2009

a.
If diagnosed January 1, 2009
or later, what month and
year were you diagnosed?

Has a doctor or other
health professional
ever told you that
you had...

35. hypertension
or high blood
pressure?

NO
No

b.
Have you
experienced any
symptoms in the
past 12 months?

YES
Yes, first diagnosed before January 1, 2009
Yes, first diagnosed
January 1, 2009 or later 

a. What month and year
were you diagnosed?

MONTH

36. angina?

YEAR

a. What month and year
were you diagnosed?

MONTH

37. cardiac
arrhythmia
(irregular
heartbeat)?

a. What month and year
were you diagnosed?

MONTH

Yes, first diagnosed before January 1, 2009
Yes, first diagnosed
January 1, 2009 or later 

YEAR

a. What month and year
were you diagnosed?

/
MONTH

No
Yes

Yes, first diagnosed before January 1, 2009
Yes, first diagnosed
January 1, 2009 or later 

No
Yes

YEAR

/
38. congestive
heart failure?

Yes, first diagnosed before January 1, 2009
Yes, first diagnosed
January 1, 2009 or later 

No
Yes

0
YEAR

Draft

Has a doctor or
other health
professional told
you that you had...
39. a heart
attack or
myocardial
infarction?

NO
No

b.
Have you had another
incident since then?

YES
Yes, my first heart attack was
before January 1, 2009

Yes, my first heart attack was
January 1, 2009 or later

Yes



MONTH

40. a stroke (this
does not
include TIA or
"mini-stroke")?

Yes, my first stroke was
before January 1, 2009

Yes, my first stroke was
January 1, 2009 or later

Yes

MONTH

YEAR



a. What month and year was
your first stroke?

41. a mini-stroke
or TIA
(transient
ischemic
attack)?

c. What month and year was your
most recent heart attack?


c. What month and year was your
most recent stroke?

0
MONTH

YEAR

Yes, my first mini-stroke was
before January 1, 2009

Yes, my first mini-stroke was
January 1, 2009 or later

Yes



a. What month and year was
your first mini-stroke?

MONTH

YEAR


c. What month and year was your
most recent mini-stroke?

0
YEAR

YEAR

MONTH

YEAR

Draft

Please use a ballpoint pen for this form

a. What month and year was
your first heart attack?



Since January 1,
2009, have you
had...

NEVER OR BEFORE
1/1/2009

1/1/2009
OR LATER

42. a hip
fracture?

Never
Before January 1,
2009

January 1,
2009 or later

43. a wrist
fracture?

Never
Before January 1,
2009

January 1,
2009 or later

a.
How many times
has this happened
since January 1,
2009?

b.
What was the month
and year that this first
happened since
January 1, 2009?

/
# TIMES

0
YEAR

MONTH

/
# TIMES

0
YEAR

MONTH

44. Since January 1, 2009, have you had any other broken bones?
Never
Yes, before
January 1, 2009

Yes, January 1,
2009 or later

GO TO QUESTION 45

What broken bones did you have?
44a.

What was the month and
year that this happened?

MONTH

0
YEAR

44b.
FIRST BROKEN BONE

44c.

What was the month and
year that this happened?

/
MONTH

0
YEAR

44d.
SECOND BROKEN BONE

45. Have you ever had a serious head
injury that resulted in unconsciousness,
coma, or hospitalization?

a.
If yes, how
many times?

b.
Age at first
injury?

c.
Age at most
recent injury?

# TIMES

AGE

Yes

Draft

46. Since January 1, 2009, have you had any other major injury that required hospitalization?
Never
GO TO QUESTION 47

Yes, before
January 1, 2009

If you were injured January 1, 2009 or later, what type of
injuries did you have?

Yes, January 1,
2009 or later

46a.

What month and year
were you injured?

MONTH

YEAR

FIRST OTHER MAJOR INJURY

46c.

What month and year
were you injured?

MONTH

YEAR

46d.
SECOND OTHER MAJOR INJURY

Has a doctor or other
health professional ever
told you that you had...
47. diabetes?

NO
No

YES
Yes, first diagnosed before January 1, 2009
Yes, first diagnosed January 1, 2009 or later 

a. What month and year
were you diagnosed?

/
b. Do you still have this condition?

MONTH

0
YEAR

No
Yes
c. Do you currently take insulin for diabetes?
No  GO TO THE NEXT PAGE, QUESTION 48
Yes
d. If yes, when did you first use insulin?

/
MONTH

YEAR
Draft

Please use a ballpoint pen for this form

46b.

Has a doctor or other
health professional
ever told you that
you had...
48. allergic
rhinitis, hay
fever, or seasonal
allergies?

NO
No

b.
Have you
experienced
any symptoms
in the past 12
months?

YES
Yes, first diagnosed before January 1, 2009
Yes, first diagnosed
January 1, 2009 or later  a. What month and year
were you diagnosed?

MONTH

49. asthma?

0
YEAR

Yes, first diagnosed before January 1, 2009
Yes, first diagnosed
January 1, 2009 or later  a. What month and year
were you diagnosed?

MONTH

50. depression?

YEAR

Yes, first diagnosed before January 1, 2009

MONTH

No
Yes

Yes, first diagnosed
January 1, 2009 or later  a. What month and year
were you diagnosed?

51. periodontal
(gum) disease?

No
Yes

0
YEAR

No
Yes

Yes, first diagnosed before January 1, 2009
Yes, first diagnosed
January 1, 2009 or later  a. What month and year
were you diagnosed?

/
MONTH

0
YEAR

Draft

Since January 1, 2009, has a
doctor or other health
professional told you that you
had...

DIAGNOSED
1/1/2009 OR LATER

Never diagnosed
Diagnosed before
January 1, 2009

Diagnosed January 1,
2009 or later

Never diagnosed
Diagnosed before
January 1, 2009

Diagnosed January 1,
2009 or later

54. chronic obstructive
pulmonary disease
(COPD)?

Never diagnosed
Diagnosed before
January 1, 2009

Diagnosed January 1,
2009 or later

55. Graves' disease?

Never diagnosed
Diagnosed before
January 1, 2009

Diagnosed January 1,
2009 or later

56. other hyperthyroidism
(overactive thyroid)?

Never diagnosed
Diagnosed before
January 1, 2009

Diagnosed January 1,
2009 or later

57. Hashimoto's thyroiditis?

Never diagnosed
Diagnosed before
January 1, 2009

Diagnosed January 1,
2009 or later

58. other hypothyroidism
(underactive thyroid)?

Never diagnosed
Diagnosed before
January 1, 2009

Diagnosed January 1,
2009 or later

59. an enlarged thyroid or
goiter?

Never diagnosed
Diagnosed before
January 1, 2009

Diagnosed January 1,
2009 or later

60. thyroid nodules?

Never diagnosed
Diagnosed before
January 1, 2009

Diagnosed January 1,
2009 or later

Never diagnosed
Diagnosed before
January 1, 2009

Diagnosed January 1,
2009 or later

52. chronic bronchitis?

53. emphysema?

61. another thyroid problem?
Please do not include
thyroid cancer.

MONTH

0
YEAR

MONTH

0
YEAR

MONTH

0
YEAR

MONTH

0
YEAR

MONTH

0
YEAR

MONTH

0
YEAR

MONTH

0
YEAR

MONTH

0
YEAR

MONTH

0
YEAR

a. MONTH/YEAR DIAGNOSED

/
MONTH

0
YEAR

b. Please specify the problem:

Draft

Please use a ballpoint pen for this form

NEVER OR BEFORE
1/1/2009

a.
If diagnosed January 1, 2009
or later, what month and
year were you diagnosed?

Since January 1, 2009, has a
doctor or other health
professional told you that you
had...

NEVER OR BEFORE
1/1/2009

DIAGNOSED
1/1/2009 OR LATER

Never diagnosed
Diagnosed before
January 1, 2009

Diagnosed January 1,
2009 or later

Never diagnosed
Diagnosed before
January 1, 2009

Diagnosed January 1,
2009 or later

Never diagnosed
Diagnosed before
January 1, 2009

Diagnosed January 1,
2009 or later

Never diagnosed
Diagnosed before
January 1, 2009

Diagnosed January 1,
2009 or later

Never diagnosed
Diagnosed before
January 1, 2009

Diagnosed January 1,
2009 or later

67. scleroderma or systemic
sclerosis?

Never diagnosed
Diagnosed before
January 1, 2009

Diagnosed January 1,
2009 or later

68. systemic lupus
erythematosus (SLE)?

Never diagnosed
Diagnosed before
January 1, 2009

Diagnosed January 1,
2009 or later

69. discoid lupus?

Never diagnosed
Diagnosed before
January 1, 2009

Diagnosed January 1,
2009 or later

Never diagnosed
Diagnosed before
January 1, 2009

Diagnosed January 1,
2009 or later

Never diagnosed
Diagnosed before
January 1, 2009

Diagnosed January 1,
2009 or later

Never diagnosed
Diagnosed before
January 1, 2009

Diagnosed January 1,
2009 or later

Never diagnosed
Diagnosed before
January 1, 2009

Diagnosed January 1,
2009 or later

62. osteoporosis?

63. osteopenia, or low bone
density?

64. osteoarthritis
(age-related arthritis)?

65. rheumatoid arthritis?

66. multiple sclerosis?

70. Sjögren’s syndrome?

71. Crohn’s disease?

72. ulcerative colitis?

73. shingles?

a.
If diagnosed January 1, 2009
or later, what month and
year were you diagnosed?

MONTH

YEAR

MONTH

0
YEAR

MONTH

0
YEAR

MONTH

0
YEAR

MONTH

0
YEAR

MONTH

0
YEAR

MONTH

0
YEAR

MONTH

0
YEAR

MONTH

0
YEAR

MONTH

0
YEAR

MONTH

0
YEAR

/
MONTH

0
YEAR
Draft

Has a doctor or
other health
professional
ever told you
that you had...
74. migraine
headaches?

NO
No

YES
Yes, first diagnosed before January 1, 2009
Yes, first diagnosed January 1, 2009 or later 

MONTH

Please use a ballpoint pen for this form

a. What month and year
were you diagnosed?

0
YEAR

b. Was the diagnosis of migraine made by a...
(Please mark all that apply.)
Headache specialist
Neurologist
Other physician
Other health professional
c. Which kind of migraines do you get?
With visual aura
Without visual aura
Both types with similar frequency
d. During the past 12 months, how often have you had a migraine?
Never
Monthly or less
Biweekly
Weekly
Daily
e. During the past 12 months, how long on average have your
migraines usually lasted?
A few hours or less
About half a day
A day
Several days
One week or longer

Draft

Has a doctor or other
health professional told
you that you had...

NEVER OR BEFORE
1/1/2009

DIAGNOSED
1/1/2009 OR LATER

75. polyps in the colon or
rectum?

Never diagnosed
Diagnosed before
January 1, 2009

Diagnosed January 1,
2009 or later

76. polycystic ovarian
syndrome or PCOS?

Never diagnosed
Diagnosed before
January 1, 2009

Diagnosed January 1,
2009 or later

77. ovarian cysts?

Never diagnosed
Diagnosed before
January 1, 2009

Diagnosed January 1,
2009 or later

Never diagnosed
Diagnosed before
January 1, 2009

Diagnosed January 1,
2009 or later

79. uterine fibroids or fibroid
tumors?

Never diagnosed
Diagnosed before
January 1, 2009

Diagnosed January 1,
2009 or later

80. gallstones or gallbladder
disease?

Never diagnosed
Diagnosed before
January 1, 2009

Diagnosed January 1,
2009 or later

81. Parkinson’s disease?

Never diagnosed
Diagnosed before
January 1, 2009

Diagnosed January 1,
2009 or later

Never diagnosed
Diagnosed before
January 1, 2009

Diagnosed January 1,
2009 or later

83. mild cognitive
impairment?

Never diagnosed
Diagnosed before
January 1, 2009

Diagnosed January 1,
2009 or later

84. kidney failure requiring
dialysis or transplant?

Never diagnosed
Diagnosed before
January 1, 2009

Diagnosed January 1,
2009 or later

85. kidney stones?

Never diagnosed
Diagnosed before
January 1, 2009

Diagnosed January 1,
2009 or later

Never diagnosed
Diagnosed before
January 1, 2009

Diagnosed January 1,
2009 or later

78. endometriosis?

82. Alzheimer’s disease?

86. other kidney disease?

a.
If diagnosed January 1, 2009
or later, what month and
year were you diagnosed?

MONTH

YEAR

MONTH

0
YEAR

MONTH

0
YEAR

MONTH

0
YEAR

MONTH

0
YEAR

MONTH

0
YEAR

MONTH

0
YEAR

MONTH

0
YEAR

MONTH

0
YEAR

MONTH

0
YEAR

MONTH

0
YEAR

/
MONTH

0
YEAR
Draft

Has a doctor or other health
professional told you that
you had...

87. gout?

88. cataracts?

90. macular degeneration?

91. hearing loss?

DIAGNOSED
1/1/2009 OR LATER

Never diagnosed
Diagnosed before
January 1, 2009

Diagnosed January 1,
2009 or later

Never diagnosed
Diagnosed before
January 1, 2009

Diagnosed January 1,
2009 or later

Never diagnosed
Diagnosed before
January 1, 2009

Diagnosed January 1,
2009 or later

Never diagnosed
Diagnosed before
January 1, 2009

Diagnosed January 1,
2009 or later

Never diagnosed
Diagnosed before
January 1, 2009

Diagnosed January 1,
2009 or later

MONTH

0
YEAR

MONTH

0
YEAR

MONTH

0
YEAR

MONTH

0
YEAR

MONTH

0
YEAR

The following are some conditions we have not asked about in the past. Please tell us if you
have ever been diagnosed with any of these conditions and when you were first diagnosed.
Has a doctor or other health professional ever
told you that you had...

91b.

pulmonary embolism?

YES

a.
If yes, what year were
you first diagnosed?

Yes
YEAR

91c.

deep vein thrombosis, DVT, or deep vein blood
clots in your legs or somewhere else?

Yes
YEAR

Draft

Please use a ballpoint pen for this form

89. glaucoma?

NEVER OR BEFORE
1/1/2009

a.
If diagnosed January 1, 2009
or later, what month and
year were you diagnosed?

92. Since January 1, 2009, have you experienced any of the following medical
symptoms? (Please mark a response for each item below.)
No

Yes

a. swelling in your wrist, finger, elbow, or knee joints lasting six or more weeks?
b. joint stiffness in the mornings, lasting at least one hour, and for more than six
weeks (do not include stiffness related or due to an injury or surgery)?
c. daily, persistent, troublesome dry eyes for more than 3 months, or a recurrent feeling
of sand or gravel in your eyes, or use of tear substitutes more than 3 times a day?
d. a daily feeling of dry mouth for more than 3 months, or frequent drinking of liquids to
aid in swallowing dry foods, or recurrently or persistently swollen salivary glands?
e. a tremor or trembling in either of your hands?
f. walking or other movements getting noticeably slower?
g. handwriting getting noticeably smaller?
h. difficulty getting started when walking or making other movements?
i. wheezing or whistling in your chest?
j. shortness of breath when hurrying on level ground, or when walking up a slight hill,
or when climbing a flight of stairs at your usual pace?
k. shortness of breath when at rest?
l. shortness of breath when lying down?
m. shortness of breath when walking?
n. swelling (or edema) in your legs?
o. excessive sweating other than due to menopause?
p. unexplained and unintentional weight loss of 10 or more pounds?

Draft

93.

Do you suffer from a decrease in or loss of your sense of smell?
No

GO TO QUESTION 94

93a.

Yes

93b.

How old were you the first time you
noticed this problem?

AGE

No
Yes, specify:

94. Have you experienced the following at least once a week in the past year?
(Please mark a response for each item below.)
a. Heartburn (a burning discomfort behind the breast bone in your chest)
No
Yes

b. Acid regurgitation/reflux (a bitter or sour tasting fluid coming into your throat or mouth)
No
Yes

95. Since January 1, 2009, have you
experienced coughing on most days for
three months or more out of a year?
96. Since January 1, 2009, have you brought
up phlegm on most days for three months
or more out of a year (do not count
phlegm from the nose)?

YES

a.
If yes, for how many years
have you had this symptom?

Yes

1 year
2 or more years

Yes

1 year
2 or more years

Draft

Please use a ballpoint pen for this form

Are there any reasons (such as head injury) that
explain the decrease in your sense of smell?

97.

Since January 1, 2009, have you had a mammogram, breast ultrasound, or breast MRI?
No

Yes

GO TO THE NEXT PAGE, QUESTION 98
97a. How many times did you have a
mammogram, breast ultrasound, or
breast MRI since January 1, 2009?
97b. What was the month and year of your
most recent mammogram, breast
ultrasound, or breast MRI?
97c. Since January 1, 2009, have you
been told you had abnormal findings
on a mammogram, breast
ultrasound, or breast MRI?
97d. What was the month and year of
your most recent test with
abnormal findings?

# TIMES

MONTH

0
YEAR

No GO TO THE NEXT PAGE,
QUESTION 98
Yes



MONTH

0
YEAR

97e. Which breast showed abnormal
findings at the most recent test?

Left breast
Right breast
Both breasts

97f. After completing the work-up
for this abnormal test, what was
the doctors’ recommendation?
Did they tell you to...

Come back in 12 months or
more for usual follow-up
Come back in 6-11 months
Come back in 3-5 months
Come back in less than 3 months
Have a breast biopsy, surgery,
or other treatment
Don't know

97g. Were you told this test showed
any of the following?
(Please mark all that apply.)

Breast cysts
Fibrocystic breasts
Breast calcifications
Dense breasts
Uneven or one-sided densities
Fibroadenoma
Other
Don't know
Draft

98.

Since January 1, 2009, have you had a breast cyst or cysts drained (aspirated) or removed?
No

Yes

GO TO QUESTION 99
98a. On how many occasions have you
had this since January 1, 2009?

# OCCASIONS

98b. What was the month and year of
your most recent procedure?
MONTH

0
YEAR

98c. On which breast was the most
recent cyst aspiration or
removal performed?

Left breast
Right breast
Both breasts

98d. Following the most recent
procedure, what was the
doctors’ recommendation?
Did they tell you to...

Come back in 12 months or
more for usual follow-up
Come back in 6-11 months
Come back in 3-5 months
Come back in less than 3 months
Have a breast biopsy, surgery,
or other treatment
Don't know

Since January 1, 2009, have you had a needle biopsy to diagnose or rule out a breast condition?
No

Yes

GO TO THE NEXT PAGE, QUESTION 100
99a. On how many occasions have you
had this since January 1, 2009?
99b. What was the month and year of
your most recent procedure?

# OCCASIONS

MONTH

0
YEAR

99c. On which breast was the
most recent needle biopsy
performed?

Left breast
Right breast
Both breasts

99d. Following the most recent
procedure, what was the
doctors’ recommendation?
Did they tell you to...

Come back in 12 months or
more for usual follow-up
Come back in 6-11 months
Come back in 3-5 months
Come back in less than 3 months
Have a different type of breast
biopsy, surgery, or other treatment
Don't know
Draft

Please use a ballpoint pen for this form

99.

100.

Since January 1, 2009, have you had a surgical biopsy or a biopsy other than a needle biopsy to
diagnose or rule out a breast condition?
No

Yes

GO TO THE NEXT PAGE, QUESTION 101
100a. On how many occasions have you
had this since January 1, 2009?
100b. What was the month and year
of your most recent procedure?

# OCCASIONS

MONTH

0
YEAR

100c. On which breast was the most
recent biopsy performed?

Left breast
Right breast
Both breasts

100d. Following the most recent
procedure, what was the
doctors’ recommendation?
Did they tell you to...

Draft

101.

Since January 1, 2009, have you had a breast lump or lumps removed (lumpectomy or excisional
biopsy)?
No

GO TO QUESTION 102

Yes

101a. On how many occasions have
you had this since January 1,
2009?

Since January 1,
2009, have you had...
102.

103.

MONTH

0
YEAR

101c. On which breast was the most
recent lumpectomy or
excisional biopsy performed?

Left breast
Right breast
Both breasts

101d. Following the most recent
procedure, what was the
doctors’ recommendation?
Did they tell you to...

Come back in 12 months or
more for usual follow-up
Come back in 6-11 months
Come back in 3-5 months
Come back in less than 3 months
Have a different type of biopsy,
surgery, or other treatment
Don't know

NEVER OR
BEFORE
1/1/2009

a mastectomy
of your
left breast?

Never

a mastectomy
of your
right breast?

Never

Yes, before
January 1, 2009

a.
Why was
this done?
1/1/2009
OR LATER
Yes,
January 1,
2009 or later

To treat
breast cancer
To prevent
breast cancer
Both

Yes,
January 1,
2009 or later

To treat
breast cancer
To prevent
breast cancer
Both

b.
If you had this procedure
January 1, 2009 or later,
what was the month and
year?

MONTH

YEAR

/
MONTH

0
YEAR

Draft

Please use a ballpoint pen for this form

101b. What was the month and year
of your most recent procedure?

# OCCASIONS

Since January 1, 2009, were you told you had any of the following after a cyst aspiration, cyst
removal, needle biopsy, surgical biopsy, lumpectomy, or mastectomy?

Since January 1, 2009,
have you had...
104.

105.

fibrocystic or benign
nonproliferative changes
within normal range?
For example, cysts, mild
hyperplasia, benign
calcifications, fibrosis, etc.
fibroadenoma?

NEVER OR
BEFORE
1/1/2009

1/1/2009
OR LATER

Never
Yes, before
January 1, 2009

Yes,
January 1,
2009 or later

Never
Yes, before
January 1, 2009

Yes,
January 1,
2009 or later

a.
If you had this January 1, 2009
or later, what was the month
and year?

MONTH

0
YEAR

MONTH

0
YEAR

b. What type?
Simple fibroadenoma
Complex fibroadenoma
Both
Don't know
106.

107.

proliferation without atypia?
For example, sclerosing
adenosis, intraductal
papilloma, moderate
hyperplasia, suspicious
calcifications, etc.
atypical hyperplasia?

Never
Yes, before
January 1, 2009

Yes,
January 1,
2009 or later

Never
Yes, before
January 1, 2009

Yes,
January 1,
2009 or later

MONTH

0
YEAR

MONTH

0
YEAR

b. What type?
Atypical ductal hyperplasia
Atypical lobular hyperplasia
Both
Don't know
108.

109.

110.

111.

ductal carcinoma in situ
(DCIS)?

Never
Yes, before
January 1, 2009

Yes,
January 1,
2009 or later

lobular carcinoma in situ
(LCIS)?

Never
Yes, before
January 1, 2009

Yes,
January 1,
2009 or later

breast cancer?

Never
Yes, before
January 1, 2009

Yes,
January 1,
2009 or later

Never
Yes, before
January 1, 2009

Yes,
January 1,
2009 or later

other changes?

MONTH

YEAR

MONTH

0
YEAR

MONTH

0
YEAR

/
MONTH

0
YEAR
Draft

112.

Regardless of the findings, did you keep a copy of the pathology report(s) from the cyst aspiration,
cyst removal, needle biopsy, surgical biopsy, lumpectomy, or mastectomy that you are willing to
share with us?
No
Yes

PLEASE INCLUDE A COPY WITH YOUR COMPLETED QUESTIONNAIRE.

Not applicable

Other than during breastfeeding or pregnancy, were you ever diagnosed with mastitis?
No
Yes

Since January 1, 2009,
have you had...
114.

115.

1/1/2009
OR LATER

NEVER OR
BEFORE1/1/2009

breast reduction
surgery on your
left breast?

Never
Yes, before
January 1, 2009

Yes, January 1,
2009 or later

breast reduction
surgery on your
right breast?

Never
Yes, before
January 1, 2009

Yes, January 1,
2009 or later

a.
If you had this procedure January
1, 2009 or later, what was the
month and year?

MONTH

YEAR

/
MONTH

0
YEAR

Draft

Please use a ballpoint pen for this form

113.

Since January 1, 2009,
have you had...
116.

117.

118.

119.

121.

1/1/2009
OR LATER

breast
reconstruction
surgery on your
left breast?

Never
Yes, before
January 1, 2009

Yes, January 1,
2009 or later

breast
reconstruction
surgery on your
right breast?

Never
Yes, before
January 1, 2009

Yes, January 1,
2009 or later

breast
enlargement
surgery on your
left breast?

Never
Yes, before
January 1, 2009

Yes, January 1,
2009 or later

breast
enlargement
surgery on your
right breast?

Never
Yes, before
January 1, 2009

Yes, January 1,
2009 or later

Since January 1, 2009,
have you had...
120.

NEVER OR BEFORE
1/1/2009

a.
If you had this procedure
January 1, 2009 or later, what
was the month and year?

1/1/2009
OR LATER

a breast implant
surgically removed
from your left
breast?

Never
Yes, before
January 1, 2009

Yes, January 1,
2009 or later

a breast implant
surgically removed
from your right
breast?

Never
Yes, before
January 1, 2009

Yes, January 1,
2009 or later

MONTH

b.
Did you have
a silicone gel
implant?

YEAR

Yes

YEAR

Yes

YEAR

Yes

YEAR

Yes

a.
If you had this procedure
January 1, 2009 or later,
what was the month and year?

MONTH

YEAR

/
MONTH

0
YEAR

b.
Was this a
silicone gel
implant?
No
Yes

No
Yes

Draft

122.

Since January 1, 2009, have you had any other major health condition?
Never diagnosed
Diagnosed before
January 1, 2009

If you were diagnosed January 1, 2009 or later, what other
major health conditions did you have?
122a. What month and year
were you diagnosed?

MONTH

0
YEAR

122b.
FIRST OTHER MAJOR HEALTH CONDITION

122c. What month and year
were you diagnosed?

MONTH

0
YEAR

122d.
SECOND OTHER MAJOR HEALTH CONDITION

MENSTRUAL HISTORY

123. Have you had a menstrual period or pregnancy in the past 10 years?
No

GO TO PAGE 34, QUESTION 132

Yes GO TO PAGE 30, QUESTION 124

Draft

Please use a ballpoint pen for this form

Diagnosed January 1,
2009 or later

GO TO QUESTION 123

124.

Are you currently pregnant or breastfeeding?
No

GO TO NEXT QUESTION, 124a

Yes GO TO PAGE 32, QUESTION 125
124a. Have you had a menstrual period in the past 12 months?
No

ANSWER BOX A BELOW

Yes

ANSWER BOX B ON THE NEXT PAGE

BOX A
THIS BOX IS FOR WOMEN WHO HAVE NOT HAD A MENSTRUAL PERIOD IN THE PAST 12 MONTHS AND
ARE NOT PREGNANT OR BREASTFEEDING. ALL OTHERS GO TO QUESTION 124d.
124b. Why did your periods stop?
My periods stopped on their own (naturally).
My periods stopped on their own but I began taking hormone replacement therapy
before my periods fully stopped.
My periods stopped after my uterus or ovaries were removed
(be sure to answer questions 163 and 164).
My periods stopped due to radiation or chemotherapy.
My periods stopped due to medicine that causes the ovaries to make less hormones or
medicine that has this as a side effect.
My periods stopped because I am taking the kind of birth control pills that
make me not have periods.
My periods stopped for some other reason, please describe:

124c. What month and year did you have your last menstrual period or how old were you
when you had your last menstrual period?

/
MONTH

OR
YEAR

AGE

GO TO PAGE 32, QUESTION 125
Draft

BOX B
THIS BOX IS FOR WOMEN WHO HAVE HAD A MENSTRUAL PERIOD IN THE PAST 12 MONTHS.
124d. When was your last menstrual period?

/
MONTH

0
YEAR

Please use a ballpoint pen for this form

124e. What statement best describes you?
My periods have not stopped and I am not taking hormones.
My periods have not stopped but I am taking hormones.
My periods stopped temporarily but restarted when I
stopped taking birth control pills.
My periods stopped temporarily, but I have had episodes of
bleeding since the time when I started taking hormones.

GO TO PAGE 32,
QUESTION 125

My periods stopped temporarily but restarted when I began
taking hormone replacement therapy.
OR
My periods stopped sometime in the last 12 months.

GO TO QUESTION 124f

124f. Why did your periods stop?
My periods stopped on their own (naturally).
My periods stopped on their own but I began taking hormone replacement
therapy before my periods fully stopped.
My periods stopped after my uterus or ovaries were removed
(be sure to answer questions 163 and 164).
My periods stopped due to radiation or chemotherapy.
My periods stopped due to medicine that causes the ovaries to make
less hormones or medicine that has this as a side effect.
My periods stopped because I am taking the kind of birth control pills that
make me not have periods.
My periods stopped for some other reason, please describe:

Draft

REPRODUCTIVE HISTORY AND HORMONES
125.

Have you had a pregnancy since January 1, 2009?
No

Yes

GO TO PAGE 34, QUESTION 132

125a. Are you currently pregnant?

125b. How many times have you been
pregnant since January 1, 2009
(including your current pregnancy,
if you are pregnant now)?

No
Yes

# TIMES

Draft

THIS SECTION IS FOR WOMEN WHO HAVE BEEN PREGNANT SINCE JANUARY 1, 2009.
ALL OTHERS GO TO THE NEXT PAGE, QUESTION 132.

126.

How did this
pregnancy end?

FIRST PREGNANCY

SECOND PREGNANCY

(since January 1, 2009)

Still pregnant now
Single live birth
Twins, live births
Other multiple live births



Stillbirth(s)

128.

129.

130.

How many weeks
did this pregnancy
last (or has it
lasted so far, if
now pregnant)?

How long did you
breastfeed (or
have you been
breastfeeding)?

Induced abortion

Molar or ectopic pregnancy

Less than 8 weeks
8 to 12 weeks
13 to 16 weeks
17 to 24 weeks
25 to 36 weeks

37 to 41 weeks

42 weeks or more

MONTH

YEAR

MONTH

YEAR

Still pregnant now

Single male
Single female
Multiple
Don't know



# MALES # FEMALES

Less than one month
1-3 months
4-6 months
7-12 months

GO TO 131

Single male
Single female
Multiple
Don't know



# MALES # FEMALES

Less than one month
1-3 months
4-6 months
7-12 months

GO TO 131

13-24 months

More than 24 months



Are you still
breastfeeding?

# BABIES

Miscarriage

Did not breastfeed/
not applicable

131.

Stillbirth(s)

Miscarriage

What month and
year did this
pregnancy end?

What was the sex
of the baby or
babies?



GO TO NEXT
PREGNANCY OR
QUESTION 132

Did not breastfeed/
not applicable

Yes

IF YOU HAVE HAD MORE THAN 2 PREGNANCIES SINCE JANUARY 1, 2009,
PLEASE ANSWER THE SAME QUESTIONS FOR EACH PREGNANCY AND
RECORD YOUR ANSWERS ON A SEPARATE SHEET OF PAPER.
33



GO TO NEXT
PREGNANCY OR
QUESTION 132

Draft

Please use a ballpoint pen for this form

127.

# BABIES

Still pregnant now
Single live birth
Twins, live births
Other multiple live births

132.

Since January 1, 2009, have you used any hormonal birth control?
No

GO TO QUESTION 140

Yes

Since January 1, 2009, have
you used...

133.

birth control pills?

NO
No

YES

a.
If yes, how many months in
all have you used this since
January 1, 2009?

b.
Are you currently
using this?

No
Yes

Yes
# MONTHS

134.

birth control patches?

No
Yes

Yes
# MONTHS

135.

a hormonal IUD
(intrauterine device)?

No
Yes

Yes
# MONTHS

136.

a Norplant implant?

No
Yes

Yes
# MONTHS

137.

a Nuva Ring?

No
Yes

Yes
# MONTHS

138.

Depo Provera?

No
Yes

Yes
# MONTHS

139.

any other hormonal
birth control?

No
Yes

Yes
# MONTHS

140.

Have you ever tried for more than one year to become pregnant and did not get pregnant?
No
Yes

141.

Since January 1, 2009, have you visited a doctor, clinic, or hospital to seek help for you to
become pregnant?
No
Yes

Draft

142.

Since January 1, 2009, have you used any fertility medications?
No

GO TO QUESTION 145

Yes

143.

Clomiphene, Clomid, or Serophene?

YES
Yes

# MONTHS/CYCLES

144.

145.

drugs that contain follicle-stimulating
hormones (FSH) — Follistim, Puregon,
Gonal-F, Urofollitropin, Metrodin,
Fertinex, Bravelle, human menopausal
gonadotropin (hMG), menotropin,
Pergonal, Humegon, or Repronex?

Yes
# MONTHS/CYCLES

Have you ever conceived a pregnancy in a menstrual cycle where you were treated with the
fertility drug Clomiphene, Clomid, or Serophene?
No

Yes

GO TO THE NEXT PAGE, QUESTION 146

145a. How many times?
# TIMES

145b. When did the first
such pregnancy
end?

145c. When did the last
such pregnancy
end?

/
MONTH

/
DAY

/
MONTH

YEAR

/
DAY

YEAR

Draft

Please use a ballpoint pen for this form

Since January 1, 2009, have you taken...

a.
If yes, how many months or
menstrual cycles in all have you
used this since January 1, 2009?

146.

Have you ever conceived a pregnancy in a menstrual cycle where you were treated with
drugs that contain follicle-stimulating hormone (FSH) (Metrodin, human menopausal
gonadotropin (hMG), Pergonal, menotropin, Follistim, Puregon, Gonal-F, Urofollitropin,
Fertinex, Bravelle, Repronex, Humegon)?
No

Yes

GO TO QUESTION 147

146a. How many times?
# TIMES

146b. When did the first such
pregnancy end?
146c. When did the last such
pregnancy end?

147.

/
MONTH

/
DAY

/
MONTH

YEAR

/
DAY

YEAR

Has a doctor or other health professional ever told you that you had mastitis while you were
breastfeeding (postnatal or lactational mastitis)?
No

Yes

GO TO THE NEXT PAGE, QUESTION 148

147a. How many times have you
had this?
147b. What was the month and
year of your most recent
mastitis?

# TIMES

/
MONTH

147c. Were you ever given
antibiotics to treat mastitis?

No
Yes

147d. Were you ever given
pain medication to treat
mastitis?

No
Yes

147e. Did you ever stop breastfeeding
sooner than planned because of
mastitis?

No
Yes

YEAR

Draft

The next questions are about female hormone products often used for hormone replacement therapy (HRT).

Since January 1, 2009, have you used...
148.

150.

151.

152.

153.

154.

a combined pill containing both
estrogen and progesterone (such
as Prempro)?

an estrogen-only pill (such as
Premarin) with no additional
progesterone in any form?

an estrogen pill (such as Premarin)
and a separate progesterone pill (such
as Provera) or progesterone shot?

an estrogen-only patch with no
additional progesterone in any form?

a patch containing both estrogen and
progesterone (such as Combipatch)?

an estrogen-only patch and a separate
progesterone pill or progesterone shot?

progesterone alone
(not for birth control)?

YES

Yes
# MONTHS

b.
Do you currently
use this female
hormone
product(s)?

No
Yes

Draft

Please use a ballpoint pen for this form

149.

a.
If yes, how many
months in all have
you used this since
January 1, 2009?

Since January 1, 2009,
have you used...
155.

vaginal estrogen creams,
rings, or suppositories?

YES

Yes

If yes, how many months in all have
you used this since January 1, 2009?

a.
# MONTHS

b. Do you currently use this female
hormone product(s)?
No
Yes
c. Does this product also contain
progesterone?
No
Yes
Don't know
d. Did you also take progesterone in
another form (e.g., patch, pill)
during the time you were using
vaginal estrogen creams, rings, or
suppositories?
No
Yes

156.

any other estrogen
products, including
“natural” estrogens?

Yes

a.
# MONTHS

b. Do you currently use this female
hormone product(s)?
No
Yes
c. Which of the following products
have you used since January 1, 2009?
(Please mark all that apply.)
Capsules
Gel or cream applied to the skin
Injection
Liquid
Troche or lozenge (dissolved
under the tongue)
Other
Draft

Since January 1, 2009, have
you used...
157.

tamoxifen or Nolvadex?

YES

a.
If yes, how many months in
all have you used this since
January 1, 2009?

b.
Do you
currently
use this?
No
Yes

Yes
# MONTHS

158.

raloxifene or Evista?

# MONTHS

159.

Herceptin?

No
Yes

Yes
# MONTHS

Aromatase inhibitors:
160a. anasterozole or Arimidex?

No
Yes

Yes
# MONTHS

160b. exemestane or Aromasin?

No
Yes

Yes
# MONTHS

160c.

letrozole or Femara?

No
Yes

Yes
# MONTHS

160d. other aromatase inhibitor?

Please specify:

161.

testosterone supplements?

No
Yes

Yes
# MONTHS

No
Yes

Yes
# MONTHS

162.

Estratest?

No
Yes

Yes
# MONTHS

Draft

Please use a ballpoint pen for this form

No
Yes

Yes

Since January 1, 2009,
have you had...
163.

a hysterectomy
(surgical
removal of
the uterus)?

NEVER OR BEFORE
1/1/2009
Never had procedure
Had procedure before
January 1, 2009

HAD PROCEDURE
1/1/2009 OR LATER
Had procedure
January 1, 2009
or later

If you had this procedure
January 1, 2009 or later, what
was the month and year?
a. MONTH/YEAR HAD PROCEDURE

MONTH

0
YEAR

b. Did you have all or part of
either of your ovaries
removed at the same time
you had the hysterectomy?
No  GO TO QUESTION 164
Yes
c. Did you have...
both ovaries completely removed?
one ovary and part of the
other ovary removed?
one ovary removed?
part of one or part of both
ovaries removed?
d. Did you have all or part of
either ovary left after this
surgery?
No
Yes
164.

a separate
surgery to
remove part or
all of one or
both ovaries
(but not your
uterus)?

Never had procedure
Had procedure before
January 1, 2009

Had procedure
January 1, 2009
or later

a. MONTH/YEAR HAD PROCEDURE

MONTH

0
YEAR

b. Did you have...
both ovaries completely removed?
one ovary and part of the
other ovary removed?
one ovary removed?
part of one or part of both
ovaries removed?
c. Did you have all or part of
either ovary left after this
surgery?
No
Yes
Draft

SYMPTOMS OF MENOPAUSE OR PRE-MENOPAUSE

Have you ever experienced
any of the following
menopausal symptoms?

165.

Hot flashes

YES

Yes

a.
On average, how would
you rate the severity of
your symptom?

Mild
Moderate
Severe

b.
Have you
experienced any
symptoms in the
past 12 months?
No
Yes

Please use a ballpoint pen for this form

How often did/do these
occur in a typical week?
1 time or less
2-3 times
4 or more times
Don't know
For about how many total months
or years did you have hot flashes?
Less than 3 months
3 to less than 6 months
6 months to less than 1 year
1 to less than 2 years
2 to less than 3 years
3 or more years

166.

Night sweats

Yes

Mild
Moderate
Severe

No
Yes

167.

Other excessive
sweating

Yes

Mild
Moderate
Severe

No
Yes

168.

Vaginal dryness

Yes

Mild
Moderate
Severe

No
Yes

169.

Pain with
intercourse

Yes

Mild
Moderate
Severe

No
Yes

170.

Irregular menstrual
bleeding

Yes

Mild
Moderate
Severe

No
Yes

Draft

Have you ever experienced
any of the following
menopausal symptoms?

171.

Bladder problems

172.

Depression, anxiety,
or emotional distress

173.

Insomnia

a.
On average, how would
you rate the severity of
your symptom?

b.
Have you
experienced any
symptoms in the
past 12 months?

YES

Yes

Mild
Moderate
Severe

No
Yes

Yes

Mild
Moderate
Severe

No
Yes

Yes

Mild
Moderate
Severe

No
Yes

SURGERIES

Since January 1, 2009, have
you had...
174.

175.

176.

NEVER OR BEFORE
1/1/2009

HAD PROCEDURE
1/1/2009 OR LATER

gallbladder
surgery?

Never had procedure
Had procedure before
January 1, 2009

Had procedure
January 1, 2009
or later

angioplasty or
coronary
artery stent?

Never had procedure
Had procedure before
January 1, 2009

Had procedure
January 1, 2009
or later

coronary artery
bypass graft
surgery?

Never had procedure
Had procedure before
January 1, 2009

Had procedure
January 1, 2009
or later

a.
If you had this procedure
January 1, 2009 or later,
what was the month and year?

MONTH

YEAR

MONTH

0
YEAR

/
MONTH

0
YEAR

MEDICATIONS
Since January 1, 2009, have you used any
prescription medicines to treat or to prevent...

YES

a.
If yes, are you currently
taking this?

177.

hypertension (high blood pressure)?

Yes

No
Yes, regularly
Yes, as needed

178.

high cholesterol?

Yes

No
Yes, regularly
Yes, as needed
Draft

MEDICATIONS
Since January 1, 2009, have you used any
prescription medicines to treat or to prevent...

179.

180.

cardiac arrhythmia (irregular heartbeat)?

congestive heart failure?

diabetes?

YES
Yes

No
Yes, regularly
Yes, as needed

Yes

No
Yes, regularly
Yes, as needed

Yes

No
Yes, regularly
Yes, as needed

182.

thyroid disease?

Yes

No
Yes, regularly
Yes, as needed

183.

osteoporosis (bone loss, or bone thinning)?
Do not count calcium or vitamin D.

Yes

No
Yes, regularly
Yes, as needed

Yes

No
Yes, regularly
Yes, as needed

184.

rheumatoid arthritis?

185.

osteoarthritis?

Yes

No
Yes, regularly
Yes, as needed

186.

migraines?

Yes

No
Yes, regularly
Yes, as needed

187.

depression?

Yes

No
Yes, regularly
Yes, as needed

188.

asthma?

Yes

No
Yes, regularly
Yes, as needed

189.

Parkinson’s disease?

Yes

No
Yes, regularly
Yes, as needed

Yes

No
Yes, regularly
Yes, as needed

190.

anxiety?

Draft

Please use a ballpoint pen for this form

181.

a.
If yes, are you
currently taking this?

Since January 1, 2009, have you
regularly (at least once a week for at
least three months in a row) taken...

YES

a.
If yes, for about how long have you taken this
regularly (at least once a week for at least
three months in a row) since January 1, 2009?

191.

acetaminophen (Tylenol)?

Yes

Less than 12 months
1 year
2 years

3 years
4 years
More than 4 years

192.

“baby aspirin” or low-dose
aspirin (100mg/tablet or less)?

Yes

Less than 12 months
1 year
2 years

3 years
4 years
More than 4 years

193.

aspirin or other aspirin containing
products (325 mg/tablet or more)?

Yes

Less than 12 months
1 year
2 years

3 years
4 years
More than 4 years

194.

ibuprofen (such as Advil,
Motrin, Nuprin, etc.)?

Yes

Less than 12 months
1 year
2 years

3 years
4 years
More than 4 years

195.

Celebrex or other COX-2
inhibitors?

Yes

Less than 12 months
1 year
2 years

3 years
4 years
More than 4 years

196.

Aleve or Naprosyn?

Yes

Less than 12 months
1 year
2 years

3 years
4 years
More than 4 years

Yes

Less than 12 months
1 year
2 years

3 years
4 years
More than 4 years

Yes

Less than 12 months
1 year
2 years

3 years
4 years
More than 4 years

44
197.

198.

Relafen, Ketoprofen, Anaprox,
or other non-steroidal
anti-inflammatories?

antibiotics?

Draft

c.
On days when you take it, how
many times do you take it?

d.
Are you currently taking this?

1 day per week
2-3 days per week
4-5 days per week
6-7 days per week

1 time per day
2 times per day
3 times per day
4 times per day
5 or more times per day

No
Yes

1 day per week
2-3 days per week
4-5 days per week
6-7 days per week

1 time per day
2 times per day
3 times per day
4 times per day
5 or more times per day

No
Yes

1 day per week
2-3 days per week
4-5 days per week
6-7 days per week

1 time per day
2 times per day
3 times per day
4 times per day
5 or more times per day

No
Yes

1 day per week
2-3 days per week
4-5 days per week
6-7 days per week

1 time per day
2 times per day
3 times per day
4 times per day
5 or more times per day

No
Yes

1 day per week
2-3 days per week
4-5 days per week
6-7 days per week

1 time per day
2 times per day
3 times per day
4 times per day
5 or more times per day

No
Yes

1 day per week
2-3 days per week
4-5 days per week
6-7 days per week

1 time per day
2 times per day
3 times per day
4 times per day
5 or more times
45 per day

No
Yes

1 day per week
2-3 days per week
4-5 days per week
6-7 days per week

1 time per day
2 times per day
3 times per day
4 times per day
5 or more times per day

No
Yes

1 day per week
2-3 days per week
4-5 days per week
6-7 days per week

1 time per day
2 times per day
3 times per day
4 times per day
5 or more times per day

No
Yes

Please use a ballpoint pen for this form

b.
On average, how many days per
week have you taken this?

Draft

These last questions are about prescription and non-prescription medications that you currently take
regularly. This includes all pills, patches, shots, inhaled medicines, vitamins, and herbal supplements.
Please include inhalers, even if you use them occasionally and include all medicines prescribed in once
a month or once a year doses, such as some medicines to prevent osteoporosis.
Do not include:
· Medicines used only occasionally, such as a pain reliever once in a while for a headache
· Aspirin or other pain medications already reported in previous questions
199.

Do you currently take any prescription or non-prescription medications regularly or seasonally?
Please include inhalers that you currently use as needed.
No

GO TO END, PAGE 51

Yes

TOTAL #

a.
What is/are the name(s) of the prescription or non-prescription medication(s) that
you currently take regularly?

b.
For how long have you
used this regularly?

Less than 12 months
1 year
2 years
3 years
4 years
More than 4 years

Less than 12 months
1 year
2 years
3 years
4 years
More than 4 years
Draft

d.
On days when you take
it, how many times do
you take it?

Once a month or less
Less than once a week
Once a week
2-3 days a week
4-5 days a week
6-7 days a week

1 time per day
2 times per day
3 times per day
4 times per day
5 or more times per day

Pill

Patch

Inhaler

Spray

Cream

Shot

Liquid

Other

Once a month or less
Less than once a week
Once a week
2-3 days a week
4-5 days a week
6-7 days a week

1 time per day
2 times per day
3 times per day
4 times per day
5 or more times per day

Pill

Patch

Inhaler

Spray

Cream

Shot

Liquid

Other

Once a month or less
Less than once a week
Once a week
2-3 days a week
4-5 days a week
6-7 days a week

1 time per day
2 times per day
3 times per day
4 times per day
5 or more times per day

Pill

Patch

Inhaler

Spray

Cream

Shot

Liquid

Other

Once a month or less
Less than once a week
Once a week
2-3 days a week
4-5 days a week
6-7 days a week

1 time per day
2 times per day
3 times per day
4 times per day
5 or more times per day

Pill

Patch

Inhaler

Spray

Cream

Shot

Liquid

Other

Once a month or less
Less than once a week
Once a week
2-3 days a week
4-5 days a week
6-7 days a week

1 time per day
2 times per day
3 times per day
4 times per day
5 or more times per day

Pill

Patch

Inhaler

Spray

Cream

Shot

Liquid

Other

Please use a ballpoint pen for this form

c.
How often do you take it?

e.
In what form did you take this?
(Please mark all that apply.)

Draft

a.
What is/are the name(s) of the prescription or non-prescription medication(s) that you
currently take regularly? (If you need more space, answer the same questions for each
medication and record it on a separate sheet.)

b.
For how long have you
used this regularly?

Less than 12 months
1 year
2 years
3 years
4 years
More than 4 years

10.

Less than 12 months
1 year
2 years
3 years
4 years
More than 4 years

11.

Less than 12 months
1 year
2 years
3 years
4 years
More than 4 years

12.

Less than 12 months
1 year
2 years
3 years
4 years
More than 4 years
Draft

d.
On days when you take
it, how many times do
you take it?

e.
In what form did you take this?
(Please mark all that apply.)

Once a month or less
Less than once a week
Once a week
2-3 days a week
4-5 days a week
6-7 days a week

1 time per day
2 times per day
3 times per day
4 times per day
5 or more times per day

Pill

Patch

Inhaler

Spray

Cream

Shot

Liquid

Other

Once a month or less
Less than once a week
Once a week
2-3 days a week
4-5 days a week
6-7 days a week

1 time per day
2 times per day
3 times per day
4 times per day
5 or more times per day

Pill

Patch

Inhaler

Spray

Cream

Shot

Liquid

Other

Once a month or less
Less than once a week
Once a week
2-3 days a week
4-5 days a week
6-7 days a week

1 time per day
2 times per day
3 times per day
4 times per day
5 or more times per day

Pill

Patch

Inhaler

Spray

Cream

Shot

Liquid

Other

Once a month or less
Less than once a week
Once a week
2-3 days a week
4-5 days a week
6-7 days a week

1 time per day
2 times per day
3 times per day
4 times per day
5 or more times per day

Pill

Patch

Inhaler

Spray

Cream

Shot

Liquid

Other

Once a month or less
Less than once a week
Once a week
2-3 days a week
4-5 days a week
6-7 days a week

1 time per day
2 times per day
3 times per day
4 times per day
5 or more times per day

Pill

Patch

Inhaler

Spray

Cream

Shot

Liquid

Other

Once a month or less
Less than once a week
Once a week
2-3 days a week
4-5 days a week
6-7 days a week

1 time per day
2 times per day
3 times per day
4 times per day
5 or more times per day

Pill

Patch

Inhaler

Spray

Cream

Shot

Liquid

Other

Once a month or less
Less than once a week
Once a week
2-3 days a week
4-5 days a week
6-7 days a week

1 time per day
2 times per day
3 times per day
4 times per day
5 or more times per day

Pill

Patch

Inhaler

Spray

Cream

Shot

Liquid

Other

Please use a ballpoint pen for this form

c.
How often do you take it?

Draft

Please check to see that all questions are answered.

Thank you for completing this questionnaire and for your
continued participation in the Sister Study.
Please mail this form to us at the address below.
A postage-paid envelope is provided.
The Sister Study, 1009 Slater Road, Suite 120, Durham, NC 27703
phone: 1-877-4SISTER (1-877-474-7837); email: [email protected]

If you have a pathology report from a cyst aspiration, cyst
removal, needle biopsy, surgical biopsy, lumpectomy, or
mastectomy that you are willing to share with us, please include
a copy with your completed questionnaire.
Thank you!

Draft

Form: 50

Vers:

ID#: SIS

OMB No. 0925-0522

The Sister Study
Lifestyle
Version 2

Like this:

Not like this:

 

If you must change an answer, please mark a single horizontal line through the incorrect answer
and bubble in the correct answer completely.

Like this:

YES

Not like this:



YES

Please write responses in all capital letters and numbers without touching the sides of the boxes.

A B C D E F G H I J K L M N O P Q R S T U V W X Y Z

1 2 3 4 5 6 7 8 9 0
When writing dates, please
follow this example.

EXAMPLE: June 7, 2011 =

0 6 / 0 7 / 2 0 1 1
(month)

(day)

(year)

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

Draft

Your continued participation in the Sister Study is completely voluntary and greatly appreciated. If
you are not comfortable answering a question, just skip it and go to the next one. All information
you share will be kept confidential.

Today's Date:
(month)

/
(day)

0
(year)

1. Which of the following best describes your current marital status?
Never married
Widowed
Divorced

GO TO QUESTION 2

Separated
Married, civil
union or living
with someone as
though married

1a.

How many years have you been married
or living as though married with this
spouse/partner?
OR

Less than 1 year

# YEARS

1b.

Is your spouse/partner a
man or a woman?

Man
Woman

2. Thinking about last year, which of the following best describes your total family income from
all household members before taxes? Please include income from all sources such as annuities,
social security, stocks, alimony, and child support earned in the past year.
Less than $20,000
$20,000 to $49,999
$50,000 to $99,999
$100,000 to $200,000
More than $200,000

3. Last year, how many people, including yourself, were supported by that income?
1
2
3-4
5-6
7-8
More than 8
Draft

4. Did you smoke at least 10 cigarettes since January 1, 2009?
No

GO TO QUESTION 5
When did you first start
smoking?

Before 2009
2009
2010
2011
2012
2013

4b.

When did you last smoke
cigarettes?

I am a current smoker
I last smoked in 2013
I last smoked in 2012
I last smoked in 2011
I last smoked in 2010
I last smoked in 2009

4c.

During the years you
smoked since January 1,
2009, how many days per
week do/did you smoke?

Less than one day per week
1-3 days per week
4-6 days per week
Every day

4d.

During the years you
smoked since January 1,
2009, how many cigarettes
do/did you usually smoke
per day on the days that
you smoked?

Yes

Please use a ballpoint pen for this form

4a.

# CIGARETTES

5. Since January 1, 2009, how many regular smokers have you lived with (not counting
yourself, if you smoke)?
None
1
2
3-4
5 or more

Draft

6. About how many hours or minutes per day are you exposed to other people’s tobacco smoke
(include all locations—home, work, and all other places you spend time where others might
smoke)?
None
Less than 30 minutes
30-59 minutes
1-2 hours
3-4 hours
5-6 hours
7-8 hours
More than 8 hours

Since January 1, 2009...

7. have you drunk
beer or other
malt beverages?

8. have you drunk
white wine or
white wine
coolers?

9. have you drunk
red wine or red
wine coolers?

10. have you drunk
liquor?

YES

a.
IF YES, in which years
since January 1, 2009
did you drink alcohol?
(Please mark all that
apply.)

b.
About how often did
you drink alcohol?

c.
On average, how
many drinks did
you have on the
days that you
drank alcohol?

Every day
5-6 times per week
3-4 times per week
2 times per week
Once per week
2-3 times per month
Once per month
A few times per year

7 or more
6
5
4
3
2
1

Yes

2009
2010
2011
2012
2013

Every day
5-6 times per week
3-4 times per week
2 times per week
Once per week
2-3 times per month
Once per month
A few times per year

7 or more
6
5
4
3
2
1

Yes

2009
2010
2011
2012
2013

Every day
5-6 times per week
3-4 times per week
2 times per week
Once per week
2-3 times per month
Once per month
A few times per year

7 or more
6
5
4
3
2
1

Yes

2009
2010
2011
2012
2013
4

Every day
5-6 times per week
3-4 times per week
2 times per week
Once per week
2-3 times per month
Once per month
A few times per year

7 or more
6
5
4
3
2
1

Yes

2009
2010
2011
2012
2013

Draft

11. Since January 1, 2009, did you ever drink four or more alcoholic beverages in a row, in one sitting?
No

Yes

GO TO QUESTION 12

11a.

How often has
this happened since
January 1, 2009?

Please use a ballpoint pen for this form

More than once a week
Once a week
More than once a month
but less than once a week
Once a month
7-11 times a year
4-6 times a year
2-3 times a year
Once a year
Once or twice

12. Since January 1, 2009, has a doctor or other health professional told you that your drinking
was hurting your health?
No
Yes

Draft

We are interested in finding out about the kinds of physical activities that people do as part of
their everyday lives. The questions will ask you about the time you spent being physically active in
the past 7 days. Please answer each question even if you do not consider yourself to be an active
person. Please think about the activities you do at work, as part of your house and yard work, to
get from place to place, and in your spare time for recreation, exercise, or sport.
a.
How much time did you usually
spend doing these physical
activities on one of those days?

During the past 7 days, on how many days did you...
13. do vigorous physical activities? These take hard
physical effort and make you breathe much harder
than normal, for example running or swimming at
a fast pace. Think only about activities that you
did for at least 10 minutes at a time.

# DAYS



No vigorous
physical activity

14. do moderate physical activities? These take
moderate physical effort and make you breathe
somewhat harder than normal, for example
dancing or doing yard work. Think only about
those physical activities that you did for at least
10 minutes at a time. Do not include walking.

# DAYS

AND
HOURS
PER DAY

Not sure



No moderate
physical activity

AND
HOURS
PER DAY

Not sure



15. walk for at least 10 minutes at a time? This
includes walking at work and at home, walking to
travel from place to place, and any other walking
you might do solely for recreation, sport, exercise,
or leisure.

# DAYS
OR

No walking for at
least 10 mins

MINUTES
PER DAY
(up to 59)

AND
HOURS
PER DAY

Not sure

MINUTES
PER DAY
(up to 59)

During the past 7 days, how much time did you...
16. usually spend sitting on a weekday? This includes sitting while at
work, at home, while doing course work, and during leisure time. This
may include time spent sitting at a desk, visiting friends, reading, or
sitting or lying down to watch television.

AND
HOURS
PER DAY

MINUTES
PER DAY
(up to 59)

Not sure
AND

17. usually spend standing on a weekday? This includes standing
while at work, at home, and during leisure time.

HOURS
PER DAY

Not sure

MINUTES
PER DAY
(up to 59)

18. How similar was your level of activity this past week to your usual level of activity?
Less than usual
About the same
More than usual
Draft

19. In the past year, did you swim in a pool during summer (June-August)?
No
Yes

GO TO QUESTION 20

19a.

How many times per week?

Less than 1
1-2 times
3-4 times
5 or more times

On average, how many minutes
per time?

Please use a ballpoint pen for this form

19b.

Less than 15 minutes
15-30 minutes
31-45 minutes
46-60 minutes
More than 60 minutes

19c.

How often did you swim in an
INDOOR pool during June-August?

Never
Seldom
Half the time
Often
Almost always

Draft

20. In the past year, did you swim in a pool during the rest of the year (September-May)?
No

GO TO QUESTION 21

Yes

20a.

How many times per week?

Less than 1
1-2 times
3-4 times
5 or more times

20b.

On average, how many minutes
per time?

Less than 15 minutes
15-30 minutes
31-45 minutes
46-60 minutes
More than 60 minutes

20c.

How often did you swim
in an INDOOR pool during
September-May?

Never
Seldom
Half the time
Often
Almost always

21. Since January 1, 2009, have you done any of the following hobbies at least 5 hours per
week for at least 6 weeks? (Please mark all that apply.)
Oil painting or other artistic painting
Developing photographs chemically
Woodworking
Refinishing furniture
Ceramics or pottery making
Glass blowing
Etching
Hobbies that involve soldering such as stained glass or jewelry making
Hobbies that involve welding
Leather crafting
Print making or silk screening
Auto or engine repair
Gardening
I have not done any of these hobbies
Draft

22. Since January 1, 2009, have you used hair dye to color your hair?
GO TO NEXT PAGE, QUESTION 23

Yes

22a.

In what years did you
do this? (Please mark
all that apply.)

2009
2010
2011
2012
2013

22b.

What color did you
usually use?

Black
Light brown
Dark brown
Light blonde
Dark blonde
Light red
Dark red
Other

22c.

What type of hair dye do you use most often?
Temporary dyes (wash out with a few shampoos)
Semi-permanent dyes (colors are pre-mixed or require
mixing but no other chemicals are added; color fades out
in about 4-8 weeks)
Demi-permanent dyes (other chemicals are mixed with the
color; has strong smell; color fades out)
Permanent dyes (other chemicals are mixed with the color;
has strong smell; color grows out over time, sometimes
leaving your “roots” showing)

Draft

Please use a ballpoint pen for this form

23. Since January 1, 2009, about how often have you used chemical insect repellents on your skin,
hair, or clothing in the summer? Please do not include products that contain only citronella.
Never
A few times
Once per month
2-3 times per month
Once or twice per week
3-6 times per week
Every day

24. Since January 1, 2009, about how often have you used chemical insect repellents on your skin,
hair, or clothing the rest of the year? Please do not include products that contain only citronella.
Never
A few times
Once per month
2-3 times per month
Once or twice per week
3-6 times per week
Every day

25. Since January 1, 2009, about how often have you used an over-the-counter or prescription lice
control product on yourself, or applied it to someone else’s skin, hair, or clothing?
Never
Once
Twice
Three times
Four or more times

Draft

Since January 1, 2009, about how many hours per day do
you usually spend outdoors in daylight...

26. on weekend or vacation days
in the summer?

28. on weekend or vacation days
the rest of the year?

29. on other days the rest of
the year?

Less than 1 hour per day
1-2 hours per day
3-4 hours per day
5-8 hours per day
9-12 hours per day
More than 12 hours per day

Never
Rarely
Sometimes
Usually
Always

Less than 1 hour per day
1-2 hours per day
3-4 hours per day
5-8 hours per day
9-12 hours per day
More than 12 hours per day

Never
Rarely
Sometimes
Usually
Always

Less than 1 hour per day
1-2 hours per day
3-4 hours per day
5-8 hours per day
9-12 hours per day
More than 12 hours per day

Never
Rarely
Sometimes
Usually
Always

Less than 1 hour per day
1-2 hours per day
3-4 hours per day
5-8 hours per day
9-12 hours per day
More than 12 hours per day

Never
Rarely
Sometimes
Usually
Always

Please use a ballpoint pen for this form

27. on other days in the
summer?

a.
During this time, about how
often did you use sunscreen
or wear protective clothing
such as hats or long sleeves?

Draft

30. Have you moved since January 1, 2009?
No
Yes

GO TO QUESTION 31

30a.

30b.

What month and year did you
move into your current residence?

2
MONTH

0
YEAR

Please write down your current address.

STREET #

STREET NAME

APT #

STATE

30c.

CITY OR TOWN

ZIP CODE

COUNTY

Please write down the name of the nearest cross street (the
street that intersects with the street where you live):

NAME OF NEAREST CROSS STREET

31. How many lanes of traffic in total does the street where you live have?
# LANES

32. Which best describes the traffic condition during rush hour on the road where you live?
Little or no traffic
Light traffic, moving at or above the speed limit
Heavy traffic, moving below the speed limit
Congested or "stop and go"
Heavy traffic, moving at or above the speed limit

Draft

33. Since January 1, 2009, about how often has your residence been treated with insecticides or
pesticides to control insects, rodents, or other pests, either inside or around the foundation?
Never

GO TO THE NEXT PAGE, QUESTION 34

33a.

For what kinds of pests
were pest control
chemicals used at your
residence? (Please mark
all that apply.)

Ants
Cockroaches
Bees or wasps
Bed bugs
Flies
Spiders
Mosquitoes
Fleas or ticks, not on pets
Termites
Any other pest such as
moths, silverfish,
caterpillars, mice, rats,
gophers, or moles

33b.

When pest control
chemicals were applied
since January 1, 2009,
about how often did you
personally apply them?

All of the time
Most of the time
About half the time
Some of the time
Never
Not applicable

Every 4-6 months
Every 2-3 months
Monthly
Weekly
Daily

Draft

Please use a ballpoint pen for this form

Less than once
a year
Once a year

34. Since January 1, 2009, about how often was the garden or yard around this residence treated with
weed killers or insecticides, including those labeled organic such as pyrethrum or rotenone?
Never
Not applicable

GO TO QUESTION 35

Less than once
a year

34a.

Once a year
Every 4-6 months
Every 2-3 months
Monthly
Weekly
Daily

All of the time
Most of the time
About half the time
Some of the time
Never
Not applicable

When weed killers or
insecticides were used
in the garden or yard
since January 1, 2009,
about how often did you
personally apply them?

35.Since January 1, 2009, about how often have you used household cleaning solutions other than dish
washing and laundry detergents?
Never
Less than once a year
Once a year
Every 4-6 months
Every 2-3 months
Monthly
Weekly
Daily

36. Do you currently have any household pets?
No

Yes

GO TO THE NEXT PAGE, QUESTION 37

How many of each of the following do you have?
None
36a.
36b.
36c.
36d.

3-4

5 or more

Dogs
Birds
Cats
Other furry animals

Draft

37. Since January 1, 2009, have you regularly used air fresheners in your home? Please include air
fresheners that plug in, hang, sit on a shelf, or stick on the wall, as well as sprays that are used
at least three times a week.
No

Yes

GO TO QUESTION 38
37a.

Aerosol sprays
Solid table top
Stick-on (disc shaped)
Plug-in
Candle style
Other

38. Since January 1, 2009, have you regularly used air fresheners in your car? Please include the
hanging types, as well as those that plug in, and sprays that are used at least three times a week.
No

Yes

GO TO QUESTION 39

38a.

Aerosol sprays
Hanging type - paper
Hanging type - gel
Hanging type - other
Canister type
Attached to car air vent - oil filled
Attached to car air vent - gel filled
Attached to car air vent - stick filled

What types of air
fresheners do you use
in your car? (Please
mark all that apply.)

39. How much time per day do you spend traveling by car, van, truck, or bus on most days?
Never

GO TO THE NEXT PAGE, QUESTION 40

Less than 15 minutes
15-29 minutes
30-44 minutes
45-59 minutes
60-89 minutes
90-119 minutes
2-3 hours
4-5 hours
More than 5 hours

39a.

What is the traffic condition that best describes your
travel time (by car, van, truck, or bus) on most days?
Little or no traffic
Light traffic, moving at or above the speed limit
Heavy traffic, moving below the speed limit
Congested or "stop and go"
Heavy traffic, moving at or above the speed limit
Draft

Please use a ballpoint pen for this form

What types of air
fresheners do you use at
home? (Please mark all
that apply.)

40. How much time per day do you spend traveling by bicycle or motorcycle on most days?
Never

GO TO QUESTION 41

Less than 15 minutes
15-29 minutes
30-44 minutes
45-59 minutes
60-89 minutes
90-119 minutes
2-3 hours
4-5 hours
More than 5 hours

40a.

What is the traffic condition that best describes your
travel time by bicycle or motorcycle on most days?
Little or no traffic
Light traffic, moving at or above the speed limit
Heavy traffic, moving below the speed limit
Congested or "stop and go"
Heavy traffic, moving at or above the speed limit

41. How much time per day do you spend traveling by foot on most days?
Never

GO TO QUESTION 42

Less than 15 minutes
15-29 minutes
30-44 minutes
45-59 minutes
60-89 minutes
90-119 minutes
2-3 hours
4-5 hours
More than 5 hours

41a.

What is the traffic condition that best describes your
travel time by foot on most days?
Little or no traffic
Light traffic, moving at or above the speed limit
Heavy traffic, moving below the speed limit
Congested or "stop and go"
Heavy traffic, moving at or above the speed limit

42. Since January 1, 2009 have you had a full-time or part-time job other than homemaking that you
held for at least 12 months (at least 9 months if it was a teaching job)?
No

42a.

Which of the following
best describes your
current situation?

Homemaker
Student
Unemployed
Retired
On medical leave
Disabled

GO TO THE END
Yes

GO TO THE NEXT PAGE, QUESTION 43

Draft

43. How many different jobs have you had since January 1, 2009?

# OF JOBS

Please tell us about the jobs you have had since January 1, 2009, starting with the most recent and
working backwards.
JOB 2

When did you first start
this job?

Before 2009
2009
2010
2011
2012
2013

45.

When did you last have
this job?

2009
2010
2011
2012
2013
I still work there

46.

Where did you work?
Please write down the
name of the company
you worked for and the
full street address of
this workplace.

44.

Knowing the name and
addresses of the places you
work will allow us to evaluate
the impact of air pollution and
other factors in the general
environment on your health.
We will never use this
information for any other
purpose and will never contact
your employer.

NAME OF COMPANY/PLACE OF WORK

STREET #

STREET NAME

APT #

CITY OR TOWN

STATE

ZIP CODE

COUNTY

SPACE IS PROVIDED FOR TWO JOBS. IF YOU HAVE HAD MORE THAN TWO JOBS LASTING 12 MONTHS
OR MORE SINCE JANUARY 1, 2009, PLEASE ANSWER THE SAME QUESTIONS FOR EACH JOB AND
RECORD YOUR ANSWERS ON A SEPARATE SHEET OF PAPER.
Draft
17

Please use a ballpoint pen for this form

JOB 1

JOB 2

47.

On a scale from
1 to 5, how
physically
demanding was
this job?

1 Not demanding
2
3
4
5 Extremely demanding

48.

On a scale from
1 to 5, how
emotionally
demanding was
this job?

1 Not demanding
2
3
4
5 Extremely demanding

49.

What was/is your
job title?

50.

51.

What type of
company or
organization
do/did you work
for? (What do
they make or what
services do they
provide?)

JOB TITLE

INDUSTRY

JOB DUTIES

What are the
specific tasks that
you usually do/did
in your job?

Draft

JOB 1

52.

How many hours
per week do/did
you usually work at
this job?

Less than 10
11-20
21-30
31-40
More than 40

What hours of the
day do/did you
usually work at this
job?

Less than 10
11-20
21-30
31-40
More than 40

(mark one)
AM

:
(hr)

(min)

STOP TIME:

(mark one)

(min)

How many times
per month do/did
you work at night?
“Work at night”
means any shift
that includes at
least one hour
between midnight
and 2:00 AM.

(min)

STOP TIME:

(mark one)
AM

:
(hr)

(min)

I work(ed) irregular hours
I work(ed) rotating shifts

54.

(hr)

(mark one)
AM

:
(hr)

START TIME:

Please use a ballpoint pen for this form

START TIME:
53.

JOB 2

I work(ed) irregular hours
I work(ed) rotating shifts

Never
1-2 times/month
3-5 times/month
6-10 times/month

11-15 times/month

More than 15 times per month

Draft

JOB 1

JOB 2
NO YES

55.

While working at
this job do/did
you regularly...

NO YES

a. work in dusty conditions?

b. breathe in chemical
vapors or fumes?

c. get chemicals or oils on
your skin or clothing?

d. come in contact with
solvents or degreasers?

e. come in contact with
metal chips, dust, or
fumes?

f. come in contact with
pesticides?

g. use cleaning solutions
(not counting dish or
laundry detergents)?

h. travel in a vehicle?

Please check to see that all questions are answered.

Draft

Form: 51

Vers:

ID#: SIS

OMB No. 0925-0522

The Sister Study
Quality of Life
and Special Topics
Version 2
Instructions:
Please use DARK BLUE OR BLACK BALLPOINT PEN.
Mark only one answer for each question unless otherwise indicated.
Follow the arrow from your response to find the next question.
Only write comments in the spaces provided.
Please keep this questionnaire clean, flat, and dry.
Do not fold or tear any of the pages.

Fill in the bubbles COMPLETELY for each of the questions in this form.

Like this:

 

Not like this:

If you must change an answer, please mark a single horizontal line through the incorrect answer
and bubble in the correct answer completely.

Like this:

YES

Not like this:



YES

Please write responses in all capital letters and numbers without touching the sides of the boxes.

A B C D E F G H I J K L M N O P Q R S T U V W X Y Z

1 2 3 4 5 6 7 8 9 0
When writing dates, please
follow this example.

EXAMPLE: June 7, 2011 =

0 6 / 0 7 / 2 0 1 1
(month)

(day)

(year)

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

Draft

Your continued participation in the Sister Study is completely voluntary and greatly appreciated. If you are
not comfortable answering a question, just skip it and go to the next one. All information you share will be
kept confidential.

Please mark the category that best describes your response. There are no right or wrong answers. Try not
to let your response to one statement influence your responses to other statements. Answer according to
your own feelings, rather than how you think “most people” would answer. Don’t take too long thinking
over your replies; your immediate reaction will probably be more accurate than a long thought out
response.

Today's Date:
MONTH

/
DAY

0
YEAR

Please respond to each item by marking one answer per row.

Excellent

Very
good

Good

Fair

Poor

1. In general, would you say your health is...
2. In general, would you say your quality of life is...
3. In general, how would you rate your physical
health?
4. In general, how would you rate your mental health,
including your mood and your ability to think?
5. In general, how would you rate your satisfaction with
your social activities and relationships?
6. In general, please rate how well you carry out your
usual social activities and roles. (This includes
activities at home, at work and in your community,
and responsibilities as a parent, child, spouse,
employee, friend, etc.)

To what extent are you able to carry out your everyday physical activities such as walking,
climbing stairs, carrying groceries, or moving a chair?
Completely
Mostly
Moderately
A little
Not at all

Draft

In the past 7 days, how often have you been bothered by emotional problems such as feeling
anxious, depressed, or irritable?
Never
Rarely
Sometimes
Often
Always

Please use a ballpoint pen for this form

In the past 7 days, how would you rate your fatigue on average?
None
Mild
Moderate
Severe
Extremely severe

10.

In the past 7 days, how would you rate your pain on average?
Worst
imaginable
pain

No
pain

11.

How often during the past 30 days, have you...

Never

Almost
Never

Sometimes

Fairly
often

Very
often

a. felt that you were unable to control the
important things in your life?
b. felt confident about your ability to handle
your personal problems?
c. felt that things were going your way?
d. felt difficulties were piling up so high that
you could not overcome them?
Draft

12.

For each statement below, choose the answer that best indicates how often the statement
is true for you.
None of
the time

A little of
the time

Some of
the time

Most of
the time

All of
the time

a. I can count on someone to provide me with
emotional support (someone to confide in
about myself or a problem or who will listen
to me when I need to talk).
b. I can count on someone if I need help (for
example, to take me to the doctor or help
with daily chores if I am sick).
c. There is someone in my immediate family
who believes in me and wants me to succeed.
d. There is someone in my immediate family
who makes me feel important or special.

13.

In general, how many relatives or friends do you feel close to (people you feel at ease with,
can talk to about private matters, or call on for help)?
None
1-2
3-5
6-9
10 or more

Draft

14.

During the past 12 months, about how many hours per week on average did you provide care for
children or grandchildren?

None

GO TO QUESTION 15

1-8 hours
9-20 hours

14a.

21-40 hours

14b.

15.

Not at all

During the past 12 months,
for whom did you provide
such care? (Please mark all
that apply.)

My children

A little
A moderate amount
A lot

My grandchildren
Other children

During the past 12 months, about how many hours per week on average did you provide care for
an ill or disabled person? This might be a parent, child, sibling, spouse, partner, other relative, or
personal friend.
None

GO TO THE NEXT PAGE, QUESTION 16

1-8 hours
9-20 hours

15a.

21-40 hours
41 or more hours

15b.

How stressful would
you say it is to provide
care for these disabled
or ill individuals?

Not at all

During the past 12
months, for whom did
you provide such care?
(Please mark all that
apply.)

Parent
Child
Sibling
Spouse
Partner
Other relative
Friend

A little
A moderate amount
A lot

Draft

Please use a ballpoint pen for this form

41 or more hours

How stressful would
you say it is to provide
care for these children
or grandchildren?

16.

Below is a list of some of the ways you may have felt or behaved. During the past week, how
often did you feel or act this way?
Rarely or
none of
the time

A little
of the
time

A moderate
amount of
the time

Most or
all of
the time

a. I was bothered by things that usually don’t bother me.
b. I had trouble keeping my mind on what I was doing.
c. I felt depressed.
d. I felt that everything I did was an effort.
e. I felt hopeful about the future.
f. I felt fearful.
g. My sleep was restless.
h. I was happy.
i. I felt lonely.
j. I could not “get going.”

Draft

Since January 1, 2009, have you
experienced the death of...

17. your spouse or partner?

YES

Yes

a.
Regardless of when this happened, how
much distress or anxiety has this caused
you in the past 4 weeks?
None
A little
A moderate amount
A lot

Yes

Please use a ballpoint pen for this form

18. your sister with breast cancer?

None
A little
A moderate amount
A lot

19. another sibling?

Yes

None
A little
A moderate amount
A lot

20. a child?

Yes

None
A little
A moderate amount
A lot

21. a parent?

Yes

None
A little
A moderate amount
A lot

22. a close personal friend?

Yes

None
A little
A moderate amount
A lot

Draft

Since January 1, 2009, have you
experienced...

23. a major illness that was life threatening or
severely disabling to you?

YES

Yes

a.
Regardless of when this happened, how
much distress or anxiety has this caused
you in the past 4 weeks?
None
A little
A moderate amount
A lot

24. the recurrence or worsening of your sister's
breast cancer?

Yes

None
A little
A moderate amount
A lot

25. any other close relative's diagnosis of breast
cancer?

Yes

None
A little
A moderate amount
A lot

26. a major change in, or serious difficulty with
a personal relationship (such as a divorce, or
child custody issues)?

27. serious financial or legal troubles such as
arrest or bankruptcy (either you or another
family member whose troubles would directly
affect you)?

Yes

None
A little
A moderate amount
A lot

Yes

None
A little
A moderate amount
A lot

Draft

28.

In the past 12 months, have you had to quit, reduce your hours, or change your job because of
your health or to meet the needs of your family?
No
Not applicable

Yes

Why did you have to do this?
(Please mark all that apply.)

Because of my health
To meet the needs of my family

Please use a ballpoint pen for this form

29.

28a.

In the past 12 months, have you been forced to leave your job, reduce your hours, or change
your job for other reasons such as the economy?
No
Not applicable
Yes

30a.

Are you currently unemployed and looking for work?
No
Yes

30b.

Are you currently unemployed and not looking for work?
No
Yes

Draft

As people age, some begin to worry about their ability to think clearly, make decisions and remember
things.
In the last several years…

31.

have you noticed that your judgment (e.g., ability to
make decisions and think clearly) is not as good as it
used to be?

32.

has your interest in hobbies or activities decreased?

33.

have you noticed that you tend to repeat things over
and over (questions, stories, or statements) more often
than you used to?

34.

has it become harder to learn how to use a new tool,
appliance or gadget (e.g., computer, microwave,
remote control)?

35.

have you noticed more problems remembering the
month or year?

36.

have you had more problems handling complicated
financial affairs (e.g., balancing checkbook, preparing
income taxes, paying bills) than you used to?

37.

has it become more difficult to remember
appointments?

38.

do you notice more daily problems with thinking
and/or memory?

Yes

Don't
Know

Not
applicable

Please answer the following questions about sleep.
39.

To feel your best, how many hours of sleep do you need?

# HOURS

40.

In the past year, how many hours of sleep per night on average did you typically get?

# HOURS

Draft

41.

In the past month, how many hours of sleep per night on average did you typically get?

# HOURS

42.

Do you have difficulty falling asleep or staying asleep on a regular basis?
No

43.

How many nights in a typical
month do you have trouble
sleeping?

# NIGHTS

Do you ever feel excessively sleepy during the day, even after getting your usual sleep?
No
Yes

44.

42a.

GO TO QUESTION 44
43a.

In the past month, about
how often did you feel
excessively sleepy during
the day?

Less than once a week
1 - 2 days per week
3 - 5 days per week
6 days per week or daily

Have you ever been told, or suspected yourself, that you seem to "act out your dreams" while
asleep, for example, punching or flailing arms in the air, making running movements, shouting,
or screaming?
No
Yes

GO TO NEXT PAGE, QUESTION 45
44a.

How often do you do this?

Less than 3 times in total
Less than once a month
1 - 3 times a month
Once a week
More than once a week

44b.

How old were you when you
first knew you did this?

AGE
Draft

Please use a ballpoint pen for this form

Yes

GO TO QUESTION 43

45.

Has a doctor or other health professional ever told you that you have restless leg syndrome?
No
Yes

46.

Do you have, or have you had, recurrent uncomfortable
feelings or sensations in your legs while you are sitting or
lying down?

47.

Do you have, or have you had, a recurrent need or urge to
move your legs while you were sitting or lying down?

IF YOU
ANSWERED NO
TO BOTH, GO
TO QUESTION
58, PAGE 15

Yes

IF YOU
ANSWERED YES
TO EITHER OF
THE ABOVE,
GO TO
QUESTION 48

If you answered Yes to either 46 or 47:
48.

Are you more likely to have these feelings when you are resting (either sitting or lying down) or
when you are physically active?
Resting
Active

49.

If you get up or move around when you have these feelings do these feelings get any better
while you actually keep moving?
No
Yes
Don't know

Draft

50.

Which times of day are these feelings in your legs most likely to occur?
(Please mark all that apply.)
Morning
Mid-day
Afternoon
Evening
Night
About equal at all times

Will simply changing leg position by itself once without continuing to move usually relieve these
feelings?
Usually relieves
Does not usually relieve
Don't know

52.

Are these feelings ever due to muscle cramps?
No

Don't know

Yes

GO TO QUESTION 53

52a.

Are they always due to muscle
cramps?

No
Yes
Don't know

53.

Do these feelings occur when sitting or when lying down?
Only when sitting
Only when lying down
Both when sitting and when lying down
Neither
Draft

Please use a ballpoint pen for this form

51.

54.

When you experience the feelings in your legs, how distressing are they?
Not at all distressing
A little bit
Moderately
Extremely distressing

55.

In the past 12 months, how often did you experience these feelings in your legs?
(Please mark the best single answer.)
6 times per week or daily
4 - 5 days per week
2 - 3 days per week
1 day per week
2 - 3 days per month
1 day per month or less
Never

56.

Approximately how old were you when you first noticed these feelings in your legs?
(Please write age.)

AGE

57.

Did you first notice these feelings during a pregnancy?
No
Never been
pregnant

Yes

GO TO NEXT PAGE, QUESTION 58

57a.

Other than pregnancy, about
how old were you when you
first noticed these feelings in
your legs?

AGE

Never felt this
outside of pregnancy
Draft

58.

During the past 12 months, have you taken any vitamins or minerals regularly, at least once a
month?
No, not regularly

GO TO PAGE 21, QUESTION 79

Yes, fairly regularly

NO
Multiple Vitamins
59. One A Day, Centrum,
or Thera type multiple
vitamins?

YES
Yes

b.
For how many
years in all have
you taken this?

c.
Did you usually take
types that...

A few days
per month

Less than 1 year
1 year

contain minerals,
iron, zinc, etc.?

1 - 3 days
per week

2 years

do not contain
minerals?

4 - 6 days
per week

3 - 4 years
5 - 9 years
10+ years

Don't know

Every day
60. Stress-tabs or
B-Complex type
multiple vitamins?

Yes

A few days
per month

Less than 1 year
1 year

1 - 3 days
per week

2 years

4 - 6 days
per week

3 - 4 years
5 - 9 years
10+ years

Every day
61. Antioxidant
combination-type
multiple vitamins?

Yes

A few days
per month

Less than 1 year
1 year

1 - 3 days
per week

2 years

4 - 6 days
per week

3 - 4 years
5 - 9 years
10+ years

Every day

Draft

Please use a ballpoint pen for this form

a.
How often?

During the past 12 months,
have you taken...

a.
How often?
NO

YES

b.
For how many
years in all have
you taken this?

c.
How much did you
usually take on the
days you took it?

Single Vitamins and Minerals
(not part of multiple vitamins)
62. Vitamin A
(not beta-carotene)?

Yes

A few days
per month

Less than 1 year
1 year

1 - 3 days
per week

2 years

4 - 6 days
per week

3 - 4 years
5 - 9 years
10+ years

Less than
8000 IU
8000 IU
More than
8000 IU

Every day

63. Beta-carotene?

Yes

A few days
per month

Less than 1 year
1 year

1 - 3 days
per week

2 years

4 - 6 days
per week

3 - 4 years
5 - 9 years
10+ years

Every day
64. Thiamin (B1)?

Yes

A few days
per month

Less than 1 year
1 year

1 - 3 days
per week

2 years

4 - 6 days
per week

3 - 4 years
5 - 9 years
10+ years

Less than
100 mg
100-250 mg
More than
250 mg

Every day

65. Niacin (B3)?

Yes

A few days
per month

Less than 1 year
1 year

1 - 3 days
per week

2 years

4 - 6 days
per week

3 - 4 years
5 - 9 years
10+ years

Less than
500 mg
500 mg
More than
500 mg

Every day

Draft

During the past 12 months,
have you taken...

a.
How often?
NO

YES

b.
For how many
years in all have
you taken this?

c.
How much did you
usually take on the
days you took it?

Single Vitamins and Minerals
(not part of multiple vitamins)
66. Vitamin B6?

Yes

Less than 1 year
1 year

1 - 3 days
per week

2 years

4 - 6 days
per week

3 - 4 years
5 - 9 years
10+ years

Less than
100 mg
100 mg

Please use a ballpoint pen for this form

A few days
per month

More than
100 mg

Every day

67. Vitamin B12?

Yes

A few days
per month

Less than 1 year
1 year

Less than
500 mcg

1 - 3 days
per week

2 years

500 mcg

3 - 4 years
5 - 9 years
10+ years

1000 mcg

4 - 6 days
per week

More than
2000 mcg

Every day

68. Vitamin C?

Yes

A few days
per month

Less than 1 year
1 year

1 - 3 days
per week

2 years

4 - 6 days
per week

3 - 4 years
5 - 9 years
10+ years

Yes

Less than
500 mg
500 mg
1000 mg
More than
1000 mg

Every day

69. Vitamin D alone?

2000 mcg

A few days
per month

Less than 1 year
1 year

1 - 3 days
per week

2 years

2000 IU

3 - 4 years
5 - 9 years
10+ years

More than
2000 IU

4 - 6 days
per week

Less than 2000 IU

Every day
Draft

During the past 12 months,
have you taken...

a.
How often?

b.
For how many
years in all have
you taken this?

A few days
per month

Less than 1 year
1 year

1 - 3 days
per week

2 years

YES

c.
How much did you
usually take on the
days you took it?

Single Vitamins and Minerals
(not part of multiple vitamins)
70. Vitamin E?

Yes

4 - 6 days
per week

3 - 4 years
5 - 9 years
10+ years

Less than
400 IU
400 IU
More than
400 IU

Every day

71. Folic acid, folate?

Yes

A few days
per month

Less than 1 year
1 year

1 - 3 days
per week

2 years

4 - 6 days
per week

3 - 4 years
5 - 9 years
10+ years

Less than
400 mcg
400 mcg
More than
400 mcg

Every day

72. Calcium plus vitamin D?

Yes

A few days
per month

Less than 1 year
1 year

1 - 3 days
per week

2 years

4 - 6 days
per week

3 - 4 years
5 - 9 years
10+ years

Every day

73. Calcium without
vitamin D?

Yes

A few days
per month

Less than 1 year
1 year

1 - 3 days
per week

2 years

4 - 6 days
per week

3 - 4 years
5 - 9 years
10+ years

Less than
600 mg
600 mg
More than
600 mg

Every day
Draft

During the past 12 months,
have you taken...

a.
How often?
NO

YES

b.
For how many
years in all have
you taken this?

c.
How much did you
usually take on the
days you took it?

Single Vitamins and Minerals
(not part of multiple vitamins)
74. Chromium?

Yes

Less than 1 year
1 year

1 - 3 days
per week

2 years

4 - 6 days
per week

3 - 4 years
5 - 9 years
10+ years

Less than
200 mcg
200 - 1000 mcg
More than
1000 mcg

Every day

75. Iron?

Yes

A few days
per month

Less than 1 year
1 year

1 - 3 days
per week

2 years

4 - 6 days
per week

3 - 4 years
5 - 9 years
10+ years

Less than
65 mg
65 mg
More than
65 mg

Every day

76. Magnesium?

Yes

A few days
per month

Less than 1 year
1 year

1 - 3 days
per week

2 years

4 - 6 days
per week

3 - 4 years
5 - 9 years
10+ years

Less than
250 mg
250 mg
More than
250 mg

Every day

77. Selenium?

Yes

A few days
per month

Less than 1 year
1 year

1 - 3 days
per week

2 years

4 - 6 days
per week

3 - 4 years
5 - 9 years
10+ years

Less than
200 mcg
200 mcg
More than
200 mcg

Every day
Draft

Please use a ballpoint pen for this form

A few days
per month

During the past 12 months,
have you taken...

a.
How often?
NO

YES

b.
For how many
years in all have
you taken this?

c.
How much did you
usually take on the
days you took it?

Single Vitamins and Minerals
(not part of multiple vitamins)
78. Zinc, alone or combined
with something else?

Yes

A few days
per month

Less than 1 year
1 year

1 - 3 days
per week

2 years

4 - 6 days
per week

3 - 4 years
5 - 9 years
10+ years

Less than
50 mg
50 mg
More than
50 mg

Every day

Draft

In the past 12 months, did you
take any of these supplements
at least once a month?
79. Black cohosh

a.
How frequently did
you take this?

YES

Yes

b.
For how many
years in all have
you taken this?

Less than 3 days per week
3 - 5 days per week

Less than 1 year
1 year

6 - 7 days per week

2 years
3 - 4 years
5 - 9 years
10+ years

Yes

Less than 3 days per week
3 - 5 days per week

Less than 1 year
1 year

6 - 7 days per week

2 years
3 - 4 years
5 - 9 years
10+ years

81. Co-enzyme Q10 (CoQ10)

Yes

Less than 3 days per week
3 - 5 days per week

Less than 1 year
1 year

6 - 7 days per week

2 years
3 - 4 years
5 - 9 years
10+ years

82. Cod liver oil

Yes

Less than 3 days per week
3 - 5 days per week

Less than 1 year
1 year

6 - 7 days per week

2 years
3 - 4 years
5 - 9 years
10+ years

83. Cranberry pills

Yes

Less than 3 days per week
3 - 5 days per week

Less than 1 year
1 year

6 - 7 days per week

2 years
3 - 4 years
5 - 9 years
10+ years

84. DHEA

Yes

Less than 3 days per week
3 - 5 days per week

Less than 1 year
1 year

6 - 7 days per week

2 years
3 - 4 years
5 - 9 years
10+ years
Draft

Please use a ballpoint pen for this form

80. Chamomile

In the past 12 months, did you
take any of these supplements
at least once a month?
85. Echinacea

NO
No

a.
How frequently did
you take this?

YES
Yes

b.
For how many
years in all have
you taken this?

Less than 3 days per week
3 - 5 days per week

Less than 1 year
1 year

6 - 7 days per week

2 years
3 - 4 years
5 - 9 years
10+ years

86. Evening primrose oil

Yes

Less than 3 days per week
3 - 5 days per week

Less than 1 year
1 year

6 - 7 days per week

2 years
3 - 4 years
5 - 9 years
10+ years

87. Fiber supplement

Yes

Less than 3 days per week
3 - 5 days per week

Less than 1 year
1 year

6 - 7 days per week

2 years
3 - 4 years
5 - 9 years
10+ years

88. Fish oil (EPA)

Yes

Less than 3 days per week
3 - 5 days per week

Less than 1 year
1 year

6 - 7 days per week

2 years
3 - 4 years
5 - 9 years
10+ years

89. Flax seed/flax seed oil

Yes

Less than 3 days per week
3 - 5 days per week

Less than 1 year
1 year

6 - 7 days per week

2 years
3 - 4 years
5 - 9 years
10+ years

90. Garlic pills

Yes

Less than 3 days per week
3 - 5 days per week

Less than 1 year
1 year

6 - 7 days per week

2 years
3 - 4 years
5 - 9 years
10+ years
Draft

In the past 12 months, did you
take any of these supplements
at least once a month?
91. Ginger

a.
How frequently did
you take this?
NO
No

YES
Yes

b.
For how many
years in all have
you taken this?

Less than 3 days per week
3 - 5 days per week

Less than 1 year
1 year

6 - 7 days per week

2 years

92. Ginkgo

Yes

Less than 3 days per week
3 - 5 days per week

Less than 1 year
1 year

6 - 7 days per week

2 years
3 - 4 years
5 - 9 years
10+ years

93. Ginseng

Yes

Less than 3 days per week
3 - 5 days per week

Less than 1 year
1 year

6 - 7 days per week

2 years
3 - 4 years
5 - 9 years
10+ years

94. Glucosamine/Chondroitin

Yes

Less than 3 days per week
3 - 5 days per week

Less than 1 year
1 year

6 - 7 days per week

2 years
3 - 4 years
5 - 9 years
10+ years

95. Kava Kava

Yes

Less than 3 days per week
3 - 5 days per week

Less than 1 year
1 year

6 - 7 days per week

2 years
3 - 4 years
5 - 9 years
10+ years

96. Lecithin

Yes

Less than 3 days per week
3 - 5 days per week

Less than 1 year
1 year

6 - 7 days per week

2 years
3 - 4 years
5 - 9 years
10+ years
Draft

Please use a ballpoint pen for this form

3 - 4 years
5 - 9 years
10+ years

In the past 12 months, did you
take any of these supplements
at least once a month?
97.

Lutein

a.
How frequently did
you take this?
NO
No

YES
Yes

b.
For how many
years in all have
you taken this?

Less than 3 days per week
3 - 5 days per week

Less than 1 year
1 year

6 - 7 days per week

2 years
3 - 4 years
5 - 9 years
10+ years

98.

Melatonin

Yes

Less than 3 days per week
3 - 5 days per week

Less than 1 year
1 year

6 - 7 days per week

2 years
3 - 4 years
5 - 9 years
10+ years

99.

Milk thistle

Yes

Less than 3 days per week
3 - 5 days per week

Less than 1 year
1 year

6 - 7 days per week

2 years
3 - 4 years
5 - 9 years
10+ years

100.

Mixed carotenoids

Yes

Less than 3 days per week
3 - 5 days per week

Less than 1 year
1 year

6 - 7 days per week

2 years
3 - 4 years
5 - 9 years
10+ years

101.

Omega-3 or omega-3
fatty acids

Yes

Less than 3 days per week
3 - 5 days per week

Less than 1 year
1 year

6 - 7 days per week

2 years
3 - 4 years
5 - 9 years
10+ years

102.

Probiotics/acidophilus

Yes

Less than 3 days per week
3 - 5 days per week

Less than 1 year
1 year

6 - 7 days per week

2 years
3 - 4 years
5 - 9 years
10+ years
Draft

In the past 12 months, did you
take any of these supplements
at least once a month?
103.

Soy isoflavones

a.
How frequently did
you take this?
NO
No

YES
Yes

b.
For how many
years in all have
you taken this?

Less than 3 days per week
3 - 5 days per week

Less than 1 year
1 year

6 - 7 days per week

2 years

104.

St. John's Wort

Yes

Less than 3 days per week
3 - 5 days per week

Less than 1 year
1 year

6 - 7 days per week

2 years
3 - 4 years
5 - 9 years
10+ years

105.

Turmeric capsules

Yes

Less than 3 days per week
3 - 5 days per week

Less than 1 year
1 year

6 - 7 days per week

2 years
3 - 4 years
5 - 9 years
10+ years

106.

Valerian

Yes

Less than 3 days per week
3 - 5 days per week

Less than 1 year
1 year

6 - 7 days per week

2 years
3 - 4 years
5 - 9 years
10+ years

107.

Something else

Yes

Less than 3 days per week
3 - 5 days per week

Less than 1 year
1 year

6 - 7 days per week

2 years
3 - 4 years
5 - 9 years
10+ years

Draft

Please use a ballpoint pen for this form

3 - 4 years
5 - 9 years
10+ years

Have you used any of the
following complementary or
alternative practices within
the past 12 months?
108.

Juicing

a.
How frequently?
NO

YES

Yes

b.
For how many
years in all?

Less than once a month
1-4 times a month

Less than 1 year
1 year

More than 4 times a month

2 years
3 - 4 years
5 - 9 years
10+ years

109.

Acupuncture

Yes

Less than once a month
1-4 times a month

Less than 1 year
1 year

More than 4 times a month

2 years
3 - 4 years
5 - 9 years
10+ years

110.

Yoga

Yes

Less than once a month
1-4 times a month

Less than 1 year
1 year

More than 4 times a month

2 years
3 - 4 years
5 - 9 years
10+ years

111.

Spirituality, meditation,
prayer

Yes

Less than once a month
1-4 times a month

Less than 1 year
1 year

More than 4 times a month

2 years
3 - 4 years
5 - 9 years
10+ years

112.

Therapeutic touch/massage

Yes

Less than once a month
1-4 times a month

Less than 1 year
1 year

More than 4 times a month

2 years
3 - 4 years
5 - 9 years
10+ years

113.

Tai chi

Yes

Less than once a month
1-4 times a month

Less than 1 year
1 year

More than 4 times a month

2 years
3 - 4 years
5 - 9 years
10+ years
Draft

Have you used any of the
following complementary or
alternative practices within
the past 12 months?
114.

Qi gong

a.
How frequently?
NO
No

YES
Yes

b.
For how many
years in all?

Less than once a month
1-4 times a month

Less than 1 year
1 year

More than 4 times a month

2 years
3 - 4 years
5 - 9 years
10+ years

Chiropractic

Yes

Less than once a month
1-4 times a month

Less than 1 year
1 year

More than 4 times a month

2 years
3 - 4 years
5 - 9 years
10+ years

116.

Reiki

Yes

Less than once a month
1-4 times a month

Less than 1 year
1 year

More than 4 times a month

2 years
3 - 4 years
5 - 9 years
10+ years

117.

Biofeedback

Yes

Less than once a month
1-4 times a month

Less than 1 year
1 year

More than 4 times a month

2 years
3 - 4 years
5 - 9 years
10+ years

118.

Homeopathy

Yes

Less than once a month
1-4 times a month

Less than 1 year
1 year

More than 4 times a month

2 years
3 - 4 years
5 - 9 years
10+ years

119.

Visualization/guided
imagery

Yes

Less than once a month
1-4 times a month

Less than 1 year
1 year

More than 4 times a month

2 years
3 - 4 years
5 - 9 years
10+ years
Draft

Please use a ballpoint pen for this form

115.

Have you used any of the
following complementary or
alternative practices within
the past 12 months?
120.

Deep breathing exercises

a.
How frequently?
NO
No

YES
Yes

b.
For how many
years in all?

Less than once a month
1-4 times a month

Less than 1 year
1 year

More than 4 times a month

2 years
3 - 4 years
5 - 9 years
10+ years

121.

Typically, how often do you have bowel movements?
Less than once every other day
Once every other day
Once per day
2 or more times per day

122.

How often do you use laxatives, not including fiber or fiber tabs?
Never
Less than once a month
1 - 3 times per month
1 - 3 times per week
4 - 6 times per week
Daily or more

Draft

Some people follow special diets as part of their lifestyle. Others change their diet when there is a
change in their life or when they are trying to achieve a goal like losing weight.
Since January 1, 2009, which (if any)
of these special diets have you
followed for longer than a month,
other than during pregnancy?

High fiber

YES

Yes

Less than 8 weeks
8 weeks - 1 year
More than 1 year

124.

Low fat

Yes

Less than 8 weeks
8 weeks - 1 year
More than 1 year

125.

Restricted calories

Yes

Less than 8 weeks
8 weeks - 1 year
More than 1 year

126.

Liquid/juice

Yes

Less than 8 weeks
8 weeks - 1 year
More than 1 year

127.

Vegetarian

Yes

Less than 8 weeks
8 weeks - 1 year
More than 1 year

128.

Low salt

Yes

Less than 8 weeks
8 weeks - 1 year
More than 1 year

129.

Macrobiotic

Yes

Less than 8 weeks
8 weeks - 1 year
More than 1 year

130.

Diabetic diet

Yes

Less than 8 weeks
8 weeks - 1 year
More than 1 year

131.

Atkins

Yes

Less than 8 weeks
8 weeks - 1 year
More than 1 year

132.

Zone (Barry Sears)

Yes

Less than 8 weeks
8 weeks - 1 year
More than 1 year

b.
Have you followed this
diet for at least a
month in the past year?
Yes
No

Please use a ballpoint pen for this form

123.

a.
How long did you
follow this diet?

Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No

Draft

Since January 1, 2009, which (if any)
of these special diets have you
followed for longer than a month,
other than during pregnancy?

133.

Weight Watchers

a.
How long did you
follow this diet?
NO
No

YES

b.
Have you followed this
diet for at least a
month in the past year?

Less than 8 weeks
8 weeks - 1 year

Yes

Yes
No

More than 1 year
134.

Tried to gain weight

Less than 8 weeks
8 weeks - 1 year

Yes

Yes
No

More than 1 year
135.

Diet with pre-prepared meals

Less than 8 weeks
8 weeks - 1 year

Yes

Yes
No

More than 1 year
136.

137.

Physician-based diet with special
supplements such as puddings,
beverages or vitamins

South Beach diet

Less than 8 weeks
8 weeks - 1 year

Yes

Yes
No

More than 1 year
Less than 8 weeks
8 weeks - 1 year

Yes

Yes
No

More than 1 year
138.

Raw food diet

Less than 8 weeks
8 weeks - 1 year

Yes

Yes
No

More than 1 year
139.

HCG diet

Less than 8 weeks
8 weeks - 1 year

Yes

Yes
No

More than 1 year
140.

Other diet, please specify:

Less than 8 weeks
8 weeks - 1 year

Yes

Yes
No

More than 1 year

Have you ever had any of the following
weight loss procedures?
141.

NO
No

Lap band

YES

a.
What age did you have this?

Yes
AGE

142.

Bariatric surgery

Yes
AGE

Draft

143.

Do you have, or have you ever had, a food allergy?
No

GO TO PAGE 33, QUESTION 156

Don't know
Yes

144. Milk

NO
No

YES
Yes, it started before age 18
Yes, it started
age 18 or later 

b.
Have you
eaten this
item in the
past year?

c.
Are you still
allergic to
this food?

No
Yes

No
Yes
Don't know

No
Yes

No
Yes
Don't know

No
Yes

No
Yes
Don't know

No
Yes

No
Yes
Don't know

a. Age it started

AGE

145. Egg

Yes, it started before age 18
Yes, it started
age 18 or later 

a. Age it started

AGE

146. Peanuts

Yes, it started before age 18
Yes, it started
age 18 or later 

a. Age it started

AGE

147. Other nuts

Yes, it started before age 18
Yes, it started
age 18 or later 

a. Age it started

AGE

Draft

Please use a ballpoint pen for this form

Do you have, or
have you ever
had, an allergy to
the following
foods?

Do you have, or
have you ever
had, an allergy to
the following
foods?
148. Shellfish

YES

NO
No

b.
Have you
eaten this
item in the
past year?

Yes, it started before age 18
Yes, it started
age 18 or later 

c.
Are you still
allergic to
this food?

No
Yes

No
Yes
Don't know

No
Yes

No
Yes
Don't know

No
Yes

No
Yes
Don't know

No
Yes

No
Yes
Don't know

No
Yes

No
Yes
Don't know

a. Age it started

AGE

149. Fish

Yes, it started before age 18
Yes, it started
age 18 or later 

a. Age it started

AGE

150. Any kind
of fruit

Yes, it started before age 18
Yes, it started
age 18 or later 

a. Age it started

AGE

151. Wheat

Yes, it started before age 18
Yes, it started
age 18 or later 

a. Age it started

AGE

152. Soy

Yes, it started before age 18
Yes, it started
age 18 or later 

a. Age it started

AGE

Draft

Do you have, or
have you ever
had, an allergy to
the following
foods?
153. Rye

YES

NO
No

b.
Have you
eaten this
item in the
past year?

Yes, it started before age 18
Yes, it started
age 18 or later 

c.
Are you still
allergic to
this food?

No
Yes
Don't know

No
Yes

No
Yes
Don't know

No
Yes

No
Yes
Don't know

a. Age it started

AGE

154. Vegetable(s)

Yes, it started before age 18
Yes, it started
age 18 or later 

a. Age it started

AGE

155. Other food,
specify:

Yes, it started before age 18
Yes, it started
age 18 or later 

a. Age it started

AGE

156.

Do you have lactose intolerance?
No
Don't know

Yes

GO TO NEXT PAGE, QUESTION 157

156a. Do you consume any type of dairy
products on most days?

No
Yes

Draft

Please use a ballpoint pen for this form

No
Yes

157.

During the past month, did you eat any hot or cold cereals?
No

Yes

GO TO NEXT PAGE, QUESTION 158

157a. During the past month, how often
did you eat hot or cold cereals?
You can report per day, per week,
or per month.

# TIMES

Per day
Per week
Per month

157b. During the past month, what kind of cereal did you usually eat?
Please record the name using the enclosed card. If your cereal is
not listed, please enter the cereal name.

FIRST CEREAL

157c. Was there another cereal that you usually ate?
No GO TO NEXT PAGE, QUESTION 158
Yes

157d. During the past month, what second kind of cereal did you usually
eat? Please record the name using the enclosed card. If your
cereal is not listed, please enter the cereal name.

SECOND CEREAL

Draft

158.

During the past month, did you have any milk (either to drink or on cereal)? Include regular
milks, chocolate or other flavored milks, lactose-free milk, buttermilk. Do not include soy
milk or small amounts of milk in coffee or tea.
No
Don't know

GO TO NEXT PAGE, QUESTION 159

158a. During the past month, how
often did you have any milk
(either to drink or on cereal)?
You can report per day, per
week, or per month.
158b. During the past month, what
kind of milk did you usually
drink? Pick one.

# TIMES

Per day
Per week
Per month

Whole or regular milk
Fat-free, skim, or non-fat milk
2% fat or reduced-fat milk
Soy milk
1%, ½%, or low-fat milk
Other, specify:

Draft

Please use a ballpoint pen for this form

Yes

During the past month, did you...
159.

160.

161.

162.

163.

164.

165.

166.

167.

168.

drink any regular soda or pop that contains sugar?
Do not include diet soda.
drink any 100% pure fruit juices such as orange, mango,
apple, grape and pineapple juices? Do not include
fruit-flavored drinks with added sugar or fruit juice
you made at home and added sugar to.

drink any coffee or tea that had sugar or honey added
to it? Include coffee and tea you sweetened yourself and
presweetened tea and coffee drinks such as Arizona Iced
Tea and Frappuccino. Do not include artificially
sweetened coffee or diet tea.

drink any sweetened fruit drinks, sports or energy drinks,
such as Kool-aid, lemonade, Hi-C, cranberry drink,
Gatorade, Red Bull, or Vitamin Water? Include fruit juices
you made at home and added sugar to. Do not include
diet drinks or artificially sweetened drinks.

eat any fruit? Include fresh, frozen, or canned fruit. Do
not include juices.

eat a green leafy or lettuce salad, with or without
other vegetables?

eat any kind of fried potatoes including french fries,
home fries, or hash brown potatoes?

eat any other kind of potatoes, such as baked, boiled,
mashed potatoes, sweet potatoes, or potato salad?

eat any refried beans, baked beans, beans in soup,
pork and beans or other cooked dried beans? Do not
include green beans.

eat any brown rice or other cooked whole grains, such
as bulgur, cracked wheat, or millet? Do not include
white rice.

YES

a.
How often?

# TIMES

Per day
Per week
Per month

# TIMES

Per day
Per week
Per month

# TIMES

Per day
Per week
Per month

# TIMES

Per day
Per week
Per month

# TIMES

Per day
Per week
Per month

# TIMES

Per day
Per week
Per month

# TIMES

Per day
Per week
Per month

# TIMES

Per day
Per week
Per month

# TIMES

Per day
Per week
Per month

# TIMES

Per day
Per week
Per month

Yes

Draft

During the past month, did you...

169.

170.

172.

173.

174.

175.

eat any other vegetables? Do not include green
salads, potatoes, and cooked dried beans.

eat any Mexican-type salsa made with tomato?

eat any pizza? Include frozen pizza, fast food pizza, and
homemade pizza.

have any tomato sauces such as with spaghetti or
noodles or mixed into foods such as lasagna? Do not count
tomato sauce on pizza.
eat any kind of cheese? Include cheese as a snack,
cheese on burgers, sandwiches, and cheese in foods
such as lasagna, quesadillas, or casseroles. Do not
include cheese on pizza.
eat any red meat, such as beef, pork, ham, or sausage?
Do not include chicken, turkey or seafood. Include red
meat you had in sandwiches, lasagna, stew, and other
mixtures. Red meats may also include veal, lamb, and
any lunch meats made with these meats.
eat any processed meat, such as bacon, lunch meats,
or hot dogs? Include processed meats you had in
sandwiches, soups, pizza, casseroles, and other
mixtures.

YES

177.

eat any whole grain bread including toast, rolls and in
sandwiches? Whole grain breads include whole wheat,
rye, oatmeal and pumpernickel. Do not include white
bread.
eat any chocolate or any other types of candy? Do not
include sugar-free candy.

# TIMES

Per day
Per week
Per month

# TIMES

Per day
Per week
Per month

# TIMES

Per day
Per week
Per month

# TIMES

Per day
Per week
Per month

# TIMES

Per day
Per week
Per month

# TIMES

Per day
Per week
Per month

# TIMES

Per day
Per week
Per month

# TIMES

Per day
Per week
Per month

Yes

Processed meats are those preserved by smoking,
curing, or salting, or by the addition of preservatives.
Examples are: ham, bacon, pastrami, salami, sausages,
bratwursts, frankfurters, hot dogs, and spam.
176.

# TIMES

Per day
Per week
Per month

Yes

Draft

Please use a ballpoint pen for this form

171.

a.
How often?

During the past month, did you...

178.

179.

180.

181.

eat any doughnuts, sweet rolls, Danish, muffins, pan
dulce or pop-tarts? Do not include sugar-free items.

eat any cookies, cake, pie, or brownies? Do not include
sugar-free kinds.

eat any ice cream or other frozen desserts? Do not
include sugar-free kinds.

eat any popcorn?

YES

a.
How often?

# TIMES

Per day
Per week
Per month

# TIMES

Per day
Per week
Per month

# TIMES

Per day
Per week
Per month

# TIMES

Per day
Per week
Per month

Yes

Draft

Please check to see that all questions are answered.

Draft

The Sister Study
Quality of Life and Special Topics
5)&

4JTUFS
4UVEZ
#SFBTU$BODFS3FTFBSDI

Cereal Card

Cheerios

Cocoa Wheats

100% Bran

Cheerios, Apple Cinnamon

Complete Bran Flakes

100% Low Fat Natural Granola

Cheerios, Berry Burst

Complete Oat Bran Flakes

100% Natural Cereal

Cheerios, Berry Burst Strawberry

Complete Wheat Bran Flakes

100% Natural Cereal, with oats,
honey and raisins

Cheerios, Berry Burst Triple Berry

Cookie-Crisp (all flavors)

Cheerios, Berry Burst, Cherry
Vanilla

Corn Bursts, Malt-O-Meal

100% Natural Granola, Oats &
Honey
100% Natural Wholegrain Cereal
with raisins, lowfat
A
All-Bran
All-Bran Bran Buds
All-Bran with Extra Fiber

Cheerios, Berry Burst, Strawberry
Banana
Cheerios, Frosted
Cheerios, Honey Nut
Cheerios, Multi Grain
Cheerios, Team

Corn Pops
Corn Puffs
Corn flakes
Corn flakes, low sodium
Cornmeal mush
Count Chocula

Frosted Mini Wheats
Frosted Shredded Wheat
Frosted Wheat Bites
Frosted cereal, with marshmallows
Frosted corn flakes
Frosted flakes
Frosted rice
Frosty O’s
Fruit & Fibre (fiber)
Fruit & Fibre (fiber) with Dates,
Raisins and Walnuts

Cranberry Almond Crunch Cereal

Fruit & Fibre (fiber) with Peaches,
Raisins, Almonds, and Oat
Clusters

Cream of Rice

Fruit Harvest

Cream of Rye

Fruit Harvest Apple Cinnamon

Cream of Wheat

Fruit Harvest Strawberry Blueberry

Crisp Crunch

Fruit Loops

Crispix

Fruit Rings

Crispy Brown Rice Cereal

Fruit Whirls

Crispy Rice

Fruit and Cream Oatmeal

Crispy Rice, Malt-O-Meal

Fruity Dyno Bites, Malt-O-Meal

Crispy Wheats ’N Raisins

Fruity Pebbles

Crunchy Corn Bran

Golden Crisp

Disney Cereal

Golden Grahams

Disney Hunny B’s

Golden Puffs, Malt-O-Meal

Disney Mickey’s Magix

Granola

Disney Mud & Bugs

Granola, homemade

Granola, lowfat

Ener-G Pure Rice Bran

Granola, lowfat, Kellogg’s

Cinnamon Toast Crunch

F
Familia

Buckwheat groats

Cinnamon Toast Crunch, Reduced
Sugar

Granola, lowfat, with Raisins,
Kellogg’s

Bulgur

Coco-Roos, Malt-O-Meal

Fiber 7 Flakes

Cocoa Blasts

Fiber One

Cap’n Crunch

Cocoa Comets

Frankenberry

Cap’n Crunch’s Christmas Crunch

Cocoa Dyno Bites, Malt-O-Meal

French Toast Crunch

Cap’n Crunch’s Crunch Berries

Cocoa Krispies

Froot Loops

Great Grains, Raisins, Dates, and
Pecans Whole Grain Cereal

Cap’n Crunch’s Oops! ChocoDonuts

Cocoa Pebbles

Frosted Flakes, Kellogg’s

Grits

Cap’n Crunch’s Peanut Butter
Crunch

Cocoa Puffs

Frosted Flakes, Malt-O-Meal

Cocoa Puffs, Reduced Sugar

Frosted Fruit Rings

Alpen
Alpha-Bits
Alpha-Bits with marshmallows
Amaranth Flakes
Apple Jacks
Apple Zaps
Apple Zings, Malt-O-Meal
B
Banana Nut Crunch Cereal
Barley
Basic 4
Berry Colossal Crunch, Malt-OMeal
Blueberry Morning
Booberry
Bran
Bran Buds
Bran flakes
Bran, Nabisco
Branola
Brown Sugar Bliss

Cheerios, Yogurt Burst, Strawberry

Corn Flakes, Kellogg’s

Frosted Mini Spooners, Malt-OMeal

Cheerios, Yogurt Burst, Vanilla
Cheese grits
Chex
Chex Morning Mix Banana Nut
Chex Morning Mix Cinnamon
Chex Morning Mix Fruit & Nut
Chex Morning Mix Honey Nut
Chex, Bran
Chex, Corn
Chex, Honey Nut
Chex, Multi-Bran
Chex, Rice
Chex, Wheat
Chocolate frosted cereal
Cinnamon Cluster Raisin Bran
Cinnamon Crunch Crispix
Cinnamon Grahams Cereal
Cinnamon Marshmallow Scooby
Doo!

Cracklin’ Oat Bran

Farina

Grape Nut O’s
Grape-Nuts
Grape-Nuts Flakes
Great Grains Crunchy Pecan Whole
Grain Cereal

Special K Low Carb Lifestyle
Protein Plus

Oh’s, Fruitangy

Harina de maize con leche

Magic Stars

Oh’s, Honey Graham

Harmony Vanilla Almond Oats

Malt-O-Meal

Old Wessex Irish Style Oatmeal

Healthy Choice

Malt-O-Meal, chocolate

Optimum Slim, Nature’s Path

Honey Bunches of Oat Honey
Roasted

Maltex

Optimum, Nature’s Path

Marshmallow Mateys, Malt-O-Meal

Oreo O’s Cereal

Marshmallow Safari

Masa harina

Peanut Butter Toast Crunch

Maypo

Polenta

Millet

Product 19

Honey Buzzers, Malt-O-Meal

Millet, puffed

Puffed Rice, Malt-O-Meal

Honey Crisp Corn Flakes

Mini-Wheats

Puffed Wheat, Malt-O-Meal

Toasted Cinnamon Twists, MaltO-Meal

Honey Crunch Corn Flakes

Mini-Wheats Frosted Bite Size

Toasted Oatmeal Cereal

Honey Graham Squares, Malt-OMeal

Mini-Wheats Frosted Original

Quaker Dinosaur Eggs oatmeal

Toasted Oatmeal, Honey Nut

Mini-Wheats Frosted Raisin

Quaker Fruit and Cream Oatmeal

Toasted oat cereal

Honey Nut Clusters

Mini-Wheats Frosted Strawberry

Quaker Instant Grits, all flavors

Toasties

Honey Nut Heaven

Quaker Multigrain Oatmeal

Honey Nut Shredded Wheat

Mother’s Natural Foods Cereal,
Quaker

Quaker Oatmeal Express

Toasty O’s, Apple Cinnamon, MaltO-Meal

Honey Smacks

Muesli

Honeycomb

Muesli(x)

Quaker Oatmeal Nutrition for
Women

Toasty O’s, Honey and Nut, MaltO-Meal

Honeycomb, strawberry

Multigrain Oatmeal

Quaker Oatmeal Squares

Toasty O’s, Malt-O-Meal

Multigrain cereal

Quisp

Tony’s Cinnamon Crunchers

Instant Grits, all flavors

Tootie Fruities, Malt-O-Meal

Natural Bran Flakes

Raisin Bran Crunch

Total

Jenny O’s

Nature Valley Granola

Raisin Bran, Kellogg’s

Total Brown Sugar & Oats

Just Right

Nature Valley Granola, with fruit
and nuts

Raisin Bran, Post

Total Corn Flakes

Raisin Nut Bran

Total Instant Oatmeal

Raisin bran

Total Raisin Bran

Reese’s Peanut Butter Puffs

Trix

Rice Krispies

Trix, Reduced Sugar

Rice Krispies, Frosted

Rice Krispies, Treats Cereal

Uncle Sam’s Hi Fiber Cereal

Rice bran, uncooked

Under Cover Bears

Nutty Nuggets

Rice cereal

Rice flakes

Waffle Crisp

Rice polishings

Weetabix Whole Wheat Cereal

Oat Bran Cereal, Quaker

Rice, puffed

Wheat Hearts

Oat Bran Flakes, Health Valley

Roman Meal

Oat bran cereal

Wheat bran, unprocessed (miller’s
bran)

Oat bran uncooked

Seven-grain Cereal

Oat cereal

Seven-grain cereal

Oat flakes

Shredded Wheat

Oatmeal

Shredded Wheat ‘N Bran

Oatmeal Crisp

Shredded Wheat Spoon Size

Wheat, puffed, presweetened
with sugar

Oatmeal Crisp with Almonds

Shredded Wheat, 100%

Wheatena

Oatmeal Crisp, Apple Cinnamon

Shredded Wheat, Original

Wheaties

Oatmeal Crisp, Raisin

Smacks

Wheaties Energy Crunch

Oatmeal Squares

Smart Start

Wheaties Raisin Bran

Oatmeal Swirlers

Smorz

Whole wheat cereal

Oats, raw

Special K

Whole wheat, cracked

Oh’s

Special K Fruit & Yogurt

Honey Bunches of Oat with
Strawberry
Honey Bunches of Oats
Honey Bunches of Oats with
Almonds

Just Right with Fruit & Nut
K
Kaboom
Kasha
Kashi
Kashi GOLEAN
Kashi Good Friends
Kashi Good Friends Cinna-Raisin
Crunch
Kashi Heart to Heart Cereal
Kashi Honey Puffed
Kashi Medley
Kashi Organic Promise
Kashi Pilaf
Kashi Pillows
Kashi Seven in the Morning
Kashi, Puffed
Kix
Kix, Berry Berry
L
Life (plain and cinnamon)
Lucky Charms
Lucky Charms, Berry
Lucky Charms, Chocolate

Nesquik
Nestum
Nu System Cuisine Toasted Grain
Circles
Nutri-Grain
Nutri-Grain Golden Wheat and
Raisin

Oh’s, Apple Cinnamon

Special K Red Berries
Special K Vanilla Almond
Strawberry Squares
Sun Country 100% Natural Granola,
with Almonds
Sweet Crunch
Sweet Puffs
T
Tasteeos

Wheat cereal
Wheat germ
Wheat germ, with sugar and honey
Wheat, puffed

Zoom

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

File Type	application/pdf
File Modified	2012-10-22
File Created	2012-05-22