3A Health Status Questionnaire (Male-HSQ)

Prostate, Lung, Colorectal and Ovarian Cancer Screening Trial (PLCO) (NCI)

Attach_03A_HSQ-Male9_24_12

Health Status Questionnaire (HSQ) for PLCO

OMB: 0925-0407

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Version No: 3/05 Form Approved OMB No.: 0925-0407

Expiration Date: xx/xx/xxxx

Prostate, Lung, Colorectal and Ovarian Cancer Screening Trial

Collection of this information is authorized by the Public Health Services ACT, Section 412 (42 USC 285 a-1). Rights of study participants are protected by the Privacy Act of 1974. Participation is voluntary, and there are no penalties for not participating or withdrawing from the study at any time. Refusal to participate will not affect your benefits in any way. The information collected in this study will be kept private under the Privacy Act. Names and other identifiers will be separated from information provided and will not appear in any report of the study. Information provided will be combined for all study participants and reported as statistical summaries.

Public Reporting Burden for this collection of information is estimated to average 5 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 Officer, 6701 Rockledge Drive, MSC 7730, Bethesda, MD 20892-7730. Attention: PRA (0925-0407). Do not return the completed form to this address.


Men's Health Status Questionnaire (HSM)









*HSM*


HSM-C





1. What is your date of birth?


|___|___| / |___|___| / |___|___|___|___|

MO DAY YEAR


PHYSICAL EXAMINATIONS Please complete each question by placing a ( ) in the box next to the answer that best fits your situation. (Mark only one answer for each question.)


2a. Have you ever had an eye examination for glaucoma or cataracts?


1 Yes

2 No (GO TO ITEM 3a)

3 Don't Know (GO TO ITEM 3a)


2b. When did you have your most recent eye examination for glaucoma or cataracts?


1 Within the past year

2 1 to 2 years ago

3 2 to 3 years ago

4 More than 3 years ago

5 Don't Know


2c. What was the main reason you had this eye examination for glaucoma or cataracts?


1 Because of a specific eye problem

2 Follow-up to a previous eye problem

3 Part of a routine physical exam

4 Part of a routine eye exam


Men's Health Status Questionnaire (HSM)


3a. Have you ever had a chest x-ray?


1 Yes

2 No (GO TO ITEM 4a)

3 Don't Know (GO TO ITEM 4a)


3b. When did you have your most recent chest

x-ray?


1 Within the past year

2 1 to 2 years ago

3 2 to 3 years ago

4 More than 3 years ago

5 Don't Know


3c. What was the main reason you had this chest x‑ray?


1 Because of a specific health problem

2 Follow-up to a previous health problem

3 Part of a routine physical exam



4a. Have you ever had a Spiral CT (Computed Tomography) of your chest?



1 Yes

2 No (GO TO ITEM 5a)

3 Don't Know (GO TO ITEM 5a)


4b. When did you have your most recent Spiral CT of your chest?


1 Within the past year

2 1 to 2 years ago

3 2 to 3 years ago

4 More than 3 years ago

5 Don't Know


4c. What was the main reason you had this Spiral CT of your chest?


1 Because of a specific health problem

2 Follow-up to a previous health problem

3 Part of a routine physical exam


5a. Have you ever had a digital rectal examination of the prostate?

1 Yes

2 No (GO TO ITEM 6a)

3 Don't Know (GO TO ITEM 6a)


5b. When did you have your most recent digital rectal examination of the prostate?


1 Within the past year

2 1 to 2 years ago

3 2 to 3 years ago

4 More than 3 years ago

5 Don't Know


5c. What was the main reason you had this digital rectal examination of the prostate?


1 Because of a specific prostate problem

2 Follow up to a previous health problem

3 Part of a routine physical exam

Men's Health Status Questionnaire (HSM)












6a. Have you ever had a barium enema to examine your colon and rectum?


1 Yes

2 No (GO TO ITEM 7a)

3 Don't Know (GO TO ITEM 7a)


6b. When did you have your most recent barium enema to examine your colon and rectum?


1 Within the past year

2 1 to 2 years ago

3 2 to 3 years ago

4 3 to 4 years ago

5 4 to 5 years ago

6 More than 5 years ago

7 Don't Know


6c. What was the main reason you had this barium enema to examine your colon and rectum?


1 Because of a specific health problem

2 Follow-up to a previous health problem

3 Part of a routine physical exam


7a. Have you ever had a flexible sigmoidoscopy examination of your colon and rectum?


1 Yes

2 No (GO TO ITEM 8a)

3 Don't Know (GO TO ITEM 8a)


7b. When did you have your most recent flexible sigmoidoscopy examination of your colon and rectum?


1 Within the past year

2 1 to 2 years ago

3 2 to 3 years ago

4 3 to 4 years ago

5 4 to 5 years ago

6 More than 5 years ago

7 Don't Know

7c. What was the main reason you had this flexible sigmoidoscopy examination of your colon and rectum?

1 Because of a specific health problem

2 Follow-up to a previous health problem

3 Part of a routine physical exam

Men's Health Status Questionnaire (HSM)

8a. Have you ever had a colonoscopic examination of your colon and rectum?

1 Yes

2 No (GO TO ITEM 9a)

3 Don't Know (GO TO ITEM 9a)


8b. When did you have your most recent colonoscopic examination of your colon and rectum?

1 Within the past year

2 1 to 2 years ago

3 2 to 3 years ago

4 3 to 4 years ago

5 4 to 5 years ago

6 More than 5 years ago

7 Don't Know


8c. What was the main reason you had this colonoscopic examination of your colon and rectum?

1 Because of a specific health problem

2 Follow-up to a previous health problem

3 Part of a routine physical exam


9a. Have you ever had a test for blood in the stool?



1 Yes

2 No (GO TO ITEM 10a)

3 Don't Know (GO TO ITEM 10a)


9b. When did you have your most recent test for blood in the stool?


1 Within the past year

2 1 to 2 years ago

3 2 to 3 years ago

4 3 to 4 years ago

5 4 to 5 years ago

6 More than 5 years ago

7 Don't Know


9c. What was the main reason you had this test for blood in the stool?


1 Because of a specific health problem

2 Follow-up to a previous health problem

3 Part of a routine physical exam


10a. Have you ever had your blood pressure checked?

1 Yes

2 No (GO TO ITEM 11a)

3 Don't Know (GO TO ITEM 11a)


10b. When did you have your most recent blood pressure check?


1 Within the past year

2 1 to 2 years ago

3 2 to 3 years ago

4 More than 3 years ago

5 Don't Know


10c. What was the main reason you had this blood pressure check?

1 Because of a specific health problem

2 Follow-up to a previous health problem

3 Part of a routine physical exam



Men's Health Status Questionnaire (HSM)














BLOOD TESTS Please complete each question by placing a (√) in the box next to the answer that best fits your situation. (Mark only one answer for each question.)

11a. Have you ever had a test to check your blood cholesterol level?

1 Yes

2 No (GO TO ITEM 12a)

3 Don't Know (GO TO ITEM 12a)

11b. When did you have your most recent test to check your blood cholesterol level?

1 Within the past year

2 1 to 2 years ago

3 2 to 3 years ago

4 More than 3 years ago

5 Don't Know



11c. What was the main reason you had this test to check your blood cholesterol level?

1 Because of a specific health problem

2 Follow-up to a previous health problem

3 Part of a routine physical exam


12a. Have you ever had a test to check your blood glucose (sugar) level?

1 Yes

2 No (GO TO ITEM 13a)

3 Don't Know (GO TO ITEM 13a)

12b. When did you have your most recent test to check your blood glucose (sugar) level?


1 Within the past year

2 1 to 2 years ago

3 2 to 3 years ago

4 More than 3 years ago

5 Don't Know

12c. What was the main reason you had this test to check your blood glucose (sugar) level?

1 Because of a specific health problem

2 Follow-up to a previous health problem

3 Part of a routine physical exam


Men's Health Status Questionnaire (HSM)

13a. Have you ever had a PSA blood test for prostate cancer?

1 Yes

2 No (GO TO ITEM 14)

3 Don't Know (GO TO ITEM 14)

13b. When did you have your most recent PSA blood test for prostate cancer?

1 Within the past year

2 1 to 2 years ago

3 2 to 3 years ago

4 More than 3 years ago

5 Don't Know

13c. What was the main reason you had this PSA blood test for prostate cancer?


1 Because of a specific prostate problem

2 Follow-up to a previous health problem

3 Part of a routine physical exam

14. Today's Date:


|___|___| / |___|___| / |___|___|___|___|

MO DAY YEAR





Thank you for completing this questionnaire. Please return this form to:


SC Name

Address


FOR OFFICE USE ONLY

1. Method of Administration:

1 Self-Administered

2 Self-Administered with Assistance

3 Telephone Administered

4 In-person Interview

2. If Completion Date was estimated, check: 1



1

File Typeapplication/msword
File TitleForm Approved OMB No.: 0925-0407
AuthorDebra Reames
Last Modified ByVivian Horovitch-Kelley
File Modified2012-09-27
File Created2012-09-17

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