Form 5 Medication Use Questionnaire (MUQ)

OMB No.: 0925-0407
Expires: XX/XX/XXXX

Sam Sample 
1234 Main Street 
Anywhere, ST, 00101‐0000   

July 30, 2012 

Dear Sam Sample: 

We want to thank you for your continued participation in the Prostate, Lung, Colorectal and Ovarian (PLCO) 
Cancer Screening Trial.  We are honored that you take the time to be an active participant in this study. Your 
ongoing participation has been a valuable contribution to the success of this important study and to our fight 
against cancer. 

We use the data we collect to determine if screening for PLCO cancers reduces the number of deaths from 
these diseases and to look for possible causes of cancer. 

The enclosed questionnaire asks for information about your weight, smoking status and use of medications and 
for your permission to obtain health information from electronic records such as Medicare and Medicaid. The 
questionnaire is being sent to every active participant and should take about 15 minutes to complete. When 
you have finished completing the questionnaire, please place it in the enclosed postage‐paid envelope, and 
mail it back to us. 

The validity of our research depends directly on complete and accurate follow‐up information for all study 
members. As always, the information you provide is kept private under the Privacy Act  and is used for medical 
statistical purposes only. 

Thank you again for your participation. The time and care that you have consistently offered to the fight against 
cancer is deeply appreciated. 

Sincerely, 

Barbara O’Brien, MPH 
Project Director, PLCO CDCC 

PRIVACY ACT NOTIFICATION STATEMENT 
Collection of this information is authorized by The Public Health Service Act, Section 412 (42 USC 285 a‐1). Rights of study participants are 
protected by the Privacy Act of 1974. Participation is voluntary, and there are no penalties for not participating or withdrawing from the 
study at any time. Refusal to participate will not affect your benefits in any way. The information collected in this study will be held in 
professional confidence. Names and other identifiers will be separated from information provided and will appear in any report of the 
study. Information provided will be combined for all study participants and reported as statistical summaries. 
NOTIFICATION TO RESPONDENT OF ESTIMATED BURDEN 
Public reporting burden for this collection of information is estimated to average x 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 mat not conduct or sponsor, and a person is not required to respond to, a collection of 
information unless it displays a currently valid OMB control number. Send comments regarding this burden estimate or any other 
aspect of this collection of information, including suggestions for reducing this burden, to: NIH, Project Clearance Branch, 6705 
Rockledge Drive, MSC 7974, Bethesda, MD 20892‐7974, ATTN: PRA (0925‐0407). Do not return the completed form to this address. 

Patient ID No.:12245

Prostate, Lung, Colorectal and Ovarian Cancer Screening Trial
Medication Use Questionnaire
INSTRUCTIONS
 Use a black or blue ink pen or dark pencil. Do not use felt tip markers or gel pens.
 Please answer by putting X in the box. Do not check, dot, fill-in, or half fill-in the box. Try not

to go outside the lines.
 Correct mark:
Incorrect marks: 
x
 If you make a mistake, completely fill in the box for the incorrectly marked answer then mark
the correct box
x
 Correct mark:

/

 Please PRINT IN CAPITAL LETTERS where applicable. Example:

D R U G

Enter only one letter or number per box.
 Please return the survey in the pre-paid envelope.
 Always round down the number of years you have taken a medication. For example, if you
have been taking a prescription medication for 5 years and 6 months, round it down to 5
years and record it in the category option for 3-5 years.
 Please see the consent box at the end of this form and indicate your choice.

Today's Date:

m m

/

d

d

/ 20

y

y

1. Do you currently smoke cigarettes?
YES
NO



On average, how many cigarettes per day?
1-5 cigarettes

6-20

21-30

31-40

More than 40 cigarettes

2. What is your current weight in pounds?
Pounds
Questions 3 to 10 concern drugs (either prescription or over-the-counter) that are
anti-inflammatory or pain relievers.

4. When you took aspirin, what strength or
dose did you usually take?

3. During the last 12 months, about how
often did you usually take aspirin
(examples of aspirin include Bayer,
Bufferin, Anacin and baby aspirin)?
None or less than 1 time per month

None


Adult strength (usually 325 mg)
Baby strength (usually 81 mg)

1 to 3 times per month

Some other strength

1 to 2 times per week

Don't know strength

3 to 6 times per week
7 or more times per week

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1

5. For how many years have you taken
aspirin at least once per week?

8. Not including aspirin, during the last 12
months, did you take any of the following
nonsteroidal anti-inflammatory drugs
(NSAIDs) at least once a week?
(MARK ALL THAT APPLY)

None
Less than 10 years
10 to 19 years

Aleve

20 to 39 years

Celebrex

Indocin

Motrin, Advil, generic Ibuprofen

40 or more years

Naproxyn

6. During the last 12 months, about how
often did you usually take acetaminophen
(examples of acetaminophen include
Tylenol and Panedol)?

Other



None or less than 1 time per month
1 to 3 times per month



9. During the last 12 months, about how often did
you usually take NSAIDs?
None or less than 1 time per month
1 to 3 times per month

1 to 2 times per week
3 to 6 times per week

1 to 2 times per week
3 to 6 times per week

7 or more times per week

7 or more times per week

7. For how many years have you taken
acetaminophen at least once per week?

10. For how many years have you taken NSAIDs
at least once per week?

None

None

Less than 10 years

Less than 10 years

10 to 19 years

10 to 19 years

20 to 39 years

20 to 39 years

40 or more years

40 or more years

For the next set of questions, please include all prescription drugs (including pills, patches, and
injections) you took in the past 30 days (exclude any NSAID drugs you indicated in Question 8).
Please refer to the labels on your prescription containers to help answer these questions. Please
write the drug name as written on your prescription container label. Write the total number of days
per month and the number of years you have taken this medication. PRINT IN CAPITAL LETTERS.
Number of
days taken
per month?

11. Name of Drug #1:
For how many
years?

Less than 1 year
6-10 years

1-2 years
11-15 years

3-5 years
Greater than 15

Number of
days taken
per month?

12. Name of Drug #2:
For how many
years?

Less than 1 year
6-10 years

1-2 years
11-15 years

3-5 years
Greater than 15

Number of
days taken
per month?

13. Name of Drug #3:
For how many
years?

Less than 1 year
6-10 years

1-2 years
11-15 years

3-5 years
Greater than 15

PLEASE CONTINUE TO NEXT PAGE
2



Draft

14. Name of Drug #4:
For how many
years?

Less than 1 year
6-10 years

1-2 years
11-15 years

3-5 years
Greater than 15

15. Name of Drug #5:
For how many
years?

Less than 1 year
6-10 years

1-2 years
11-15 years

3-5 years
Greater than 15

16. Name of Drug #6:
For how many
years?

Less than 1 year
6-10 years

1-2 years
11-15 years

3-5 years
Greater than 15

17. Name of Drug #7:
For how many
years?

Less than 1 year
6-10 years

1-2 years
11-15 years

3-5 years
Greater than 15

18. Name of Drug #8:
For how many
years?

Less than 1 year
6-10 years

1-2 years
11-15 years

3-5 years
Greater than 15

19. Name of Drug #9:
For how many
years?

Less than 1 year
6-10 years

1-2 years
11-15 years

If you need to list additional drugs, please put an X in this box
please list the name, times taken per month, and years of use.

3-5 years
Greater than 15

Number of
days taken
per month?

Number of
days taken
per month?

Number of
days taken
per month?

Number of
days taken
per month?

Number of
days taken
per month?

Number of
days taken
per month?

and on a separate sheet of paper,

20. MEDICARE & MEDICAID
The PLCO Study would like to collect additional information to conduct research into possible
causes of other health conditions besides cancer. We would like to use your personal information
(such as name and date of birth) to obtain health information from electronic records such as
Medicare and Medicaid. Providing this information is voluntary. This will have no effect on any
benefits you may receive. PLCO will maintain confidentiality of your information to the full extent
permitted by law.
Please read the following sentence and check one box to indicate your choice:
I consent to the use of my personal information to obtain health information from electronic records
such as Medicare and Medicaid.
Yes

No
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