Form 2 HSQ Male

Attachment 2a
HSQ Male

Version No: 3/05

Form Approved OMB No.: 0925-0407
Expiration Date: xx/xx/xxxx

Prostate, Lung, Colorectal and Ovarian Cancer Screening Trial
OMB No.: 0925-0407
Expiration Date: xx/xx/20xx
Collection of this information is authorized by the Public Health Services ACT, Section 411 (42 USC 285a). 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 to the extent provided by law.
Names and other identifiers will not appear in any report of the study. Information provided will be combined for all study participants and reported as
summaries. You are being contacted by mail to complete this instrument so that we can learn about the status of your health.
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, 6705 Rockledge Drive, MSC 7974, Bethesda, MD 20892-7974. Attention: PRA (0925-0407).
Do not return the completed form to this address.

Men's Health Status Questionnaire (HSM)

*HSM*
HSM-C
1.

|___|___| / |___|___| / |___|___|___|___|
MO
DAY
YEAR

What is your date of birth?

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.)
1

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

2
3
1
2

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

3
4
5
1

2c.

2

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

3
4

1

Yes
No (GO TO ITEM 3a)
Don't Know (GO TO ITEM 3a)
Within the past year
1 to 2 years ago
2 to 3 years ago
More than 3 years ago
Don't Know
Because of a specific eye problem
Follow-up to a previous eye problem
Part of a routine physical exam
Part of a routine eye exam

Version No: 3/05

Form Approved OMB No.: 0925-0407
Expiration Date: xx/xx/xxxx

Men's Health Status Questionnaire (HSM)
1

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

2
3
1
2

3b. When did you have your most recent chest
x-ray?

3
4
5
1

3c.

What was the main reason you had this chest
x-ray?

2
3

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

1
2
3
1
2

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

3
4
5
1

4c.

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

2
3

1

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

2
3
1
2

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

3
4
5
1

5c.

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

2
3

2

Yes
No (GO TO ITEM 4a)
Don't Know (GO TO ITEM 4a)
Within the past year
1 to 2 years ago
2 to 3 years ago
More than 3 years ago
Don't Know
Because of a specific health problem
Follow-up to a previous health problem
Part of a routine physical exam
Yes
No (GO TO ITEM 5a)
Don't Know (GO TO ITEM 5a)
Within the past year
1 to 2 years ago
2 to 3 years ago
More than 3 years ago
Don't Know
Because of a specific health problem
Follow-up to a previous health problem
Part of a routine physical exam
Yes
No (GO TO ITEM 6a)
Don't Know (GO TO ITEM 6a)
Within the past year
1 to 2 years ago
2 to 3 years ago
More than 3 years ago
Don't Know
Because of a specific prostate problem
Follow up to a previous health problem
Part of a routine physical exam

Version No: 3/05

Form Approved OMB No.: 0925-0407
Expiration Date: xx/xx/xxxx

Men's Health Status Questionnaire (HSM)

1

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

2
3
1
2
3

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

4
5
6
7
1

6c.

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

2
3

1

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

2
3
1
2

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

3
4
5
6
7

7c.

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

1
2
3

3

Yes
No (GO TO ITEM 7a)
Don't Know (GO TO ITEM 7a)
Within the past year
1 to 2 years ago
2 to 3 years ago
3 to 4 years ago
4 to 5 years ago
More than 5 years ago
Don't Know
Because of a specific health problem
Follow-up to a previous health problem
Part of a routine physical exam
Yes
No (GO TO ITEM 8a)
Don't Know (GO TO ITEM 8a)
Within the past year
1 to 2 years ago
2 to 3 years ago
3 to 4 years ago
4 to 5 years ago
More than 5 years ago
Don't Know
Because of a specific health problem
Follow-up to a previous health problem
Part of a routine physical exam

Version No: 3/05

Form Approved OMB No.: 0925-0407
Expiration Date: xx/xx/xxxx

Men's Health Status Questionnaire (HSM)
1

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

2
3
1
2
3

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

4
5
6
7

8c.

9a.

1

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

2
3

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

1
2
3
1
2

9b.

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

3
4
5
6
7

9c.

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

1
2
3
1

10a.

Have you ever had your blood pressure
checked?

2
3
1

10b.

2

When did you have your most recent blood
pressure check?

3
4
5
1

10c.

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

2
3

4

Yes
No (GO TO ITEM 9a)
Don't Know (GO TO ITEM 9a)
Within the past year
1 to 2 years ago
2 to 3 years ago
3 to 4 years ago
4 to 5 years ago
More than 5 years ago
Don't Know
Because of a specific health problem
Follow-up to a previous health problem
Part of a routine physical exam
Yes
No (GO TO ITEM 10a)
Don't Know (GO TO ITEM 10a)
Within the past year
1 to 2 years ago
2 to 3 years ago
3 to 4 years ago
4 to 5 years ago
More than 5 years ago
Don't Know
Because of a specific health problem
Follow-up to a previous health problem
Part of a routine physical exam
Yes
No (GO TO ITEM 11a)
Don't Know (GO TO ITEM 11a)
Within the past year
1 to 2 years ago
2 to 3 years ago
More than 3 years ago
Don't Know
Because of a specific health problem
Follow-up to a previous health problem
Part of a routine physical exam

Version No: 3/05

Form Approved OMB No.: 0925-0407
Expiration Date: xx/xx/xxxx

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.)
1

11a.

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

2
3
1
2

11b.

3

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

4
5

1

11c.

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

2
3

1

12a.

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

2
3

1

12b.

2

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

3
4
5
1

12c.

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

2
3

5

Yes
No (GO TO ITEM 12a)
Don't Know (GO TO ITEM 12a)
Within the past year
1 to 2 years ago
2 to 3 years ago
More than 3 years ago
Don't Know

Because of a specific health problem
Follow-up to a previous health problem
Part of a routine physical exam
Yes
No (GO TO ITEM 13a)
Don't Know (GO TO ITEM 13a)
Within the past year
1 to 2 years ago
2 to 3 years ago
More than 3 years ago
Don't Know
Because of a specific health problem
Follow-up to a previous health problem
Part of a routine physical exam

Version No: 3/05

Form Approved OMB No.: 0925-0407
Expiration Date: xx/xx/xxxx

Men's Health Status Questionnaire (HSM)
1

13a.

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

2
3
1
2

13b.

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

3
4
5

13c.

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

1
2
3

14.

Today's Date:

Yes
No (GO TO ITEM 14)
Don't Know (GO TO ITEM 14)
Within the past year
1 to 2 years ago
2 to 3 years ago
More than 3 years ago
Don't Know
Because of a specific prostate problem
Follow-up to a previous health problem
Part of a routine physical exam

|___|___| / |___|___| / |___|___|___|___|
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

6