Form 3 HSQ Female

Attachment 2b
HSQ Female

Version No: 3/05

Form Approved OMB No.: 0925-0407
Expiry 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.

Women's Health Status Questionnaire (HSW)

*HSW*
HSW-C
1.

What is your date of birth?

PHYSICAL EXAMINATIONS

|___|___| / |___|___| / |___|___|___|___|
MO
DAY
YEAR
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
2

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

3
1
2

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

3
4
5

3c.

1

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

2
3

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
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

Version No: 3/05

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

Women's Health Status Questionnaire (HSW)
1
Yes
4a. Have you ever had a Spiral CT (Computed 2
No (GO TO ITEM 5a)
Tomography) of your chest?
3
Don't Know (GO TO ITEM 5a)
1
2

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

3
4
5

4c.

1

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

2
3
1
2

5a. Have you ever had a pelvic examination?

3
1
2

5b. When did you have your most recent pelvic
examination?

3
4
5

5c.

1

What was the main reason you had this pelvic
examination?

2
3

1

6a. Have you ever had a transvaginal ultrasound
examination?

2
3
1
2

6b. When did you have your most recent transvaginal
ultrasound examination?

3
4
5
1

6c.

What was the main reason you had this
transvaginal ultrasound examination?

2
3

2

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 health problem
Follow-up to a previous health problem
Part of a routine physical exam
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
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
Expiry Date: xx/xx/xxxx

Women's Health Status Questionnaire (HSW)

2

Yes
No (GO TO ITEM 8a)

3

Don't Know (GO TO ITEM 8a)

1

Within the past year
1 to 2 years ago
2 to 3 years ago
More than 3 years ago
Don't Know

1

7a. Have you ever had a mammogram?

2

7b. When did you have your most recent
mammogram?

3
4
5

7c.

1

What was the main reason you had this
mammogram?

2
3
1

8a. Have you ever had a barium enema to examine
your colon and rectum?

2
3

1
2
3

8b. When did you have your most recent barium
enema to examine your colon and rectum?

4
5
6
7

8c.

1

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

2
3

3

Because of a specific breast problem
Follow-up to a previous health problem
Part of a routine physical exam
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

Version No: 3/05

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

Women's Health Status Questionnaire (HSW)
1

9a. Have you ever had a flexible sigmoidoscopy
examination of your colon and rectum?

2
3
1
2
3

9b. When did you have your most recent flexible
sigmoidoscopy examination of your colon and
rectum?

4
5
6
7

9c.

1

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

2
3
1

10a.

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

2
3
1
2

10b.

3

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

4
5
6
7

10c.

1

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

2
3
1

11a.

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

2
3
1
2

11b.

3

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

4
5
6
7

11c.

1

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

2
3

4

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
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 12a)
Don't Know (GO TO ITEM 12a)
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
Expiry Date: xx/xx/xxxx

Women's Health Status Questionnaire (HSW)

1

12a.

Have you ever had your blood pressure
checked?

2
3
1

12b.

2

When did you have your most recent blood
pressure check?

3
4
5
1

12c.

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

BLOOD TESTS

2
3

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

2
3
1
2

13b.

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

3
4
5
1

13c.

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

2
3
1

14a.

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

2
3
1
2

14b.

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

3
4
5

14c.

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

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

13a.

Yes
No (GO TO ITEM 13a)

1

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

2
3

5

Yes
No (GO TO ITEM 14a)
Don't Know (GO TO ITEM 14a)
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 15a)
Don't Know (GO TO ITEM 15a)
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
Expiry Date: xx/xx/xxxx

Women's Health Status Questionnaire (HSW)
1

15a.

Have you ever had a CA-125 blood test for
ovarian cancer?

2
3
1
2

15b.

When did you have your most recent CA-125
blood test for ovarian cancer?

3
4
5
1

15c.

16.

What was the main reason you had this
CA-125 blood test for ovarian cancer?

2
3

Today's Date:

Yes
No (GO TO ITEM 16)
Don't Know (GO TO ITEM 16)
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 problem with your ovaries
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