Form 4 MUQ

Attachment 4
Medication Use Questionniare

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?

and on a separate sheet of paper,

Medication Use Questionnaire

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 PLCO CDCC, 1600 Research Boulevard, RC B16, Rockville, Maryland 20850-3129.
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,

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.
No

PLCO

Prostate, Lung, Colorectal, & Ovarian
CANCER SCREENING TRIAL

Number of
days taken
per month?

20. MEDICARE & MEDICAID

Yes

OMB No.: 0925-0407
Expires: 12/31/2015

NATIONAL CANCER INSTITUTE

Please sign here:
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Barbara O’Brien, MPH
Project Director, PLCO CDCC
OMB No.: 0925-0407 Expiration Date: xx/xx/20xx
Collection of this information is authorized by The Public Health Service Act, Section 411 (42 USC 285 a). 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 tha twe can learn about the medication that you take.
Public reporting burden for this collection of information is estimated to average 15 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 (0925‐0407). Do not return the completed form to this address.

Prostate, Lung, Colorectal and Ovarian Cancer Screening Trial
Medication Use Questionnaire
INSTRUCTIONS
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.

m m

d

d

/ 20

y



y

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

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
10. For how many years have you taken NSAIDs
at least once per week?
None

More than 40 cigarettes

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.

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.

None


For how many
years?

For how many
years?

Adult strength (usually 325 mg)

Don't know strength

3 to 6 times per week

For how many
years?

7 or more times per week
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1-2 years
11-15 years

3-5 years
Greater than 15

Number of
days taken
per month?

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:

Some other strength

1 to 2 times per week

Less than 1 year
6-10 years

12. Name of Drug #2:

Baby strength (usually 81 mg)

1 to 3 times per month

Number of
days taken
per month?

11. Name of Drug #1:

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

Less than 10 years

10 to 19 years
31-40



9. During the last 12 months, about how often did
you usually take NSAIDs?

None

21-30

Indocin

Naproxyn

Less than 10 years
6-20

Celebrex

Motrin, Advil, generic Ibuprofen

40 or more years

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

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

Aleve

20 to 39 years

7 or more times per week

1. Do you currently smoke cigarettes?
YES
NO

None
10 to 19 years

 Please answer by putting X in the box. Do not check, dot, fill-in, or half fill-in the box. Try not

/

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)

Less than 10 years

 Use a black or blue ink pen. Do not use felt tip markers or gel pens.

Today's Date:

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

Less than 1 year
6-10 years

1-2 years
11-15 years

3-5 years
Greater than 15

MORE QUESTIONS ON NEXT PAGE
2

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