Attachment 2A FollowUp Form

SISOMB2016ATTACHMENT2aFOLLOWUPform20160219.pdf

The Sister Study: PHASE 3 Environmental and Generic Risk Factors for Breast Cancer

Attachment 2A FollowUp Form

OMB: 0925-0522

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SISOMB2016 ATTACHMENT 2A: FOLLOW-UP III FORM
Form: 63

Vers:

ID#: SIS

OMB No. 0925-0522

The Sister Study
Health and Medical History
A-Version 1
Instructions:
Please use DARK BLUE OR BLACK BALLPOINT PEN.
Mark only one answer for each question unless otherwise indicated.
Follow the arrow from your response to find the next question.
Only write comments in the spaces provided.
Please keep this questionnaire clean, flat, and dry.
Do not fold or tear any of the pages.
Fill in the bubbles COMPLETELY for each of the questions in this form.

Not like this:

 

Please write responses in all capital letters and numbers without touching the sides of the boxes.

A B C D E F G H I J K L M N O P Q R S T U V W X Y Z

1 2 3 4 5 6 7 8 9 0

When writing dates, please
follow this example.

EXAMPLE: June 7, 2012 =

0 6 / 0 7 / 2 0 1 2
(month)

(day)

(year)

Public reporting burden for this collection of information is estimated to average 40 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 (0925-0522). Do not return the completed form to this address.

U.S. Department of Health and Human Services / National Institutes of Health / National Institute of Environmental Health Sciences

30023

Version 1

Like this:

Your continued participation in the Sister Study is completely voluntary and greatly appreciated. If you
are not comfortable answering a question, just skip it and go to the next one. All information you share
will be kept confidential.

Today's Date:
MONTH

DAY

0
YEAR

GENERAL HEALTH
1.

In the past 24 months, would you say your health has generally been…
excellent,
very good,
good,
fair, or
poor?

In the past 24 months, have you...
No

Yes

a. had a routine physical exam?
b. been to a dentist for a routine check-up or cleaning?
c. had a Pap smear?
d. had a breast exam by a doctor or other health professional?
e. had a screening mammogram?
f. had a screening ultrasound of the breast?
g. had a screening MRI of the breast?
h. had a bone density scan or osteoporosis screening?
i. had a screening colonoscopy or sigmoidoscopy exam?
j. had an ultrasound of the uterus?
k. had an ultrasound of the ovaries?
l. had a flu vaccination (either a flu shot or nasal spray)?
m. had a vaccination for shingles (herpes zoster)?
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Do you have any form of general health care coverage, including health insurance, prepaid plans
such as HMOs, or government plans such as Medicare or Medicaid?
No
Yes

No
Yes

Since January 1, 2012, have you ever been unable to get screening mammography because your
insurance doesn't cover it or you don't have access to screening through your work or other
sources?
No
Yes

What is your current weight (in pounds)?

POUNDS

What is your current height? Please round to the nearest inch.

FEET

INCHES

Since January 1, 2012, how many times have you lost 20 pounds (9 kilograms) or more and then
later gained all the weight back? (If none, please enter "00".)

# TIMES
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Was there a time in the past 12 months when you needed to see a doctor but did not because
of the cost?

FAMILY MEDICAL HISTORY
9.

Since January 1, 2012, were any of your sisters diagnosed with breast cancer for the first time?
No
Yes

9a.

In all, how many of your full or half sisters have ever been diagnosed with breast cancer?
1
2
3
4
5 or more

10.

Since January 1, 2012, have any other close blood relatives of yours been diagnosed with breast
cancer for the first time?
No



GO TO QUESTION 11
10a.

Yes

What is/are the relative(s)’
relationship to you?
(Please mark all that apply.)

Mother
Father
Brother
Daughter
Son
Grandmother
Grandfather
Other relative related
to you by blood

11.

Since January 1, 2012, have any close blood relatives of yours been diagnosed with ovarian
cancer for the first time?
No

Yes



GO TO THE NEXT PAGE, QUESTION 12
11a.

What is/are the relative(s)’
relationship to you?
(Please mark all that apply.)

Sister
Mother
Daughter
Grandmother
Other relative related
to you by blood
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In previous questionnaires, we have asked whether any of your grandparents have had cancer. However,
we did not ask you which grandparent was diagnosed with cancer.
a.
If Yes, at what age were
they diagnosed?

Were any of the following blood relatives
EVER diagnosed with BREAST cancer?
12. Grandmother on mother's side.

14. Grandfather on mother's side.

15. Grandfather on father's side.

I don't know

17. Grandmother on father's side.

I don't know

AGE

a.
If Yes, at what age were
they diagnosed?

Were any of the following blood relatives
EVER diagnosed with OVARIAN cancer?
16. Grandmother on mother's side.

I don't know

AGE

Yes

OR
AGE

Yes

I don't know

AGE

Yes

No
I don't know

I don't know

AGE

Yes

AGE

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13. Grandmother on father's side.

Yes

18.

Have any close blood relatives of yours ever been diagnosed with Parkinson's disease?
No



GO TO QUESTION 19
18a.

Yes

What is/are the relative(s)’
relationship to you?
(Please mark all that apply.)

Mother
Father
Sister
Brother
Daughter
Son
Other relative related
to you by blood

19.

Have any close blood relatives of yours ever been diagnosed with Alzheimer's disease?
No



GO TO QUESTION 20
19a.

Yes

What is/are the relative(s)’
relationship to you?
(Please mark all that apply.)

Mother
Father
Sister
Brother
Daughter
Son
Other relative related
to you by blood

20.

Have any close blood relatives of yours ever been diagnosed with diabetes?
No

Yes



GO TO THE NEXT PAGE, QUESTION 21
20a.

What is/are the relative(s)’
relationship to you?
(Please mark all that apply.)

Mother
Father
Sister
Brother
Daughter
Son
Other relative related
to you by blood
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21.

Have any close blood relatives of yours ever been diagnosed with heart disease?
No



GO TO QUESTION 22
21a.

Yes

What is/are the relative(s)’
relationship to you?
(Please mark all that apply.)

Mother
Father
Sister
Brother

22.

Have any close blood relatives of yours ever had a stroke?
No

Yes



GO TO THE NEXT PAGE, QUESTION 23
22a.

What is/are the relative(s)’
relationship to you?
(Please mark all that apply.)

Mother
Father
Sister
Brother
Daughter
Son
Other relative related
to you by blood

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Daughter
Son
Other relative related
to you by blood

PERSONAL MEDICAL HISTORY
We are interested in changes to your health in the past few years. Please think about your medical
history since January 1, 2012.
Has a doctor or other health
professional told you that you
had...
23. breast cancer? Please
do not include in situ
cancer.
24. ductal (breast)
carcinoma in situ (DCIS)?

25. lobular (breast)
carcinoma in situ (LCIS)?

NEVER OR
BEFORE 1/1/2012

DIAGNOSED
1/1/2012 OR LATER

Never diagnosed

Diagnosed January 1,
2012 or later

Diagnosed before
January 1, 2012
Never diagnosed
Diagnosed before
January 1, 2012
Never diagnosed
Diagnosed before
January 1, 2012
Never diagnosed

26. lung cancer?

Diagnosed before
January 1, 2012
Never diagnosed

27. ovarian cancer?

28. cancer of the uterus or
endometrium? Please do not
include non-cancerous
conditions such as fibroids,
endometriosis, or pre-cancer.
29. cancer of the colon or
rectum?

30. Hodgkin's disease or
Hodgkin's lymphoma?

31. non-Hodgkin’s
lymphoma?

Diagnosed before
January 1, 2012
Never diagnosed
Diagnosed before
January 1, 2012
Never diagnosed
Diagnosed before
January 1, 2012
Never diagnosed
Diagnosed before
January 1, 2012
Never diagnosed
Diagnosed before
January 1, 2012
Never diagnosed

32. leukemia?

Diagnosed before
January 1, 2012

a.
If diagnosed January 1, 2012
or later, what month and
year were you diagnosed?

MONTH

YEAR

Diagnosed January 1,
2012 or later

MONTH

Diagnosed January 1,
2012 or later

MONTH

0
YEAR

/
MONTH

0
YEAR

Diagnosed January 1,
2012 or later

0
YEAR

Diagnosed January 1,
2012 or later

0
YEAR

Diagnosed January 1,
2012 or later

0
YEAR

Diagnosed January 1,
2012 or later

0
YEAR

Diagnosed January 1,
2012 or later

0
YEAR

Diagnosed January 1,
2012 or later

0
YEAR

Diagnosed January 1,
2012 or later

0
YEAR
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Has a doctor or other
health professional told
you that you had...

33. melanoma?

DIAGNOSED
1/1/2012 OR LATER

NEVER OR
BEFORE1/1/2012
Never diagnosed

Diagnosed January 1,
2012 or later

Diagnosed before
January 1, 2012

MONTH

Never diagnosed

Diagnosed January 1,
2012 or later

Diagnosed before
January 1, 2012

0
YEAR

a. MONTH/YEAR DIAGNOSED

MONTH

If diagnosed before
January 1, 2012, was
it... (Please mark all
that apply.)

35. any other type of
cancer not already
listed?

0
YEAR

b. Was it...
(Please mark all
that apply.)

basal cell?

squamous cell?

other?

Never diagnosed

Diagnosed January 1,

a. MONTH/YEAR DIAGNOSED

2012 or later

Diagnosed before
January 1, 2012

MONTH

0
YEAR

b. Please specify what
type of cancer:

If diagnosed before
January 1, 2012, please
specify what type(s) of
cancer:

c. If you were diagnosed
with a second other
type of cancer January
1, 2012 or later, what
month and year were
you diagnosed?

/
MONTH

0
YEAR

d. Please specify what
type of cancer:

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34. skin cancer
(not melanoma)?

a.
If diagnosed January 1, 2012
or later, what month and
year were you diagnosed?

Has a doctor or other
health professional
ever told you that
you had...

36. hypertension
or high blood
pressure?

NO
No

b.
Have you had
this condition
in the past 12
months?

YES
Yes, first diagnosed before January 1, 2012
Yes, first diagnosed
January 1, 2012 or later 

a. What month and year
were you diagnosed?

MONTH

37. angina?

YEAR

a. What month and year
were you diagnosed?

MONTH

38. cardiac
arrhythmia
(irregular
heartbeat)?

a. What month and year
were you diagnosed?

MONTH

Yes, first diagnosed before January 1, 2012
Yes, first diagnosed
January 1, 2012 or later 

YEAR

a. What month and year
were you diagnosed?

/
MONTH

No
Yes

Yes, first diagnosed before January 1, 2012
Yes, first diagnosed
January 1, 2012 or later 

No
Yes

YEAR

/
39. congestive
heart failure?

Yes, first diagnosed before January 1, 2012
Yes, first diagnosed
January 1, 2012 or later 

No
Yes

0
YEAR

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Has a doctor or
other health
professional told
you that you had...
40. a heart
attack or
myocardial
infarction?

NO
No

b.
Have you had another
incident since then?

YES
Yes, my first heart attack was
before January 1, 2012

Yes, my first heart attack was
January 1, 2012 or later

Yes



MONTH

41. a stroke (this
does not
include TIA or
"mini-stroke")?

Yes, my first stroke was
before January 1, 2012

Yes, my first stroke was
January 1, 2012 or later

Yes

MONTH

YEAR



a. What month and year was
your first stroke?

42. a mini-stroke
or TIA
(transient
ischemic
attack)?

c. What month and year was your
most recent heart attack?


c. What month and year was your
most recent stroke?

0
MONTH

YEAR

Yes, my first mini-stroke was
before January 1, 2012

Yes, my first mini-stroke was
January 1, 2012 or later

Yes



a. What month and year was
your first mini-stroke?

MONTH

YEAR


c. What month and year was your
most recent mini-stroke?

0
YEAR

YEAR

MONTH

YEAR

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a. What month and year was
your first heart attack?



Since January 1,
2012, have you
had...

43. a hip
fracture?

44. a wrist
fracture?

45. a spine
(vertebral)
fracture?
46. a rib
fracture?

NEVER OR BEFORE
1/1/2012
Never
Before January 1,
2012
Never
Before January 1,
2012
Never
Before January 1,
2012
Never
Before January 1,
2012

47. Have you ever had a serious head
injury that resulted in unconsciousness,
coma, or hospitalization?

a.
How many times
has this happened
since January 1,
2012?

1/1/2012
OR LATER

January 1,
2012 or later

# TIMES

0
YEAR

MONTH

0
YEAR

MONTH

January 1,
2012 or later

0
YEAR

January 1,
2012 or later

MONTH

January 1,
2012 or later

b.
What was the month
and year that this first
happened since
January 1, 2012?

MONTH

0
YEAR

a.
If yes, how
many times?

b.
Age at first
injury?

c.
Age at most
recent injury?

# TIMES

AGE

Yes

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Has a doctor or other
health professional ever
told you that you had...
48. diabetes?

NO
No

YES
Yes, first diagnosed before January 1, 2012
Yes, first diagnosed January 1, 2012 or later 

a. What month and year
were you diagnosed?

/
MONTH

0
YEAR

Please use a ballpoint pen for this form

b. Do you still have this condition?

No
Yes
c. Do you currently take insulin for diabetes?
No  GO TO 48e
Yes 

d. If yes, when did you first use insulin?

/
MONTH

YEAR

e. Do you currently take other medications for diabetes?
No
Yes  (Please report medications in question 174.)

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Has a doctor or other
health professional
ever told you that
you had...
49. asthma?

NO
No

b.
Have you had
this condition
in the past 12
months?

YES
Yes, first diagnosed before January 1, 2012
Yes, first diagnosed
January 1, 2012 or later  a. What month and year
were you diagnosed?

MONTH

50. depression?

0
YEAR

Yes, first diagnosed before January 1, 2012
Yes, first diagnosed
January 1, 2012 or later  a. What month and year
were you diagnosed?

MONTH

51. periodontal
(gum) disease?

Yes, first diagnosed before January 1, 2012
Yes, first diagnosed
January 1, 2012 or later  a. What month and year
were you diagnosed?

MONTH

No
Yes

YEAR

/
52. lost any adult
teeth due to
disease or decay
(please do not
count wisdom
teeth extractions,
or teeth lost due
to accidents,
violence, or
orthodontistry)?

No
Yes

0
YEAR

No
Yes

Yes, first diagnosed before January 1, 2012
Yes, first diagnosed
January 1, 2012 or later  a. What month and year
were you diagnosed?

/
MONTH

0
YEAR

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Since January 1, 2012, has a
doctor or other health
professional told you that you
had...

53. allergic rhinitis, hay
fever, or seasonal
allergies?

NEVER OR BEFORE
1/1/2012

DIAGNOSED
1/1/2012 OR LATER

Never diagnosed

Diagnosed January 1,
2012 or later

Diagnosed before
January 1, 2012

55. chronic obstructive
pulmonary disease
(COPD)?

Diagnosed January 1,
2012 or later

Diagnosed before
January 1, 2012
Never diagnosed

Diagnosed January 1,
2012 or later

Diagnosed before
January 1, 2012
Never diagnosed

56. Graves' disease?

57. other hyperthyroidism
(overactive thyroid)?

Diagnosed January 1,
2012 or later

Diagnosed before
January 1, 2012
Never diagnosed

Diagnosed January 1,
2012 or later

Diagnosed before
January 1, 2012
Never diagnosed

58. Hashimoto's thyroiditis?

59. other hypothyroidism
(underactive thyroid)?

60. an enlarged thyroid or
goiter?

Diagnosed January 1,
2012 or later

Diagnosed before
January 1, 2012
Never diagnosed

/
MONTH

MONTH

Diagnosed January 1,
2012 or later

Diagnosed before
January 1, 2012

MONTH

0
YEAR

MONTH

0
YEAR

MONTH

0
YEAR

MONTH

0
YEAR

/
MONTH

0
YEAR

MONTH

Never diagnosed

0
YEAR

Diagnosed January 1,
2012 or later

Diagnosed before
January 1, 2012

Please use a ballpoint pen for this form

Never diagnosed
54. emphysema?

a.
If diagnosed January 1, 2012
or later, what month and
year were you diagnosed?

0
YEAR

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Since January 1, 2012, has a
doctor or other health
professional told you that you
had...

61. thyroid nodules?

NEVER OR BEFORE
1/1/2012

DIAGNOSED
1/1/2012 OR LATER

Never diagnosed

Diagnosed January 1,
2012 or later

Diagnosed before
January 1, 2012
62. another thyroid problem?
Please do not include
thyroid cancer.

Never diagnosed

Diagnosed January 1,
2012 or later

Diagnosed before
January 1, 2012

a.
If diagnosed January 1, 2012
or later, what month and
year were you diagnosed?

MONTH

0
YEAR

a. MONTH/YEAR DIAGNOSED

MONTH

0
YEAR

b. Please specify the problem:

Never diagnosed
63. osteoporosis?

Diagnosed before
January 1, 2012

64. osteopenia, or low bone
density?

Never diagnosed

65. osteoarthritis
(age-related arthritis)?

Never diagnosed

Diagnosed January 1,
2012 or later

Diagnosed before
January 1, 2012

Diagnosed January 1,
2012 or later

Diagnosed before
January 1, 2012
Never diagnosed

66. rheumatoid arthritis?

Diagnosed January 1,
2012 or later

Diagnosed before
January 1, 2012
Never diagnosed

67. multiple sclerosis?

68. scleroderma or systemic
sclerosis?

/
MONTH

MONTH

Diagnosed January 1,
2012 or later

Diagnosed before
January 1, 2012

MONTH

0
YEAR

MONTH

0
YEAR

/
MONTH

0
YEAR

MONTH

Never diagnosed

0
YEAR

Diagnosed January 1,
2012 or later

Diagnosed before
January 1, 2012

0
YEAR

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Since January 1, 2012, has a
doctor or other health
professional told you that you
had...

69. systemic lupus
erythematosus (SLE)?

NEVER OR BEFORE
1/1/2012

DIAGNOSED
1/1/2012 OR LATER

Never diagnosed

Diagnosed January 1,
2012 or later

Diagnosed before
January 1, 2012

Diagnosed January 1,
2012 or later

Diagnosed before
January 1, 2012
Never diagnosed

71. Sjögren’s syndrome?

Diagnosed January 1,
2012 or later

Diagnosed before
January 1, 2012
Never diagnosed

72. Crohn’s disease?

Diagnosed January 1,
2012 or later

Diagnosed before
January 1, 2012
Never diagnosed

73. ulcerative colitis?

Diagnosed January 1,
2012 or later

Diagnosed before
January 1, 2012
Never diagnosed

74. shingles?

Diagnosed January 1,
2012 or later

Diagnosed before
January 1, 2012

MONTH

YEAR

MONTH

0
YEAR

MONTH

0
YEAR

MONTH

0
YEAR

MONTH

0
YEAR

/
MONTH

Please use a ballpoint pen for this form

Never diagnosed
70. discoid lupus?

a.
If diagnosed January 1, 2012
or later, what month and
year were you diagnosed?

0
YEAR

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Has a doctor or other
health professional told
you that you had...

75. polyps in the colon or
rectum?

76. polycystic ovarian
syndrome or PCOS?

NEVER OR BEFORE
1/1/2012

DIAGNOSED
1/1/2012 OR LATER

Never diagnosed

Diagnosed January 1,
2012 or later

Diagnosed before
January 1, 2012
Never diagnosed

78. uterine fibroids or fibroid
tumors?

79. gallstones or gallbladder
disease?

80. Parkinson’s disease?

Diagnosed before
January 1, 2012

82. cognitive
impairment?

83. kidney failure requiring
dialysis or transplant?

MONTH

Diagnosed January 1,
2012 or later

Diagnosed before
January 1, 2012

Diagnosed January 1,
2012 or later

Diagnosed before
January 1, 2012

Diagnosed January 1,
2012 or later

Diagnosed before
January 1, 2012

Diagnosed January 1,
2012 or later

Never diagnosed

Diagnosed before
January 1, 2012

MONTH

Diagnosed January 1,
2012 or later

Diagnosed before
January 1, 2012

Diagnosed January 1,
2012 or later

Diagnosed before
January 1, 2012

0
YEAR

/
MONTH

0
YEAR

MONTH

Never diagnosed

0
YEAR

MONTH

Never diagnosed

0
YEAR

Diagnosed January 1,
2012 or later

0
YEAR

MONTH

Never diagnosed

0
YEAR

MONTH

Never diagnosed

0
YEAR

MONTH

Never diagnosed

0
YEAR

MONTH

Diagnosed before
January 1, 2012

81. Alzheimer’s disease?

Diagnosed January 1,
2012 or later

Never diagnosed
77. ovarian cysts?

a.
If diagnosed January 1, 2012
or later, what month and
year were you diagnosed?

0
YEAR
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Has a doctor or other health
professional told you that
you had...
84. kidney stones?

NEVER OR BEFORE
1/1/2012

DIAGNOSED
1/1/2012 OR LATER
Diagnosed January 1,
2012 or later

Never diagnosed
Diagnosed before
January 1, 2012

86. cataracts?

Never diagnosed

Diagnosed January 1,
2012 or later

Diagnosed before
January 1, 2012
Never diagnosed

Never diagnosed

Diagnosed January 1,
2012 or later

Diagnosed before
January 1, 2012

0
YEAR

/
MONTH

0
YEAR

MONTH

Never diagnosed

0
YEAR

MONTH

Never diagnosed

0
YEAR

MONTH

Never diagnosed

0
YEAR

Diagnosed January 1,
2012 or later

Diagnosed before
January 1, 2012
90. deep vein thrombosis, DVT,
or deep vein blood clots in
your legs or somewhere
else?

MONTH

Never diagnosed

0
YEAR

Diagnosed January 1,
2012 or later

Diagnosed before
January 1, 2012

89. pulmonary embolism?

MONTH

Diagnosed before
January 1, 2012

88. macular degeneration?

Diagnosed January 1,
2012 or later

0
YEAR

MONTH

Diagnosed before
January 1, 2012

87. glaucoma?

MONTH

Diagnosed before
January 1, 2012

86a. detached retina?

0
YEAR

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85. gout?

a.
If diagnosed January 1, 2012
or later, what month and
year were you diagnosed?

Endometriosis is a health problem in women in which tissue that looks and acts like the lining of the uterus
grows outside of the uterus. Endometriosis is different from endometrial polyps or endometrial cancer.

91.

Has any doctor told you that you have endometriosis?
No
Yes



GO TO THE NEXT PAGE, QUESTION 94
92. How old were you when you were first diagnosed
with endometriosis?

AGE

Age at
procedure?

Was your endometriosis confirmed by...
93a. Laparoscopy (insertion of a thin, lighted
tube through a small incision in the
abdomen to examine organs)?

93b. Laparotomy (traditional abdominal surgery,
which requires a larger incision)?

93c. Ultrasound?

Yes
AGE

93d. Magnetic Resonance Imaging (MRI)?

Yes
AGE

93e. Hysterectomy for suspected endometriosis?

Yes
AGE

93f. Hysterectomy for other reason?

Yes
AGE

93g. Other, please specify:

Yes
AGE

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94.

Some people experience problems with urinary incontinence, the leakage of urine. In the past 12
months, have you accidentally leaked urine?
No



GO TO THE NEXT PAGE, QUESTION 95

I don't know

Yes

How frequently does this happen?

94b.

How much of a problem, if any,
is/was the urine leakage for you?

A big problem
A small problem
Not a problem

94c.

Have you talked with your doctor
or other health provider about
your urine leakage?

No
Yes

94d.

Have you taken any medications
for your urinary incontinence?

No
Yes

94e.

Have you had any other
treatments for your urinary
incontinence?

No  GO TO QUESTION 95

94f.

Bladder training

If so, what treatments have
you had for your urinary
incontinence?
(Please mark all that apply.)

Yes

Exercises
Surgery
Other, specify:

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Every day
3 - 6 times per week
Once or twice per week
2 - 3 times per month
Once per month
A few times per year

94a.

95.

Have you been told that you have pelvic prolapse? You may have heard it called "cystocele,"
"rectocele," "urethrocele," or "dropped bladder."
No

Yes



GO TO THE NEXT PAGE, QUESTION 96

95a.

Have you had surgery to correct
pelvic prolapse?

95b.

95c.

95d.

95e.

How many surgeries have
you had to correct pelvic
prolapse?

How old were you when you
had your first surgery?

How old were you when you
had your second surgery?

How old were you when you
had your third surgery?

No  GO TO QUESTION 96
Yes

# SURGERIES

AGE

30023

SURGERIES

Since January 1, 2012, have
you had...
96.

gallbladder surgery?

NEVER OR BEFORE
1/1/2012
Never had procedure

97.

98.

balloon angioplasty,
stent placement, or
other procedure to open
or widen a heart artery?
These procedures are
different from the test
used to diagnose a
blockage.

Never had procedure

coronary artery
bypass graft
surgery?

Never had procedure

Had procedure before
January 1, 2012

Had procedure
January 1, 2012
or later

MONTH

YEAR

MONTH

0
YEAR

30023

Please use a ballpoint pen for this form

Had procedure before
January 1, 2012

HAD PROCEDURE
1/1/2012 OR LATER

a.
If you had this procedure
January 1, 2012 or later,
what was the month and
year?

99. Since January 1, 2012, have you experienced any of the following medical
symptoms? (Please mark a response for each item below.)
No

Yes

a. swelling in your wrist, finger, elbow, or knee joints lasting six or more weeks?
b. joint stiffness in the mornings, lasting at least one hour, and for more than six
weeks (do not include stiffness related or due to an injury or surgery)?
c. daily, persistent, troublesome dry eyes for more than 3 months, or a recurrent feeling
of sand or gravel in your eyes, or use of tear substitutes more than 3 times a day?
d. a daily feeling of dry mouth for more than 3 months, or frequent drinking of liquids to
aid in swallowing dry foods, or recurrently or persistently swollen salivary glands?
e. a tremor or trembling in either of your hands?
f. walking or other movements getting noticeably slower?
g. handwriting getting noticeably smaller?
h. difficulty getting started when walking or making other movements?
i. wheezing or whistling in your chest?
j. shortness of breath when hurrying on level ground, or when walking up a slight hill,
or when climbing a flight of stairs at your usual pace?
k. shortness of breath when at rest?
l. shortness of breath when lying down?
m. shortness of breath when walking?
n. swelling (or edema) in your legs?
o. excessive sweating other than due to menopause?
p. unexplained and unintentional weight loss of 10 or more pounds?
q. A problem with sneezing or a runny nose or blocked nose when you did not have a
cold or the flu?

30023

99. Since January 1, 2012, have you experienced any of the following medical
symptoms? (Please mark a response for each item below.)
No

Yes

r. feeling light-headed, dizzy, or weak when standing from sitting or lying down?
s. getting up regularly at night to pass urine?
t. unexplained pains (not due to known conditions such as arthritis)?

100.

Do you suffer from a decrease in or loss of your sense of smell?
No

Yes



GO TO QUESTION 101

100a. How old were you the first time you
noticed this problem?

AGE

100b. Are there any reasons (such as head injury) that
explain the decrease in your sense of smell?
No
Yes, specify:

101. Since January 1, 2012, have you
experienced coughing on most days for
three months or more out of a year?
102. Since January 1, 2012, have you brought
up phlegm on most days for three
months or more out of a year (do not
count phlegm from the nose)?

YES

a.
If yes, for how many years
have you had this symptom?

Yes

1 year
2 or more years

Yes

1 year
2 or more years

30023

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u. dribbling of saliva during daytime?

103.

Since January 1, 2012, have you had a mammogram, breast ultrasound, or breast MRI?
No

Yes



GO TO THE NEXT PAGE, QUESTION 104
103a. How many times did you have a
mammogram, breast ultrasound, or
breast MRI since January 1, 2012?
103b. What was the month and year of
your most recent mammogram,
breast ultrasound, or breast MRI?
103c. Since January 1, 2012, have you
been told you had abnormal
findings on a mammogram, breast
ultrasound, or breast MRI?
103d. What was the month and year
of your most recent test with
abnormal findings?

# TIMES

MONTH

No 

0
YEAR

GO TO THE NEXT PAGE,
QUESTION 104

Yes



MONTH

103e. Which breast showed abnormal
findings at the most recent
test?

Left breast

103f. Were you told this test showed
any of the following?
(Please mark all that apply.)

Breast cysts

YEAR

Right breast
Both breasts

Fibrocystic breasts
Breast calcifications
Dense breasts
Uneven or one-sided densities
Fibroadenoma
Other
Don't know

30023

104.

Since January 1, 2012, have you had a breast cyst or cysts drained (aspirated) or removed?
No



Yes

GO TO QUESTION 105
104a. On how many occasions have you
had this since January 1, 2012?

# OCCASIONS

104b. What was the month and year
of your most recent procedure?
104c. On which breast was the most
recent cyst aspiration or
removal performed?

105.

0
YEAR

Left breast
Right breast
Both breasts

Since January 1, 2012, have you had a needle biopsy to diagnose or rule out a breast condition?
No

Yes



GO TO THE NEXT PAGE, QUESTION 106
105a. On how many occasions have you
had this since January 1, 2012?
105b. What was the month and year
of your most recent procedure?
105c. On which breast was the most
recent needle biopsy performed?

# OCCASIONS

MONTH

0
YEAR

Left breast
Right breast
Both breasts

30023

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MONTH

106.

Since January 1, 2012, have you had a surgical biopsy or a biopsy other than a needle biopsy to
diagnose or rule out a breast condition?
No



GO TO QUESTION 107
106a. On how many occasions have you
had this since January 1, 2012?

Yes

106b. What was the month and year
of your most recent procedure?
106c. On which breast was the most
recent biopsy performed?

107.

# OCCASIONS

MONTH

0
YEAR

Left breast
Right breast
Both breasts

Since January 1, 2012, have you had a breast lump or lumps removed (lumpectomy or excisional
biopsy)?
No

Yes



GO TO THE NEXT PAGE, QUESTION 108

107a. On how many occasions have
you had this since January 1,
2012?
107b. What was the month and year
of your most recent procedure?

107c. On which breast was the most
recent lumpectomy or
excisional biopsy performed?

# OCCASIONS

MONTH

0
YEAR

Left breast
Right breast
Both breasts

30023

Since January 1,
2012, have you had...
108.

a mastectomy
of your
left breast?

NEVER OR
BEFORE
1/1/2012
Never
Yes, before
January 1, 2012

1/1/2012
OR LATER
Yes,
January 1,
2012 or later

b.
If you had this procedure
January 1, 2012 or later,
what was the month and
year?

a.
Why was
this done?

To treat
breast cancer

MONTH

To prevent
breast cancer

0
YEAR

109.

a mastectomy
of your
right breast?

Never
Yes, before
January 1, 2012

Yes,
January 1,
2012 or later

To treat
breast cancer

/
MONTH

To prevent
breast cancer

0
YEAR

Both

Since January 1, 2012,
have you had...
110.

111.

NEVER OR BEFORE
1/1/2012

breast
reconstruction
surgery on your
left breast?

Never

breast
reconstruction
surgery on your
right breast?

Never

Yes, before
January 1, 2012

1/1/2012
OR LATER
Yes, January 1,
2012 or later

Yes, January 1,
2012 or later

a.
If you had this procedure
January 1, 2012 or later, what
was the month and year?

MONTH

b.
Did you have
a silicone gel
implant?

YEAR

Yes

YEAR

Yes

30023

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Both

Since January 1, 2012, were you told you had any of the following after a cyst aspiration, cyst removal,
needle biopsy, surgical biopsy, lumpectomy, or mastectomy?

Since January 1, 2012,
have you had...
112.

113.

NEVER OR
BEFORE
1/1/2012

fibrocystic or benign
nonproliferative changes
within normal range?
For example, cysts, mild
hyperplasia, benign
calcifications, fibrosis, etc.

Never

fibroadenoma?

Never

1/1/2012
OR LATER

Yes, before
January 1, 2012

Yes,
January 1,
2012 or later

a.
If you had this January 1, 2012
or later, what was the month
and year?

MONTH

0
YEAR

b. What type?
Simple fibroadenoma
Complex fibroadenoma
Both
Don't know

30023

Since January 1, 2012, were you told you had any of the following after a cyst aspiration, cyst removal,
needle biopsy, surgical biopsy, lumpectomy, or mastectomy?

Since January 1, 2012,
have you had...
114.

benign breast disease?

NEVER OR
BEFORE
1/1/2012

1/1/2012
OR LATER

Never
Yes, before
January 1, 2012

116.

proliferation without atypia?
For example, sclerosing
adenosis, intraductal
papilloma, moderate
hyperplasia, suspicious
calcifications, etc.
atypical hyperplasia?

Never
Yes, before
January 1, 2012

Yes,
January 1,
2012 or later

MONTH

0
YEAR

MONTH

0
YEAR

MONTH

0
YEAR

b. What type?
Atypical ductal hyperplasia
Atypical lobular hyperplasia
Both
Don't know
117.

118.

ductal carcinoma in situ
(DCIS)?
lobular carcinoma in situ
(LCIS)?

Never
Yes, before
January 1, 2012
Never
Yes, before
January 1, 2012
Never

119.

breast cancer?

Yes, before
January 1, 2012
Never

120.

other changes?

Yes, before
January 1, 2012

Yes,
January 1,
2012 or later
Yes,
January 1,
2012 or later
Yes,
January 1,
2012 or later
Yes,
January 1,
2012 or later

MONTH

YEAR

MONTH

0
YEAR

MONTH

0
YEAR

/
MONTH

0
YEAR

30023

Please use a ballpoint pen for this form

115.

Yes,
January 1,
2012 or later

a.
If you had this January 1, 2012
or later, what was the month
and year?

121.

Regardless of the findings, did you keep a copy of the pathology report(s) from the cyst aspiration,
cyst removal, needle biopsy, surgical biopsy, lumpectomy, or mastectomy that you are willing to
share with us?
No
Yes 

PLEASE INCLUDE A COPY WITH YOUR COMPLETED QUESTIONNAIRE.

Not applicable

Since January 1, 2012,
have you had...
122.

123.

breast reduction
surgery on your
left breast?

Never

breast reduction
surgery on your
right breast?

Never

Since January 1, 2012,
have you had...
124.

125.

NEVER OR
BEFORE 1/1/2012

1/1/2012
OR LATER

Never

breast
enlargement
surgery on your
right breast?

Never

Yes, before
January 1, 2012

1/1/2012
OR LATER
Yes, January 1,
2012 or later

Yes, January 1,
2012 or later

MONTH

a.
If you had this procedure
January 1, 2012 or later, what
was the month and year?

MONTH

0
YEAR

Yes, January 1,
2012 or later

Yes, before
January 1, 2012

breast
enlargement
surgery on your
left breast?

Yes, January 1,
2012 or later

Yes, before
January 1, 2012

NEVER OR BEFORE
1/1/2012

a.
If you had this procedure January
1, 2012 or later, what was the
month and year?

0
YEAR

b.
Did you have
a silicone gel
implant?

YEAR

Yes

YEAR

Yes

30023

Since January 1, 2012,
have you had...
126.

a breast implant
surgically removed
from your left
breast?

Never

a breast implant
surgically removed
from your right
breast?

Never

Yes, before
January 1, 2012

1/1/2012
OR LATER
Yes, January 1,
2012 or later

MONTH

Yes, January 1,
2012 or later

0
YEAR

/
MONTH

0
YEAR

b.
Was this a
silicone gel
implant?
No
Yes

No
Yes

MENSTRUAL HISTORY

127a. Have you had a menstrual period or pregnancy in the past 10 years?
No



GO TO PAGE 39, QUESTION 128

Yes  GO TO THE NEXT PAGE, QUESTION 127b1

30023

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127.

NEVER OR BEFORE
1/1/2012

a.
If you had this procedure
January 1, 2012 or later,
what was the month and year?

127b1.

Are you currently pregnant or breastfeeding?
No



Yes 
127b2.

GO TO NEXT QUESTION, 127b2
GO TO PAGE 36, QUESTION 127h
Have you had a menstrual period in the past 12 months?
No



ANSWER BOX A BELOW

Yes



ANSWER BOX B ON THE NEXT PAGE

BOX A
THIS BOX IS FOR WOMEN WHO HAVE NOT HAD A MENSTRUAL PERIOD IN THE PAST 12 MONTHS AND
ARE NOT PREGNANT OR BREASTFEEDING. ALL OTHERS GO TO QUESTION 127e.
127c. Why did your periods stop? Please choose one response that best
describes your situation.
My periods stopped on their own (naturally).
My periods stopped on their own but I began taking hormone replacement therapy
before my periods fully stopped.
My periods stopped after my uterus or ovaries were removed
(be sure to answer questions 147 and 148).
My periods stopped due to radiation or chemotherapy.
My periods stopped due to medicine that causes the ovaries to make less hormones or
medicine that has this as a side effect.
My periods stopped because I am taking the kind of birth control pills that
make me not have periods.
My periods stopped for some other reason, please describe:

127d. What month and year did you have your last menstrual period or how old were you
when you had your last menstrual period?

/
MONTH

OR
YEAR

AGE

GO TO PAGE 36, QUESTION 127h
30023

BOX B
THIS BOX IS FOR WOMEN WHO HAVE HAD A MENSTRUAL PERIOD IN THE PAST 12 MONTHS.
127e. When was your last menstrual period?

/
MONTH

0
YEAR

Please use a ballpoint pen for this form

127f. What statement best describes you?
My periods have not stopped and I am not taking hormones.
My periods have not stopped but I am taking hormones.
My periods stopped temporarily but restarted when I
stopped taking birth control pills.

GO TO PAGE 36,
QUESTION 127h

My periods stopped temporarily, but I have had episodes of
bleeding since the time when I started taking hormones.
My periods stopped temporarily but restarted when I began
taking hormone replacement therapy.
OR
My periods stopped sometime in the last 12 months.



GO TO QUESTION 127g

127g. Why did your periods stop? Please choose one response that best
describes your situation.
My periods stopped on their own (naturally).
My periods stopped on their own but I began taking hormone replacement
therapy before my periods fully stopped.
My periods stopped after my uterus or ovaries were removed
(be sure to answer questions 147 and 148).
My periods stopped due to radiation or chemotherapy.
My periods stopped due to medicine that causes the ovaries to make
less hormones or medicine that has this as a side effect.
My periods stopped because I am taking the kind of birth control pills that
make me not have periods.
My periods stopped for some other reason, please describe:

30023

REPRODUCTIVE HISTORY AND HORMONES
127h. Have you had a pregnancy since January 1, 2012?
No

Yes



GO TO PAGE 38, QUESTION 127o

127h1.

Are you currently pregnant?

127h2.

How many times have you been
pregnant since January 1, 2012
(including your current
pregnancy, if you are pregnant
now)?

No
Yes

# TIMES

30023

THIS SECTION IS FOR WOMEN WHO HAVE BEEN PREGNANT SINCE JANUARY 1, 2012.
ALL OTHERS GO TO THE NEXT PAGE, QUESTION 127o.

127i. How did this
pregnancy end?

FIRST PREGNANCY

SECOND PREGNANCY

(since January 1, 2012)

Still pregnant now
Single live birth
Twins, live births
Other multiple live births



Stillbirth(s)

127m. How long did you
breastfeed (or
have you been
breastfeeding)?

# BABIES

Miscarriage

Induced abortion

Molar or ectopic pregnancy

Less than 8 weeks
8 to 12 weeks
13 to 16 weeks
17 to 24 weeks
25 to 36 weeks

37 to 41 weeks

42 weeks or more

MONTH

YEAR

MONTH

YEAR

Still pregnant now

Single male
Single female
Multiple
Don't know



# MALES # FEMALES

Less than one month
1-3 months
4-6 months
7-12 months

GO TO 127n

Single male
Single female
Multiple
Don't know



# MALES # FEMALES

Less than one month
1-3 months
4-6 months
7-12 months

GO TO 127n

13-24 months

More than 24 months

Did not breastfeed/
not applicable



127n. Are you still
breastfeeding?

Stillbirth(s)

Miscarriage

127k. What month and
year did this
pregnancy end?

127l. What was the sex
of the baby or
babies?



GO TO NEXT
PREGNANCY OR
QUESTION 127o

Did not breastfeed/
not applicable

Yes

IF YOU HAVE HAD MORE THAN 2 PREGNANCIES SINCE JANUARY 1, 2012,
PLEASE ANSWER THE SAME QUESTIONS FOR EACH PREGNANCY AND
RECORD YOUR ANSWERS ON A SEPARATE SHEET OF PAPER.
37



GO TO NEXT
PREGNANCY OR
QUESTION 127o

30023

Please use a ballpoint pen for this form

127j. How many weeks
did this pregnancy
last (or has it
lasted so far, if
now pregnant)?

# BABIES

Still pregnant now
Single live birth
Twins, live births
Other multiple live births

127o. Since January 1, 2012, have you used any hormonal birth control?
No

 GO TO THE NEXT PAGE, QUESTION 128

Yes

Since January 1, 2012, have
you used...

127p. birth control pills?

NO
No

YES

If yes, how many months in
all have you used this since
January 1, 2012?

Are you currently
using this?

No
Yes

Yes
# MONTHS

127q. birth control patches?

No
Yes

Yes
# MONTHS

127r.

a hormonal IUD
(intrauterine device)?

No
Yes

Yes
# MONTHS

127s.

a Norplant implant?

No
Yes

Yes
# MONTHS

127t.

a Nuva Ring?

No
Yes

Yes
# MONTHS

127u. Depo Provera?

No
Yes

Yes
# MONTHS

127v.

any other hormonal
birth control?

No
Yes

Yes
# MONTHS

30023

The next questions are about female hormone products often used for hormone replacement therapy (HRT).

Since January 1, 2012, have you used...
128.

130.

131.

132.

133.

134.

a combined pill containing both
estrogen and progesterone (such
as Prempro)?

an estrogen-only pill (such as
Premarin) with no additional
progesterone in any form?

an estrogen pill (such as Premarin)
and a separate progesterone pill (such
as Provera) or progesterone shot?

an estrogen-only patch with no
additional progesterone in any form?

a patch containing both estrogen and
progesterone (such as Combipatch)?

an estrogen-only patch and a separate
progesterone pill or progesterone shot?

progesterone alone
(not for birth control)?

YES

Yes
# MONTHS

b.
Do you currently
use this female
hormone
product(s)?

No
Yes

30023

Please use a ballpoint pen for this form

129.

a.
If yes, how many
months in all have
you used this since
January 1, 2012?

Since January 1, 2012,
have you used...
135.

vaginal estrogen creams,
rings, or suppositories?

If yes, how many months in all have
you used this since January 1, 2012?

YES

Yes

a.
# MONTHS

b. Do you currently use this female hormone
product(s)?
No
Yes
c. Does this product also contain progesterone?
No
Yes
Don't know
d. Did you also take progesterone in another
form (e.g., patch, pill) during the time you
were using vaginal estrogen creams, rings,
or suppositories?
No
Yes

136.

any other estrogen
products, including
“natural” estrogens?

Yes

a.
# MONTHS

b. Do you currently use this female hormone
product(s)?
No
Yes
c. Which of the following products have you
used since January 1, 2012?
(Please mark all that apply.)
Capsules
Gel or cream applied to the skin
Injection
Liquid
Troche or lozenge (dissolved
under the tongue)
Other

30023

Since January 1, 2012, have
you used...
137.

138.

YES

Yes

b.
Do you
currently
use this?

No
Yes

Treat breast cancer
Prevent breast cancer
Another reason

No
Yes

Treat breast cancer
Prevent breast cancer
Another reason

No
Yes

Treat breast cancer
Prevent breast cancer
Another reason

No
Yes

Treat breast cancer
Prevent breast cancer
Another reason

# MONTHS

ospemifene or
Osphena?

raloxifene or
Evista?

Yes
# MONTHS

Yes

c.
Why did
you use
this?

# MONTHS

Aromatase inhibitors:
140.

141.

142.

anastrozole or
Arimidex?

exemestane or
Aromasin?

letrozole or Femara?

Yes
# MONTHS

143.

other aromatase
inhibitor?

Yes
# MONTHS

No
Yes

Please specify:

144.

Herceptin?

No
Yes

Yes
# MONTHS

145.

testosterone?

No
Yes

Yes
# MONTHS

146.

Estratest?

No
Yes

Yes
# MONTHS

30023

Please use a ballpoint pen for this form

139.

tamoxifen or
Nolvadex?

a.
If yes, how many
months in all have
you used this since
January 1, 2012?

Since January 1, 2012,
have you had...
147.

a hysterectomy
(surgical
removal of
the uterus)?

NEVER OR BEFORE
1/1/2012
Never had procedure
Had procedure before
January 1, 2012

HAD PROCEDURE
1/1/2012 OR LATER
Had procedure
January 1, 2012
or later

If you had this procedure
January 1, 2012 or later, what
was the month and year?
a. MONTH/YEAR HAD PROCEDURE

MONTH

0
YEAR

b. Did you have all or part of
either of your ovaries
removed at the same time
you had the hysterectomy?
No  GO TO QUESTION 148
Yes
c. Did you have...
both ovaries completely removed?
one ovary and part of the
other ovary removed?
one ovary removed?
part of one or part of both
ovaries removed?
d. Did you have all or part of
either ovary left after this
surgery?
No
Yes
148.

a separate
surgery to
remove part or
all of one or
both ovaries
(but not your
uterus)?

Never had procedure
Had procedure before
January 1, 2012

Had procedure
January 1, 2012
or later

a. MONTH/YEAR HAD PROCEDURE

MONTH

0
YEAR

b. Did you have...
both ovaries completely removed?
one ovary and part of the
other ovary removed?
one ovary removed?
part of one or part of both
ovaries removed?
c. Did you have all or part of
either ovary left after this
surgery?
No
Yes
30023

SYMPTOMS OF MENOPAUSE OR PRE-MENOPAUSE
a.
On average, how would
you rate the severity of
your symptom?

Have you ever experienced
any of the following
menopausal symptoms?

YES

b.
Have you
experienced any
symptoms in the
past 12 months?

vaginal dryness

Yes

Mild
Moderate
Severe

No
Yes

150.

night sweats

Yes

Mild
Moderate
Severe

No
Yes

Have you ever
experienced any of the
following menopausal
symptoms?

151.

hot flashes

YES

Yes

a.
On average,
how would
you rate the
severity of
your symptom?
Mild
Moderate
Severe

b.
How often
did/do these
occur in a
typical week?

1 time or less
2-3 times
4 or more times
Don't know

c. For about how many total
months or years did you
have hot flashes?
Less than 3 months
3 to less than 6 months
6 months to less
than 1 year
1 to less than 2 years
2 to less than 3 years
3 or more years
d. Have you experienced any
symptoms in the past 12
months?
No
Yes

30023

Please use a ballpoint pen for this form

149.

MEDICATIONS
Since January 1, 2012, have you used any
prescription medicines to treat or to prevent...

YES

a.
If yes, are you
currently taking this?

152.

hypertension (high blood pressure)?

Yes

No
Yes, regularly
Yes, as needed

153.

high cholesterol?

Yes

No
Yes, regularly
Yes, as needed

154.

cardiac arrhythmia (irregular heartbeat)?

Yes

No
Yes, regularly
Yes, as needed

155.

congestive heart failure?

Yes

No
Yes, regularly
Yes, as needed

Yes

No
Yes, regularly
Yes, as needed

Yes

No
Yes, regularly
Yes, as needed

Yes

No
Yes, regularly
Yes, as needed

Yes

No
Yes, regularly
Yes, as needed

155a. angina?

156.

diabetes?

157.

thyroid disease?

158.

osteoporosis (bone loss, or bone thinning)?
Do not count calcium or Vitamin D.

30023

Since January 1, 2012, have you used any
prescription medicines to treat or to prevent...

YES

a.
If yes, are you
currently taking this?

rheumatoid arthritis?

Yes

No
Yes, regularly
Yes, as needed

160.

osteoarthritis?

Yes

No
Yes, regularly
Yes, as needed

161.

migraines?

Yes

No
Yes, regularly
Yes, as needed

162.

depression?

Yes

No
Yes, regularly
Yes, as needed

163.

asthma?

Yes

No
Yes, regularly
Yes, as needed

164.

Parkinson’s disease?

Yes

No
Yes, regularly
Yes, as needed

Yes

No
Yes, regularly
Yes, as needed

165.

anxiety?

30023

Please use a ballpoint pen for this form

159.

Since January 1, 2012, have you
regularly (at least once a week for at
least three months in a row) taken...

YES

a.
If yes, for about how long have you taken this
regularly (at least once a week for at least
three months in a row) since January 1, 2012?

166.

acetaminophen (Tylenol)?

Yes

Less than 12 months
1 year
2 years

3 years
4 years
More than 4 years

167.

“baby aspirin” or low-dose
aspirin (100mg/tablet or less)?

Yes

Less than 12 months
1 year
2 years

3 years
4 years
More than 4 years

168.

aspirin or other aspirin containing
products (325 mg/tablet or more)?

Yes

Less than 12 months
1 year
2 years

3 years
4 years
More than 4 years

169.

ibuprofen (such as Advil,
Motrin, Nuprin, etc.)?

Yes

Less than 12 months
1 year
2 years

3 years
4 years
More than 4 years

170.

Celebrex or other COX-2
inhibitors?

Yes

Less than 12 months
1 year
2 years

3 years
4 years
More than 4 years

171.

Aleve or Naprosyn?

Yes

Less than 12 months
1 year
2 years

3 years
4 years
More than 4 years

Yes

Less than 12 months
1 year
2 years

3 years
4 years
More than 4 years

Yes

Less than 12 months
1 year
2 years

3 years
4 years
More than 4 years

46
172.

173.

Relafen, Ketoprofen, Anaprox,
or other non-steroidal
anti-inflammatories?

antibiotics?

30023

c.
On days when you take it, how
many times do you take it?

d.
Are you currently taking this?

1 day per week
2-3 days per week
4-5 days per week
6-7 days per week

1 time per day
2 times per day
3 times per day
4 times per day
5 or more times per day

No
Yes

1 day per week
2-3 days per week
4-5 days per week
6-7 days per week

1 time per day
2 times per day
3 times per day
4 times per day
5 or more times per day

No
Yes

1 day per week
2-3 days per week
4-5 days per week
6-7 days per week

1 time per day
2 times per day
3 times per day
4 times per day
5 or more times per day

No
Yes

1 day per week
2-3 days per week
4-5 days per week
6-7 days per week

1 time per day
2 times per day
3 times per day
4 times per day
5 or more times per day

No
Yes

1 day per week
2-3 days per week
4-5 days per week
6-7 days per week

1 time per day
2 times per day
3 times per day
4 times per day
5 or more times per day

No
Yes

1 day per week
2-3 days per week
4-5 days per week
6-7 days per week

1 time per day
2 times per day
3 times per day
4 times per day
5 or more times
47 per day

No
Yes

1 day per week
2-3 days per week
4-5 days per week
6-7 days per week

1 time per day
2 times per day
3 times per day
4 times per day
5 or more times per day

No
Yes

1 day per week
2-3 days per week
4-5 days per week
6-7 days per week

1 time per day
2 times per day
3 times per day
4 times per day
5 or more times per day

No
Yes

Please use a ballpoint pen for this form

b.
On average, how many days per
week have you taken this?

30023

These last questions are about prescription and non-prescription medications that you currently take
regularly, seasonally, or as needed. This includes all pills, patches, shots, inhaled medicines,
vitamins, and herbal supplements. Please include inhalers, nasal sprays, and other medications even
if you use them occasionally and include all medicines prescribed in once a month or once a year
doses, such as some medicines to prevent osteoporosis, or treat asthma symptoms or migraines.
Do not include:
· Aspirin or other pain medications already reported in previous questions
174.

Do you currently take any prescription or other medications regularly, seasonally, or as needed? Please
include all medicines, including inhalers, nasal sprays, and other medications, even if you use them only
as needed, for example to treat asthma symptoms or migraines.
No



GO TO END, PAGE 52

Yes

TOTAL #

a.
What is/are the name(s) of the prescription or non-prescription medication(s) that
you currently take regularly, seasonally, or as needed?

b.
For how long have you
used this regularly,
seasonally, or as
needed?
Less than 12 months
1 year
2 years
3 years
4 years
More than 4 years

Less than 12 months
1 year
2 years
3 years
4 years
More than 4 years

Less than 12 months
1 year
2 years
3 years
4 years
More than 4 years
30023

d.
On days when you take
it, how many times do
you take it?

Once a month or less
Less than once a week
Once a week
2-3 days a week
4-5 days a week
6-7 days a week

1 time per day
2 times per day
3 times per day
4 times per day
5 or more times per day

Pill

Patch

Inhaler

Spray

Cream

Shot

Liquid

Other

Once a month or less
Less than once a week
Once a week
2-3 days a week
4-5 days a week
6-7 days a week

1 time per day
2 times per day
3 times per day
4 times per day
5 or more times per day

Pill

Patch

Inhaler

Spray

Cream

Shot

Liquid

Other

Once a month or less
Less than once a week
Once a week
2-3 days a week
4-5 days a week
6-7 days a week

1 time per day
2 times per day
3 times per day
4 times per day
5 or more times per day

Pill

Patch

Inhaler

Spray

Cream

Shot

Liquid

Other

Once a month or less
Less than once a week
Once a week
2-3 days a week
4-5 days a week
6-7 days a week

1 time per day
2 times per day
3 times per day
4 times per day
5 or more times per day

Pill

Patch

Inhaler

Spray

Cream

Shot

Liquid

Other

Once a month or less
Less than once a week
Once a week
2-3 days a week
4-5 days a week
6-7 days a week

1 time per day
2 times per day
3 times per day
4 times per day
5 or more times per day

Pill

Patch

Inhaler

Spray

Cream

Shot

Liquid

Other

Please use a ballpoint pen for this form

c.
How often do you take it?

e.
In what form did you take this?
(Please mark all that apply.)

30023

a.
What is/are the name(s) of the prescription or non-prescription medication(s) that you
currently take regularly, seasonally, or as needed? (If you need more space, answer the
same questions for each medication and record it on a separate sheet.)

b.
For how long have you
used this regularly,
seasonally, or as
needed?
Less than 12 months
1 year
2 years
3 years
4 years
More than 4 years

Less than 12 months
1 year
2 years
3 years
4 years
More than 4 years

10.

Less than 12 months
1 year
2 years
3 years
4 years
More than 4 years

11.

Less than 12 months
1 year
2 years
3 years
4 years
More than 4 years

12.

Less than 12 months
1 year
2 years
3 years
4 years
More than 4 years
30023

d.
On days when you take
it, how many times do
you take it?

e.
In what form did you take this?
(Please mark all that apply.)

Once a month or less
Less than once a week
Once a week
2-3 days a week
4-5 days a week
6-7 days a week

1 time per day
2 times per day
3 times per day
4 times per day
5 or more times per day

Pill

Patch

Inhaler

Spray

Cream

Shot

Liquid

Other

Once a month or less
Less than once a week
Once a week
2-3 days a week
4-5 days a week
6-7 days a week

1 time per day
2 times per day
3 times per day
4 times per day
5 or more times per day

Pill

Patch

Inhaler

Spray

Cream

Shot

Liquid

Other

Once a month or less
Less than once a week
Once a week
2-3 days a week
4-5 days a week
6-7 days a week

1 time per day
2 times per day
3 times per day
4 times per day
5 or more times per day

Pill

Patch

Inhaler

Spray

Cream

Shot

Liquid

Other

Once a month or less
Less than once a week
Once a week
2-3 days a week
4-5 days a week
6-7 days a week

1 time per day
2 times per day
3 times per day
4 times per day
5 or more times per day

Pill

Patch

Inhaler

Spray

Cream

Shot

Liquid

Other

Once a month or less
Less than once a week
Once a week
2-3 days a week
4-5 days a week
6-7 days a week

1 time per day
2 times per day
3 times per day
4 times per day
5 or more times per day

Pill

Patch

Inhaler

Spray

Cream

Shot

Liquid

Other

Once a month or less
Less than once a week
Once a week
2-3 days a week
4-5 days a week
6-7 days a week

1 time per day
2 times per day
3 times per day
4 times per day
5 or more times per day

Pill

Patch

Inhaler

Spray

Cream

Shot

Liquid

Other

Once a month or less
Less than once a week
Once a week
2-3 days a week
4-5 days a week
6-7 days a week

1 time per day
2 times per day
3 times per day
4 times per day
5 or more times per day

Pill

Patch

Inhaler

Spray

Cream

Shot

Liquid

Other

Please use a ballpoint pen for this form

c.
How often do you take it?

30023

Please check to see that all questions are answered.

Thank you for completing this questionnaire and for your
continued participation in the Sister Study.
Please mail this form to us at the address below.
A postage-paid envelope is provided.
The Sister Study, 1009 Slater Road, Suite 120, Durham, NC 27703
phone: 1-877-4SISTER (1-877-474-7837); email: [email protected]

If you have a pathology report from a cyst aspiration, cyst
removal, needle biopsy, surgical biopsy, lumpectomy, or
mastectomy that you are willing to share with us, please include
a copy with your completed questionnaire.
Thank you!

30023

Form: 65

Vers:

ID#: SIS

OMB No. 0925-0522

The Sister Study
Lifestyle and
Quality of Life
Version 1

Instructions:
Please use DARK BLUE OR BLACK BALLPOINT PEN.
Mark only one answer for each question unless otherwise indicated.
Follow the arrow from your response to find the next question.
Only write comments in the spaces provided.
Please keep this questionnaire clean, flat, and dry.
Do not fold or tear any of the pages.
Fill in the bubbles COMPLETELY for each of the questions in this form.

Not like this:

 

Please write responses in all capital letters and numbers without touching the sides of the boxes.

A B C D E F G H I J K L M N O P Q R S T U V W X Y Z

1 2 3 4 5 6 7 8 9 0

When writing dates, please
follow this example.

EXAMPLE: June 7, 2012 =

0 6 / 0 7 / 2 0 1 2
(month)

(day)

(year)

Public reporting burden for this collection of information is estimated to average 20 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 (0925-0522). Do not return the completed form to this address.

U.S. Department of Health and Human Services / National Institutes of Health / National Institute of Environmental Health Sciences

35294

Version 1

Like this:

Your continued participation in the Sister Study is completely voluntary and greatly appreciated. If
you are not comfortable answering a question, just skip it and go to the next one. All information
you share will be kept confidential.

Today's Date:
(month)

/
(day)

0
(year)

1. Which of the following best describes your current marital status? Please choose the one response
that best describes your current situation.
Never married
Widowed
Divorced

GO TO QUESTION 2

Separated
Married, civil
union or living
with someone as
though married

1a.

How many years have you been married or living as
though married with this spouse/partner?
OR

Less than 1 year

# YEARS

1b.

Is your spouse/partner a
man or a woman?

Man
Woman

2. Thinking about last year, which of the following best describes your total family income from
all household members before taxes? Please include income from all sources such as annuities,
social security, stocks, alimony, and child support earned in the past year.
Less than $20,000
$20,000 to $49,999
$50,000 to $99,999
$100,000 to $200,000
More than $200,000

3. Last year, how many people, including yourself, were supported by that income?
1
2
3-4
5-6
7-8
More than 8
35294

4. Have you ever smoked at least 10 cigarettes or more?
No



Yes

GO TO QUESTION 5

What is your current
smoking status?

Former smoker
Current smoker

4b.

When did you first start
smoking?

Before 2012
2012
2013
2014
2015

4c.

Did you smoke at least 10
cigarettes since January 1,
2012?

No
Yes

4d.

When did you last smoke?

I am a current smoker
I last smoked in 2015
I last smoked in 2014
I last smoked in 2013
I last smoked in 2012
I last smoked before 2012

4e.

During the years you
smoked, how many days
per week do/did you smoke?

Less than one day per week
1-3 days per week
4-6 days per week
Every day

4f.

During the years you smoked,
how many cigarettes do/did
you usually smoke per day on
the days you smoked?

# CIGARETTES

5. Since January 1, 2012, how many regular smokers have you lived with (not counting
yourself, if you smoke)?
None
1
2
3-4
5 or more
35294

Please use a ballpoint pen for this form

4a.

6. About how many hours or minutes per day are you exposed to other people’s tobacco smoke
(include all locations—home, work, and all other places you spend time where others might
smoke)?
None
Less than 30 minutes
30-59 minutes
1-2 hours
3-4 hours
5-6 hours
7-8 hours
More than 8 hours

6a. Have you ever used an electronic cigarette or e-cigarette, such as NJOY, Blu, or Smoking Everywhere,
even one or two times?
No

Yes



GO TO QUESTION 7

6b.

Do you now use e-cigarettes…

6c.

What brand of e-cigarette
do/did you use?

Every day
Some days
Not at all

BRAND

6d.

About how many disposable
e-cigarettes or e-cigarette
cartridges have you used in
the past year?

None
1 or more puffs but
never a whole one
1-10
11-20
21-50
51-99
100 or more

35294

Since January 1, 2012...

8. have you drunk
white wine or
white wine
coolers?

9. have you drunk
red wine or red
wine coolers?

10. have you drunk
liquor?

YES

Yes

b.
About how often did
you drink alcohol?

c.
On average, how
many drinks did
you have on the
days that you
drank alcohol?

2012
2013
2014
2015

Every day
5-6 times per week
3-4 times per week
2 times per week
Once per week
2-3 times per month
Once per month
A few times per year

7 or more
6
5
4
3
2
1

2012
2013
2014
2015

Every day
5-6 times per week
3-4 times per week
2 times per week
Once per week
2-3 times per month
Once per month
A few times per year

7 or more
6
5
4
3
2
1

2012
2013
2014
2015

Every day
5-6 times per week
3-4 times per week
2 times per week
Once per week
2-3 times per month
Once per month
A few times per year

7 or more
6
5
4
3
2
1

2012
2013
2014
2015
5

Every day
5-6 times per week
3-4 times per week
2 times per week
Once per week
2-3 times per month
Once per month
A few times per year

7 or more
6
5
4
3
2
1

35294

Please use a ballpoint pen for this form

7. have you drunk
beer or other
malt beverages?

a.
IF YES, in which years
since January 1, 2012
did you drink alcohol?
(Please mark all that
apply.)

11.

Since January 1, 2012, did you ever drink four or more alcoholic beverages in a row, in one sitting?
No

Yes

12.



GO TO QUESTION 12

11a.

How often has
this happened since
January 1, 2012?

More than once a week
Once a week
More than once a month
but less than once a week
Once a month
7-11 times a year
4-6 times a year
2-3 times a year
Once a year
Once or twice

Since January 1, 2012, has a doctor or other health professional told you that your drinking
was hurting your health?
No
Yes

35294

Since January 1, 2012...

13. have you drunk
regular coffee?

15. have you drunk
tea or iced tea
(not herbal teas)?

16. have you drunk
decaffeinated tea
or decaffeinated
iced tea?

YES

Yes

b.
About how often did
you drink this?

c.
On average, how
many drinks did
you have on the
days that you
drank this?

2012
2013
2014
2015

Every day
5-6 times per week
3-4 times per week
2 times per week
Once per week
2-3 times per month
Once per month
A few times per year

7 or more
6
5
4
3
2
1

2012
2013
2014
2015

Every day
5-6 times per week
3-4 times per week
2 times per week
Once per week
2-3 times per month
Once per month
A few times per year

7 or more
6
5
4
3
2
1

2012
2013
2014
2015

Every day
5-6 times per week
3-4 times per week
2 times per week
Once per week
2-3 times per month
Once per month
A few times per year

7 or more
6
5
4
3
2
1

2012
2013
2014
2015

Every day
5-6 times per week
3-4 times per week
2 times per week
Once per week
2-3 times per month
Once per month
A few times per year

7 or more
6
5
4
3
2
1

35294

Please use a ballpoint pen for this form

14. have you drunk
decaffeinated
coffee?

a.
IF YES, in which years
since January 1, 2012
did you drink this?
(Please mark all that
apply.)

Since January 1, 2012...

17. have you drunk
regular green tea?

18. have you drunk
decaffeinated
green tea?

19. have you drunk
regular soft
drinks?

20. have you drunk
decaffeinated
soft drinks?

YES

Yes

a.
IF YES, in which years
since January 1, 2012
did you drink this?
(Please mark all that
apply.)

b.
About how often did
you drink this?

c.
On average, how
many drinks did
you have on the
days that you
drank this?

2012
2013
2014
2015

Every day
5-6 times per week
3-4 times per week
2 times per week
Once per week
2-3 times per month
Once per month
A few times per year

7 or more
6
5
4
3
2
1

2012
2013
2014
2015

Every day
5-6 times per week
3-4 times per week
2 times per week
Once per week
2-3 times per month
Once per month
A few times per year

7 or more
6
5
4
3
2
1

2012
2013
2014
2015

Every day
5-6 times per week
3-4 times per week
2 times per week
Once per week
2-3 times per month
Once per month
A few times per year

7 or more
6
5
4
3
2
1

2012
2013
2014
2015

Every day
5-6 times per week
3-4 times per week
2 times per week
Once per week
2-3 times per month
Once per month
A few times per year

7 or more
6
5
4
3
2
1

35294

In all, how many years did you regularly drink...

20d.

20f.

20g.

decaffeinated coffee?

Never
Less than one year
1-5 years
6-10 years
11-15 years
More than 15 years

tea or iced tea (not herbal teas)?

Never
Less than one year
1-5 years
6-10 years
11-15 years
More than 15 years

Please use a ballpoint pen for this form

20e.

regular coffee?

Never
Less than one year
1-5 years
6-10 years
11-15 years
More than 15 years

decaffeinated tea or decaffeinated iced
tea?

35294

In all, how many years did you regularly drink...

20h.

20i.

20j.

20k.

regular green tea?

Never
Less than one year
1-5 years
6-10 years
11-15 years
More than 15 years

decaffeinated green tea?

Never
Less than one year
1-5 years
6-10 years
11-15 years
More than 15 years

regular soft drinks?

Never
Less than one year
1-5 years
6-10 years
11-15 years
More than 15 years

decaffeinated soft drinks?

Never
Less than one year
1-5 years
6-10 years
11-15 years
More than 15 years

35294

We are interested in finding out about the kinds of physical activities that people do as part of
their everyday lives. The questions will ask you about the time you spent being physically active in
the past 7 days. Please answer each question even if you do not consider yourself to be an active
person. Please think about the activities you do at work, as part of your house and yard work, to
get from place to place, and in your spare time for recreation, exercise, or sport.
a.
How much time did you usually
spend doing these physical
activities on one of those days?

During the past 7 days, on how many days did you...

# DAYS



No vigorous
physical activity

22. do moderate physical activities? These take
moderate physical effort and make you breathe
somewhat harder than normal, for example
dancing or doing yard work. Think only about
those physical activities that you did for at least
10 minutes at a time. Do not include walking.

# DAYS

AND

Not sure



No moderate
physical activity

AND
HOURS
PER DAY

# DAYS
OR

No walking for at
least 10 mins

MINUTES
PER DAY

Not sure



23. walk for at least 10 minutes at a time? This
includes walking at work and at home, walking to
travel from place to place, and any other walking
you might do solely for recreation, sport, exercise,
or leisure.

MINUTES
PER DAY

HOURS
PER DAY

AND
MINUTES
PER DAY

HOURS
PER DAY

Not sure

During the past 7 days, how much time did you...
24. usually spend sitting on a weekday? This includes sitting while at
work, at home, while doing course work, and during leisure time. This
may include time spent sitting at a desk, visiting friends, reading, or
sitting or lying down to watch television.

AND
HOURS
PER DAY

MINUTES
PER DAY

Not sure
AND

25. usually spend standing on a weekday? This includes standing
while at work, at home, and during leisure time.

HOURS
PER DAY

MINUTES
PER DAY

Not sure

26. How similar was your level of activity this past week to your usual level of activity?
Less than usual
About the same
More than usual
35294

Please use a ballpoint pen for this form

21. do vigorous physical activities? These take hard
physical effort and make you breathe much harder
than normal, for example running or swimming at
a fast pace. Think only about activities that you
did for at least 10 minutes at a time.

27.

What percentage of your head hair is naturally gray right now? If you color your hair, what
percentage would be gray if you didn't color it? (Please mark one.)
Not gray at all
Less than 25%
25-49%
50-74%
75-99%
100%
I don't know

27a.

How old were you when your hair turned at least 50% gray? (Please mark one.)
My hair is not gray at all or it is less than 50% gray
I was younger than 40
I was between 40 and 49
I was 50 years of age or older
I don't know if my hair is 50% gray
I know my hair is at least 50% gray but I do not know how old I was when it happened
I don't know

35294

27b.

Since January 1, 2012, have you used hair dye to color your hair?
No

Yes



GO TO THE NEXT PAGE, QUESTION 28

In what years did you
do this? (Please mark
all that apply.)

2012
2013
2014
2015

27d.

What color did you
usually use?

Black
Light brown
Dark brown
Light blonde
Dark blonde
Light red
Dark red
Other

27e.

What type of hair dye do you use most often?
Temporary dyes (wash out with a few shampoos)
Semi-permanent dyes (colors are pre-mixed or require
mixing but no other chemicals are added; color fades out
in about 4-8 weeks)
Demi-permanent dyes (other chemicals are mixed with the
color; has strong smell; color fades out)
Permanent dyes (other chemicals are mixed with the color;
has strong smell; color grows out over time, sometimes
leaving your “roots” showing)

35294

Please use a ballpoint pen for this form

27c.

28.

Since January 1, 2012, about how often have you used chemical insect repellents on your skin,
hair, or clothing in the summer? Please do not include products that contain only citronella.
Never
A few times
Once per month
2-3 times per month
Once or twice per week
3-6 times per week
Every day

29.

Since January 1, 2012, about how often have you used chemical insect repellents on your skin,
hair, or clothing the rest of the year? Please do not include products that contain only citronella.
Never
A few times
Once per month
2-3 times per month
Once or twice per week
3-6 times per week
Every day

30.

Since January 1, 2012, about how often have you used an over-the-counter or prescription lice
control product on yourself, or applied it to someone else’s skin, hair, or clothing?
Never
Once
Twice
Three times
Four or more times

35294

31.

Since January 1, 2012, about how often have you used chemical products for fleas or ticks on
any pets in your household?
I don't have any pets

Never

31a.

Which of the following kinds
of chemical flea or tick
treatment was used on your
pets? (Please mark all that
apply.)

Shampoos or dips
Powders
Sprays
Pills
Collars
Topical drops applied
to skin or fur
Any other type of
chemical product

31b.

32.

When flea or tick
treatment was used on
your pets, how often
did you personally
apply them?

All of the time
Most of the time
About half the time
Some of the time
Never
Not applicable

In the past month, on average, how much time per day did you usually spend outdoors in
daylight?
Not at all
Less than 30 minutes
30 minutes or more

35294

Please use a ballpoint pen for this form

Once
Twice
Three times
Four or more
times

GO TO QUESTION 32

33.

Have you moved since January 1, 2012?
No
Yes



GO TO QUESTION 34

33a.

33b.

What month and year did you
move into your current residence?

2
MONTH

0
YEAR

Please write down your current address.

STREET #

STREET NAME

APT #

STATE

33c.

CITY OR TOWN

ZIP CODE

COUNTY

Please write down the name of the nearest cross street (the
street that intersects with the street where you live):

NAME OF NEAREST CROSS STREET

34.

How many lanes of traffic in total does the street where you live have?

# LANES

35.

Which best describes the traffic condition during rush hour on the road where you live?
Little or no traffic
Light traffic, moving at or above the speed limit
Heavy traffic, moving below the speed limit
Congested or "stop and go"
Heavy traffic, moving at or above the speed limit

35294

36.

Since January 1, 2012, about how often has your residence been treated with insecticides or
pesticides to control insects, rodents, or other pests, either inside or around the foundation?
Never



GO TO THE NEXT PAGE, QUESTION 37

36a.

For what kinds of pests
were pest control
chemicals used at your
residence? (Please mark
all that apply.)

Ants
Cockroaches
Bees or wasps
Bed bugs
Flies
Spiders
Mosquitoes
Fleas or ticks, not on pets
Termites
Any other pest such as
moths, silverfish,
caterpillars, mice, rats,
gophers, or moles

36b.

When pest control
chemicals were applied
since January 1, 2012,
about how often did you
personally apply them?

All of the time
Most of the time
About half the time
Some of the time
Never
Not applicable

Every 4-6 months
Every 2-3 months
Monthly
Weekly
Daily

35294

Please use a ballpoint pen for this form

Less than once
a year
Once a year

37.

Since January 1, 2012, about how often was the garden or yard around this residence treated with
weed killers or insecticides, including those labeled organic such as pyrethrum or rotenone?
Never
Not applicable
Less than once
a year
Once a year
Every 4-6 months
Every 2-3 months
Monthly
Weekly
Daily

38.

GO TO QUESTION 38

37a.

When weed killers or
insecticides were used
in the garden or yard
since January 1, 2012,
about how often did you
personally apply them?

All of the time
Most of the time
About half the time
Some of the time
Never
Not applicable

Since January 1, 2012, about how often have you personally used household cleaning solutions
other than dish washing and laundry detergents?
Never
Less than once a year
Once a year
Every 4-6 months
Every 2-3 months
Monthly
Weekly
Daily

39.

How much time per day do you spend traveling by car, van, truck, or bus on most days?
Never



GO TO THE NEXT PAGE, QUESTION 40

Less than 15 minutes
15-29 minutes
30-44 minutes
45-59 minutes
60-89 minutes
90-119 minutes
2-3 hours
4-5 hours
More than 5 hours

39a.

What is the traffic condition that best describes your
travel time (by car, van, truck, or bus) on most days?
Little or no traffic
Light traffic, moving at or above the speed limit
Heavy traffic, moving below the speed limit
Congested or "stop and go"
Heavy traffic, moving at or above the speed limit

35294

40.

How much time per day do you spend traveling by bicycle or motorcycle on most days?
Never



GO TO QUESTION 41

41.

40a.

Little or no traffic
Light traffic, moving at or above the speed limit
Heavy traffic, moving below the speed limit
Congested or "stop and go"
Heavy traffic, moving at or above the speed limit

How much time per day do you spend traveling by foot on most days?
Never



GO TO QUESTION 42

Less than 15 minutes
15-29 minutes
30-44 minutes
45-59 minutes
60-89 minutes
90-119 minutes
2-3 hours
4-5 hours
More than 5 hours

42.

What is the traffic condition that best describes your
travel time by bicycle or motorcycle on most days?

41a.

What is the traffic condition that best describes your
travel time by foot on most days?
Little or no traffic
Light traffic, moving at or above the speed limit
Heavy traffic, moving below the speed limit
Congested or "stop and go"
Heavy traffic, moving at or above the speed limit

Since January 1, 2012 have you had a full-time or part-time job other than homemaking that you
held for at least 12 months (at least 9 months if it was a teaching job)?
No

42a.

Which of the following
best describes your
current situation?

Homemaker
Student
Unemployed
Retired
On medical leave
Disabled

GO TO PAGE 24, QUESTION 56.
Yes



GO TO THE NEXT PAGE, QUESTION 43
35294

Please use a ballpoint pen for this form

Less than 15 minutes
15-29 minutes
30-44 minutes
45-59 minutes
60-89 minutes
90-119 minutes
2-3 hours
4-5 hours
More than 5 hours

IF YOU DID NOT HAVE A JOB SINCE JANUARY 1, 2012, GO TO PAGE 24, QUESTION 56.
43. How many different jobs have you had since January 1, 2012?

# OF JOBS

Please tell us about the jobs you have had since January 1, 2012, starting with the most recent and
working backwards.

44.

When did you first start
this job?

45.

When did you last have
this job?

46.

Where did/do you work?
Please write down the
name of the company
you worked for and the
full street address of
this workplace.

Knowing the name and
addresses of the places you
work will allow us to evaluate
the impact of air pollution and
other factors in the general
environment on your health.
We will never use this
information for any other
purpose and will never contact
your employer.

JOB 1

JO B 2

Before 2012
2012
2013
2014
2015

2012
2013
2014
2015
I still work there

NAME OF COMPANY/PLACE OF WORK

STREET #

STREET NAME

APT #

CITY OR TOWN

STATE

ZIP CODE

COUNTY

ZIP CODE

COUNTY

SPACE IS PROVIDED FOR TWO JOBS. IF YOU HAVE HAD MORE THAN TWO JOBS LASTING 12 MONTHS
OR MORE SINCE JANUARY 1, 2012, PLEASE ANSWER THE SAME QUESTIONS FOR EACH JOB AND
RECORD YOUR ANSWERS ON A SEPARATE SHEET OF PAPER.
35294
20

JOB 1

JO B 2

On a scale from
1 to 5, how
physically
demanding was/is
this job?

1 Not demanding
2
3
4
5 Extremely demanding

48.

On a scale from
1 to 5, how
emotionally
demanding was/is
this job?

1 Not demanding
2
3
4
5 Extremely demanding

49.

What was/is your
job title?

50.

51.

What type of
company or
organization
did/do you work
for? (What do
they make or what
services do they
provide?)

JOB TITLE

INDUSTRY

JOB DUTIES

What are the
specific tasks that
you usually did/do
in your job?

35294

Please use a ballpoint pen for this form

47.

JOB 1

52.

How many hours
per week did/do
you usually work at
this job?

Less than 10
11-20
21-30
31-40
More than 40

START TIME:
53.

What hours of the
day did/do you
usually work at this
job?

JO B 2

Less than 10
11-20
21-30
31-40
More than 40

(mark one)

:
(hr)

(min)

(mark one)

:
(min)

“Work at night”
means any shift
that includes at
least one hour
between midnight
and 2:00 AM.

(min)

STOP TIME:

(mark one)

:
(hr)

(mark one)

(min)

I work(ed) irregular hours
I work(ed) rotating shifts

How many times
per month did/do
you work at night?

(hr)

54.

STOP TIME:

(hr)

START TIME:

I work(ed) irregular hours
I work(ed) rotating shifts

Never
1-2 times/month
3-5 times/month
6-10 times/month

11-15 times/month

More than 15 times per month

35294

JOB 1

JO B 2
NO YES

55.

While working at
this job did/do
you regularly...

NO YES

a. work in dusty conditions?

b. breathe in chemical
vapors or fumes?

c. get chemicals or oils on
your skin or clothing?

d. come in contact with
solvents or degreasers?

e. come in contact with
metal chips, dust, or
fumes?

f. come in contact with
pesticides?

g. use cleaning solutions
(not counting dish or
laundry detergents)?

h. travel in a vehicle?

35294

Please mark the category that best describes your response. There are no right or wrong answers. Try not to
let your response to one statement influence your responses to other statements. Answer according to your
own feelings, rather than how you think “most people” would answer. Don’t take too long thinking over your
replies; your immediate reaction will probably be more accurate than a long thought out response.

56.

Please respond to each item by marking one answer per row.

Excellent

Very
good

Good

Fair

Poor

a. In general, would you say your health is...
b. In general, would you say your quality of life is...
c. In general, how would you rate your physical
health?
d. In general, how would you rate your mental health,
including your mood and your ability to think?
e. In general, how would you rate your satisfaction with
your social activities and relationships?
f. In general, please rate how well you carry out your
usual social activities and roles. (This includes
activities at home, at work and in your community,
and responsibilities as a parent, child, spouse,
employee, friend, etc.)

57.

To what extent are you able to carry out your everyday physical activities such as walking,
climbing stairs, carrying groceries, or moving a chair?
Completely
Mostly
Moderately
A little
Not at all

35294

58.

In the past 7 days, how often have you been bothered by emotional problems such as feeling
anxious, depressed, or irritable?
Never
Rarely
Sometimes
Often
Always

Please use a ballpoint pen for this form

59.

In the past 7 days, how would you rate your fatigue on average?
None
Mild
Moderate
Severe
Extremely severe

60.

In the past 7 days, how would you rate your pain on average?
Worst
imaginable
pain

No
pain

61.

How often during the past 30 days, have you...

Never

Almost
Never

Sometimes

Fairly
often

Very
often

a. felt that you were unable to control the
important things in your life?
b. felt confident about your ability to handle
your personal problems?
c. felt that things were going your way?
d. felt difficulties were piling up so high that
you could not overcome them?
35294

62.

For each statement below, choose the answer that best indicates how often the statement
is true for you.
None of
the time

A little of
the time

Some of
the time

Most of
the time

All of
the time

a. I can count on someone to provide me with
emotional support (someone to confide in
about myself or a problem or who will listen
to me when I need to talk).
b. I can count on someone if I need help (for
example, to take me to the doctor or help
with daily chores if I am sick).
c. There is someone in my immediate family
who believes in me and wants me to succeed.
d. There is someone in my immediate family
who makes me feel important or special.

63.

Over the past 2 weeks, how often have you been bothered by any of the following problems?
Not at all

Several
days

More than
half of
the days

Nearly
every day

a. Little interest or pleasure in doing things.
b. Feeling down, depressed, or hopeless.
c. Feeling nervous, anxious, or on edge.
d. Not being able to stop or control worrying.

35294

Since January 1, 2012, have you
experienced the death of...

64. your spouse or partner?

YES

Yes

a.
Regardless of when this happened, how
much distress or anxiety has this caused
you in the past 4 weeks?
None
A little
A moderate amount
A lot

Yes

Please use a ballpoint pen for this form

65. your sister with breast cancer?

None
A little
A moderate amount
A lot

66. another sibling?

Yes

None
A little
A moderate amount
A lot

67. a child?

Yes

None
A little
A moderate amount
A lot

68. a parent?

Yes

None
A little
A moderate amount
A lot

69. a close personal friend?

Yes

None
A little
A moderate amount
A lot

35294

Since January 1, 2012, have you
experienced...

70. a major illness that was life threatening or
severely disabling to you?

YES

Yes

a.
Regardless of when this happened, how
much distress or anxiety has this caused
you in the past 4 weeks?
None
A little
A moderate amount
A lot

71. the recurrence or worsening of your sister's
breast cancer?

Yes

None
A little
A moderate amount
A lot

72. any other close relative's diagnosis of breast
cancer?

Yes

None
A little
A moderate amount
A lot

73. a major change in, or serious difficulty with
a personal relationship (such as a divorce or
child custody issues)?

74. serious financial or legal troubles such as
arrest or bankruptcy (either you or another
family member whose troubles would directly
affect you)?

Yes

None
A little
A moderate amount
A lot

Yes

None
A little
A moderate amount
A lot

35294

As people age, some begin to worry about their ability to think clearly, make decisions and remember things.
75.

In the last several years…

Yes

Don't
Know

Not
applicable

a. have you noticed that your judgment (e.g., ability to
make decisions and think clearly) is not as good as it
used to be?
b. has your interest in hobbies or activities decreased?

Please use a ballpoint pen for this form

c. have you noticed that you tend to repeat things over and
over (questions, stories, or statements) more often than
you used to?
d. has it become harder to learn how to use a new tool,
appliance or gadget (e.g., computer, microwave,
remote control)?
e. have you noticed more problems remembering the
month or year?
f. have you had more problems handling complicated
financial affairs (e.g., balancing checkbook, preparing
income taxes, paying bills) than you used to?
g. has it become more difficult to remember
appointments?
h. do you notice more daily problems with thinking and/or
memory?

Please answer the following questions about sleep.
76.

To feel your best, how many hours of sleep do you need?

# HOURS

77.

In the past year, how many hours of sleep per night on average did you typically get?

# HOURS

35294

78.

In the past month, how many hours of sleep per night on average did you typically get?

# HOURS

79.

Do you have difficulty falling asleep or staying asleep on a regular basis?
No



79a.

Yes

80.

How many nights in a typical
month do you have trouble
sleeping?

# NIGHTS

Do you ever feel excessively sleepy during the day, even after getting your usual sleep?
No



GO TO QUESTION 81
80a.

Yes

81.

GO TO QUESTION 80

In the past month, about
how often did you feel
excessively sleepy during
the day?

Less than once a week
1 - 2 days per week
3 - 5 days per week
6 days per week or daily

Have you ever been told, or suspected yourself, that you seem to "act out your dreams" while
asleep, for example, punching or flailing arms in the air, making running movements, shouting,
or screaming?
No
Yes



GO TO THE NEXT PAGE, QUESTION 82a
81a.

81b.

Has this happened more than
3 times?

How old were you when you
first knew you did this?

Yes
No

AGE

35294

Do you snore loudly (louder than talking or loud enough to be heard
through closed doors)?

82b.

Has anyone observed you stop breathing during your sleep?

82c.

Do you often feel tired or fatigued during daytime?

82d.

Have you ever been told that you sleepwalk?

How likely are you to doze off or fall asleep in the following situations, in contrast to feeling just tired?
This refers to your usual way of life in recent times. Even if you have not done some of these things
recently try to work out how they would have affected you.
Would
never
doze

82e.

Sitting and reading

82f.

Watching television

82g.

Sitting inactive in a public place (e.g. a theater
or meeting)

82h.

A passenger in a car for an hour without a break

82i.

Lying down to rest in the afternoon when
circumstances permit

82j.

Sitting and talking to someone

82k.

Sitting quietly after a lunch without alcohol

82l.

In a car, while stopped for a few minutes in traffic

Slight
chance of
dozing

Moderate
chance of
dozing

High
chance of
dozing

35294

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82a.

Yes

83.

During the past 12 months, have you taken any vitamins or minerals regularly, at least once a
month?
No, not regularly 

GO TO PAGE 35, QUESTION 95

Yes, fairly regularly

a.
How often?

During the past 12 months,
have you taken...
NO
Multiple Vitamins
84. One A Day, Centrum,
or Thera type multiple
vitamins?

YES
Yes

b.
For how many
years in all have
you taken this?

c.
Did you usually take
types that...

A few days
per month

Less than 1 year
1 year

contain minerals,
iron, zinc, etc.?

1 - 3 days
per week

2 years

do not contain
minerals?

4 - 6 days
per week

3 - 4 years
5 - 9 years
10+ years

Don't know

Every day
85. Stress-tabs or
B-Complex type
multiple vitamins?

Yes

A few days
per month

Less than 1 year
1 year

1 - 3 days
per week

2 years

4 - 6 days
per week

3 - 4 years
5 - 9 years
10+ years

Every day
86. Antioxidant
combination-type
multiple vitamins?

Yes

A few days
per month

Less than 1 year
1 year

1 - 3 days
per week

2 years

4 - 6 days
per week

3 - 4 years
5 - 9 years
10+ years

Every day

35294

During the past 12 months,
have you taken...

a.
How often?
NO

YES

b.
For how many
years in all have
you taken this?

c.
How much did you
usually take on the
days you took it?

Single Vitamins and Minerals
(not part of multiple vitamins)
87. Beta-carotene?

Yes

Less than 1 year
1 year

1 - 3 days
per week

2 years

4 - 6 days
per week

3 - 4 years
5 - 9 years
10+ years

Every day
88. Vitamin C?

Yes

A few days
per month

Less than 1 year
1 year

1 - 3 days
per week

2 years

4 - 6 days
per week

3 - 4 years
5 - 9 years
10+ years

Yes

1000 mg

A few days
per month

Less than 1 year
1 year

1 - 3 days
per week

2 years

4 - 6 days
per week

500 mg

More than

Every day
89. Vitamin E?

Less than
500 mg

3 - 4 years
5 - 9 years
10+ years

Less than
400 IU
400 IU
More than
400 IU

Every day

90. Folic acid, folate?

Yes

A few days
per month

Less than 1 year
1 year

1 - 3 days
per week

2 years

4 - 6 days
per week

3 - 4 years
5 - 9 years
10+ years

Less than
400 mcg
400 mcg
More than
400 mcg

Every day

35294

Please use a ballpoint pen for this form

A few days
per month

During the past 12 months,
have you taken...

a.
How often?
NO

YES

b.
For how many
years in all have
you taken this?

c.
How much did you
usually take on the
days you took it?

Single Vitamins and Minerals
(not part of multiple vitamins)
91. Vitamin D alone?

Yes

A few days
per month

Less than 1 year
1 year

1 - 3 days
per week

2 years

4 - 6 days
per week

3 - 4 years
5 - 9 years
10+ years

Less than
2000 IU
2000 IU
More than
2000 IU

Every day

92. Calcium plus vitamin D?

Yes

A few days
per month

Less than 1 year
1 year

1 - 3 days
per week

2 years

4 - 6 days
per week

3 - 4 years
5 - 9 years
10+ years

Every day

93. Calcium without
vitamin D?

Yes

A few days
per month

Less than 1 year
1 year

1 - 3 days
per week

2 years

4 - 6 days
per week

3 - 4 years
5 - 9 years
10+ years

Less than
600 mg
600 mg
More than
600 mg

Every day
94. Iron?

Yes

A few days
per month

Less than 1 year
1 year

1 - 3 days
per week

2 years

4 - 6 days
per week

3 - 4 years
5 - 9 years
10+ years

Less than
65 mg
65 mg
More than
65 mg

Every day

35294

In the past 12 months, did you
take any of these supplements
at least once a month?
95. Co-enzyme Q10 (CoQ10)

a.
How frequently did
you take this?

YES

Yes

b.
For how many
years in all have
you taken this?

Less than 3 days per week
3 - 5 days per week

Less than 1 year
1 year

6 - 7 days per week

2 years
3 - 4 years
5 - 9 years
10+ years

Yes

Less than 1 year
1 year

6 - 7 days per week

2 years
3 - 4 years
5 - 9 years
10+ years

97. Fish oil (EPA)

Yes

Less than 3 days per week
3 - 5 days per week

Less than 1 year
1 year

6 - 7 days per week

2 years
3 - 4 years
5 - 9 years
10+ years

98. Flax seed/flax seed oil

Yes

Less than 3 days per week
3 - 5 days per week

Less than 1 year
1 year

6 - 7 days per week

2 years
3 - 4 years
5 - 9 years
10+ years

99. Melatonin

Yes

Less than 3 days per week
3 - 5 days per week

Less than 1 year
1 year

6 - 7 days per week

2 years
3 - 4 years
5 - 9 years
10+ years

100. Omega-3 or omega-3
fatty acids

Yes

Less than 3 days per week
3 - 5 days per week

Less than 1 year
1 year

6 - 7 days per week

2 years
3 - 4 years
5 - 9 years
10+ years
35294

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96. Cod liver oil

Less than 3 days per week
3 - 5 days per week

In the past 12 months, did you
take any of these supplements
at least once a month?
101.

Probiotics/acidophilus

a.
How frequently did
you take this?
NO
No

YES
Yes

b.
For how many
years in all have
you taken this?

Less than 3 days per week
3 - 5 days per week

Less than 1 year
1 year

6 - 7 days per week

2 years
3 - 4 years
5 - 9 years
10+ years

102.

Soy isoflavones

Yes

Less than 3 days per week
3 - 5 days per week

Less than 1 year
1 year

6 - 7 days per week

2 years
3 - 4 years
5 - 9 years
10+ years

103.

Turmeric capsules

Yes

Less than 3 days per week
3 - 5 days per week

Less than 1 year
1 year

6 - 7 days per week

2 years
3 - 4 years
5 - 9 years
10+ years

35294

Have you used any of the
following complementary or
alternative practices within
the past 12 months?
104.

Acupuncture

a.
How frequently?
NO
No

YES
Yes

b.
For how many
years in all?

Less than once a month
1-4 times a month

Less than 1 year
1 year

More than 4 times a month

2 years
3 - 4 years
5 - 9 years
10+ years

Yoga

Yes

Less than once a month
1-4 times a month

Less than 1 year
1 year

More than 4 times a month

2 years
3 - 4 years
5 - 9 years
10+ years

106.

Meditation/deep breathing
exercises

Yes

Less than once a month
1-4 times a month

Less than 1 year
1 year

More than 4 times a month

2 years
3 - 4 years
5 - 9 years
10+ years

107.

Massage/therapeutic touch

Yes

Less than once a month
1-4 times a month

Less than 1 year
1 year

More than 4 times a month

2 years
3 - 4 years
5 - 9 years
10+ years

108.

Tai chi/Qi gong

Yes

Less than once a month
1-4 times a month

Less than 1 year
1 year

More than 4 times a month

2 years
3 - 4 years
5 - 9 years
10+ years

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105.

109.

Typically when not taking laxatives, how often do you have bowel movements?
Two or more times per day
Once per day
5 to 6 times per week
3 to 4 times per week
Less than three times per week

110.

How often do you use laxatives, not including fiber or fiber tabs?
Never
Less than once a month
1 - 3 times per month
1 - 3 times per week
4 - 6 times per week
Daily or more

Some people follow special diets as part of their lifestyle. Others change their diet when there is a
change in their life or when they are trying to achieve a goal like losing weight.
Since January 1, 2012, which (if any)
of these special diets have you
followed for longer than a month,
other than during pregnancy?

111.

Vegetarian

a.
How long did you
follow this diet?
NO

YES

Yes

Less than 8 weeks
8 weeks - 1 year
More than 1 year

112.

Vegan

Yes

Less than 8 weeks
8 weeks - 1 year
More than 1 year

113.

Macrobiotic

Yes

Less than 8 weeks
8 weeks - 1 year
More than 1 year

114.

Gluten-free diet

Yes

Less than 8 weeks
8 weeks - 1 year
More than 1 year

115.

Raw food diet

Yes

Less than 8 weeks
8 weeks - 1 year
More than 1 year

b.
Have you followed this
diet for at least a
month in the past year?
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No

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Have you ever had any of the following
weight loss procedures?
116.

NO
No

Lap band

YES

a.
What age did you have this?

Yes
AGE

117.

Bariatric surgery

Yes
AGE

Please use a ballpoint pen for this form
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Please check to see that all questions are answered.

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File Type	application/pdf
Author	sdollar
File Modified	2016-02-19
File Created	2015-07-29