28 Attachment 26-3 AHS Phase IV Health Follow-up Paper & Pe

26-3. AHS Phase IV Health Follow-Up Paper & Pen Proxy Survey

Form #

Version #

Version date:

ID #

Attachment 26-3: Agricultural Health Study - Phase
IV Follow-Up Proxy Questionnaire

● 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.
● Do not write comments on the form.
● 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.
Like this:  Yes

Not like this:



If you have to change an answer, please mark a single horizontal line through it and
then bubble in the correct answer completely.
Like this:  Yes

Not like this:  YES

When we ask for dates or ages, if you can’t remember the exact year, or how old
the study participant was when something happened, it’s fine to give us your best
guess.
When we ask how many years the study participant did something, please round
to the nearest whole number.
OMB No.: 0925-0406
Expiration Date: 09/30/2016
Collection of this information is authorized by The Public Health Service A ct(4
2 USC 285l). Rights of study participants are protected by The Privacy Act of
1974. Participation is voluntary, and there are no penalties for not participating or withdrawing from the study at any time. Refusal to participate will not affect
your benefits in any way. The information collected in this study will be kept private to the extent provided by law. Names and other identifiers will not appear in
any report of the study. Information provided will be combined for all study participants and reported as summaries. You are being contacted by mail to
complete this health follow-up survey on behalf of the Agricultural Health Study cohort member because continued involvement can help us learn more about
how agricultural and environmental factors may affect the health of farmers and their families.
Public reporting burden for this collection of information is estimated to average 10 - 15 minutes per response, including the time for reviewing instructions,
searching existing data sources, gathering and maintaining the data needed, and completing and reviewing the collection of information. An agency may not
conduct or sponsor, and a person is not required to respond to, a collection of information unless it displays a currently valid OMB control number.
Send comments regarding this burden estimate or any other aspect of this collection of information, including suggestions for reducing this burden to: NIH,
Project Clearance Branch, 6705 Rockledge Drive, MSC 7974, Bethesda, MD 20892-7974, ATTN: PRA (0925-0406). Do not return the completed form to this
address.

1

A1.

Did he/she smoke a total of 100 cigarettes or more during his/her lifetime?



〇 No

Go to A5

〇 Yes


A2.

How old was he/she when he/she first started smoking cigarettes?
|__|__|__|
Age

A3.

How old was he/she when he/she last smoked cigarettes?
|__|__|__|
Age

A4.

Thinking about all the years that he/she smoked, about how many cigarettes per
day did he/she usually smoke on days when he/she smoked?
|__|__|__|
# Cigarettes/day

A5.

The following questions ask about drinking alcoholic beverages including beer or ale,
wine, wine coolers, champagne, mixed drinks, and liquor.
When you are asked about a “drink,” think about a 12-ounce bottle or can of beer, a 5ounce glass of wine or champagne, one wine cooler, one shot of liquor, or one mixed
drink or cocktail.
Did he/she ever drink any type of alcoholic beverage?



〇 No

Go to A7

〇 Yes


A6.

How old was he/she when he/she last consumed an alcoholic beverage?
|__|__|__|
Age

A7.

About how tall was he/she? Please answer in feet and inches, and round to the nearest
inch.
|__|__|
Feet

|__|__|
Inches

Page 2 of 17

A8.

About how much did he/she weigh?
|__|__|__|
# Pounds

A9.

Has anyone in his/her immediate family related by blood (his/her mother, father,
sisters, brothers, or children) ever been diagnosed with asthma?
〇 No
〇 Yes

A10. Has anyone in his/her immediate family related by blood (his/her mother, father,
sisters, brothers, or children) ever been diagnosed with Parkinson’s Disease?
〇 No
〇 Yes
A11. Has anyone in his/her immediate family related by blood (his/her mother, father,
sisters, brothers, or children) ever had cancer?



〇 No

Go to Health Conditions (on next page)

〇 Yes


A12. What type(s) of cancer? Mark all that apply.
〇 Bladder

〇 Lymphoma

〇 Bone

〇 Melanoma

〇 Brain

〇 Multiple myeloma

〇 Breast

〇 Ovarian

〇 Cervical

〇 Pancreatic

〇 Colon or rectal

〇 Prostate

〇 Esophagus

〇 Stomach

〇 Kidney

〇 Thyroid

〇 Leukemia

〇 Uterine or endometrial

〇 Liver

〇 Don’t know type

〇 Lung

Page 3 of 17

Health Conditions
These questions are about medical conditions. Please only report conditions that were
diagnosed by a doctor or other health professional.
We are interested in what age he/she was diagnosed with a specific condition. If you do not
know the exact age, please give us your best guess.

B1.

Was he/she ever diagnosed with Parkinson’s disease?



〇 No

Go to B6

〇 Yes


B2.

How old was he/she when first diagnosed with Parkinson’s disease?
|__|__|__|
Age

B3.

Was the diagnosis made or confirmed by a neurologist or movement disorder
specialist?
〇 No
〇 Yes

B4.

Did he/she ever take any prescribed medicines for Parkinson’s disease?
Examples include:
Carbidopa or levodopa (brand names such as Sinemet, Stalevo, or Parcopa);
Mirapex or Pramipexole; Requip or Ropinirole; Permax or Pergolide



〇 No

Go to B6

〇 Yes


B5.

Did his/her symptoms ever improve after taking any of these medicines?
〇 No
〇 Yes

Page 4 of 17

B6.

Was he/she ever diagnosed with depression?



〇 No

Go to B8

〇 Yes


B7.

How old was he/she when first diagnosed with depression?
|__|__|__|
Age

B8.

Was he/she ever diagnosed with high blood pressure or hypertension?
(WOMEN: Please do not count this condition if it occurred only during pregnancy.)



〇 No

Go to B10

〇 Yes


B9.

How old was he/she when first diagnosed with high blood pressure or
hypertension?
|__|__|__|
Age

B10. Was he/she ever diagnosed with a heart attack (or myocardial infarction)?



〇 No

Go to B12

〇 Yes


B11. How old was he/she when first diagnosed with a heart attack (or myocardial
infarction)?
|__|__|__|
Age

Page 5 of 17

B12. Was he/she ever diagnosed with heart failure?



〇 No

Go to B14

〇 Yes


B13. How old was he/she when first diagnosed with heart failure?
|__|__|__|
Age

B14. Was he/she ever diagnosed with a stroke? Do not include TIAs or mini-strokes.



〇 No

Go to B16

〇 Yes


B15. How old was he/she when were first diagnosed with a stroke?
|__|__|__|
Age

B16. Was he/she ever diagnosed with asthma?



〇 No

Go to B18

〇 Yes


B17. How old was he/she when first diagnosed with asthma?
|__|__|__|
Age

B18. Was he/she ever diagnosed with Farmer’s Lung?



〇 No

Go to B20

〇 Yes


B19. How old was he/she when first diagnosed with Farmer’s Lung?
|__|__|__|
Age

Page 6 of 17

B20. Was he/she ever diagnosed with idiopathic pulmonary fibrosis?



〇 No

Go to B22

〇 Yes


B21. How old was he/she when first diagnosed with idiopathic pulmonary fibrosis?
|__|__|__|
Age

B22. Was he/she ever diagnosed with emphysema?



〇 No

Go to B24

〇 Yes


B23. How old was he/she when first diagnosed with emphysema?
|__|__|__|
Age

B24. Was he/she ever diagnosed with chronic bronchitis?



〇 No

Go to B26

〇 Yes


B25. How old was he/she when first diagnosed with chronic bronchitis?
|__|__|__|
Age

Page 7 of 17

B26. Was he/she ever diagnosed with chronic obstructive pulmonary disease (COPD)?



〇 No

Go to B28

〇 Yes


B27. How old was he/she when first diagnosed with chronic obstructive pulmonary
disease (COPD)?
|__|__|__|
Age

B28. Was he/she ever diagnosed with diabetes, (WOMEN: other than when pregnant)?



〇 No

Go to B32

〇 Yes


B29. How old was he/she when first diagnosed with diabetes?
|__|__|__|
Age

B30. Did he/she ever take any prescribed medicines for diabetes?



〇 No

Go to B32

〇 Yes


B31. Did he/she ever take insulin?
〇 No
〇 Yes

Page 8 of 17

B32. Was he/she ever diagnosed with thyroid disease or thyroid problems?



〇 No

Go to B39

〇 Yes


B33. Was he/she ever diagnosed with an overactive thyroid (hyperthyroidism)?



〇 No

Go to B36

〇 Yes


B34. How old was he/she when first diagnosed with an overactive thyroid?
|__|__|__|
Age
B35. Was this Graves’ disease or some other type of thyroid condition that
caused the overactive thyroid gland?
〇 Graves’ disease
〇 Other overactive thyroid condition
〇 Don’t know
B36. Was he/she ever diagnosed with an underactive thyroid (hypothyroidism)?



〇 No

Go to B39

〇 Yes


B37. How old was he/she when first diagnosed with an underactive thyroid
(hypothyroidism)?
|__|__|__|
Age
B38. Was this thyroiditis (sometimes called Hashimoto’s thyroiditis) or was this
some other type of thyroid condition that caused the underactive thyroid
gland?
〇 Thyroiditis (also called Hashimoto’s thyroiditis)
〇 Other underactive thyroid condition
〇 Don’t know

Page 9 of 17

B39. Was he/she ever diagnosed with kidney stones?



〇 No

Go to B42

〇 Yes


B40. How old was he/she when first diagnosed with kidney stones?
|__|__|__|
Age
B41. How many times has he/she had kidney stones?
|__|__|__|
# Times

B42. Was he/she ever diagnosed with kidney disease? Do not include kidney stones.



〇 No

Go to B46

〇 Yes


B43. How old was he/she when first diagnosed with kidney disease?
|__|__|__|
Age

B44. Was he/she ever treated with dialysis?
〇 No
〇 Yes

B45. How old was he/she when first treated with dialysis?
|__|__|__|
Age

Page 10 of 17

B46. Was he/she ever diagnosed with rheumatoid arthritis (an autoimmune disease)? Do
not include osteoarthritis (the most common type of arthritis).



〇 No

Go to B50

〇 Yes


B47. How old was he/she when first diagnosed with rheumatoid arthritis?
|__|__|__|
Age

B48. Did he/she see a rheumatologist (a physician who specializes in bone, joint, and
skin diseases) for rheumatoid arthritis?
〇 No
〇 Yes

B49. Has he/she ever taken any of the following medicines for rheumatoid arthritis?
Mark an answer for each row below:

No

Yes

Don’t
know

a. Hydroxychloroquine or chloroquine (Plaquenil),
Methotrexate (Rheumatrex or Trexall)

〇

〇

〇

b. Leuflunomide (Arava), Sulfasalazine (Azulfidine)

〇

〇

〇

c. Biologics, given by infusion or injection, such as
iflixamab (Remicade) adalimumab (Humera),
enteracept (Enbrel), rituximab (Rituxan).
Do not include steroid injections in the joints)

〇

〇

〇

B50. Was he/she ever diagnosed with lupus?



〇 No

Go to B54

〇 Yes


B51. How old was he/she when first diagnosed with lupus?
|__|__|__|
Age

Page 11 of 17

B52. Did he/she see a rheumatologist (a physician who specializes in bone, joint, and
skin diseases) for lupus?
〇 No
〇 Yes

B53. Has he/she ever taken any of the following medicines for lupus?
Mark an answer for each row below:

No

Yes

Don’t
know

a. Hydroxychloroquine or chloroquine (Plaquenil),
Methotrexate (Rheumatrex or Trexall)

〇

〇

〇

b. Azathioprine (Imuran), Cellcept, Cytoxan, or
Cyclosporine

〇

〇

〇

c. Biologics, given by infusion or injection, such as
belimumab (Benlysta). Do not include steroid
injections in the joints or skin)

〇

〇

〇

B54. Was he/she ever diagnosed with Sjögren’s disease?



〇 No

Go to B58

〇 Yes


B55. How old was he/she when first diagnosed with Sjögren’s disease?
|__|__|__|
Age

B56. Did he/she see a rheumatologist (a physician who specializes in bone, joint, and
skin diseases) or ear, nose and throat specialist for Sjögren’s disease?
〇 No
〇 Yes

Page 12 of 17

B57. Has he/she ever taken any of the following medicines for Sjögren’s disease?
Mark an answer for each row below:

No

Yes

Don’t
know

a. Hydroxychloroquine or chloroquine (Plaquenil),
or Methotrexate (Rheumatrex, or Trexall)

〇

〇

〇

b. Pilocarpine (Salagen) or Cevimeline (Evoxac),
or Cyclosporine Opthalmic (Restasis)

〇

〇

〇

c. Biologics, given by infusion or injection, such
as Rituximab (Rituxan)

〇

〇

〇

B58. Was he/she ever diagnosed with sarcoidosis?



〇 No

Go to B60

〇 Yes


B59. How old was he/she when first diagnosed with sarcoidosis?
|__|__|__|
Age

B60. Was he/she ever diagnosed with pesticide poisoning?



〇 No

Go to B63

〇 Yes


B61. How old was he/she when first diagnosed with pesticide poisoning?
|__|__|__|
Age

B62. How many times was he/she poisoned by pesticides?
|__|__|
# Times

Page 13 of 17

B63. Has he/she ever had a head injury requiring medical attention?



〇 No

Go to B67

〇 Yes


B64. Has he/she ever had a head injury that resulted in loss of consciousness (got
knocked out)?



〇 No

Go to B67

〇 Yes


B65. How old was he/she the first time he/she lost consciousness from a head
injury?
|__|__|__|
Age

B66. How many times has he/she had a head injury with loss of
consciousness?
|__|__|
# Times

B67. Has he/she ever had hay fever, seasonal allergies or allergic rhinitis, whether or not it
was diagnosed by a doctor?
〇 No
〇 Yes

B68. Can we contact you again in the future ?
〇 No
〇 Yes



Please go to the next page to fill out the contact information sheet.

Page 14 of 17

Contact Information
We would like to make sure that our records include your accurate contact information should
we need to contact you in the future.
1.

Please provide your updated phone numbers and e-mail address.
Phone Numbers:
HOME:
CELL:
OTHER:

(|__|__|__|)
(|__|__|__|)
(|__|__|__|)

|__|__|__| - |__|__|__|__|
|__|__|__| - |__|__|__|__|
|__|__|__| - |__|__|__|__|

□ Home

What is the best number to reach you?

□ Cell

□ Other

E-mail Address: |__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|
E-mail Address: |__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|
E-mail Address: |__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|
What is your preferred method of contact?

2.

□ Phone

□ Email

□ Mail

Our records indicate that your current address is:
XXXXXXXXXX
XXXXXXXXXX
XXXXXXXXXX
Is this correct?

□
□

No  Please enter corrections in the space provided below
Yes  Question 3

|__|__|__|__|__|__|__|__|__|
Street Number
|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|
Street Name
|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|
City
In what year did you move into your current address?

Page 15 of 17

|__|__|__|__|__|__|
Apt. Number

|__|__|
State

|__|__|__|__|
Year

|__|__|__|__|__|
Zip Code

3.

In case we are unable to reach you, please list the name and contact information for two
people who do not live with you but will know how to reach you in case you move. It is best
to give the name of someone who is about your age or younger.

Person 1:
|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|
First name
|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|
Last name
Relationship to you: ___________________________________________________________

Phone Numbers:
HOME:
CELL:
OTHER:

(|__|__|__|)
(|__|__|__|)
(|__|__|__|)

|__|__|__| - |__|__|__|__|
|__|__|__| - |__|__|__|__|
|__|__|__| - |__|__|__|__|

Address:
|__|__|__|__|__|__|__|__|__|
Street Number
|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|
Street Name
|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|
City

|__|__|__|__|__|__|
Apt. Number

|__|__|
State

|__|__|__|__|__|
Zip Code

Person 2:
|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|
First name
|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|
Last name
Relationship to you: ___________________________________________________________

Page 16 of 17

Person 2 (continued):
Phone Numbers:
HOME:
CELL:
OTHER:

(|__|__|__|)
(|__|__|__|)
(|__|__|__|)

|__|__|__| - |__|__|__|__|
|__|__|__| - |__|__|__|__|
|__|__|__| - |__|__|__|__|

Address:
|__|__|__|__|__|__|__|__|__|
Street Number
|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|
Street Name
|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|
City

4.

|__|__|__|__|__|__|
Apt. Number

|__|__|
State

|__|__|__|__|__|
Zip Code

Lastly, we are interested in hearing about what you would like to gain from the Agricultural
Health Study. What findings are you interested in learning about from this study?

___________________________________________________________________________
___________________________________________________________________________
___________________________________________________________________________
___________________________________________________________________________
___________________________________________________________________________
___________________________________________________________________________

Page 17 of 17