Adult questionnaire

[ATSDR] Human Health Effects of Drinking Water Exposures to Per- and Polyfluoroalkyl Substances (PFAS): A Multi-site Cross-sectional Study

M_Att16_AdltQstnnr_20200714_updt

OMB: 0923-0063

Document [docx]
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Form Approved

OMB No. 0923-0063

Exp. Date 05/31/2023

Attachment 16.



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ATSDR estimates the average public reporting burden for this collection of information as 30 minutes per response, including the time for reviewing instructions, searching existing data/information sources, gathering and maintaining the data/information 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 CDC/ATSDR Information Collection Review Office, 1600 Clifton Road NE, MS D-74, Atlanta, Georgia 30333; ATTN: PRA (0923-0063).

Multi-site Study Adult Questionnaire

Parent Study ID No. |_________________| (alias, if applicable)

Adult Study ID No. |_________________|



Section A: Demographic Information

A1. What is your age in years?

___ years

___Refused to answer



A2. What is your sex:

___Male

___Female

___Refused to answer



A3. Do you consider yourself to be Hispanic or Latino?

___Yes

___No

___Refused to answer


A4. What race do you consider yourself to be? Mark all that apply.

___American Indian or Alaska Native

___Asian

___Black or African American

___Native Hawaiian or Other Pacific Islander

___White

___Refused to answer


A5. What is the highest level of education you completed?

___Less than high school

___Some high school

___High school graduate or equivalent (GED)

___Some university/college

___Technical or trade school

___University/college graduate

___Graduate school or higher


A6. What is your household income (from all sources)?

___Less than $25,000

___$25,000 to $69,000

___$70,000 to $149,000

___More than $150,000

___Don’t know

___Refused to answer


A7. During the last 12 months did you have any kind of health insurance?

___Yes

___No

___Don’t know

___Refused


A8. Did you participate in prior PFAS testing?

___Yes

___No

___Don’t know

___Refused


IF yes:

When did you participate ______Year

Who conducted the testing: _________________


A9. Have you been a firefighter and/or took part in firefighting training exercises while stationed or employed at the nearby military bases?

___Yes

___No

___Don’t know

___Refused


IF yes:

Name of the base: _____________________

Stationed from – to (years): ______________

Employed from – to (years): ______________




Section B: Residential History and Potential Drinking Water Exposures


B1. Is your current address in the study area [enter SITEs/Communities of interest e.g. Hyannis, Ayer public water supply area]?

If not, please go to B3.

If yes, please provide the following information:

Street Apt

City State __ __ Zip Code:


B2 .When did you move to this address?

Month____ Year_______


B3. What is the source of tap water at your current address?

____ Public water system

____ Private well

____ Other: specify ____________________________________

____ Don’t know

____ Refused to answer


B4. Has this source changed while you’ve lived at your current address?

____ Yes

____ No → go to Question B7

____ Don’t know → go to Question B7

____ Refused to answer → go to Question B7


If yes: B5. What was the previous source?

____ Public water system

____ Private well

____ Other: specify ____________________________________

____ Don’t know

____ Refused to answer


B6. When did this change occur?

Month____ Year_______


B7. What proportion of the water you drink at home is tap water versus bottled water at your current address? Include water used for beverages like coffee and tea.

____ All tap, no bottled water

____ Mostly tap, a little bottled water

____ Similar amounts of tap and bottled

____ Mostly bottled, little to no tap

____ All bottled water

____ Don’t know

____ Refused to answer → go to Question B11


B8. Has this pattern changed over time, while you’ve been living at your current address?

____ Yes

____ No → go to Question B11

____ Don’t know → go to Question B11

____ Refused to answer → go to Question B11


B9. If yes: When your water consumption pattern used to be different than it is now, how would you describe it?

____ All tap, no bottled water

____ Mostly tap, a little bottled water

____ Similar amounts of tap and bottled

____ Mostly bottled, little to no tap

____ All bottled water

____ Don’t know

____ Refused to answer


B10. When did this change occur?

Month____ Year_______


B11. Do you currently filter the tap water that you drink at home? [Skip this question if answered “All bottled water” above]

____ Yes

____ No → go to Question B15

____ Don’t know → go to Question B15

____ Refused to answer → go to Question B15


B12. If yes:

Where is the filter located?

____ Filter pitcher

____ Under the kitchen sink

____ In the refrigerator

____ Whole-house filtration

____ Other: specify ____________________________________

____ Don’t know

____ Refused to answer


B13. What type of filter?

____ Granular activated carbon (Brita, PUR, others…)

____ Solid block carbon

____ Reverse osmosis

____ Other: specify ____________________________________

____ Don’t know

____ Refused to answer


B14. Have you always used this type of filter while you’ve lived at your current address?

____ Yes

____ No

____ Don’t know

____ Refused to answer


If no: When did you start using this filter?

Month____ Year_______


B15. On average, how many 8 oz. cups of tap water or beverages prepared with tap water do you currently drink per day at home?

___ Cups

___ Don’t drink tap water

___ Don’t know

___ Refused to answer


Note: 1 cup = 8 oz.; 2 cups = 1 pint (16 oz.); 4 cups = 1 quart (32 oz.); 16 cups = 1 Gallon (128 oz.)


B16. What was your previous address in the designated study area [insert site/community served by PFAS contaminated water]?

Street ______________________________ Apt_______

City ________________________________ State __ __ Zip Code:_________


B17. When did you move into your previous home? Month____ Year_______


B18. What was the main source of tap water at that address?

____ Public water system

____ Private well

____ Other: specify ____________________________________

____ Don’t know

____ Refused to answer

B19. Did this source change while you lived at this address?

____ Yes

____ No → go to Question B22

____ Don’t know → go to Question B22

____ Refused to answer → go to Question B22


B20. If yes: What was the previous source of tap water at that address?

____ Public water system

____ Private well

____ Other: specify ____________________________________

____ Don’t know

____ Refused to answer


B21. When did it change?

Month____ Year_______


B22. What proportion of the water you drank while you lived at that address was tap water versus bottled water? Include water used for beverages like coffee and tea.

____ All tap, no bottled water

____ Mostly tap, a little bottled water

____ Similar amounts of tap and bottled

____ Mostly bottled, little to no tap

____ All bottled water

____ Don’t know

____ Refused to answer


B23. Did this pattern change over time while you lived at this address?

____ Yes

____ No → go to Question B26

____ Don’t know → go to Question B22

____ Refused to answer → go to Question B22


B24. If yes: When your water consumption pattern changed at this address, how would you describe it?

____ All tap, no bottled water

____ Mostly tap, a little bottled water

____ Similar amounts of tap and bottled

____ Mostly bottled, little to no tap

____ All bottled water [IF yes then Go to B6]

____ Don’t know

____ Refused to answer


B25. When did this change occur?

Month____ Year_______


B26. Did you filter the tap water you drank while you lived at this address? [Skip this question if answered “All bottled water” above]

____ Yes

____ No → go to Question B31

____ Don’t know → go to Question B31

____ Refused to answer → go to Question B31


B27. If yes:

Where was the filter located?

____ Filter pitcher

____ Under the kitchen sink

____ In the refrigerator

____ Whole-house filtration

____ Other: specify ____________________________________

____ Don’t know

____ Refused to answer


B28. What type of filter was it?

____ Granular activated carbon

____ Solid block carbon

____ Reverse osmosis

____ Other: specify ____________________________________

____ Don’t know

____ Refused to answer


B29. Did you always use this type of filter while you lived at this address?

____ Yes → go to Question B31

____ No

____ Did not drink tap water → go to Question B31

____ Don’t know → go to Question B31

____ Refused to answer → go to Question B31


B30. If no: When did you start using this filter at this address?

Month____ Year_______


B31. On average, how many 8 oz. cups of tap water or beverages prepared with tap water did you drink per day when you lived at that address?

___ Cups

___Don’t drink tap water

___Don’t know

___Refused to answer


Note: 1 cup = 8 oz.; 2 cups = 1 pint (16 oz.); 4 cups = 1 quart (32 oz.); 16 cups = 1 Gallon (128 oz.)


B32. Have you lived at any other address within the designated study area since January 2000?

___ Yes Go to B8.

___ No → go to Section C

___ Don’t know → go to Section C

___ Refused to answer → go to Section C


B33. Please fill out the table below for these other residences where you lived since January 2000.


Street Address, City, State

Move in (mm/yy)

Average consumption of tap water per day (# cups)

Main source of tap water at this address (public water system or private well?)



















Section C: History of Potential Exposure Modifiers


C1. Have you ever had a blood transfusion?

___Yes → Please specify how many times you had a blood transfusion__________

___No →go to Question C3

___Don’t know →go to Question C3

___Refused to answer →go to Question C3


C2. When did you last have a blood transfusion?

________Month/Year


C3. Have you ever donated blood?

___Yes→ Please specify how many times you have donated blood__________

___No →go to Question D1

___Don’t know →go to Question D1

___Refused to answer →go to Question D1


C4. When did you last donate blood?

________ Month/Year


C5. On average, how often do you donate blood in a year?

__________



Section D: Occupational History


D1. What is your primary occupation?

_______________________________________


D2. On average, how many 8 oz. cups of tap water or beverages prepared with tap water do you currently drink per day at work?

___ Cups

___Don’t drink tap water

___Don’t know

___Refused to answer


Note: 1 cup = 8 oz.; 2 cups = 1 pint (16 oz.); 4 cups = 1 quart (32 oz.); 16 cups = 1 Gallon (128 oz.)


D3. Please fill out the table below for each job that lasted one month or more starting from the present and working back to 2000.

Job information

Job 1

Job 2

Job 3

Job 4

a. Where did you work (City, State)






b. Name of the employer





c. Start date (month, year)





d. End date (month, year)





e. Job title/description






f. Did you work as a firefighter?



If you worked as a firefighter, did you come into contact with firefighting foam used for fires that involve flammable liquids (also known as Class B fires)?

Yes___

No____ go to question g.



Yes____

No____

Don’t know____


Yes___

No____ go to question g.



Yes____

No____

Don’t know____


Yes___

No____ go to question g.



Yes____

No____

Don’t know____


Yes___

No____ go to question g.



Yes____

No____

Don’t know____


g. Was this job in any of the following industries?

Manufacturing of nonstick cookware

____yes ____no

Manufacturing of stain resistant coatings used on carpets, upholstery, and other fabrics

_____yes ____no

Manufacturing of water resistant clothing

_____yes ____no

Manufacturing of nonstick cookware

____yes ____no

Manufacturing of stain resistant coatings used on carpets, upholstery, and other fabrics

_____yes ____no

Manufacturing of water resistant clothing

_____yes ____no

Manufacturing of nonstick cookware

____yes ____no

Manufacturing of stain resistant coatings used on carpets, upholstery, and other fabrics

_____yes ____no

Manufacturing of water resistant clothing

_____yes ____no

Manufacturing of nonstick cookware

____yes ____no

Manufacturing of stain resistant coatings used on carpets, upholstery, and other fabrics

_____yes ____no

Manufacturing of water resistant clothing

_____yes ____no

h. Did you work with or around any chemicals at this job such as solvents, metals, asbestos, or pesticides?

Yes (Please specify the chemical) _______________

No ____

Don’t know___

Yes (Please

specify the chemical) ________________

No___

D DDon’t know___

Yes (Please

specify the chemical) _______________

No____

Don’t know____

Yes (Please specify the chemical) _______________

No____

Don’t know____

i. Did you work with radiation?

Yes___

No____

Yes___

No____

Yes___

No____

Yes___

No____


Job information

Job 5

Job 6

Job 7

Job 8

a. Where did you work (City, State)






b. Name of the employer





c. Start date (month, year)





d. End date (month, year)





e. Job title/description






f. Did you work as a firefighter?



If you worked as a firefighter, did you come into contact with firefighting foam used for fires that involve flammable liquids (also known as Class B fires)?

Yes___

No____ go to question g.



Yes____

No____

Don’t know____


Yes___

No____ go to question g.



Yes____

No____

Don’t know____


Yes___

No____ go to question g.



Yes____

No____

Don’t know____


Yes___

No____ go to question g.



Yes____

No____

Don’t know____


g. Was this job in any of the following industries?

Manufacturing of nonstick cookware

____yes ____no

Manufacturing of stain resistant coatings used on carpets, upholstery, and other fabrics

_____yes ____no

Manufacturing of water resistant clothing

_____yes ____no

Manufacturing of nonstick cookware

____yes ____no

Manufacturing of stain resistant coatings used on carpets, upholstery, and other fabrics

_____yes ____no

Manufacturing of water resistant clothing

_____yes ____no

Manufacturing of nonstick cookware

____yes ____no

Manufacturing of stain resistant coatings used on carpets, upholstery, and other fabrics

_____yes ____no

Manufacturing of water resistant clothing

_____yes ____no

Manufacturing of nonstick cookware

____yes ____no

Manufacturing of stain resistant coatings used on carpets, upholstery, and other fabrics

_____yes ____no

Manufacturing of water resistant clothing

_____yes ____no

h. Did you work with or around any chemicals at this job such as solvents, metals, asbestos, or pesticides?

Yes (Please specify the chemical) _______________

No ____

Don’t know___

Yes (Please

specify the chemical) ________________

No___

D DDon’t know___

Yes (Please

specify the chemical) _______________

No____

Don’t know____

Yes (Please specify the chemical) _______________

No____

Don’t know____

i. Did you work with radiation?

Yes___

No____

Yes___

No____

Yes___

No____

Yes___

No____



Job information

Job 9

Job 10

Job 11

Job 12

a. Where did you work (City, State)





b. Name of the employer





c. Start date (month, year)





d. End date (month, year)





e. Job title/description






f. Did you work as a firefighter?



If you worked as a firefighter, did you come into contact with firefighting foam used for fires that involve flammable liquids (also known as Class B fires)?

Yes___

No____ go to question g.



Yes____

No____

Don’t know____


Yes___

No____ go to question g.



Yes____

No____

Don’t know____


Yes___

No____ go to question g.



Yes____

No____

Don’t know____


Yes___

No____ go to question g.



Yes____

No____

Don’t know____


g. Was this job in any of the following industries?

Manufacturing of nonstick cookware

____yes ____no

Manufacturing of stain resistant coatings used on carpets, upholstery, and other fabrics

_____yes ____no

Manufacturing of water resistant clothing

_____yes ____no

Manufacturing of nonstick cookware

____yes ____no

Manufacturing of stain resistant coatings used on carpets, upholstery, and other fabrics

_____yes ____no

Manufacturing of water resistant clothing

_____yes ____no

Manufacturing of nonstick cookware

____yes ____no

Manufacturing of stain resistant coatings used on carpets, upholstery, and other fabrics

_____yes ____no

Manufacturing of water resistant clothing

_____yes ____no

Manufacturing of nonstick cookware

____yes ____no

Manufacturing of stain resistant coatings used on carpets, upholstery, and other fabrics

_____yes ____no

Manufacturing of water resistant clothing

_____yes ____no

h. Did you work with or around any chemicals at this job such as solvents, metals, asbestos, or pesticides?

Yes (Please specify the chemical) _______________

No ____

Don’t know___

Yes (Please

specify the chemical) ________________

No___

D Don’t know___

Yes (Please

specify the chemical) _______________

No____

Don’t know____

Yes (Please specify the chemical) _______________

No____

Don’t know____

i. Did you work with radiation?

Yes___

No____

Yes___

No____

Yes___

No____

Yes___

No____


Section E: Medical History


E1. Have you ever been told by a doctor or other health care provider that you have or had any of the following medical conditions? If yes, we may request access to your medical records. Fill out the table below. Circle appropriate response and ask the respondent to specify as directed.


Medical condition


If yes, what year were you diagnosed?

  1. High cholesterol?

Yes

No

Don’t know


_ _ _ _ year

  1. High blood pressure? (not including pregnancy induced hypertension)

Yes

No

Don’t know

_ _ _ _ year

  1. Heart Disease?

Yes

No

Don’t know

_ _ _ _ year

  1. Liver disease?

Yes (Please specify) ______________________

No

Don’t know

_ _ _ _ year

  1. Kidney disease?

Yes (Please specify) ______________________

No

Don’t know

_ _ _ _ year

  1. Diabetes (not related to pregnancy)?

Yes (Please specify) _____________________

No

Don’t know

_ _ _ _ year

  1. Thyroid disease?

Yes (Please specify) _____________________

No

Don’t know

_ _ _ _ year

  1. Osteoporosis

Yes

No

Don’t know

_ _ _ _ year

  1. Osteoarthritis?


Yes

No

Don’t know

_ _ _ _ year

  1. Rheumatoid arthritis?

Yes

No

Don’t know

_ _ _ _ year

  1. Fibromyalgia

Yes

No

Don’t know

_ _ _ _ year

  1. Lupus?

Yes

No

Don’t know

_ _ _ _ year

  1. Multiple sclerosis?

Yes

No

Don’t know

_ _ _ _ year

  1. Ulcerative colitis?

Yes

No

Don’t know

_ _ _ _ year

  1. Crohn’s Disease

Yes

No

Don’t know

_ _ _ _ year

  1. Celiac Disease

Yes

No

Don’t know

_ _ _ _ year

  1. Scleroderma?

Yes

No

Don’t know

_ _ _ _ year

  1. Atopic dermatitis/eczema?

Yes (Please specify) _____________________

No

Don’t know

_ _ _ _ year

  1. Allergies?

Yes (Please specify) _____________________

No

Don’t know

_ _ _ _ year

  1. Asthma

Yes

No

Don’t know

_ _ _ _ year

  1. Chronic bronchitis

Yes

No

Don’t know

_ _ _ _ year

  1. Emphysema

Yes

No

Don’t know

_ _ _ _ year

  1. Endometriosis?

Yes

No

Don’t know

_ _ _ _ year

  1. Parkinson’s Disease

Yes

No

Don’t know

_ _ _ _ year



E2. Have you ever been told by a doctor or other health care provider that you have or had a cancer?

____Yes, please specify the cancer_______________

____No → go to Question F1 if male; go to Question E7 if female

____Don’t know → go to Question F1 if male; go to Question E7 if female


E3. In what state were you diagnosed with the cancer and when were you diagnosed?

________State where you were diagnosed

_______Year you were diagnosed


E4. Have you been diagnosed with another cancer?

____Yes, please specify the cancer_______________

____No → go to Question F1 if male; go to Question E7 if female


E5. In what state were you diagnosed with the other cancer and when were you diagnosed?

________State where you were diagnosed

_______Year you were diagnosed


E6. Please list any additional cancer that you were diagnosed with, the year that you were diagnosed, and the state where you were diagnosed:

__________Type of cancer ____________Type of cancer

__________Year diagnosed ___________Year diagnosed

__________State where you were diagnosed __________State where you were diagnosed




FOR WOMEN ONLY



E7. Have you ever used an oral contraceptive (“birth control pill”)?

___Yes

___No → go to Question E9

___Don’t know → go to Question E9

___Refused to answer → go to Question E9


E8. When did you last use an oral contraceptive (“birth control pill”)?


________ Month/Year


E9. At what age did you begin menstruation (have your first period)?

___Age when you began menstruation

___Never menstruated → go to Section F

___Don’t know


E10. Does your period occur regularly (every month)?

___Yes → go to Question E13

___No, it is irregular → go to Question E13

___No, I don’t have a period

___Don’t know → go to Question E13


E11. Why did your periods stop?

___Pregnant

___Menopausal

___Had hysterectomy

___Don’t know


E12. What age was your last period?

___ years

___Don’t know



E12a. During the period when you had periods, what was your usual period flow?

___Light→ go to Question 16

___Medium→ go to Question 16

___Heavy→ go to Question 16

___Don’t know→ go to Question 16


E13. When was your last period before this study blood draw?

Date:______________

___Don’t know


E14. How many days has been your cycle on average during the last year?

___>26 days

___27-29 days

___30-32

___>32 days

___Don’t know


E15. Can you characterize your usual period flow during the last year?

___Light

___Medium

___Heavy

___Don’t know


E16. Have you ever been pregnant?

___Yes

___No → go to Section F

___Don’t know


E17. How many times have you been pregnant in your life?

_______ times


E18. Now I’d like to get more information about each of your pregnancies. Let’s start with your most recent pregnancy. Fill out the table below. Circle appropriate response and ask the respondent to specify as directed.



Pregnancy 1

Pregnancy 2

Pregnancy 3

Pregnancy 4

a. What month and year did this pregnancy start?

_ _ / _ _ _ _

_ _ / _ _ _ _

_ _ / _ _ _ _

_ _ / _ _ _ _

b. What month and year did this pregnancy end?

_ _ / _ _ _ _

_ _ / _ _ _ _

_ _ / _ _ _ _

_ _ / _ _ _ _

c. Did the pregnancy result in a live birth?

Yes

No (go to g)

Don’t Know

Yes

No (go to g)

Don’t Know

Yes

No (go to g)

Don’t Know

Yes

No (go to g)

Don’t Know

d. Did you breastfed this child/these children?

Yes

No → go to k.

Don’t know

Yes

No → go to k.

Don’t know

Yes

No → go to k.

Don’t know

Yes

No → go to k.

Don’t know

e. How long did you breastfeed [this child/these children]?

__ months

__ months

__ months

__ months

f. When did you stop breastfeeding this child/these children?


__month ____ year


__month ____ year


__month ____ year


__month ____ year

g. Did a doctor or nurse say that you had pre-eclampsia during your

pregnancy?

Yes

No

Don’t know

Yes

No

Don’t know

Yes

No

Don’t know

Yes

No

Don’t know

h. Did a doctor or nurse say that you had pregnancy-induced hypertension?

Yes

No

Don’t know

Yes

No

Don’t know

Yes

No

Don’t know

Yes

No

Don’t know

i. Did a doctor or nurse say that you had gestational diabetes?

Yes

No

Don’t know

Yes

No

Don’t know

Yes

No

Don’t know

Yes

No

Don’t know



Section F: Social History


The following questions ask about smoking and alcohol use.


F1. Have you ever smoked cigarettes?

___Yes

___No → go to Question F7


F2. Do you currently smoke cigarettes?

___Yes

___No → go to Question F5


F3. On average, how many cigarettes do you smoke a day? 1 pack = 20 cigarettes. Enter ‘00’ if less than 1 cigarette per day.

_____ cigarettes per day


F4. In total, how many years have you smoked, excluding any times you may have quit? Enter ‘00’ if less than 1 year.

____ years → go to Question F7




F5. How many years did you smoke before you quit?

___years

___ Don’t know


F5a. How long ago did you quit?

___Less than 5 years ago

___5-9 years ago

___More than 10 years ago

___Don’t know


F6. On average, when you were smoking, about how many cigarettes per day did you smoke? 1 pack = 20 cigarettes. Enter ‘00’ if less than 1 cigarette per day.

_____ cigarettes per day


F7. Have you ever used any other tobacco products (such as chewing tobacco, smokeless tobacco, cigars, a pipe, etc.)?

___Yes

___No → go to Question F10


F8. Do you currently use any of these tobacco products?

___Yes

___No


F9. Have you ever drunk alcoholic beverages? (This includes beer, wine, wine coolers, hard

lemonade, and spirits.)

___Yes

___No → go to Section G


F10. Do you currently drink alcoholic beverages? (This includes beer, wine, wine coolers, hard lemonade, and spirits.)

___Yes

___No → go to Section G.


F11. On average, how often do you drink alcoholic beverages?

___Every day or almost every day

___2 to 4 times a week

___1 time a week

___1 to 3 times a month

___Less than once a month


F12. When you drink, how many servings of alcohol do you usually have? One “serving” equals any of the following: 1 can of beer, 1 glass of wine, 1 can or bottle of wine cooler, or 1 shot of liquor.

___ servings


F13. In total, how many years have you drank, excluding any times you may have quit? Enter ‘00’ if less than 1 year.

____ years → go to Section G


F14. When you were consuming alcoholic beverages, how often did you drink on average?

___Every day or almost every day

___2 to 4 times a week

___1 time a week

___1 to 3 times a month

___Less than once a month


F15. When you drank, how many servings of alcohol did you usually have? One “serving” equals any of the following: 1 can of beer, 1 glass of wine, 1 can or bottle of wine cooler, or 1 shot of liquor.

___ servings


F16. In total, how many years did you drink? Enter ‘00’ if less than 1 year.

____ years


F17. How long ago did you quit?

___Less than 5 years ago

___More than 5 years ago

___Don’t know



Section G: Family Medical History

G1. Do any of your blood relatives - children, parents, or siblings - currently have cancer or have they had cancer? We are only asking about family members who are blood relatives: children, parents, and siblings.

___Yes

___No → go to Question G4


G2. In all, how many family members (not including yourself) have had (or now have) cancer?

___number

___Don’t know


G3. Now I’d like to get more information about each of your relatives who had/has cancer. Fill out the table below. Circle appropriate response and ask the respondent to specify as directed. Complete the information for the first relative completely before asking about the next relative. Once information about all blood relatives with cancer has been collected, go to Question G4.



First relative

Second relative

Third relative

Fourth relative

a. Was this relative a . . .

Child

Parent

Sibling

Child

Parent

Sibling

Child

Parent

Sibling

Child

Parent

Sibling

b. What type of cancer did this relative have













c. Is this relative

Living

Deceased

Living

Deceased

Living

Deceased

Living

Deceased

d. What year was your relative diagnosed with cancer?


_ _ _ _

Don’t know


_ _ _ _

Don’t know


_ _ _ _

Don’t know


_ _ _ _

Don’t know


G4. Have any of your blood relatives (that is children, parents, or siblings) ever been told by a health professional that they have or had any of the following conditions? Fill out the table below. Circle appropriate response and ask the respondent to specify as directed.



Medical condition


If yes, ask: Which relative had this condition?

  1. High cholesterol?

Yes

No

Don’t know


Child

Parent

Sibling

  1. High blood pressure? (not including pregnancy induced hypertension)

Yes

No

Don’t know

Child

Parent

Sibling

  1. Heart Disease?

Yes

No

Don’t know

Child

Parent

Sibling

  1. Liver disease?

Yes (Please specify) _____________________

No

Don’t know

Child

Parent

Sibling

  1. Kidney disease?

Yes (Please specify) ______________________

No

Don’t know

Child

Parent

Sibling

  1. Diabetes (not related to pregnancy)?

Yes (Please specify) _____________________

No

Don’t know


Child

Parent

Sibling

  1. Thyroid disease?

Yes (Please specify) ______________________

No

Don’t know


Child

Parent

Sibling

  1. Osteoporosis

Yes

No

Don’t know

Child

Parent

Sibling

  1. Osteoarthritis

Yes

No

Don’t know


Child

Parent

Sibling

  1. Rheumatoid arthritis?

Yes

No

Don’t know

Child

Parent

Sibling

  1. Fibromyalgia

Yes

No

Don’t know

Child

Parent

Sibling

  1. Lupus?

Yes

No

Don’t know

Child

Parent

Sibling

  1. Multiple sclerosis?

Yes

No

Don’t know

Child

Parent

Sibling

  1. Ulcerative colitis?

Yes

No

Don’t know

Child

Parent

Sibling

  1. Crohn’s Disease

Yes

No

Don’t know

Child

Parent

Sibling

  1. Celiac Disease

Yes

No

Don’t know

Child

Parent

Sibling

  1. Scleroderma?

Yes

No

Don’t know

Child

Parent

Sibling

  1. Atopic dermatitis/eczema?

Yes (Please specify) _____________________

No

Don’t know


Child

Parent

Sibling

  1. Allergies?

Yes (Please specify) _____________________

No

Don’t know


Child

Parent

Sibling

  1. Asthma

Yes

No

Don’t know

Child

Parent

Sibling

  1. Chronic bronchitis

Yes

No

Don’t know

Child

Parent

Sibling

  1. Emphysema

Yes

No

Don’t know

Child

Parent

Sibling

  1. Endometriosis?

Yes

No

Don’t know

Child

Parent

Sibling

  1. Parkinson’s Disease

Yes

No

Don’t know

Child

Parent

Sibling




CONCLUSION: That completes this survey. I would like to sincerely thank you for your time.

14


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