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Personal and Physical Characteristics

Questions

Year(s) Asked on Long Forms

(Click on year to view PDF of questionnaire.)
Date of birth x x x x x x x x x x x x x x
Major Ancestry x
Current marital status x x x x
Academic/professional degrees earned x
Husband's highest level of education x
Current employment status x x x x x
Living arrangement (ie alone, with spouse) x x x
Years worked in OR x x
Number of years working rotating shifts (at least 3 nights/month) x x
Height x
Current weight x x x x x x x x x x x x x x
Weight at age 18 x
How many times (in the past 10 years) have you donated blood? x
Blood type / RH factor x
Weight change over last 2 years--difference between min/max x x x x
Weight in last 20 years:
- Minimum lbs at age
- Maximum lbs at age		 x
Times in the last 20 years you've lost:
- 5-9 lbs.
- 10-19 lbs.
- 20-49 lbs.
- 50+ lbs.		 x
Weight in last 4 years:
- Minimum lbs at age
- Maximum lbs at age		 x
Times in the last 4 years you've lost:
- 5-9 lbs.
- 10-19 lbs.
- 20-49 lbs.
- 50+ lbs.		 x
Methods of weight loss of 10+ lbs. x x x x
Waist measurement x x x
Hip measurement x x x
Upper arm measurement x
In which state were you born? x
Where did you live at age 15? x
How many natural teeth do you have? x
In the last 2 years, have you had periodontal surgery? x
How many teeth have you lost in the last 2 years? x
How many teeth have you lost in the last 4 years? x
How many of your teeth have had root canal therapy? x
In the past 2 years, did you forego any of the following for financial reasons? (medical care, dental, screening, eye care, mental health care) x
During the last month, how often did you have pain or discomfort in your knee? x
When did knee pain begin? x
During the last year, did you have any knee pain/discomfort doing the following activities: walking, bending/squatting, getting up from chair w/o using arms? x
Have you ever had a knee injury due to traumatic event that was treated with cane, brace, crutches, etc.? x
Have you ever noticed pain/ stiffness/ enlargement/ swelling of the joints nearest your fingernails? x
Are you naturally right or left handed (or forced to change or ambidextrous)? x
How frequently do you have a bowel movement? x
How often do you have difficulty holding your urine until you can get to a toilet? x x
During the last 12 months, how often have you leaked urine or lost control of your urine? x x x
When you lose your urine, how much do you usually lose? x x x
Have you ever regularly had heartburn/acid reflux 1 or more times/week?
- How long did this last?		 x
In the past year, how often have you had heartburn/acid reflux? x
How many years have you worked in operating rooms? x
Number of moles on your left arm (>3mm) x
Total hours of sleep per day (24hr) x x x
Usual sleeping position x
Do you snore? x x x
Do you have difficulty with your balance? x x
# times you've fallen to the ground in the past year x x
DIAGRAM of women's body sizes - which fits you at each age? What about parents (age 50)? x
Between the ages of 18-30, how many times did you purposefully lose 10 or more pounds (excluding illness or pregnancy)? x

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Reproductive History

Questions

 Year(s) Asked on Long Forms

(Click on year to view PDF of questionnaire.)
Age at menarche x
Patern of menstrual cycles at ages 18-22 x
Pattern of menstrual cycles missed (menarche to age 22) x
Menstrual cycle regularity (age 20-35) x
Had a pregnancy lasting > 6 months? How many? x
Had a pregnancy lasting > 6 months in the last 2 years? Delivery date? x x x
Age at first pregnancy x
Any stillbirths? If so, how many? x
Parity x x x x x x
Number of children and ages x x
Tried to become pregnant for > 2 years without success? x
- If yes, was cause found in you, husband, not found, or not investigated? x
Use of clomid to induce ovulation (total months used, age first used) x
Ever treated with DES during pregnancy? x
Have you reached menopause? x x x x x x x x x x x x x x
Age at menopause x x x x x x x x x x x x x ?
Type of menopause (e.g. natural, radiation or surgical, if so number of ovaries removed) x x x x x x x x x x x x x ?
Uterus removed? x x x x x x x x x x x x
Ovaries removed? How many? x x x x x x x x x x x x
- How many ovaries do you still have x x x x x
Ever had a tubal ligation? x x
Current contraceptive use (OC, rhythm, diaphragm, condom, IUD, foam/jelly, tubal ligation, vasectomy, other)? x x x x
Past contraceptive use? (Or previous 2 years) x x x x
Oral Contraceptive Timeline: Intervals of use and Reason for stopping x x x
Duration of OC use x x x x
Age at first OC use x
Total months breast fed children x
Birth weight of heaviest child x
Age at first delivery > 9.5 lbs. x
Age at birth of heaviest child x
Each year in which you gave birth x
Regarding your infancy: Birthweight? Were you breast fed? Full-term? 2+ weeks premature? Twin, triplet? x
Use of Postmenopausal Hormones including: x x x x x x x x x x
- Duration of use x x x x x x x x x x
- Currently using? x x x x x x x x x
- Type? x x x x x x x x x
- Dose of preparation x x x x x x x x
- Route of administration x x x
If Premarin, what dose? Daily or cyclically? x x x x x x x x x x
If Progesterone, what dose? x x x x x x x x
Pattern of hormone use (oral, patch, progesterone) x x x x x x x x
Currently using any of these meds for osteoporosis or other reason (HRT, Evista, Fosamax, etc.) How many months during last 2 years? x x x
Have you regularly used any over the counter preparations ("alternative," "herbal," "natural," or "soy-based") for HRT or to treat postmenopausal symptoms? (last 2 years, # months, type) x x

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Family History

Questions

 Year(s) Asked on Long Forms

(Click on year to view PDF of questionnaire.)
Mother's year of birth x
Mother still living? x x
Mother's age at death x x x
Cause of mother's death: trauma or disease? x x
Mother have MI? x x
Mother have breast cancer? x
Mother's age at first occurrence of breast cancer or MI x x
Father's year of birth x
Father still alive? x x x
Father's year of death x x
Cause of father's death: trauma or disease? x
Father have MI? x x
Father's age at first MI x x
Family history of disease including:
- Colon or rectal cancer x x x x x
- Breast cancer x x x x x
- Melanoma x   x x x
- Other cancer x
- Diabetes x x x
- MI x
- Stroke x
- Uterine Cancer x
- Prostate Cancer x
- Pancreatic Cancer x x
- Ovarian Cancer x x x
- Hypertension x
- Dementia prior to age 70 x
- Alcoholism x
- Parkinson's Disease x
- Down's Syndrome x
- Lung Cancer x
- Glaucoma x
Do you have any sisters? How many? x
How many sisters have had breast cancer? x
Father's occupation when participant was 16 years old x
Mother's occupation when participant was 16 years old x
How many biological brothers & sisters do you have? (incl deceased, not incl 1/2 bros) x
Has any sibling or parent had Parkinson's disease? x
Any immediate family members with Down's syndrome? x

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Environmental and Personal Exposures

Questions

 Year(s) Asked on Long Forms

(Click on year to view PDF of questionnaire.)
Do you smoke cigarettes currently? x x x x x x x x x x x x x x
How many cigs per day? x x x x x x x x x x x x x x
What brand of cigarette do you smoke? x x x x x x x x
How old when started regularly smoking? x
Since you started, ever quit for 6 months or more? x
How many cigs/day during first 5 years as a regular smoker? x
If not currently a smoker, did you smoke regularly in the past? x
How many cigs/day in the past? x
How old when you last smoked regularly? x
How old when you started? x
When you smoked regularly, ever quit for 6 months or more? x
How long have you smoked this brand? x
Is it a filter cigarette? x x
How deeply do you inhale? x x
Did your parents smoke while you were living with them? x
As an adult, how many years have you lived with a regular smoker? x
Are you currently exposed to cigarette smoke at work/home? If so how often? x
How often (each day) do you apply lipstick? x
Use a permanent hair dye currently? x x x x
Use a permanent hair dye ever? x
- How often? x x x
- For how many years? x
- At what age did you start using dye? x
What was the natural color of your hair at age 21? x
Have you ever commonly used a talcum powder/baby powder to apply to a perineal area or on sanitary napkins? x
Do you currently use artificial sweeteners? How often? For how long? x
Do you regularly spend time outdoors in the summer (at least 8 hrs/wk)? - Use sunscreen? - Use little or no sunscreen? x
As an adolescent, what was the reaction of your skin to 2+ hours in bright sun? x
As a child or adolescent, what kind of tan did you get after a prolonged (2 week) exposure? x
How often have you had severe sunburn on these specific areas of the body: Back/shoulders? Lower limbs? Face/arms? All over? x
Have you ever regularly used an electric blanket or a heated waterbed? - How often? Years? Age when started? x
Ever received a blood transfusion? (exclude own blood) How many units? At what age? x

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Diet and Supplement Use

Questions

 Year(s) Asked on Long Forms

(Click on year to view PDF of questionnaire.)
(Vitamin use including dose and duration)
Multivitamin - brand of Multivitamin x x x x x x x x x x x x
Which multi is used most frequently? (mark) Does it include iron? x
Vitamin A x x x x x x x x x x x x
Vitamin C x x x x x x x x x x x x
Vitamin E x x x x x x x x x x x x
Vitamin D x
Vitamin B6 x x x x x x x
Beta carotene x x x x
Iron x x x x x
Fish oil (omega-3 Fatty Acids) x x
Selenium x x x x x x x x
Zinc x x x x x x x x x
Calcium or dolomite x x x x x x x x x x x
Folic Acid x x
Niacin x x x
Other vitamins (specify) x x x x x
Other supplements (ie cod liver oil, brewer's yeast, etc) x x x x
How many days a week do you have breakfast? x
How many times a day to you eat? (include meals & snacks) x
Wat percent of your noon and evening meals are prepared at home? (exclude commercially prepared meals) x
How many times do you eat meat (beef, pork, lamb) per week? x
- how is it cooked (ie roasted, panfried, broiled, bbq'd, or boiled/stewed) x
What do you do with the visible fat on your meat? x x
What kind of fat do you use for frying or sauteing? x x x x x x
What kind of fat do you use for baking? x x x x x x
What form of margarine do you use? x x x x x
How often do you eat food that is fried at home? (excluding PAM spray) x x x x x x
How often do you eat fried food away from home? x x x x x x
How many teaspoons of sugar do you add to your food each day? x x x x x x
What type of cooking oil do you usually use? x x x x x x
What type of cold breakfast cereal do you usually use? x x x x x x
Are there any other important foods that you usually eat at least once a week? (specify) x x x x x
How many shakes of salt do you add to your food per day? x
How much salt is added during cooking of these foods: meat, veg, staples (rice), soup) x
In a typical week, number of days you have any form of alcoholic beverage x x x x
In a typical month during the last year, what was the largest number of drinks you had in one day? x x x
HIGH SCHOOL FFQ x
When you were 18-20, how many alcoholic beverages did you consume per week? x
Alcohol consumption per week during these age intervals: 18-22,25-30,35-40, past year x
How many cups/glasses of home tap water do you drink daily? x
How many cups/glasses oftap water do you drink daily outside your house? x
When you have beef/lamb as main dish, how well-done is it cooked? x
How often do you eat meat that was charred during cooking? x
How much of the fat of the meat do you remove before eating? x x x x
Do these apply to you: "I eat anything I want, anytime I want" or "I pay great attention to changes in my figure" x

During the past year, how often did you eat the following:
- Pan-fried chicken; appearance (lightly browned....blackened)
- Broiled chicken; appearance (lightly browned....blackened)
- Grilled chicken; appearance (lightly browned....blackened)

 x
When you eat chicken, how often is it cooked with the skin on? How often do you eat the skin? x
- Broiled fish; appearance (lightly browned....blackened) x

- Roast beef; appearance (lightly browned....blackened)
- Pan-fried steak; appearance (lightly browned....blackened)
- Grilled steak; appearance (lightly browned....blackened)
- Homemade beef gravy; appearance (lightly browned....blackened)

x

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Physical Activity


Questions

Year(s) Asked on Long Forms

(Click on year to view PDF of questionnaire.)
Physical Activity: On an average weekday/weekend day, how much time did you spend on:
- Vigorous activity (eg. Jogging)
- Moderate activity (eg. Walking)		 x
Does your health now limit you in any of these activities? (a lot, a little, none at all)
-Vigorous activities (running, etc.)
-Moderate activities (bowling, etc.)
-Lifting groceries
-Climbing stairs
-Bending/kneeling
-Walking more than a mile
-Walking several blocks
-Walking one block
-Bathing/dressing yourself		 x x x
How often do you engage in any regular activity enough to break a sweat? (# of times per week, duration) x x
How many flights of stairs do you climb daily? x x x x x x x x
How many blocks do you walk daily? x
What is your walking pace? x x x x x x x
During past year, average time/week you participated in: walking, jogging, running, bicycling, swimming, tennis, aerobics, racquet ball. (chart) x x x x x x x x
Hours per week spent sitting (home, work) x x x
Hours per week spent standing (home, work) x x x
Hours per week "other" sitting x x
Between 18-22, how often did you participate in strenuous physical activity (>twice/week) x

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Screening History

Questions

Year(s) Asked on Long Forms

(Click on year to view PDF of questionnaire.)
Have you been to a doctor/clinic for health reasons in the past year? How many visits? x
Current usual blood pressure x x x x x
Serum cholesterol x x x x
Resting pulse x
TB skin test since 1995 x x
- if ever positive, conversion date: x
Have you ever had a mammogram? x
- how many? How long since most recent? x x
How often did you practice breast self-examination in the past year? x x x
In the past 2 years have you had a:
- physical exam x x x x x x x x
- blood pressure check x x
- blood cholesterol x x
- fasting blood sugar       x x x
- rectal exam x x x x
- stool occult blood test x x x x
- colonoscopy/ sigmoidoscopy (and reason) x x x x x x x
- (bimanual) pelvic exam x x x x x
- breast exam by doctor x x x x x x x
- ovarian ultrasound     x
- mammogram x x x x x x x
- exam by eye doctor x x x x x
How often do you usually have a bimanual pelvic exam? x
In which years did you have a mammogram?   x
Have you ever had an endoscopy (esophagus or stomach)?  
Would you be willing to provide NHS with a venous blood sample? x
Have you ever had a colonoscopy or sigmoidoscopy?
- When did you have your 1st one?
- Why did you have your 1st one?
- When was your most recent one?		 x
Why did you have a colonoscopy? (bleeding, abdom pain, constipation, etc.) x x
Have you ever had any of these procedures: Breast implant, Silicone injection, Collagen injection, Parrafin injection x

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Disease Outcomes

Questions

Year(s) Asked on Long Forms

(Click on year to view PDF of questionnaire.)
High blood pressure x x x x x x x x x x x x x x
Diabetes mellitus x x x x x x x x x x x x x x
Elevated cholesterol x x x x x x x x x x x x x x
Myocardial Infarction (MI) x x x x x x x x x x x x x x
- Hospitalized for MI? x x x x x x
Angina pectoris x x x x x x x x x x x x x x
Peripheral venous thrombosis x x x
Peripheral artery disease or claudation of the legs x x x x x x x x
Pulmonary emboli x x x x x x x x x x x x
Fibrocystic breast disease x x x x x x x x x x x x x x
Other benign breast disease x x x x x x x x x
Breast cancer x x x x x x x x x x x x x x
Cancer of the cervix - in situ included x x x x x x x x x x x x
Cancer of the uterus (endometrium) x x x x x x x x x x x x x
Cancer of the ovary x x x x x x x x x x x x x
Cancer of the colon (large bowel) x x x x x x x x x x x x x
Cancer of the rectum x x x x x x x x x x x x x
Colon (or rectal) polyps x x x x x x x x x x
Cancer of the lung x x x x x x x x x x x x x
Cancer of the liver x x
Other cancer (specify) x x x x x x x x x x x x x x
Other illness (specify) x x x x x x x x x x x x x
Melanoma x x x x x x x x x x x
Osteoporosis x x x x x x x x x x x
Osteoarthritis x x x
Increasted intraocular pressure x x x
Fracture of hip or forearm x x x x x x x x x x x
Fracture of wrist x x x x x x
Vertebral fracture x x x x x x x x
Hip replacement x x x x x x x
Knee replacement x
Rheumatoid arthritis x x x x x x x x x
- Rheumatoid factor x x x x x
Other arthritis x x x x x x
Gout x x x x x
Systemic Lupus Erythematosis (SLE) x x x x x x x x
Cholecystectomy x x x x x x x x x x x
Gall stones x x x
Stroke x x x x x x
Gastric or duodenal ulcer x x x x x x x x x
Ulcerative colitis x x x x x x x x x
Coronary artery surgery x x x x x x x x x
Cataract (1st diagnosis) x x x x x
Cataract extraction x x x x x x x x x x
Basal cell skin cancer x x x x x x x x x x
Squamous cell skin cancer x x x x x x x x x x
Glaucoma x x x x x x x x x
Macular degeneration x x x x x x x x x
Asthma, Dr. diagnosed x x x x x x x x
Emphysema, Dr. diagnosed x x x x x x x x
Chronic bronchitis, Dr. diagnosed x x x x x x x x
Uterine fibroids x
Carotid artery surgery x x x x x x x
TIA x x x x x x x
Chronic kidney failure x x
Multiple Sclerosis x x x x x x
ALS x x x x x x
Diverticulitis x x x x x
Kidney Stones x x x x x x
Scleroderma x
Polymyositis/ Dermatomyositis x
Sjogren's Syndrome x
Appendectomy or Appendicitis x
Appendectomy, incidental x
Alcohol dependence problem x
Herniated Disk (confirmed by CT/MRI?) x
Surgery for varicose veins x
Parkinson's Disease x x x x x
Interstitial cystitis (Dx by cytoscopy) x x x x
Active TB (X-ray or culture Dx) x x x x

Ever been diagnosed with:
- Pernicious Anemia x x
- Congestive heart failure x x x
- Periodontal bone loss x x
- Shingles x
- Depression x x
- Epilepsy x
- Restless leg syndrome (Dr. Dx) x
- Hyperthyroidism/ Graves disease x
- Hypothyroidism x
- Barrett's Esophagus x
Ever been diagnosed with with atrial fibrillation? (and year of 1st Dx) x x
What is the pattern of your atrial fibrillation? x

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Medication Use (Prescription and Over-the-Counter)

Questions

Year(s) Asked on Long Forms

(Click on year to view PDF of questionnaire.)
Tagamet (cimetidine) x x x x x x x
Zantac (ranitidine) x x x x x
Prilosec or Prevacid x x
Thyroid hormone (extract, Synthroid) x x x
Aldomet (methyldopa) x x
Aspirin (includes Bufferin, Anacin, etc.) with days/ month and dose x x x x x x x x x x x
How many aspirin tablets do you take per week? x x x x x
How frequently do you take aspirin? x x x x x
Other non steroidal anti-inflammatory drugs (Circle: Motrin/ Indocin/ Tolectin/ Clinoril/ Alleve/ Naprosyn) x x x x x x x x
- days/week x
Baby/low-dose aspirin & days/week x x
Acetominophen x x
- days/week x x x x x x x
Ibuprofen & days/week x x
Coumadin x x x x x
Tamoxifen x x x
Lasix x x x x x
Steriods taken orally (e.g., Prednisone) x x x x x
Inhaled steroids, bronchodilator x x x x
Celebrex or Vioxx x x
Digoxin or Antiarythmic x x x x x
Valium x x x x x x x
Minor tranquilizers (e.g., Valium, Xanax) x x
Thiazide diuretics (Diuril, Hydrodiuril) x x x x x x x x
Phenothiazines (eg. Thorazine, Stelazine, Compazine, Mellaril) x
Tetracycline use (how long?) x
Griseofulvin by mouth? (duration before or after 1970) x
Other medications (specify) x x x x
No regular medications x
How often do you use a laxative? x
Beta blockers x x x x x x
Calcium Channel blockers x x x x x x
Other blood pressure medication x x x x x x
ACE inhibitors x x x x x
Insulin x x x x x
Oral diabetic medication x x x x
Oral hypoglycemic medication x x x
Cholesterol lowering drugs x x x x
"Statin" cholesterol lowering drugs (e.g., Mevacor, Zocor) and years of use x x
"Other" cholesterol lowering drugs x x
Antidepressant x x
Prozac x x
Zoloft x x
Paxil x x
Celexa x x
Other antidepressant x x
Meridia (sibutramine) x x x
Phentermine x x
Xenical x x

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Psychosocial

Questions Year(s) Asked on Long Forms

(Click on year to view PDF of questionnaire.)
Amount of stress in your daily life? At home and At work x
Do you have an unreasonable fear of being in enclosed spaces such as stores, elevators, etc.? x
Do you find yourself worried about getting some incurable illness? x
Are you scared of heights? x
Do you feel panicky in crowds? x
Do you worry unduly when relatives are late coming home? x
Do you feel more relaxed indoors? x
Do you dislike going out alone? x
Do you feel uneasy traveling on buses or trains, even if they are not crowded? x

During the past 4 weeks:
- Do you feel full of pep?
- Have you been a very nervous person?
- Have you felt so down nothing could cheer you up?
- Have you felt calm and peaceful?
- Did you have a lot of energy?
- Have you felt downhearted and blue?
- Did you feel worn out?
- Have you been a happy person?
- Did you feel tired?

 x x x
Have you felt hopeless about the future?
 x
Have you thought about or wanted to commit suicide? x
Have you felt no interest in things? x
Did you have difficulty falling asleep or staying asleep? x
In general, would you say your health is (excellent, good, fair, etc.)? x
During the past 4 weeks, how much of the time have your physical health or emotional problems interfered with your social activities? x
True or False (and in between):
Over the past 4 weks I feel much the same as I've felt over the last year x x x
I seem to get sick a little easier than other people x x x
I am as healthy as anybody I know x x x
I expect my health to get worse x x x
My health is excellent x x x
Outside your employment, do you provide any regular care to any of the following? (and # of hours)
- Your children x x x