WHI - Volume 3, Form 32 - Family History Questionnaire (Ver. 3) Page 1. Self-administered; 12-page booklet; data entered at Clinical Center (CC).
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1 WHI - Volume 3, Form 32 - Family History Questionnaire (Ver. 3) Page 1 FORM: 32 - FAMILY HISTORY QUESTIONNAIRE Version: 3 - June 1, 1995 Description: When used: Purpose: Self-administered; 12-page booklet; data entered at Clinical Center (CC). Give to participant during screening to be completed at home and brought back by Screening Visit 3 (SV3) or have completed in CC by SV3. To collect medical history information on the participant's family members before randomization. GENERAL INSTRUCTIONS 1. The form is printed in both English (Form 32) and Spanish (Form 32S). The English version is in mark-sense format and the Spanish version is in a key-entry format. For both forms, follow the instructions on the front of the form for marking the answers. 2. Place the participant's barcode label on the front page of the questionnaire and give to the participant during screening to take home, or have her complete in-person in groups or individually by SV3. The form must be completed and an encounter created before randomization at SV3. 3. In appointment reminder (letter or phone call), remind the participant to bring the completed questionnaire to SV3 (if given to her to fill out at home). 4. Review the form for completeness. If one or more pages are not completed, return to the woman to complete. If the participant is adopted, she may not be able to answer questions about her birth family. 5. Forward the form to Data Entry. 6. Data Entry: Review the form for completeness. Scan the English version of the form; key-enter the Spanish version. Initial the first page of the questionnaire after data entry. Note: You must create an encounter for this form in the Encounter screen before you can randomize the participant into Dietary Modification (DM) or Hormone Replacement Therapy (HRT). 7. File in the participant's file.
2 WHI - Volume 3, Form 32 - Family History Questionnaire (Ver. 3) Page 2 Item Instructions Date received Reviewed by Contact type Visit type Form administration Date the CC receives the completed form. Standard 3-digit number WHI employee ID. Mark appropriate oval or box. (See common data items.) Contact at which the CC received the form. If received between visits, use most recent past visit. Use Screening Visit 0 (SV0) if received before Screening Visit 1 (SV1). Mark appropriate oval or box for visit type and number. (See common data items.) Method used to administer form to participant: 1 - Self: Participant completed form by herself. 2 - Group: Participant completed the form with a group of other participants. 3 - Interview: CC staff person completed entire form as interview. 4 - Assistance: Participant needed partial assistance from CC staff or others to complete the form. 1. Full-blooded sisters No/Yes/Don't know Number of sisters The category that best corresponds with the number of sisters who reached adulthood. (Include all full-blooded sisters living or deceased who lived up to or past age 21.) 2. Full-blooded brothers No/Yes/Don't know Number of brothers The category that best corresponds with the number of brothers who reached adulthood. (Include all full-blooded brothers living or deceased who lived up to or past age 21.) 3. Daughters reached adulthood No/Yes/Don't know Number of The category that best corresponds with the number of who reached adulthood. (Include all full-blooded living or deceased who lived up to or past age 21.) 4. Sons reached adulthood No/Yes/Don't know Number of sons The category that best corresponds with the number of sons who reached adulthood. (Include all full-blooded sons living or deceased who lived up to or past age 21.) 5. Mother alive No/Yes/Don't know Mother's age at death The category that best corresponds with mother's age at death Mother's current age The category that best corresponds with mother's current age. 6. Father alive No/Yes/Don't know.
3 WHI - Volume 3, Form 32 - Family History Questionnaire (Ver. 3) Page Father's age at death The category that best corresponds with father's age at death Father's current age The category that best corresponds with father's current age. 7. Diabetes in mother, father, sisters, brothers,, or sons 7.1. Number of relatives with diabetes 8. Heart attack in mother, father, sisters, brothers,, or sons 8.1. Which relative(s) had heart attack 9. Stroke in mother, father, sisters, brothers,, or sons 9.1. How many relative(s) had stroke 10. Cancer in female relatives 11. Breast cancer in mothers, sisters,, or grandmothers Which relative(s) had breast cancer 12. Colon, rectum, intestine, or bowel cancer in Which relative(s) had bowel cancer No/Yes/Don't know. Mark "1 - Yes" if relative(s) had diabetes mellitus. Mark "0 - No" if relative(s) did not have diabetes or had hypoglycemia or low blood sugar. The category that best corresponds with the number of relatives who had diabetes mellitus. No/Yes/Don't know. Mark "1 - Yes" if participant's relative(s) had a heart attack, MI, or "coronary." Mark "0 - No" if relative(s) had no heart attacks or only angina or sudden cardiac arrest without a heart attack. Relative(s) who had heart attack and relative's ages when heart attack occurred. Mark for each relative (unless participant did not have that type of relative). We ask the participant to answer to each question to be sure she has not skipped the question. If the participant did not have that type of relative, she can leave the line blank. If she did have that type of relative, at least one line for that type should be marked No/Yes (age)/don't know. For example, if her mother had a heart attack but she had two sisters who did not have heart attacks, she should still mark "No" for at least one sister in Question 8.1. If the relative did have a heart attack, mark the age at which this relative's first heart attack occurred. No/Yes/Don't know. Mark "1 - Yes" if participant's relative(s) had a stroke or cerebrovascular accident (CVA). Mark "0 - No" if relative(s) had no strokes or only a transient ischemic attack (TIA) or reversible stroke. The category that best corresponds to the number of relatives who had a stroke. No/Yes/Don't know. Mark "1 - Yes" if any participant's female relative(s) listed had any type of cancer. No/Yes/Don't know. Mark "1 - Yes" if any of the participant's female relative(s) listed had breast as a primary site for cancer. Relative(s) who had breast cancer and relative's age when breast cancer first relative). (See directions for marking in Question 8.1.) If the relative had breast cancer, mark the age at which this relative's first breast cancer was diagnosed. No/Yes/Don't know. Mark "1 - Yes" if a female relative's colon, rectum, intestine, or bowel was a primary site for cancer. If relative(s) had abdominal surgery but participant is not sure if it was for bowel cancer, mark "0 - No." Relative(s) who had bowel cancer and relative's age when bowel cancer first relative). (See the directions for marking in Question 8.1.) If the relative(s) had bowel cancer, mark the category that best corresponds to relative's age when the cancer first occurred.
4 WHI - Volume 3, Form 32 - Family History Questionnaire (Ver. 3) Page Cancer of cervix in Number of relatives with cancer of cervix 14. Cancer of endometrium in Number of relatives with cancer of uterus or endometrium 15. Cancer of the ovaries in Number of relatives with cancer of the ovaries No/Yes/Don't know. Mark "1 - Yes" if a relative's cervix was a primary site for cancer. If relative(s) had "female surgery," but participant is not sure if it was for cervical cancer, mark "9 - Don't know." cancer of the cervix. No/Yes/Don't know. Mark "1 - Yes" if a relative's uterus or endometrium was a primary site for cancer. If relative(s) had "female surgery," but participant is not sure if it was for uterine or endometrial cancer, mark "9 - Don't know." endometrial cancer. No/Yes/Don't know. Mark "1 - Yes" if a relative's ovaries were a primary site for cancer. If relative(s) had "female surgery," but participant is not sure if it was for ovarian cancer, mark "9 - Don't know." ovarian cancer. 16. Cancer in male relatives No/Yes/Don't know. Mark "1 - Yes" if participant's male relative(s) ever had any type of cancer. 17. Colon, rectum, intestine, or bowel cancer in father, brothers, or sons Which relative(s) had bowel cancer 18. Cancer of prostate in father, brothers, or sons Number of relatives with cancer of prostate 19. Fracture(s) in mother after age Location of fracture(s) in mother No/Yes/Don't know. Mark "1 - Yes" if a male relative's colon, rectum, intestine, or bowel was a primary site for cancer. If relative(s) had abdominal surgery, but participant is not sure if it was for bowel cancer, mark "0 - No." Relative(s) who had bowel cancer and relative's age when bowel cancer first relative). (See the directions for marking in Question 8.1.) If the relative(s) had bowel cancer, mark the category that best corresponds to relative's age when the cancer first occurred. No/Yes/Don't know. Mark "1 - Yes" if a relative's prostate gland was a primary site for cancer. If relative(s) had gastrointestinal surgery or genitourinary surgery, but participant isn't sure if it was for prostate cancer, mark "9 - Don't know." Mark the category that best corresponds to the number of male relatives who had cancer of the prostate (or mark "9 - Don't know"). No/Yes/Don't know. Mark "1 - Yes" even if participant isn't sure which bone was broken or exact age (but her best guess is that mother was over 40). Mark No/Yes (age)/don't know for each type of bone listed. If the mother broke a bone, mark the category that best corresponds to the age each type of bone was first broken (or mark "9 - Don't know"). If "5 - Other" is marked, specify the bone. Data Entry: Do not key-enter the specify text.
5 WHI - Volume 3, Form 32 - Family History Questionnaire (Ver. 3) Page Fracture(s) in father after age Location of fracture(s) in father No/Yes/Don't know. Mark "1 - Yes" even if participant isn't sure which bone was broken or exact age (but her best guess is that father was over 40). Mark No/Yes (age)/don't know for each type of bone listed. If the father did break a bone, mark the category that corresponds to the age each type of bone was first broken (or mark "9 - Don't know"). If "5 - Other" is marked, specify the bone. Data Entry: Do not key-enter the specify text. 21. Date Date the participant completed this form. Comments Language Data Entry: Do not key-enter comments. Data Entry: English or Spanish version of the form. (See common data items.)
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