Form OS Follow-Up Questionnaire (Observational Study - Year 4) Ver. 1.1 Page 1
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1 Form OS Follow-Up Questionnaire (Observational Study - Year 4) Ver. 1.1 Page 1 FORM: OS FOLLOW-UP QUESTIONNAIRE (Observational Study - Year 4) Version: 1.1 July 15, 1998 Description: When used: Self-administered; 12-page booklet; scanned at the Clinical Center (CC). Mailed by the Clinical Coordinating Center (CCC) to all Observational Study (OS) participants with Form 33 - Medical History Update at the four-year follow-up contact. This form applies to OS participants only. Purpose: To update and provide more detailed information on selected exposures measured at baseline, year 1 and year 3, and to provide information on exposures not previously measured. GENERAL INSTRUCTIONS 1. The form is printed in both English (Form 144) and Spanish (Form 144S). Both English and Spanish versions are in mark-sense format. For both forms, follow the instructions on the front of the form for marking the answers. 2. The CCC places the participant barcode label on the front page of the form and mails it with Form 33 - Medical History Update to all OS participants two months before the enrollment anniversary month. (See Vol. 2, Section OS Annual Mail Contact and Follow-Up of Non-Responders.) 3. Participants are asked to mail the completed form back to the participant s CC together with Form 33- Medical History Update in the return envelope provided. 4. Review the form for completeness, looking for skipped pages. If pages have been skipped, follow-up with the participant by phone to collect those pages. Forward the form to Data Entry. 5. Complete the [Official Use Only] section on the first page. Forward the form to Data Entry. 6. Data Entry: Scan the form. Initial the first page of the form after entry. 7. File the form in the participant s file. R:\DOC\FORMS\ENGLISH\CURR\I1-199\I144V1.1 07/05/00
2 Form OS Follow-Up Questionnaire (Observational Study - Year 4) Ver. 1.1 Page 2 Item Instructions Date received Reviewed by Contact type Visit type Form Administration Language Date received at CC. Standard 3-digit WHI employee ID. (See common data items.) Mark appropriate box. (See common data items.) Contact at which the CC received the form. Mark the box ( Annual ). Fill in the visit year number four. Method used to administer form to participant: 1 - Self: Participant completed the form by herself 2. - Group: Participant completed the form with a group of other participants Interview: CC staff completed entire form as an interview Assistance: Participant needed partial assistance from CC staff or others to complete the form. Most participants are expected to complete the form by themselves ( 1 - Self ). Indication of English (E) or Spanish (S) version of the form. CC staff skip this question as the response is printed on the form. 1. Current weight Current weight in pounds. 2. Highest weight in the past year 3. Lowest weight in the past year Maximum weight in pounds in the past year. Minimum weight in pounds in the past year. 4. Number of times walked Frequency range that best represents the number of times participant walks for more than ten minutes without stopping each month or week Number of minutes walked The range of minutes that best represents the duration of time that the participant walks each time she walks for more than ten minutes without stopping Walking speed The category that best represents participant s speed during walks for more than ten minutes without stopping Frequency of strenuous exercise 5.2. Length of each strenuous exercise session 5.3. Frequency of moderate exercise 5.4. Length of each moderate exercise session 5.5. Frequency of mild exercise 5.6. Length of each mild exercise session The category that best represents the number of days each week the participant engages in strenuous exercise. The range of minutes that best represents the length of each strenuous exercise session. The category that best represents the number of days each week the participant engages in moderate exercise. The range of minutes that best represents the length of each moderate exercise session. The category that best represents the number of days each week the participant engages in mild exercise. The range of minutes that best represents the length of each mild exercise session.
3 Form OS Follow-Up Questionnaire (Observational Study - Year 4) Ver. 1.1 Page 3 6. Skin reaction to sun The category that best describes the reaction of the participant s unprotected skin to sunlight after the first minute sunlight exposure of the summer. Mark only one Hours per day spent outdoors 8. Use of dark glasses in sunlight 9. Use of brimmed hat in sunlight 10. Use of sunscreen in past year The range of minutes that best represents the length of time spent outdoors during the seasons and age periods listed. Mark one for each category. Participant should give her best estimate for each category. No/Yes/Don t know. Mark one fore each age period listed. No/Yes/Don t know. Mark one fore each age period listed. No/Yes Sun Protection Factor The Sun Protection Factor usually used. Mark one category. 11. Current cigarette smoking Cigarettes smoked per day No/Yes. The average number of cigarettes smoked per day over the past month Use of artificial sweeteners in past year Use of artificial sweeteners ten years ago Use of artificial sweeteners twenty years ago Mark one category for each. Give best guess. Mark one category for each. Give best guess. Mark one category for each. Give best guess. 15. Use of non-prescription natural hormones Type of nonprescription natural hormone used 16. Use of prescription female hormones 17. Use of combined estrogen and progestin pills Months of combined estrogen and progestin usage 18. Use of combined estrogen and testosterone pills No/Yes/Don t know. Answer yes if any type of non-prescription natural hormone was used at any time in the past year, even if the participant is not currently using the hormone. Mark all that apply. No/Yes/Don t know. Answer yes if any type of prescription female hormone (estrogen or progesterone) was used at any time in the past year, even if the participant is not currently using the hormone. No/Yes/Don t know. Answer yes if any type of combined estrogen and progestin pill was used at any time in the past year, even if the participant is not currently using a combined pill. No/Yes/Don t know. Answer yes if any type of combined estrogen and testosterone pill was used at any time in the past year, even if the participant is not currently using a combined pill.
4 Form OS Follow-Up Questionnaire (Observational Study - Year 4) Ver. 1.1 Page Months of combined estrogen and testosterone pills Type of combined estrogen and testosterone pills used longest 19. Use of estrogen pills No/Yes/Don t know. Do not include the combined pill of estrogen and progestin or the combined pill of estrogen and testosterone Months of estrogen pills Days/month estrogen pill used Type of estrogen pill used longest Usual daily estrogen pill dose Mark Other if the type of estrogen pill used the longest was something other than Premarin, conjugated equine estrogens, Estrace, or Ogen. The usual daily dose taken of the type of estrogen pill used the longest in the past year. If more than one dose amount is taken regularly, mark the lowest dose. 20. Use of estrogen shots No/Yes/Don t know Months of estrogen shots 21. Use of estrogen vaginal cream or suppository Months of estrogen vaginal cream or suppository No/Yes/Don t know. 22. Use of a skin patch No/Yes/Don t know Months of skin patch use Type of skin patch used longest Usual dose of estrogen in skin patch Times/week skin patch changed Mark Other if the participant used cut-up skin patches or used more than one skin patch at a time. The number of times that a skin patch was changed each week is the same as the number of skin patches used each week. 23. Use progestin pills No/Yes/Don t know. Do not include the combined pill of estrogen and progestin Months of progesterone pill use
5 Form OS Follow-Up Questionnaire (Observational Study - Year 4) Ver. 1.1 Page Days/month progestin pills used Type of progesterone pill used longest Usual daily dose of progesterone The usual daily dose taken of the type of progesterone pill used the longest in the past year. If more than one dose amount is taken regularly, mark the lowest dose. 24. Previous health conditions or procedures No/Yes. Participant should mark all health conditions or procedures taking place in the past year. See below for descriptions of each condition or procedure Cataract(s) An opacity of the lens of the eye (usually treated by surgery) Macular degeneration A breakdown of the area of the retina that can lead to severe loss of vision. of the retina Asthma Chronic respiratory condition associated with reversible airway obstruction, sudden wheezing, coughing and shortness of breath, often in response to environmental, physical, or emotional stressors Emphysema or chronic bronchitis Heart failure or congestive heart failure Angina (chest pains from the heart) Chronic lung disease, also known as chronic obstructive pulmonary disease or COPD. Usually associated with coronary heart disease or cardiomyopathy and characterized by such symptoms as ankle swelling and shortness of breath. Angina or angina pectoris. Chest discomfort occurring at rest or with exercise and relieved by nitrates and/or rest. This is not the same thing as a heart attack Atrial fibrillation Pulse is irregularly irregular. Usually a chronic condition, different from lifethreatening ventricular arrhythmias. Participants may be taking chronic medication (e.g., digoxin) to control this condition and/or prevent blood clots Kidney or bladder stones Dialysis for kidney or renal failure Stomach or duodenal ulcer Also called urinary or renal calculi, usually associated with severe back or suprapubic (above the pubic bone) pain and passage of blood in urine. Calculi may be passed in urine or extracted or removed surgically. Dialysis, hemodialysis or peritoneal dialysis. A procedure for filtering the blood through a machine in those with kidney or renal failure. Includes all mild to severe upper gastrointestinal ulcers. Participant may be taking chronic medications to control this condition or she may have had surgery Diverticulitis Inflammation of colonic diverticula (mucosal herniations), characterized by lower abdominal cramping and bowel irregularity (i.e., constipation and diarrhea) Pancreatitis Inflammation of the pancreas. An acute condition, usually associated with severe upper abdominal pain, nausea, vomiting, fever, and sometimes jaundice. Restriction of oral intake is usually necessary. Chronic pancreatitis is associated with episodes of severe abdominal pain and may be treated by pancreatectomy (removal of pancreas) Liver disease Chronic active hepatitis, cirrhosis, or yellow jaundice.
6 Form OS Follow-Up Questionnaire (Observational Study - Year 4) Ver. 1.1 Page Overactive thyroid Hyperthyroidism. Participant may have had this condition in the past and then undergone irradiation or surgical removal (thyroidectomy) Underactive thyroid Hypothyroidism. Participant may have this condition as a result of treatment for hyperthyroidism (see above). Participants often take thyroid supplement medication for this condition Alzheimer's disease: Senile dementia (brain disorder with progressive cognitive, personality, and motor dysfunction) Multiple sclerosis Progressive demyelination within the central nervous system. Symptoms may include weakness, speech disturbances, and vision problems Parkinson's disease Progressive neurologic disorder characterized by muscle stiffness, rigidity, pillrolling movements of hands, and lack of coordinated movements Amyotrophic Lateral Sclerosis ALS or Lou Gehrig disease. Neuromuscular disease associated with motor neuron degeneration and characterized by progressive paralysis. 25. Marital status Participant's current marital status. Mark only one.
Form OS Follow-Up Questionnaire (Observational Study - Year 6) (Ver. 1) Page 1
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