Large Granular Lymphocyte (LGL) Leukemia Registry Page 1 of 6 PATIENT INFORMATION QUESTIONNAIRE
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1 Patient Name: Patient / / Patient Information Large Granular Lymphocyte (LGL) Leukemia Registry Page 1 of 6 PATIENT INFORMATION QUESTIONNAIRE 1. On what date was this questionnaire completed? / / 2. Please print your full name in the boxes below: Last Name: First Name: Middle Name: 3. Please print your address in the boxes below: Street: Apt #: City: State: Zip Code: - 4. Please print your address in the boxes below: Area Code 5. What is your home telephone number? What is your work telephone number? - - Ext. 7. On what date were you born? / / 8. What is your Social Security Number? - - (optional) 9. What is your gender? 10. What is your race? White, not of Hispanic origin Hispanic Asian/Pacific Islander Black, not of Hispanic origin American Indian/Alaskan Native Other 11. What is the average total income for your entire household before taxes? Under $20,000 $60,000-$79,999 Decline to answer $20,000-$39,999 $80,000-$99,999 $40,000-$59,999 $100,000 or more 12. What is the highest grade or level of schooling that you completed? No Formal Education Technical or Vocational School 8 th Grade or Less Associate Degree or Some College Some High School Bachelor s Degree High School Graduate or GED Advanced Degree 13. What has been your usual occupation for most of your adult life? 14. What is your current occupation or job?
2 Page 2 of Have you experienced any of the following possible risk factors for LGL Leukemia? Please check Yes, No, or for each. Yes No Don t Know Have you shared needles or syringes to inject drugs or steroids? If you are male, have you had sex with any other males? (If you are female, leave these boxes blank.) Have you had sex with someone who you believe may have been infected with HIV? Have you had a sexually transmitted disease (STD)? Have you ever received blood transfusions or blood products? Have you ever been employed in a healthcare setting where you were exposed to bodily fluids? Have you had sex without a condom with someone who would answer yes to any of the above questions? Family Medical History Part 1 Family Members with Autoimmune Diseases: Do you have any family members who have been diagnosed with an autoimmune disease (e.g. rheumatoid arthritis, lupus, diabetes, multiple sclerosis, scleroderma, etc.)? No Yes If you answered No or to the above question, please skip to Part 2 Family Members with Cancer on page 4. If you answered Yes to the above question, please complete one box (below) for each family member diagnosed with an autoimmune disease. (Attach copies of this sheet if more space is needed.) grand grand great grand great grand great grand grand great grand great grand great _
3 Part 1 Family Members with Autoimmune Diseases (continued) Page 3 of 6 more boxes on next page grand grand great grand great grand great grand grand great grand great grand great grand grand great grand great grand great _
4 Part 2 Family Members with Cancer: Page 4 of 6 Do you have any family members who have been diagnosed with cancer? No Yes If you answered No or to the above question, you are finished. Thank you for your participation. If you answered Yes to the above question, please complete one box (below) for each family member diagnosed with cancer. (Attach copies of the sheet if more space is needed.) Non- grand grand great grand great grand great Non- grand grand great grand great grand great more boxes on next page
5 Part 2 Family Members with Cancer (continued) Page 5 of 6 Non- grand grand great grand great grand great Non- grand grand great grand great grand great more boxes on next page
6 Part 2 Family Members with Cancer (continued) Page 6 of 6 Non- grand grand great grand great grand great Non- grand grand great grand great grand great Thank you for your participation!
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