49585 Australasian Colorectal Cancer Family Study...Australia Bangladesh Canada China Croatia Cyprus...
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Interview Date ID Number 0 1 2 3 4 5 6 7 8 0 1 2 3 4 5 6 7 8 - 0 1 2 3 4 5 6 7 8 9 0 1 2 3 4 5 6 7 8 9 0 1 2 3 4 5 6 7 8 9 0 1 2 3 4 5 6 7 8 9 0 1 2 3 4 5 6 7 8 9 - 0 1 2 3 4 5 6 7 8 9 0 1 2 3 4 5 6 7 8 9 0 1 2 3 4 5 6 7 8 9 Australasian Colorectal Cancer Family Study This study is part of the Cooperative Family Registry for Colorectal Cancer Studies, and is funded by the National Institutes of Health (USA). Mother's ID Number 0 1 2 3 4 5 6 7 8 0 1 2 3 4 5 6 7 8 - 0 1 2 3 4 5 6 7 8 9 0 1 2 3 4 5 6 7 8 9 0 1 2 3 4 5 6 7 8 9 0 1 2 3 4 5 6 7 8 9 0 1 2 3 4 5 6 7 8 9 - 0 1 2 3 4 5 6 7 8 9 0 1 2 3 4 5 6 7 8 9 0 1 2 3 4 5 6 7 8 9 Father's ID Number 0 1 2 3 4 5 6 7 8 0 1 2 3 4 5 6 7 8 - 0 1 2 3 4 5 6 7 8 9 0 1 2 3 4 5 6 7 8 9 0 1 2 3 4 5 6 7 8 9 0 1 2 3 4 5 6 7 8 9 0 1 2 3 4 5 6 7 8 9 - 0 1 2 3 4 5 6 7 8 9 0 1 2 3 4 5 6 7 8 9 0 1 2 3 4 5 6 7 8 9 Spouse's ID Number 0 1 2 3 4 5 6 7 8 0 1 2 3 4 5 6 7 8 - 0 1 2 3 4 5 6 7 8 9 0 1 2 3 4 5 6 7 8 9 0 1 2 3 4 5 6 7 8 9 0 1 2 3 4 5 6 7 8 9 0 1 2 3 4 5 6 7 8 9 - 0 1 2 3 4 5 6 7 8 9 0 1 2 3 4 5 6 7 8 9 0 1 2 3 4 5 6 7 8 9 Gender Male Female Proband Yes No Centre for Genetic Epidemiology The University of Melbourne 200 Berkeley Street Carlton VIC 3053 Instructions All questions where there is a choice or a numerical reponse require you to fill in the bubble. Numeric responses should also be written in the boxes above the columns of bubbles. For example, to indicate a response of 12 the form would be filled in like the illustration to the right . Ideally, bubbles should be filled in completely but it is more important to keep marks inside the bubble as much as possible. 0 1 3 4 5 6 7 8 9 0 2 3 4 5 6 7 8 9 Text fields should be filled in using block capitals, taking care to keep the letters within the boxes: Form ID 0 1 2 3 4 5 6 7 8 9 0 1 2 3 Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 9 9 9 9 9 9 9 9 Form ID 49585
Transcript of 49585 Australasian Colorectal Cancer Family Study...Australia Bangladesh Canada China Croatia Cyprus...
Interview Date
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Australasian Colorectal Cancer Family StudyThis study is part of the Cooperative Family Registry for Colorectal Cancer Studies,
and is funded by the National Institutes of Health (USA).
Mother's ID Number
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Gender
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Proband
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Centre for Genetic EpidemiologyThe University of Melbourne200 Berkeley StreetCarlton VIC 3053
InstructionsAll questions where there is a choice or a numerical reponserequire you to fill in the bubble. Numeric responses should also bewritten in the boxes above the columns of bubbles. For example, toindicate a response of 12 the form would be filled in like theillustration to the right .
Ideally, bubbles should be filled in completely but it is moreimportant to keep marks inside the bubble as much as possible.
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Text fields should be filled in using block capitals, taking care to keep the letters within the boxes:
Form ID
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JanFebMarAprMayJunJulAugSepOctNovDec
199819992000200120022003200420052006200720082009
9 9
9 9
9 99 9
Form ID
49585
A. Background Information
I would like to begin by asking you some questions about your background.
How old are you?
A2. What is your date of birth?
years
A3. What was the highest level ofeducation that you completed?
Are you a twin or a triplet?
Yes, a twinYes, other multipleNoDon't Know
YesNo
A4. Are you currently...
MarriedSeparatedDivorcedWidowedNever marriedLiving as marriedDon't Know
A5.
Primary school (some or all)Secondary school - year 7 or year 8Secondary school - year 9 or year10Secondary school - year 11 or year 12Vocational trainingUniversity - did not graduateUniversity - graduatedDon't Know
JanFebMarAprMayJunJulAugSepOctNovDec
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May we pass your name to theAustralian Twin Registry?
Don't Know
Don'tKnow
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A1. Do you have a genetically identicaltwin or triplet?
YesNoDon't Know
Non-identical twins are no more alike thanordinary brothers and sisters. Geneticallyidentical twins, on the other hand, look somuch alike (that is, they have such a strongresemblance to each other in stature,colouring, feaures of the face, etc.) thatpeople often mistake one for the other,especially during their childhood.)
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A4.A4.
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Form ID
49585
A6. In which country were you, your parents and your grandparents born?
A7. For how many years have you lived in Australia?
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In which suburb or town do you usually live?
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Yourmother
Yourmother's
father
Yourmother'smother
Yourfather
Yourfather'smother
Yourfather'sfatherYou
AustraliaBangladeshCanadaChinaCroatiaCyprusEnglandEgyptGermanyGreeceHungaryIndiaIrelandItalyJapanMaltaNetherlandsNorthern IrelandNew ZealandPhilippinesPolandRussiaScotlandSouth AfricaSri LankaUSAVietnamWalesUnknown, not AustraliaUnknownOther
Specify:
A8.
Form ID
49585
A9. What is the ethnic background of you, your parents and your grandparents?(Mark as many as apply)
A10. In which religion were you, your parents and your grandparents born?(Religion and ethnicity sometimes affect disease risk. Scientists have found that some genetic traitsare sometimes more or less common among people of different ethnic backgrounds. We would liketo know if this is true for genes associated with colorectal cancer.)
Yourmother
Yourmother's
father
Yourmother'smother
Yourfather
Yourfather'smother
Yourfather'sfatherYou
Specify:
Protestant/AnglicanEastern OrthodoxCatholic
MuslimBuddhistHindu
Latter Day Saints/MormonSeventh Day Adventist
Sephardic JewishAshkenazi JewishOther or uncertain JewishNone
Other, specify belowDon't Know
Caucasian/WhiteAfrican American/BlackLatinoJapaneseChineseFilipino/Malay/IndonesianKoreanSouth East Asian (except Chinese)South AsianNative American, InuitMaoriMicronesianAustralian AboriginalMelanesianCarribean BlackCentral/South AmericanBlack AfricanNorth AfricanMiddle EasternOtherUnknown
Yourmother
Yourmother's
father
Yourmother'smother
Yourfather
Yourfather'smother
Yourfather'sfatherYou
Specify:
Form ID
49585
B. Medical HistoryB1. Medical Tests
Now I 'm going to ask you some questions about medical tests you may have had.
YesNoDon't Know
Have you ever had a test for blood in yourstool, called a fecal occult blood test,such as Hemoccult?(This test is frequently done as part of aroutine physical examination or it can be doneat home.)
What was your age whenyou first had this test?
To investigate a new problemFamily history of colorectal cancerRoutine/yearly exam or check upFollow-up of a previous problemOther:
What were the reasons for your first test?(Mark all that apply)
How many separatetests have you had?
If more than one test,what was your age whenyou last had this test?
YesNoDon't Know
Have you ever had a sigmoidoscopy?(A procedure that involves looking inside thelarge bowel or colon and rectum, with a lightedinstrument. This examination is usually done ina doctor's office without anaesthesia.)
What was your age whenyou first had this test?
To investigate a new problemFamily history of colorectal cancerRoutine/yearly exam or check upFollow-up of a previous problemOther:
What were the reasons for your first test?(Mark all that apply)
How many separatetests have you had?
If more than one test,what was your age whenyou last had this test?
B1.b
B1.a
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Form ID
49585
YesNoDon't Know
Have you ever had a colonoscopy?(Colonoscopy is an examination of the entirelarge bowel using a long flexible instrument.This examination is usually done undersedation.)
What was your age whenyou first had this test?
years
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To investigate a new problemFamily history of colorectal cancerRoutine/yearly exam or check upFollow-up of a previous problemOther:
What were the reasons for your first test?(Mark all that apply)
How many separatetests have you had?
tests
Don't Know
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If more than one test,what was your age whenyou last had this test?
years
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YesNoDon't Know
Has a doctor ever told you that you had polyps in your large bowel or colon or rectum?
B2. Medical History: Polyps
How old were you whenyou were first told thatyou had polyps?
years
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Have you been told thatyou had polyps morethan once?
How old were you whenyou were last told thatyou had polyps?
years
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YesNoDon't Know
BenignAdenomatous (sometimes called pre-cancerous)OtherDon't Know
Do you know if your polyps were benign, adenomatous (pre-cancerous), or something else?(Mark all that apply.) (Include all the separate times you were told you had polyps.)
B3.B3.
B2.b
B1.c
B2.a
Now I 'd like to ask you some questions about your medical history.
B2.B2.
B2.bB2.b
Form ID
49585
Have you had polypsremoved more thanonce?
How old were you whenyou last had polypsremoved?
years
Don't Know
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Has a doctor ever told you that you had familialadenomatous polyposis, known also by its initials asFAP? (This is an inherited condition in which numerouspolyps line the inside of the large bowel or colon.)
B3. Medical History
Age at which your doctor first toldyou that you had the condition
Condition
years
Don't Know
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YesNoDon't Know
Has a doctor ever told you that you had Crohn'sdisease? (This is where you have inflammation thatextends into the deeper layers of the large bowel or colonwall. It may also affect other parts of the digestive tract,including the mouth, oesophagus, stomach and smallintestine.
years
Don't Know
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YesNoDon't Know
Has a doctor ever told you that you had ulcerativecolitis? (This is where you have inflammation andulceration of the lining of the large bowel or colon andrectum. It is not a stomach ulcer.)
years
Don't Know
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Did you have the polyps removed (by a procedure called polypectomy)? (This can be doneduring a sigmoidoscopy or colonoscopy.)
YesNoDon't Know
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How old were you whenyou first had polypsremoved?
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Don't Know
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B3.
B3.
Form ID
49585
YesNoDon't Know
Has a doctor ever told you that you had irritablebowel syndrome? (This is a disorder of the large bowel orcolon that leads to cramping, gassiness, bloating andalternating diarrhea and constipation. Also known as IBS.)
Age at which your doctor first toldyou that you had the condition
Condition
years
Don't Know
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YesNoDon't Know
Has a doctor ever told you that you had diverticulardisease? (This may also be called diverticulosis ordiverticulitis. It's a condition in which the large bowel orcolon may become infected, and can lead to pain andchronic problems with bowel habits.)
years
Don't Know
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YesNoDon't Know
Have you everhad any of yourlarge bowel orcolon removed?
years
Don't Know
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Completely removedPartly removedDon't Know
Was it completelyremoved, or wasonly part of itremoved ?
years
Don't Know
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YesNoDon't Know
Have you had morethan one surgery toremove part of yourbowel or colon?
YesNoDon't Know
Have you had your gallbladderremoved?
years
Don't Know
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What was your age whenyou had your gallbladderremoved?
What was yourage when youlast had part ofyour bowelremoved?
What was yourage when youhad all yourbowel removedor first had partof your bowelremoved?
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Form ID
49585
B3.h
YesNoDon't Know
B3.iB3.i
Has a doctor ever told youthat you had diabetes? (Alsoknown as diabetes mellitus. Donot include diabetes which youhad only during pregnancy(gestational diabetes).)
years
Don't Know
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How old were youwhen this wasdiagnosed?
PillsInsulin injectionsBothDon't Know
NoDon't Know
Have you ever taken medicationto control your diabetes?
Yes
How often did you take pillsto control your diabetes?
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Were you takingthem two yearsago ?
How long, in total, have youtaken pills to control yourdiabetes?
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Don't Know
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How often did you haveinsulin injections to controlyour diabetes?
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YesNoDon't Know
Were you havingthem two yearsago ?
How long, in total, have youhad insulin to control yourdiabetes?
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Form ID
49585
B3.i
YesNoDon't Know
Has a doctor ever toldyou that you had highcholesterol?
years
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How old were youwhen this wasdiagnosed?
YesNoDon't Know
Have you ever taken medicationto control your high cholesterol?
How often did you take thismedication?
0
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YesNoDon't Know
Were you taking ittwo years ago?
How long, in total, have youtaken this medication
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Has a doctor ever toldyou that you had hightriglycerides?(Triglycerides are a type offat in your blood.)
years
Don't Know
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How old were youwhen this wasdiagnosed?
YesNoDon't Know
Have you ever taken medication tocontrol your high triglycerides ?
How often did you take thismedication?
0
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Were you taking ittwo years ago?
How long, in total, have youtaken this medication
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B4.
B4.
B4.B4.
Form ID
49585
B4. Cancer History
YesNoDon't Know
B4. Has a doctor ever told you that you had cancer, leukaemia or a malignant tumour? (This mayseem obvious, but for scientific reasons I need to ask this question for everyone.)
B5B5
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What was your age whenyour doctor first told youyou had your first cancer?
What type of cancer was your first cancer?
YesNoDon't Know
Were you treated with radiation therapy (radiotherapy)for your first cancer?
years
Don't Know
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What was your age whenyour doctor first told youyou had your second cancer?
What type of cancer was your second cancer?
YesNoDon't Know
Were you treated with radiation therapy (radiotherapy)for your second cancer?
Form ID
49585
years
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What was your age whenyour doctor first told youyou had your third cancer?
What type of cancer was your third cancer?
YesNoDon't Know
Were you treated with radiation therapy (radiotherapy)for your third cancer?
years
Don't Know
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What was your age whenyour doctor first told youyou had your fourth cancer?
What type of cancer was your fourth cancer?
YesNoDon't Know
Were you treated with radiation therapy (radiotherapy)for your fourth cancer?
B5. Medication
Now I 'd like to ask you some questions about medication you may have taken.
Have you ever takenthe followingmedications at leasttwice a week for amonth or longer?
0
1
2
3
4
5
6
7
8
9
0
1
2
3
4
5
6
7
8
9
times per dayper week
Don't Know
YesNoDon't Know
Were you takingit at least twicea week for amonth or longertwo years ago?
How long, in total,have you taken thismedication for atleast twice a week fora month or longer?
0
1
2
3
4
5
6
7
8
9
0
1
2
3
4
5
6
7
8
9
monthsyears
Don't Know
How often did youtake it, when youwere taking it at leasttwice a week for amonth or longer?
YesNoDon't Know
aspirin(such as Aspro, CodralForte, Disprin, Ecotrin,Cardiprin)
0
1
2
3
4
5
6
7
8
9
0
1
2
3
4
5
6
7
8
9
times per dayper week
Don't Know
YesNoDon't Know
0
1
2
3
4
5
6
7
8
9
0
1
2
3
4
5
6
7
8
9
monthsyears
Don't KnowYesNoDon't Know
paracetamol(such as Panadol,Panadeine, Panamax,Codral, Tylenol)
B5.a
B5.b
B5.bB5.b
B5.cB5.c
Form ID
49585
Have you ever takenthe followingmedications at leasttwice a week for amonth or longer?
0
1
2
3
4
5
6
7
8
9
0
1
2
3
4
5
6
7
8
9
times per dayper week
Don't Know
YesNoDon't Know
Were you takingit at least twicea week for amonth or longertwo years ago?
How long, in total,have you taken thismedication for atleast twice a week fora month or longer?
0
1
2
3
4
5
6
7
8
9
0
1
2
3
4
5
6
7
8
9
monthsyears
Don't Know
How often did youtake it, when youwere taking it at leasttwice a week for amonth or longer?
YesNoDon't Know
pain killinganti-inflammatorymedication(such as Naprosyn,Orudis, Voltaren, Brufen,Clinoril, Feldene, Indocid)
0
1
2
3
4
5
6
7
8
9
0
1
2
3
4
5
6
7
8
9
times per dayper week
Don't Know
YesNoDon't Know
0
1
2
3
4
5
6
7
8
9
0
1
2
3
4
5
6
7
8
9
monthsyears
Don't KnowYesNoDon't Know
bulk-forming laxatives(such as Metamucil,Normacol, Psyllium,Agiofibe, Granocol)
B5.c
B5.d
0
1
2
3
4
5
6
7
8
9
0
1
2
3
4
5
6
7
8
9
times per dayper week
Don't Know
YesNoDon't Know
0
1
2
3
4
5
6
7
8
9
0
1
2
3
4
5
6
7
8
9
monthsyears
Don't Know
YesNoDon't Know
other laxatives(such as castor oil, codliver oil, mineral oil,paraffin oil, milk ofmagnesia, Laxettes,Agarol, Agiolax, Coloxyl,Durolax, Senokot,Duphalac)
0
1
2
3
4
5
6
7
8
9
0
1
2
3
4
5
6
7
8
9
times per dayper week
Don't Know
YesNoDon't Know
0
1
2
3
4
5
6
7
8
9
0
1
2
3
4
5
6
7
8
9
monthsyears
Don't Know
YesNoDon't Know
calcium-containingantacids(such as Tums, Gaviscon,Mylanta, Dexsal, Algicon,Amphogel, Gastrogel,Mucaine, Meracote)
B5.e
B5.f
B5.dB5.d
B5.eB5.e
B5.fB5.f
B5.gB5.g
Form ID
49585
Have you ever takenthe followingmedications at leasttwice a week for amonth or longer?
0
1
2
3
4
5
6
7
8
9
0
1
2
3
4
5
6
7
8
9
times per dayper week
Don't Know
YesNoDon't Know
Were you takingit at least twicea week for amonth or longertwo years ago?
How long, in total,have you taken thismedication for atleast twice a week fora month or longer?
0
1
2
3
4
5
6
7
8
9
0
1
2
3
4
5
6
7
8
9
monthsyears
Don't Know
How often did youtake it, when youwere taking it at leasttwice a week for amonth or longer?
YesNoDon't Know
calcium supplements(such as Sandocal, VitaGlow, Caltrate, Calvita)
0
1
2
3
4
5
6
7
8
9
0
1
2
3
4
5
6
7
8
9
times per dayper week
Don't Know
YesNoDon't Know
0
1
2
3
4
5
6
7
8
9
0
1
2
3
4
5
6
7
8
9
monthsyears
Don't KnowYesNoDon't Know
multivitamin pills ortablets(not individual vitamins)(such as Bioglan, Myadec,Pluravit, Supradyn))
B5.g
B5.h
0
1
2
3
4
5
6
7
8
9
0
1
2
3
4
5
6
7
8
9
times per dayper week
Don't Know
YesNoDon't Know
0
1
2
3
4
5
6
7
8
9
0
1
2
3
4
5
6
7
8
9
monthsyears
Don't Know
YesNoDon't Know
folic acid or folatesupplements(such as Folic acid, Fefol)
B5.i
B5.hB5.h
B5.iB5.i
C1.
C1.
Form ID
49585
C2.b
C. Menstruation, reproductive history, menopause
C1. MenstruationThis next series of questions are about menstruation and pregnancy.
C1. How old were you when you hadyour first menstrual period?
years
Don't KnowNever had a menstrual period
0
1
2
3
4
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7
8
9
0
1
2
3
4
5
6
7
8
9
C2. Pregnancies
How many times have you been pregnant? (Include all pregnancies including miscarriages,still births, tubal pregnancies and abortions)(If currently pregnant exclude your currentpregnancy)
number of pregnancies
Don't Know
0
1
2
3
4
5
6
7
8
9
0
1
2
3
4
5
6
7
8
9
Have you ever been pregnant?
YesNoDon't Know
C3.C3.
C2.c How many times were you pregnant withmore than one baby? (Twins, triplets, etc.)
number of pregnancies with multiples
NeverDon't Know
0
1
2
3
4
5
6
7
8
9
0
1
2
3
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7
8
9
C2.d How many of your pregnancieslasted 6 months or longer?
number of pregnancies
Don't Know
0
1
2
3
4
5
6
7
8
9
0
1
2
3
4
5
6
7
8
9
C2.e How many of your pregnanciesresulted in live births?
number of pregnancies
Don't Know
0
1
2
3
4
5
6
7
8
9
0
1
2
3
4
5
6
7
8
9
C2.a
if 0 go toC3.
if 0 go toC3.
if 0 go toC3.
Form ID
49585
How old were you at your firstlive birth?
years
Don't Know
0
1
2
3
4
5
6
7
8
9
0
1
2
3
4
5
6
7
8
9
C2.f How old were you at your last livebirth?
years
Don't Know
0
1
2
3
4
5
6
7
8
9
0
1
2
3
4
5
6
7
8
9
C2.g
C3. Contraceptive Use
YesNoDon't Know
C4.C4.
Have you ever used birth control pills orother hormonal contraceptives (implantsor injections) for at least one year?
How old were you when you firstused birth control pills or otherhormonal contraceptives?
years
Don't Know
0
1
2
3
4
5
6
7
8
9
0
1
2
3
4
5
6
7
8
9
C3.b
YesNoDon't Know
Were you still using birth control pills orother hormonal contraceptives twoyears ago?
In total, how long did you take birthcontrol pills or other hormonalcontraceptives?
years
Don't Know
0
1
2
3
4
5
6
7
8
9
0
1
2
3
4
5
6
7
8
9
C3.d
C4. Menopause
C4.a
YesNoDon't Know
C5.
C5.
Have you had a menstrual period in the last 12 months? (Only menstrual bleeding is of interest.Do not include bleeding that results from hormone replacement therapy (HRT), or progesterones,progestins, or withdrawal bleeding.)
I f the answer to question C.1 was "Never had a menstrual period" go to section C5.
C4.b
Stopped permanentlyStopped temporarily C5.
Have your menstrual periods stopped permanently or only temporarily due to pregnancy,breastfeeding or other conditions?
C3.a C3.c
Form ID
49585
How old were you when yourperiods stopped permanently?
years
Don't Know
0
1
2
3
4
5
6
7
8
9
0
1
2
3
4
5
6
7
8
9
Why did your menstrual periods stop?
Natural menopauseGynaecological surgeryRadiation or chemotherapyOtherDon't Know
C4.c
Which of the following surgery did you have?
How old were you when you firsthad radiation or chemotherapy?
years
Don't Know
0
1
2
3
4
5
6
7
8
9
0
1
2
3
4
5
6
7
8
9
How old were you when you firsthad (other)?
years
Don't Know
0
1
2
3
4
5
6
7
8
9
0
1
2
3
4
5
6
7
8
9
Hysterectomy onlyWith one or part ovaryWith both ovariesDon't Know
NoDon't Know
Hysterectomy(uterus/womb removed)
How old wereyou when youhad this surgery?
years
Don't Know
0
1
2
3
4
5
6
7
8
9
0
1
2
3
4
5
6
7
8
9
YesNoDon't Know
One ovaryremoved in wholeor part withouthysterectomy
How old wereyou when youhad this surgery?
years
Don't Know
0
1
2
3
4
5
6
7
8
9
0
1
2
3
4
5
6
7
8
9
YesNoDon't Know
Both ovariesremoved withouthysterectomy
How old wereyou when youhad this surgery?
years
Don't Know
0
1
2
3
4
5
6
7
8
9
0
1
2
3
4
5
6
7
8
9
How old wereyou when youhad this surgery?
years
Don't Know
0
1
2
3
4
5
6
7
8
9
0
1
2
3
4
5
6
7
8
9
Have you had any gynaecological surgery? (surgery on your uterus or ovaries)
YesNoDon't Know
C4.d
C5.C5.
Specify:
Specify:
C5.C5.
YesNoDon't Know
Other surgery
Form ID
49585
C5. Hormone Replacement Therapy
Doctors prescribe hormone replacementtherapy for many reasons includingmenopausal symptoms, surgical removal ofthe ovaries, osteoporosis, and heart diseaseprevention.
YesNoDon't Know
Have you ever used a pill, patch orimplant form of hormone replacementtherapy?(Menopausal symptoms include hot flushes,sweating and depression. Please do notinclude hormone therapy that was prescribedfor birth control; hormone therapy deliveredby injections, vaginal creams or vaginalsuppositories.)
YesNoDon't Know
Were you still having periods when youfirst took these hormones?
First, I will ask about oestrogen-only therapy,and then about oestrogen given in combinationwith progesterone (progestins) . After that, I willask about tamoxifen, raloxifene and otheranti-oestrogens.
C5.d
C5.d
YesNoDon't Know
Were you prescribed an oestrogen-onlypill or patch? (such as Premarin, Climara,Dermetril, Estigyn, Estraderm, Femtran,Menorest, Ogen, Ovestin, Progynova.)
C5.cC5.c
How old were you when you firsttook oestrogen-only medication?
years
Don't Know
0
1
2
3
4
5
6
7
8
9
0
1
2
3
4
5
6
7
8
9
YesNoDon't Know
Were you still taking oestrogen-onlymedication two years ago?
In total, how long have you takenoestrogen-only medication?
Don't Know
0
1
2
3
4
5
6
7
8
9
0
1
2
3
4
5
6
7
8
9
YesNoDon't Know
Progesterone, one commmon brand isProvera, is frequently prescribed bydoctors along with oestrogen. Have youever taken progesterone along withoestrogen for menopause or otherreasons? (such as Divina, Estracombi,Estrapak, Kliogest, Menoprem, Provelle)
C5.dC5.d
How old were you when you firsttook them?
years
Don't Know
0
1
2
3
4
5
6
7
8
9
0
1
2
3
4
5
6
7
8
9
YesNoDon't Know
Were you still taking them about twoyears ago?
C5.a
C5.b
C5.c
monthsyears
Form ID
49585
In total, how long have you takenthem?
Don't Know
0
1
2
3
4
5
6
7
8
9
0
1
2
3
4
5
6
7
8
9
YesNoPossiblyDon't Know
Have you ever taken tamoxifen,raloxifene or other anti-oestrogenmedication? (such as Tamoxen, Genox,Nolvadex, Noxiton, Tamosin)
TamoxifenRaloxifeneOtherDon't Know
Did you take tamoxifen orraloxifene, or do you know whatthe other anti-oestrogen was?(mark all that apply)
How old were you when you firsttook tamoxifen, raloxifene orother anti-oestrogen medication?
years
Don't Know
0
1
2
3
4
5
6
7
8
9
0
1
2
3
4
5
6
7
8
9
I have participated in aclinical trial for tamoxifen,raloxifene or otheranti-oestrogen medication
YesNoPossiblyDon't Know
Were you still taking them about twoyears ago?
I have participated in aclinical trial for tamoxifen,raloxifene or otheranti-oestrogen medication
In total, how long have you takenthem? (If you took more than onemedication, add up together all the timeyou took any of these medications.)
Don't Know
0
1
2
3
4
5
6
7
8
9
0
1
2
3
4
5
6
7
8
9
C5.d
monthsyears
monthsyears
D1.
Form ID
49585
D. DietI n this next section, the questions ask how often you ate certain foods about two years ago. Wouldyou please tell me how often per day, per week or per month you ate the following foods.
0
1
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9
0
1
2
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9
0
1
2
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5
6
7
8
9
portions/servings
per dayper weekper month
Don't Know
D1.
0
1
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9
0
1
2
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9
0
1
2
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7
8
9
portions/servingsper dayper weekper month
Don't Know
D2.
About two years ago, on average howoften did you eat a piece or serving offruit?A serving of fruit is:
* 1 medium fresh fruit* 1/2 cup of chopped, or cooked, or
canned fruit* 1/4 cup of dried fruit* 6 ounces (200 mls or 1 glass) of
fruit juice
About two years ago, on average howoften did you eat a serving ofvegetables?A serving of vegetables is:
* 1 cup raw leafy vegetables* 1/2 cup of other vegetables, cooked or chopped raw* 6 ounces (200 mls or 1 glass) of vegetable juice
0
1
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9
0
1
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7
8
9
0
1
2
3
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7
8
9
portions/servings
per dayper weekper month
Don't Know
About two years ago, on average howmany servings of red meat did you eatthat were cooked by pan-frying orfryer pan, grilling or barbequeing?
D4.a
0
1
2
3
4
5
6
7
8
9
0
1
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7
8
9
0
1
2
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6
7
8
9
portions/servingsper dayper weekper month
About two years ago, on average howmany servings of red meat (notchicken or fish) did you eat?A serving of red meat is 2-3 ounces (60-100grams); about the size of a deck of cardsRed meat includes beef, steak, mince, lamb,hamburger, pork, bacon, sausages and veal
Did not eat red meatDon't Know
D3.a
D3.b
D3. Red Meat
D4.aDid not eat red meatcooked this way
Form ID
49585
About two years ago, on average whenyou ate red meat cooked by thesemethods, which of the following bestdescribes its inside appearance?
Red or rarePink or mediumBrown or well doneDon't Know About two years ago, on average when
you ate chicken cooked by thesemethods, which of the following bestdescribes its outside appearance?
Lightly brownedMedium brownedHeavily browned/blackenedDon't Know
0
1
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9
0
1
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9
0
1
2
3
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5
6
7
8
9
portions/servingsper dayper weekper month
About two years ago, on average howoften did you eat a serving of chicken?A serving of chicken is:
* 2-3 ounces of chicken meat* 1 drumstick* 1 thigh* half a breast* 2 wings* 3 nuggets
0
1
2
3
4
5
6
7
8
9
0
1
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8
9
0
1
2
3
4
5
6
7
8
9
portions/servingsper dayper weekper month
Did not eat chicken cooked this wayDon't Know
About two years ago, on average howmany servings of chicken did you eatthat were cooked by pan-frying orfryer pan, grilling or barbequeing?
E1.
D4.a
D4.b
D4.c
About two years ago, on average whenyou ate red meat cooked by thesemethods, which of the following bestdescribes its outside appearance?
Lightly brownedMedium brownedHeavily browned/blackenedDon't Know
D3.c
D4. Chicken
Did not eat chickenDon't Know
E1.
Form ID
49585
E. Physical Activity
By "regularly", I mean at least 30 minutes a week for a minimum of 3 months in a row.
E1.a
Did you ever jogregularly? (jogging isrunning slower than akilometre in 6 minutes ora mile in 10 minutes)
For how manyyears did youdo this activity ?
For how many months ofthe year, on average, didyou do this activity ?
For how many hoursper week, on average,did you do thisactivity ?
YesNoDon't Know
Did you ever walkregularly? Know
Don't Don't Know Don't Know
YesNoDon't Know
Don't Don't Know Don't Know
Did you ever runregularly? (running isrunning faster than akilometre in 6 minutes ora mile in 10 minutes)
YesNoDon't Know
Did you ever cycleregularly? (thisincludes stationarycycling)
YesNoDon't Know
Don't Don't Know Don't Know
Don't Don't Know Don't Know
E1.b
E1.c
E1.d
0
1
0
1
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8
9
0
1
0
1
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0
1
0
1
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9
0
1
0
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9
0
1
0
1
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3
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9
0
1
0
1
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9
0
1
0
1
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9
0
1
0
1
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9
0
1
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9
0
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9
0
1
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9
0
1
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9
0
1
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9
0
1
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9
0
1
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9
0
1
2
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7
8
9
E1. Early Adult Years
The next section contains questions about your participation in a variety of physical activitiesduring three periods of your life.
Think back to the period when you were in your 20s. I would like to know if you participatedregularly in any of the following activities.
Know
Know
Know
E1.bE1.b
E1.cE1.c
E1.dE1.d
E1.eE1.e
E1. Early AdultYears
Form ID
49585
Did you ever docalisthenics, aerobics,vigorous dance, or usea rowing machineregularly?
For how manyyears did youdo this activity ?
For how many months ofthe year, on average, didyou do this activity ?
For how many hoursper week, on average,did you do thisactivity ?
YesNoDon't Know
Did you ever playtennis, raquetball orsquash regularly?
Don't Don't KnowDon't Know
YesNoDon't Know
Don't Don't Know Don't Know
Did you ever playfootball, rugby,basketball, or netballregularly?
YesNoDon't Know
0
1
2
3
4
5
6
7
8
9
0
1
2
3
4
5
6
7
8
9
Did you ever do anystrenuous tasks inor around the houseregularly? This wouldinclude activites suchas mowing the lawnwith a non powermower, or scrubbingthe floors vigorously.
YesNoDon't Know
0
1
2
3
4
5
6
7
8
9
0
1
2
3
4
5
6
7
8
9
Don't Don't Know Don't Know
Don't Don't Know Don't Know
0
1
2
3
4
5
6
7
8
9
0
1
2
3
4
5
6
7
8
9
0
1
2
3
4
5
6
7
8
9
0
1
2
3
4
5
6
7
8
9
Do you ever swimlaps regularly? 0
1
0
1
2
3
4
5
6
7
8
9
0
1
0
1
2
3
4
5
6
7
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9
0
1
0
1
2
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9
0
1
0
1
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9
0
1
0
1
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YesNoDon't Know
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Don't Don't Know Don't Know0
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E1.e
E1.f
E1.g
E1.h
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Know
Know
Know
Know
Know
E1.fE1.f
E1.gE1.g
E1.hE1.h
E1.iE1.i
E1.jE1.j
E1. Early AdultYears
Form ID
49585
Did you ever participate regularly in any other strenuous physical activities ? (strenuousactivities means something that really increased your heart rate, made you hot, and caused you tosweat such as skiing, skating, hockey, scuba diving, surfing and other activities)
E1.j
For how manyyears did youdo this activity ?
For how many months ofthe year, on average, didyou do this activity ?
For how many hoursper week, on average,did you do thisactivity ?
Activity 1:
For how manyyears did youdo this activity ?
For how many months ofthe year, on average, didyou do this activity ?
For how many hoursper week, on average,did you do thisactivity ?
0
1
2
3
4
5
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8
9
0
1
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6
7
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Don't Know0
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Don't Know0
1
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Don't Know
0
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Don't Know0
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0
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Don't Know0
1
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0
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9
Don't Know
Activity 2:
E1. Early Adult Years
Form ID
49585
E1.k In your 20s, what was your usual occupation ? ("Usual" is the longest heldactivity including any paid or unpaid employment, such as being a student, homeduties, or unemployed.)
Don't Know
If subject is younger than 30, go to F1.
For how manyyears did youdo this activity ?
For how many months ofthe year, on average, didyou do this activity ?
For how many hoursper week, on average,did you do thisactivity ?
0
1
0
1
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3
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Don't Know0
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Don't Know0
1
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0
1
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9
Don't Know
For how manyyears did youdo this activity ?
For how many months ofthe year, on average, didyou do this activity ?
For how many hoursper week, on average,did you do thisactivity ?
0
1
0
1
2
3
4
5
6
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9
Don't Know0
1
0
1
2
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Don't Know0
1
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8
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0
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6
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8
9
Don't Know
Activity 4:
E1. Early Adult Years
Activity 3:
Form ID
49585
E2. Midlife Years
Think back to your 30s and 40s. I will be asking the same series of questions about physicalactivities during your 30s and 40s.
E2.a
Did you ever jogregularly? (jogging isrunning slower than akilometre in 6 minutes ora mile in 10 minutes)
For how manyyears did youdo this activity ?
For how many months ofthe year, on average, didyou do this activity ?
For how many hoursper week, on average,did you do thisactivity ?
YesNoDon't Know
Did you ever walkregularly?
Don't Don't Know Don't Know
YesNoDon't Know
Don't Don't Know Don't Know
Did you ever runregularly? (running isrunning faster than akilometre in 6 minutes ora mile in 10 minutes)
YesNoDon't Know
Did you ever cycleregularly? (thisincludes stationarycycling)
YesNoDon't Know
Don't Don't Know Don't Know
Don't Don't Know Don't Know
E2.b
E2.c
E2.d
0
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0
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0
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0
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0
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0
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0
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0
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Know
Know
Know
Know
E2.bE2.b
E2.cE2.c
E2.dE2.d
E2.eE2.e
E2. Midlife Years
By "regularly", I mean at least 30 minutes a week for a minimum of 3 months in a row.
Form ID
49585
Did you ever docalisthenics, aerobics,vigorous dance, or usea rowing machineregularly?
For how manyyears did youdo this activity ?
For how many months ofthe year, on average, didyou do this activity ?
For how many hoursper week, on average,did you do thisactivity ?
YesNoDon't Know
Did you ever playtennis, raquetball orsquash regularly?
Don't Don't KnowDon't Know
YesNoDon't Know
Don't Don't Know Don't Know
Did you ever playfootball, rugby,basketball, or netballregularly?
YesNoDon't Know
0
1
2
3
4
5
6
7
8
9
0
1
2
3
4
5
6
7
8
9
Did you ever do anystrenuous tasks inor around the houseregularly? This wouldinclude activites suchas mowing the lawnwith a non powermower, or scrubbingthe floors vigorously.
YesNoDon't Know
0
1
2
3
4
5
6
7
8
9
0
1
2
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4
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8
9
Don't Don't Know Don't Know
Don't Don't Know Don't Know
0
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8
9
0
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0
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9
0
1
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8
9
Did you ever swimlaps regularly? 0
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YesNoDon't Know
0
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Don't Don't Know Don't Know0
1
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0
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9
E2.e
E2.f
E2.g
E2.h
E2.i
Know
Know
Know
Know
Know
E2.fE2.f
E2.gE2.g
E2.hE2.h
E2.iE2.i
E2.jE2.j
E2. Midlife Years
0
1
0
1
2
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5
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7
8
9
Form ID
49585
Did you ever participate regularly in any other strenuous physical activities ? (strenuousactivities means something that really increased your heart rate, made you hot, and caused you tosweat such as skiing, skating, hockey, scuba diving, surfing and other activities)
E2.j
Activity 2:
For how manyyears did youdo this activity ?
For how many months ofthe year, on average, didyou do this activity ?
For how many hoursper week, on average,did you do thisactivity ?
Activity 1:
For how manyyears did youdo this activity ?
For how many months ofthe year, on average, didyou do this activity ?
For how many hoursper week, on average,did you do thisactivity ?
0
1
2
3
4
5
6
7
8
9
0
1
2
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5
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7
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9
Don't Know0
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Don't Know0
1
0
1
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Don't Know
0
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Don't Know0
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Don't Know0
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0
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5
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8
9
Don't Know
E2. Midlife Years
Form ID
49585
E2.k In your 30s and 40s, what was your usual occupation ? ("Usual" is the longestheld activity including any paid or unpaid employment, such as being a student,homeduties or unemployed.)
Don't Know
If subject is younger than 50, go to F1.
Activity 4:
For how manyyears did youdo this activity ?
For how many months ofthe year, on average, didyou do this activity ?
For how many hoursper week, on average,did you do thisactivity ?
0
1
2
0
1
2
3
4
5
6
7
8
9
Don't Know0
1
0
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Don't Know0
1
2
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8
9
0
1
2
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4
5
6
7
8
9
Don't Know
For how manyyears did youdo this activity ?
For how many months ofthe year, on average, didyou do this activity ?
For how many hoursper week, on average,did you do thisactivity ?
0
1
2
0
1
2
3
4
5
6
7
8
9
Don't Know0
1
0
1
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9
Don't Know0
1
2
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0
1
2
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4
5
6
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8
9
Don't Know
E2. Midlife Years
Activity 3:
Form ID
49585
E3. Older Ages
Now I will ask you to think about activities you have participated in since you turned 50.
E3.a
Did you ever jogregularly? (jogging isrunning slower than akilometre in 6 minutes ora mile in 10 minutes)
For how manyyears did youdo this activity ?
For how many months ofthe year, on average, didyou do this activity ?
For how many hoursper week, on average,did you do thisactivity ?
YesNoDon't Know
Did you ever walkregularly?
Don't Don't Know Don't Know
YesNoDon't Know
Don't Don't Know Don't Know
Did you ever runregularly? (running isrunning faster than akilometre in 6 minutes ora mile in 10 minutes)
YesNoDon't Know
Did you ever cycleregularly? (thisincludes stationarycycling)
YesNoDon't Know
Don't Don't Know Don't Know
Don't Don't Know Don't Know
E3.b
E3.c
E3.d
0
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0
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0
1
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8
9
Know
Know
Know
Know
E3.bE3.b
E3.cE3.c
E3.dE3.d
E3.eE3.e
E3. Older Ages
By "regularly", I mean at least 30 minutes a week for a minimum of 3 months in a row.
Form ID
49585
Did you ever docalisthenics, aerobics,vigorous dance, or usea rowing machineregularly?
For how manyyears did youdo this activity ?
For how many months ofthe year, on average, didyou do this activity ?
For how many hoursper week, on average,did you do thisactivity ?
YesNoDon't Know
Did you ever playtennis, raquetball orsquash regularly?
Don't Don't KnowDon't Know
YesNoDon't Know
Don't Don't Know Don't Know
Did you ever playfootball, rugby,basketball, or netballregularly ?
YesNoDon't Know
0
1
2
3
4
5
6
7
8
9
0
1
2
3
4
5
6
7
8
9
Did you do anystrenuous tasks inor around the houseregularly ? Thiswould include activitessuch as mowing thelawn with a non powermower, or scrubbingthe floors vigorously.
YesNoDon't Know
0
1
2
3
4
5
6
7
8
9
0
1
2
3
4
5
6
7
8
9
Don't Don't Know Don't Know
Don't Don't Know Don't Know
0
1
2
3
4
5
6
7
8
9
0
1
2
3
4
5
6
7
8
9
0
1
2
3
4
5
6
7
8
9
0
1
2
3
4
5
6
7
8
9
Do you ever swimlaps regularly?
0
1
2
3
4
5
6
0
1
2
3
4
5
6
7
8
9
0
1
0
1
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7
8
9
0
1
2
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5
6
0
1
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1
0
1
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9
0
1
0
1
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7
8
9
YesNoDon't Know
0
1
2
3
4
5
6
0
1
2
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4
5
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8
9
0
1
0
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Don't Don't Know Don't Know0
1
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8
9
0
1
2
3
4
5
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8
9
E3.e
E3.f
E3.g
E3.h
E3.i
Know
Know
Know
Know
E3.fE3.f
E3.gE3.g
E3.hE3.h
E3.iE3.i
E3.jE3.j
E3. Older Ages
Know
0
1
2
3
4
5
6
0
1
2
3
4
5
6
7
8
9
0
1
0
1
2
3
4
5
6
7
8
9
Form ID
49585
Did you ever participate regularly in any other strenuous physical activities ? (strenuousactivities means something that really increased your heart rate, made you hot, and caused you tosweat such as skiing, skating, hockey, scuba diving, surfing and other activities)
E3.j
Activity 2:
For how manyyears did youdo this activity ?
For how many months ofthe year, on average, didyou do this activity ?
For how many hoursper week, on average,did you do thisactivity ?
Activity 1:
For how manyyears did youdo this activity ?
For how many months ofthe year, on average, didyou do this activity ?
For how many hoursper week, on average,did you do thisactivity ?
0
1
2
3
4
5
6
7
8
9
0
1
2
3
4
5
6
7
8
9
Don't Know0
1
2
3
4
5
6
0
1
2
3
4
5
6
7
8
9
Don't Know0
1
0
1
2
3
4
5
6
7
8
9
Don't Know
0
1
2
3
4
5
6
0
1
2
3
4
5
6
7
8
9
Don't Know0
1
0
1
2
3
4
5
6
7
8
9
Don't Know0
1
2
3
4
5
6
7
8
9
0
1
2
3
4
5
6
7
8
9
Don't Know
E3. Older Ages
Form ID
49585
E3.k Since you turned 50, what was your usual occupation ? ("Usual" is the longestheld activity including any paid or unpaid employment, such as being a student, homeduties or unemployed.)
Don't Know
Activity 4:
For how manyyears did youdo this activity ?
For how many months ofthe year, on average, didyou do this activity ?
For how many hoursper week, on average,did you do thisactivity ?
0
1
2
3
4
5
6
0
1
2
3
4
5
6
7
8
9
Don't Know0
1
0
1
2
3
4
5
6
7
8
9
Don't Know0
1
2
3
4
5
6
7
8
9
0
1
2
3
4
5
6
7
8
9
Don't Know
For how manyyears did youdo this activity ?
For how many months ofthe year, on average, didyou do this activity ?
For how many hoursper week, on average,did you do thisactivity ?
0
1
2
3
4
5
6
0
1
2
3
4
5
6
7
8
9
Don't Know0
1
0
1
2
3
4
5
6
7
8
9
Don't Know0
1
2
3
4
5
6
7
8
9
0
1
2
3
4
5
6
7
8
9
Don't Know
E3. Older Ages
Activity 3:
Form ID
49585
F1. Early Adult Years
Think back to the period when you were in your 20s
F1.b
F1.c
Per DayPer WeekPer MonthPer YearDon't Know
F1.a
0
1
2
3
4
5
6
7
8
9
0
1
2
3
4
5
6
7
8
9
monthsyears
Don't Know
Beer - Low Alcohol(light)
YesNoDon't Know
Per DayPer WeekPer MonthPer YearDon't Know
Per DayPer WeekPer MonthPer YearDon't Know
Wine or cider
YesNoDon't Know
During the period when you were in your 20s, did you ever consume any alcoholicbeverages ? (Alcoholic beverages include beer, wine, cider, spirits, mixed drinks, or cocktails )
YesNoDon't Know
F2.F2.
F1.
Spirits
YesNoDon't Know
Per DayPer WeekPer MonthPer YearDon't Know
0
1
2
3
4
5
6
7
8
9
0
1
2
3
4
5
6
7
8
9
monthsyears
Don't Know
F1.d
Beer - Full Strength
YesNoDon't Know
0
1
2
3
4
5
6
7
8
9
0
1
2
3
4
5
6
7
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9
Don't Know
GlassesPotsStubbiesCansBottles
0
1
2
3
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5
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8
9
0
1
2
3
4
5
6
7
8
9
monthsyears
Don't Know
0
1
2
3
4
5
6
7
8
9
0
1
2
3
4
5
6
7
8
9
Don't Know
GlassesPotsStubbiesCansBottles
0
1
2
3
4
5
6
7
8
9
0
1
2
3
4
5
6
7
8
9
Don't Know
GlassesSmall BottlesBottlesCasks or
0
1
2
3
4
5
6
7
8
9
0
1
2
3
4
5
6
7
8
9
Don't Know
Shots/GlassesCansBottles
0
1
2
3
4
5
6
7
8
9
0
1
2
3
4
5
6
7
8
9
monthsyears
Don't Know
Now I will ask you questions about specific beverages.
F. Alcohol ConsumptionThe next set of questions are about alcohol consumption during three periods of your life.
Flagons
If younger than age 30, go to Section G.
F1.bF1.b
F1.cF1.c
F1.dF1.d
F2.F2.
In your 20s, did youever drink (beverage)?
How many (beverage)did you typicallydrink?
How often didyou typicallydrink(beverage)?
For how many monthsor years did youdrink?
Form ID
49585
F2. Midlife Years
Think back to the period when you were in your 30s and 40s.
During the period when you were in your 30s and 40s, did you ever consume any alcoholicbeverages ? (Alcoholic beverages include beer, wine, cider, spirits, mixed drinks, or cocktails )
YesNoDon't Know
F3.F3.
F1.
Now I will ask you some questions about specific beverages
F2.b
F2.c
Per DayPer WeekPer MonthPer YearDon't Know
F2.a
0
1
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8
9
0
1
2
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9
monthsyears
Don't Know
Beer - Low Alcohol(light)
YesNoDon't Know
Per DayPer WeekPer MonthPer YearDon't Know
Per DayPer WeekPer MonthPer YearDon't Know
Wine or cider
YesNoDon't Know
Spirits
YesNoDon't Know
Per DayPer WeekPer MonthPer YearDon't Know
0
1
2
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5
6
7
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9
0
1
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9
monthsyears
Don't Know
F2.d
Beer - Full Strength
YesNoDon't Know
0
1
2
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9
0
1
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3
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9
Don't Know
GlassesPotsStubbiesCansBottles
0
1
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0
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monthsyears
Don't Know
0
1
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8
9
0
1
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8
9
Don't Know
GlassesPotsStubbiesCansBottles
0
1
2
3
4
5
6
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8
9
0
1
2
3
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8
9
Don't Know
0
1
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8
9
0
1
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8
9
Don't Know
0
1
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9
0
1
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9
monthsyears
Don't Know
GlassesSmall BottlesBottlesCasks or
Shots/GlassesCansBottles
If younger than age 50, go to Section G.
Flagons
F2.bF2.b
F2.cF2.c
F2.dF2.d
F3.F3.
In your 20s, did youever drink (beverage)?
How many (beverage)did you typicallydrink?
How often didyou typicallydrink(beverage)?
For how many monthsor years did youdrink?
Form ID
49585
F3. Older Ages
Think back to the period since you turned 50.
Since turning 50, have you ever consumed any alcoholic beverages ? (Alcoholic beveragesinclude beer, wine, cider, spirits, mixed drinks, or cocktails )
YesNoDon't Know
Section GSection G
F3.
Now I will ask you some questions about specific beverages
F3.b
F3.c
Since turning 50, didyou ever drink(beverage)?
Per DayPer WeekPer MonthPer YearDon't Know
How often didyou typicallydrink(beverage)?
For how many monthsor years did youdrink?
How many (beverage)did you typicallydrink?
F3.a
0
1
2
3
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5
6
7
8
9
0
1
2
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6
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8
9
monthsyears
Don't Know
Beer - Low Alcohol(light)
YesNoDon't Know
Per DayPer WeekPer MonthPer YearDon't Know
Per DayPer WeekPer MonthPer YearDon't Know
Wine or cider
YesNoDon't Know
Spirits
YesNoDon't Know
Per DayPer WeekPer MonthPer YearDon't Know
0
1
2
3
4
5
6
7
8
9
0
1
2
3
4
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6
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9
monthsyears
Don't Know
F3.d
Beer - Full Strength
YesNoDon't Know
0
1
2
3
4
5
6
7
8
9
0
1
2
3
4
5
6
7
8
9
Don't Know
GlassesPotsStubbiesCansBottles
0
1
2
3
4
5
6
7
8
9
0
1
2
3
4
5
6
7
8
9
monthsyears
Don't Know
0
1
2
3
4
5
6
7
8
9
0
1
2
3
4
5
6
7
8
9
Don't Know
GlassesPotsStubbiesCansBottles
0
1
2
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4
5
6
7
8
9
0
1
2
3
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5
6
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9
Don't Know
0
1
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9
0
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8
9
Don't Know
0
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9
0
1
2
3
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9
monthsyears
Don't Know
GlassesSmall BottlesBottlesCasks or
Shots/GlassesCansBottles
Flagons
F3.bF3.b
F3.cF3.c
F3.dF3.d
G.1G.1
Form ID
49585
G. SmokingNow I 'd like to ask you a few questions about your use of tobacco.
How many years in total did you smokeat least one cigarette per day for 3months or longer? (If you have stoppedand restarted at least once, count only thetime when you were smoking)
total number of years0
1
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8
9
0
1
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9
Don't Know
G1. Cigarettes
G1.g
G1.a Have you ever smoked a cigarette a dayfor 3 months or longer ?
YesNoDon't Know G2.a
G2.a
G1.c During periods when you smokedregularly, on average how manycigarettes did you typically smoke in aday?
G1.e Do you currently smoke at least onecigarette a day ?
YesNoDon't Know
G1.g
G1.b At what age did you first startsmoking at least one cigarette perday for 3 months or longer ?
0
1
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9
0
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9
years of age
Don't Know
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9
0
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9
0
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8
9
cigarettes per day
Don't Know
G1.d About two years ago were yousmoking at least one cigarette aday ?
YesNoDon't Know
G1.f When did you last quit smokingregularly ? (One cigarette a day for 3months or longer)
age in years0
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9
0
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9
Don't Know
Form ID
49585
G2.a
YesNoDon't Know
Have you ever smoked at least one cigaror one pipe per month for at least 3months ?
Did you smoke cigars or pipes orboth ?
CigarsPipesBoth
About two years ago were yousmoking at least one (cigar or pipe) amonth ?
YesNoDon't Know
G2.f When did you last quit smokingregularly ? (One cigar or one pipeper month for 3 months or longer)
How many years in total did you smoke atleast one cigar or one pipe per month for3 months or longer ? (If you have stoppedand restarted at least once, count only the timewhen you were smoking)
total number of years0
1
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9
0
1
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9
Don't Know
G2.b At what age did you first start smoking atleast one (cigars or pipes) per month for3 months or longer ?
years of age0
1
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6
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8
9
0
1
2
3
4
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9
Don't Know
During periods when you smokedregularly, on average how many(cigars or pipes) did you typicallysmoke in a month ?
0
1
2
3
4
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7
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9
0
1
2
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0
1
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9
cigars or pipes per month
Don't Know
Do you currently smoke at least one(cigar or pipe) a month ?
YesNoDon't Know
G2.g
Section H1.
Section H1.
G2.c
G2.g
G2.d
G2.e
G2. Cigars or Pipes
0
1
2
3
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7
8
9
0
1
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8
9
age in years
Don't Know
Form ID
49585
How tall were you when you were 20 years old?
How tall are you currently without shoes on?
What is your current weight ?
What was your weight two years ago ?
H1.
H2.
H3.
H4.
H. Height and WeightThe next set of questions are about your height and weight
ORinches
Don't Know Don't Know
cm0
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0
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feet
Don't Know
AND
ORpounds
Don't Know Don't Know
kg0
1
0
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0
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stone
Don't Know
AND0
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0
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0
1
ORpounds
Don't Know Don't Know
kg0
1
0
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9
0
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stone
Don't Know
AND0
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0
1
ORinches
Don't Know Don't Know
cm0
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0
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feet
Don't Know
AND
Form ID
49585
What was your weight when you were 20 years old ?H5.
I. Other
Have you or your family participated in other research studies of familial cancer, or attended acancer family clinic ?
NoYes (specify)
Have you any comments, or information, that you think we should have asked about ?
I1.
I2.
ORpounds
Don't Know Don't Know
kg0
1
0
1
2
3
4
5
6
7
8
9
0
1
2
3
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9
0
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9
stone
Don't Know
AND0
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9
0
1
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8
9
0
1
Form ID
49585
Face-to-face at the respondents homeFace-to-face at another placeBy mail self-completed questionnaireBy telephoneOther
J. Interviewer's Assessment
Interviewer: ID:J1.
J2.
J3.
J4.
How and where was the interview conducted ?
Was an interpreter used ?
YesNo
Interview Length:0
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minutes
Form ID
49585
