This PDF version of the questionnaire form is a viewable - Mayo Clinic

This PDF version of the questionnaire form is a viewable - Mayo Clinic

This PDF version of the questionnaire form is a viewable version only and is not to be sent to Mayo Clinic Biobank staff for enrollment. If you are in...

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This PDF version of the questionnaire form is a viewable version only and is not to be sent to Mayo Clinic Biobank staff for enrollment. If you are interested in enrolling in the Biobank, please go to the link provided on the Contact Us page to email Biobank study staff and they will send you the appropriate materials.

ip a nt tic i C p ar o a py nt tic ip C op an y tC

Mayo Clinic Biobank Questionnaire

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Your name:

First Name/Middle Initial

Your date of birth:

Last Name

__ __/__ __/__ __ __ __ Month

Day

Year

Please enter today's date and your clinic number. TODAY'S DATE

MONTH DAY Jan





0

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June July

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Oct Nov Dec

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3/8" SPINE PERF

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Feb Mar

CLINIC NUMBER

YEAR

0

0

0

0

INSTRUCTIONS

Pa r

Place barcode label here.

• Please take the time to read and answer each question carefully by marking the response that best represents your answer.

• If you are not exactly sure of an answer, please provide your best guess. • When completed, mail the survey to the Mayo Clinic Biobank, Harwick Building, 6th Floor, in the pre-addressed, pre-paid envelope provided. Rochester (only) participants also have the option to drop the survey off at Desk CA in the Hilton Building subway. MARKING INSTRUCTIONS

• Use a No. 2 pencil or a blue or black ink pen only.

• Do not use pens with ink that soaks through the paper. • Make solid marks that fill the response completely.

• If you select the wrong response and cannot erase completely, please place an X through the incorrect response and mark the correct response. • Make no stray marks on this form. CORRECT:

PLEASE DO NOT WRITE IN THIS AREA

INCORRECT:

SERIAL

2

GENERAL HEALTH AND FUNCTIONING

ip a nt tic i C p ar o a py nt tic ip C op an y tC

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1. In general, would you say your health is... Very good

Excellent

Good

Fair

Poor

2. Compared to one year ago, how would you rate your health in general now? Much better now than one year ago Somewhat better now than one year ago About the same Somewhat worse now than one year ago Much worse now than one year ago

3. Thinking about people your age, would you say that you are in better physical shape, about the same, or worse physical shape compared to others your age?

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Better physical shape About the same physical shape Worse physical shape

4. How would you describe...

your overall quality of life? As bad as it can be

0

1

2

3

4

5

6

7

8

9

10

As good as it can be

your overall mental (intellectual) well-being? As bad as it can be

0

1

3

4

5

6

7

8

9

10

As good as it can be

3

4

5

6

7

8

9

10

As good as it can be

2

3

4

5

6

7

8

9

10

As good as it can be

2

3

4

5

6

7

8

9

10

As good as it can be

3

4

5

6

7

8

9

10

As good as it can be

2

your overall physical well-being? As bad as it can be

0

1

2

Pa r

your overall emotional well-being? As bad as it can be

0

1

your level of social activity? As bad as it can be

0

1

your overall spiritual well-being? As bad as it can be

0

1

2

3

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ip a nt tic i C p ar o a py nt tic ip C op an y tC

5. How much do you agree or disagree with the following statements? (Please be as honest and accurate as you can throughout. Try not to let your response to one statement influence your responses to other statements. There are no I I I neither I I "correct" or "incorrect" answers. Answer according agree agree agree nor disagree disagree to your own feelings, rather than how you think a lot a little disagree a little a lot "most people" would answer.) In uncertain times, I usually expect the best. If something can go wrong for me, it will. I'm always optimistic about my future.

I hardly ever expect things to go my way.

I rarely count on good things happening to me.

Overall, I expect more good things to happen to me than bad.

6. What is your level of fatigue today with 0 = "No fatigue" to 10 = "Greatest possible fatigue"? 0

1

2

3

4

5

3/8" SPINE PERF

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No fatigue

6

7

None of the time

7. How much of the time . . .

8

A little of the time

9

10

Some of the time

Greatest possible fatigue

Most of the time

All of the time

is there someone available to you whom you can count on to listen to you when you need to talk? is there someone available to you to give you good advice about a problem?

is there someone available to you who shows you love and affection? is there someone available to help with daily chores?

Pa r

can you count on anyone to provide you with emotional support (talking over problems or helping you make a difficult decision)?

do you have as much contact as you would like with someone you feel close to, someone in whom you can trust and confide in?

8. During the past 12 months, would you say your emotional or psychological health has been . . . Excellent

Very good

Good

PLEASE DO NOT WRITE IN THIS AREA

Fair

Poor

Don't know

SERIAL

9. During the past 2 weeks, how often have you been bothered by feeling down, depressed, or hopeless?

4

ip a nt tic i C p ar o a py nt tic ip C op an y tC

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Not at all

Some

Several days

More than half the days

Nearly every day

Don't know

10. During the past 2 weeks, how often have you been bothered by having little interest or little pleasure in doing things? Not at all

Some

Several days

More than half the days

Nearly every day

Don't know

11. Have you ever had a period lasting 4 days or longer when you became so happy or excited that you either got into trouble, people worried about you, or a doctor said you were manic? No

Yes

12. In the past 30 days, have you experienced heartburn, a burning pain, or discomfort behind the breast bone in the chest? No

Yes

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How often does this or did this heartburn occur? Less than once a month About once a month About once a week Several times a week Daily

Is your heartburn better (eased) by taking antacids? (Examples: Amphojel, ALternaGEL, Gaviscon, Maalox, Mylanta, Riopan, Rolaids, Tums.) I do not take antacids for heartburn

No

Yes

In the past 30 days, has your heartburn awakened you at night?

Pa r

No

Yes

In the past 30 days, has your heartburn often travelled up toward your neck? No

Yes

13. In the past 30 days, have you experienced acid regurgitation, a bitter or sour-tasting fluid coming up from the stomach into your mouth or throat? No

Yes

Do you experience acid regurgitation at least once a week? No

Yes

14. Has your weight varied during the past 12 months? Gone up more than 10 pounds

Gone down more than 10 pounds

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ip a nt tic i C p ar o a py nt tic ip C op an y tC

Remained stable

5

Was this weight loss intentional or unintentional?

Was this weight gain intentional or unintentional? Intentional Unintentional

Intentional Unintentional

PERSONAL AND FAMILY MEDICAL HISTORY

15. Are you adopted?

No

Yes

If known, complete the following information about your blood relatives (include children).

16. Is your father alive?

Yes, he is alive

No, he is dead

I don't know

3/8" SPINE PERF

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If dead, what was his age at death? Under 30 30 to 40

17. Is your mother alive?

Yes, she is alive

41 to 50 51 to 60

61 to 70 71 to 85

No, she is dead

Over 85

I don't know

If dead, what was her age at death? Under 30 30 to 40

18. For each kind of relative below, please tell us how many you have who are alive and how many have died. Number alive Number dead

Sisters:

Number alive Number dead

Sons:

Number alive Number dead

Daughters:

Number alive Number dead

0

1

2

61 to 70 71 to 85

3

4

5

6

Over 85

Don't 7+ know

Pa r

Brothers:

41 to 50 51 to 60

PLEASE DO NOT WRITE IN THIS AREA

SERIAL

19. Please indicate the age you were first diagnosed with the following conditions. If you have not been diagnosed with this condition, mark "None."

6

ip a nt tic i C p ar o a py nt tic ip C op an y tC

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In addition, please indicate whether or not your family members have had this condition by marking "Yes," "No," or "Don't know." We are only interested in relatives that are related to you by blood.

Self

Relatives

Age when this condition was first diagnosed.

Do or did any of your firstdegree relatives (parents, sisters, brothers, children) have this condition?

19 or None younger

20 to 49

50 to 64

65 to 79

80 or older

No

Yes

Don't know

Rheumatologic

Arthritis (osteoarthritis) Arthritis (rheumatoid) Fibromyalgia Autoimmune disorder (lupus, scleroderma)

Gynecologic

Endometriosis

Liver

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Hepatitis A, B, or C Other liver disease

Hematologic

Organ or bone marrow transplant Bleeding disorder Sickle cell anemia

Infectious Diseases HIV (AIDS) Tuberculosis

Cancer

Pa r

Thyroid cancer Lung cancer

Breast cancer Esophageal cancer Pancreatic cancer Stomach cancer

Colon or rectal cancer Liver cancer

Uterine/endometrial cancer Cervical cancer Ovarian cancer Prostate cancer

Continues on next page...

7 Relatives

Age when this condition was first diagnosed.

Do or did any of your firstdegree relatives (parents, sisters, brothers, children) have this condition?

ip a nt tic i C p ar o a py nt tic ip C op an y tC

Self

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19 or None younger

Cancer (continued)

20 to 49

50 to 64

65 to 79

80 or older

No

Yes

Don't know

Testicular cancer Melanoma

Nonmelanoma skin cancer Sarcoma Bone cancer Leukemia

Lymphoma Kidney cancer

Urinary/bladder cancer Other cancer

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Neurologic

3/8" SPINE PERF

Alzheimer's disease Parkinson's disease

Dementia Migraine headaches Stroke (CVA) TIA (mini stroke)

Epilepsy (seizure disorder) Narcolepsy

Mental Health Anxiety Depression

Pa r

Down syndrome Bipolar disorder

Autism Attention deficit/hyperactivity disorder

Alcoholism Other psychiatric or mental illness

Continues on next page...

PLEASE DO NOT WRITE IN THIS AREA

SERIAL

8 Self

Relatives

ip a nt tic i C p ar o a py nt tic ip C op an y tC

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Age when this condition was first diagnosed.

19 or None younger

20 to 49

50 to 64

65 to 79

Do or did any of your firstdegree relatives (parents, sisters, brothers, children) have this condition?

80 or older

No

Yes

Don't know

Eye

Glaucoma Cataracts

Abnormal distance vision Lazy eye (amblyopia)

Misalignment, crossing, or wandering of the eyes (strabismus) Macular degeneration

Cardiovascular

Heart attack/myocardial infarction Coronary artery disease Congestive heart failure

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Cardiomyopathy Atrial fibrillation/arrhythmia Congenital heart disease

High blood pressure (hypertension) High cholesterol (hyperlipidemia) Blood clots in a vein

Respiratory

Asthma Chronic obstructive pulmonary disease (COPD) Sleep apnea Asbestosis

Pa r

Pulmonary fibrosis

Gastrointestinal

Acid reflux or gastroesophageal reflux disorder (GERD) Barrett's esophagus Celiac disease Irritable bowel syndrome (IBS)

Crohn's disease or ulcerative colitis Lynch syndrome or HNPCC

Other polyposis syndrome (FAP, PeutzJeghers, juvenile polyposis, etc.)

Continues on next page...

9 63

Relatives

Age when this condition was first diagnosed.

Do or did any of your firstdegree relatives (parents, sisters, brothers, children) have this condition?

62 61 60 59 58 57 56 55 54 53 52 51 50 49 48 47 46 45 44 43 42 41 40 39 38 37 36 35 34 33 32 31 30 29 28 27 26 25 24 23 22 21 20 19 18 17 16 15 14 13 12 11 10 9 8 7 6 5 4 3 2 1

ip a nt tic i C p ar o a py nt tic ip C op an y tC

Self

19 or None younger

20 to 49

50 to 64

65 to 79

80 or older

No

Yes

Don't know

Endocrine

Type 1 diabetes Type 2 diabetes

Hyperthyroidism/hypothyroidism

20. Do you have any allergies?

No

Yes

What kind of allergies do you have? (Mark all that apply.) Food allergies such as shellfish or nuts

Grasses, pollen, or dust

Pets

Insect stings or bites

Other

3/8" SPINE PERF

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21. Have you ever had 5 or more moderate to severe headaches that lasted at least 4 hours and which were accompanied by either nausea OR light and sound sensitivity? No

Yes

22. Have you ever experienced episodes of a shimmering visual disturbance or blind spot; unilateral numbness/tingling; OR an inability to think of the correct word or understand what is said to you, that lasted 5 to 60 minutes? No

Yes

23. Have you ever been treated with chemotherapy (for cancer)? No

Yes

Pa r

24. Have you ever been treated with radiation for any condition? No

WOMEN ONLY

Yes

(Men — please skip to "MEN ONLY" section on page 12.)

25. How old were you when you started having menstrual periods? Less than 12 12 13

14 15 or older Don't know/don't remember

PLEASE DO NOT WRITE IN THIS AREA

Never started — Skip to question 27 on page 10.

SERIAL

26. Have you had your uterus removed or was your last menstrual period more than 12 months ago?

10

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No — Skip to question 27 below. Yes

How old were you when you entered menopause?

AGE

What was the reason your periods stopped? (Select only one answer.)

Natural menopause (change of life) Because of hysterectomy or removal of ovaries (or both) Took medication that stopped my period Radiation/chemotherapy Other

0

0

1

1

2

2

3

3

4

4

5

5

6

6

7

7

8

8

9

9

27. Have you ever been pregnant?

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No — Skip to question 28 on page 11. Yes

How many times have you been pregnant? (Include all stillbirths, miscarriages, ectopic or tubal pregnancies, induced abortions, and current pregnancy, if applicable.) 1

2

3

4

5

6

7

8

9 or more

How many pregnancies resulted in a live birth? (Count multiple births as one birth.) 0 — Skip to question 28 on page 11. 1

2

3

4

5

6

7

8

What was your age when your first child was born? 20 to 24 25 to 29 30 to 34

Pa r

17 or younger 18 19

35 to 39 40 or older

How many of your children did you breast-feed for more than one month? Did not breast-feed any 1 to 2 children 3 to 5 children

6 to 10 children 11 children or more

What was your age when your last child was born? 17 or younger 18 19

20 to 24 25 to 29 30 to 34

Are you pregnant right now? No

Yes

Don't know

35 to 39 40 or older

9 or more

28. Have you ever used birth control pills, patches, implants, or shots? Yes, currently

Yes, but not currently

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ip a nt tic i C p ar o a py nt tic ip C op an y tC

No

11 63

What is the total time you used birth control pills, patches, or shots? (If you have stopped and started several times, please count combined years of use.) 6 months or less 7 to 11 months

6 to 11 years 11 years or more

1 to 2 years 3 to 5 years

29. Have you ever taken hormone replacement therapy other than birth control pills (eg, estrogen, estrogen/progesterone combination)? No

Yes, currently

Yes, but not currently

What type are you taking now or most recently? (Mark all that apply.) Estrogen alone Estrogen and progesterone combination (eg, Provera or Prempro)

Other Don't know

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How old were you when you first began taking any hormone therapy? How many years have you taken any hormone therapy?

NUMBER OF YEARS

Pa r

30. Have you ever taken tamoxifen (Nolvadex)? No

Yes, currently

Yes, but not currently

Don't know

How long have you taken tamoxifen? 1 month or less 1 to 6 months 7 to 11 months 1 to 2 years

31. Do you perform monthly breast self-exams?

3 to 5 years 5 years or more Don't know how long

No

Yes

AGE

0

0

1

1

2

2

0

0

3

3

1

1

4

4

2

2

5

5

3

3

6

6

4

4

7

7

5

5

8

8

6

6

9

9

7

7

8

8

9

9

MEN ONLY

(Women — continue with "HEALTH BEHAVIORS" section below.)

12

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32. Do you examine your own testicles monthly? No

Yes

33. Have you ever had a prostate-specific antigen (PSA) blood test? No Yes Don't know

Did you ever have an abnormal test? No Yes Don't know

When was the last time you had an abnormal test? A year ago or less More than 1 but not more than 2 years ago More than 2 but not more than 5 years ago More than 5 years ago Don't know

HEALTH BEHAVIORS

No

Yes

35. How often do you protect your skin from the sun by using sunblock (SPF 15 or greater) or by wearing protective clothing such as a hat and a long-sleeved shirt when you go outside? Always

Sometimes

Never

36. How often do you wear a seatbelt when driving or riding in a motor vehicle? Always

Sometimes

Never

Pa r

37. How often do you drive or ride in a car or other motor vehicle when the driver has been using drugs, has had 3 or more drinks, or is driving under the influence? Daily

Rarely to weekly

Never

38. How often do you wear a helmet when riding a motorcycle, bicycle, snowmobile, rollerblades, or all-terrain vehicle? Always

Sometimes

Never

I do not participate in these activities

39. Do you have a working fire extinguisher in your home? No

Yes

Don't know

PLEASE DO NOT WRITE IN THIS AREA

Prefer not to answer

SERIAL

3/8" SPINE PERF

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34. Have you seen a dentist for a general check-up and teeth cleaning within the last 12 months?

40. Do you have working smoke detectors in your home? Yes

Don't know

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ip a nt tic i C p ar o a py nt tic ip C op an y tC

No

13 63

41. On average, how many times a day do you eat high-fat food such as red meat, fried food, whole milk, regular cheese, ice cream, baked goods, or regular salad dressing? 0 to 1

2

3 or more

42. How many servings of fruit do you eat during a typical day? (One serving: 1 medium piece of fruit or ¾ cup fruit juice.) 0 to 1

2

3

4

5 or more

43. How many servings of vegetables do you eat during a typical day? (One serving: 1 cup raw, leafy vegetables, ½ cup cooked vegetables, or ¾ cup vegetable juice.) 0 to 1

2

3

4

5 or more

44. How many servings of milk and other dairy products or calcium supplements do you get in an average day?

ar tic

1 or no servings (or less than 600 mg dose supplements) 2 to 3 servings (or between 600 and 1,200 mg dose supplements) 4 or more servings (or more than 1,200 mg dose supplements)

45. How many servings of diet soft drinks do you have per day? (A serving size is 1 can or glass.) None 1 to 2 servings 3 to 4 servings

5 to 6 servings 7 to 9 servings 10 or more servings

46. How many servings of regular (nondiet) soft drinks do you have per day? (A serving size is 1 can or glass.) 5 to 6 servings 7 to 9 servings 10 or more servings

Pa r

None 1 to 2 servings 3 to 4 servings

47. How many cups of coffee, caffeinated or decaffeinated, do you drink? None — Skip to question 48 on page 14. Less than 1 cup per month 1 cup per week 2 to 4 cups per week 5 to 6 cups per week 1 cup per day 2 to 3 cups per day 4 to 5 cups per day 6 or more cups per day

How often is the coffee you drink decaffeinated? Never or almost never About ¼ of the time About ½ of the time About ¾ of the time Always or almost always

48. For the job (includes homemaking) you have held the longest, approximately how much of the time were you engaged in each of the following physical activities?

14 None of the time

A little of the time

Some of the time

Most of the time

All of the time

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Sitting

Standing Walking

Light manual labor

Heavy manual labor

49. Considering a 7-day period (a week), how many times on average do you do the following kinds of exercise for more than 15 minutes during your free time?

None

1 time

2 times

3 times

4 times

5 times

6 times

7 times

8 times or more

Strenuous exercise (heart beats rapidly)

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(ie, running, jogging, vigorous swimming, vigorous long-distance bicycling, hockey, basketball, cross-country skiing, soccer)

3/8" SPINE PERF

Moderate exercise (not exhausting) (ie, fast walking, easy swimming, alpine skiing, popular and folk dancing, tennis, easy bicycling, baseball, volleyball)

Mild exercise (minimal effort)

(ie, easy walking, archery, bowling, horseshoes, golf, snowmobiling)

50. How often did you have a drink containing alcohol in the past 12 months? (Consider a "drink" to be a can or bottle of beer, a glass of wine, a wine cooler, or 1 cocktail or a shot of hard liquor, eg, scotch, gin, or vodka.) Never — Skip to question 51 on page 15.

Pa r

Once a month or less 2 to 4 times a month 2 to 3 times a week 4 to 5 times a week 6 or more times a week

How many drinks did you have on a typical day when you were drinking in the past 12 months? 0 to 2 drinks 3 to 4 drinks 5 to 6 drinks

7 to 9 drinks 10 or more drinks

How often did you have 6 or more drinks on one occasion in the past 12 months? Never Less than monthly Monthly

PLEASE DO NOT WRITE IN THIS AREA

Weekly Daily or almost daily

SERIAL

51. Have you used any of these tobacco products for 12 months or longer? (Please mark a response for each tobacco product.)

15 63

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Cigar

Pipe

No Yes

Snuff

No Yes

Chewing tobacco

No Yes

No Yes

For how many years?

For how many years?

For how many years?

For how many years?

NUMBER OF YEARS

NUMBER OF YEARS

NUMBER OF YEARS

NUMBER OF YEARS

0

0

0

0

0

0

0

0

1

1

1

1

1

1

1

1

2

2

2

2

2

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52. Have you smoked at least 100 cigarettes in your entire life? No

Yes

Don't know/not sure

How old were you when you first started smoking cigarettes on a regular basis?

AGE

On average, how many cigarettes do/did you smoke per day? 1 to 10 per day 11 to 20 per day 21 to 30 per day

31 to 40 per day 41 or more per day

Do you currently smoke cigarettes?

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No

Yes

What year did you quit?

YEAR

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53. Did you ever live in the same household with someone who smoked cigarettes regularly while in your presence?

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No Yes

NUMBER OF YEARS

For how many years altogether was this the case?

Please indicate the amount of secondhand exposure per day by the approximate number of cigarettes or packs smoked by the person(s) from your household. 1 to 10 cigarettes (up to ½ pack) 11 to 20 cigarettes (½ to 1 pack) 21 to 40 cigarettes (1 to 2 packs)

41 to 60 cigarettes (2 to 3 packs) More than 60 cigarettes (3 packs or more)

At what age(s) were you exposed to secondhand smoke from your household? (Mark all that apply.) Younger than 5 5 to 9 10 to 19 20 to 29

30 to 39 40 to 49 50 to 59 60 to 69

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70 to 79 80 and older

54. Did you ever work in an area where others smoked regularly in your presence?

NUMBER OF YEARS

For how many years altogether was this the case?

Please indicate the amount of secondhand exposure per day by the approximate number of cigarettes or packs smoked by the person(s) from your work area. 1 to 10 cigarettes (up to ½ pack) 11 to 20 cigarettes (½ to 1 pack) 21 to 40 cigarettes (1 to 2 packs)

41 to 60 cigarettes (2 to 3 packs) More than 60 cigarettes (3 packs or more)

At what age(s) were you exposed to secondhand smoke from your work area? (Mark all that apply.) Younger than 16 16 to 19 20 to 29

30 to 39 40 to 49 50 to 59

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60 to 69 70 to 79 80 and older

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55. During the past 12 months, which vitamins, minerals, or supplements have you taken regularly (2 times a week or more for at least 3 months)? (Mark all that apply.) None Multivitamins Prenatal vitamin Vitamin A B vitamins Vitamin C Vitamin D Vitamin E Beta carotene Calcium

Folate Iron Selenium Zinc 5-HTP Acidophilus Bee pollen or royal jelly Chondroitin CoQ10 DHEA

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Fiber supplement (Metamucil, etc.) Fish oil/omega fatty acids/EPA/DHA Glucosamine Melatonin Progesterone cream SAM-e Xanadrine Other vitamins, minerals, or supplements

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No Yes

Less than 1 year

1 to 5 years

11 6 to 10 years years or more

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56. During the past 12 months, have you used the following medicines on a regular basis, that is, at least once per week? If so, please indicate how long you have taken each medication.

Advil, Aleve, Motrin, or other nonsteroidal, anti-inflammatory drugs Celebrex, Vioxx, or Bextra Aspirin — full dose or extra strength Tylenol Other drug taken for pain relief Aspirin — low dose or baby strength taken for prevention of heart disease or stroke Insulin Glucophage DiaBeta, Diabinese, Glucotrol, or Micronase Actos, Avandia, or Rezulin Other drug taken for diabetes mellitus (sugar diabetes) None of these

ENVIRONMENT

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57. What is the nature of the business or industry where you have worked during the majority of your life? (Please select one.) Active Duty Military Construction Farming, Forestry, Fishing, and Hunting Finance, Insurance, Real Estate, and Rental and Leasing Information and Communications Manufacturing/Production Mining Public Administration Retail Trade Services: Arts, Entertainment, Recreation, Accommodations, and Food

Services: Educational, Health, and Social Services: Professional, Scientific, Management, and Administrative Services: Waste Management Services: Other (except Public Administration) Telecommunications Transportation and Warehousing Utilities Wholesale Trade Other, please specify: None of the above

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58. Are, or were you ever, regularly exposed to any of the following substances? (Please mark a response for each substance.) Asbestos

Benzene or derivatives

Chlorinated hydrocarbons (CHC), solvents, or related compounds Chromium/chromium compounds Coal dust

Nickel/nickel compounds Radioactive substance Taconite

No

Yes

Don't know

59. Where do you currently live most of the year?

18

On a working farm or ranch In a rural home or hobby farm, not a working farm or ranch

In a suburb, city, or village Other

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60. Have you ever lived on a working farm? No

Yes

What type of farm was it? (Mark all that apply.) Commercial

Dairy

Cattle

Agricultural

61. Have you ever personally mixed or applied fertilizer to add nutrients to the soil? (Include fertilizer used for farm use, commercial application, and/or personal use in your home or garden.) Yes

No

How many years did you personally mix or apply fertilizers? (One growing season = 1 year.) 2 to 5 years

6 to 10 years

11 to 20 years

21 to 30 years

31 years or more

62. Have you ever personally mixed or applied any insecticides to kill insects? (Include crop, livestock, and structural insecticides and fumigants. Include insecticides used for farm use, commercial application, and/or personal use in your home or garden.) No

Yes

How many years did you personally mix or apply insecticides? (One growing season = 1 year.) 1 year or less

2 to 5 years

6 to 10 years

11 to 20 years

21 to 30 years

31 years or more

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63. Have you ever personally mixed or applied herbicides to kill weeds or fungicides to kill mold or fungus? (Include crop and livestock herbicides or fungicides for farm use, commercial application, and/or personal use in your home or garden.) No

Yes

How many years did you personally mix or apply herbicides or fungicides? (One growing season = 1 year.) 1 year or less

2 to 5 years

6 to 10 years

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11 to 20 years

21 to 30 years

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1 year or less

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ABOUT YOU 64. Do you consider yourself to be Hispanic or Latino? No, not Hispanic/Latino Yes, Hispanic/Latino

Are you...

Mexican-American Mexican Ecuadorian

Puerto Rican Other, please specify:

65. Which of the following do you consider yourself? (Mark all that apply.) Asian

Black or African American

White

Are you...

Cambodian Laotian Hmong Vietnamese Other, please specify:

American Indian or Alaskan Native

Native Hawaiian or other Pacific Islander

Other, please specify:

Are you...

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Somali Amharic Nigerian Oromo

Liberian U.S.-born Other, please specify:

66. If you checked more than one in the previous question, with which do you identify the most? (Mark only one.) Asian Black or African American White American Indian or Alaskan Native

Native Hawaiian or other Pacific Islander Multi-racial Other

67. Are you currently...

Married Living with someone in a marriage-like relationship

Separated Divorced

Widowed Never been married

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68. Were you born in the United States? No

How many years have you lived in the United States?

NUMBER OF YEARS

Yes

What country were you born in?

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69. What is your current height and weight? (Please round to the nearest whole number. If you are currently pregnant, report your pre-pregnancy weight. )

HEIGHT FEET

WEIGHT

INCHES

20

POUNDS

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70. Which of the following best describes you? Working full time for pay (35 or more hours a week) Working part-time for pay Not working for pay at present

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If you are not working for pay at present, are you... (Mark all that apply.) A full-time homemaker A seasonal worker In school

Disabled Retired Other

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8th grade or less Some high school High school graduate or GED Vocational, technical, or business school

Some college or Associate's degree (including community college) Four-year college graduate (Bachelor's degree) Graduate or professional school Other

72. If you have an e-mail address and are willing to let us contact you, please provide your e-mail address below.

Thank you for taking the time to complete the survey!

Question 4: Linear Analogue Self Assessment (LASA). Used with permission of Jeff Sloan, PhD, Mayo Clinic.

Question 5: Measure of Optimism and Pessimism (LOT-R). Scheier, M. F., Carver, C. S., and Bridges, M. W. (1994). Distinguishing optimism from neuroticism (and trait anxiety, self mastery, and self-esteem): A re-evaluation of the Life Orientation Test. Journal of Personality and Social Psychology, 67, 1063-1078.

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Question 6: Measurement of Fatigue. Anna L. Schwartz, Paula M. Meek, Lillian M. Nail, James Fargo, Margaret Lundquist, Melissa Donofrio, Marilyn Grainger, Terry Throckmorton, and Magdalena Mateo. Measurement of fatigue: determining minimally important clinical differences. Journal of Clinical Epidemiology, Volume 55, Issue 3, March 2002, Pages 239-244.

Question 7: Social Support Measure. Enhancing recovery in coronary heart disease patients (ENRICHD): study design and methods. The ENRICHD investigators. Am Heart J. 2000;139:1-9. [PubMed] Questions 9 and 10: The Patient Health Questionnaire-2 (PHQ-2). Korenke, K, Spitzer, RL, and Williams, JB (2003). Validity of a two-item depression screener. Medical Care. 41(11),1284-92.

Question 49: Godin Leisure-Time Exercise Questionnaire. G. Godin and R. J. Shephard, A simple method to assess exercise behavior in the community, taken with permission from Can. J. Appl. Sport Sci. 10(1985), pp. 141-146. Published by NRC Research Press.

Question 50: The Alcohol Use Disorders Identification Test (AUDIT). Babor, TF, Bohn, MJ, Kranzler, HR. Validation of a screening instrument for use in medical settings. J Stud Alcohol 56(4):423-432,1995. ©2012, Mayo Foundation for Medical Education and Research (MFMER). All rights reserved.

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71. Which is the highest grade or level of school you have completed?