8 Medical History

OMB#: 0925-XXXX

Exp. XX/XXXX

Public reporting burden for this collection of information is estimated to average 07 minutes per response, including the time for reviewing instructions, searching existing data sources, gathering and maintaining the data needed, and completing and reviewing the collection of information. An agency may not conduct or sponsor, and a person is not required to respond to, a collection of information unless it displays a currently valid OMB control number. Send comments regarding this burden estimate or any other aspect of this collection of information, including suggestions for reducing this burden, to: NIH, Project Clearance Branch, 6705 Rockledge Drive, MSC 7974, Bethesda, MD 20892-7974, ATTN: PRA (0925-XXXX). Do not return the completed form to this address.

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OMB#: 0925-XXXX

Exp. XX/XXXX

CHS/SOL Medical/Family History Questionnaire

ID NUMBER:

FORM CODE: MHE VERSION: A 06/28/07

Contact Occasion

SEQ #

Acrostic:

Administrative Information

0a. Completion Date: // 0b. Staff ID:

Instructions: Place a check in the appropriate box for the response. Unless instructed, mark ONLY one response. If age of onset is unknown enter the special missing value, “==”, in the item.

Did you or any of your blood relatives have any of the following conditions? Do not include half-brothers or half-sisters.

1. Has a doctor ever said that you have high blood pressure or hypertension?

No 0

Yes 1  FOR WOMEN: GO TO QUESTION 1a

1a. Was this during pregnancy only?

No 0

Yes 1

Has a doctor ever said that these relatives had high blood pressure or hypertension?

1b. Mother No or Don’t know 0 Yes 1

1c. Father No or Don’t know 0 Yes 1

1d. Brother(s) or sister(s) No or Don’t know 0 Yes 1

2. Has a doctor ever said that you have high blood cholesterol?

No 0

Yes 1

Has a doctor ever said that these relatives had high blood cholesterol?

2b. Mother No or Don’t know 0 Yes 1

2c. Father No or Don’t know 0 Yes 1

2d. Brother(s) or sister(s) No or Don’t know 0 Yes 1

3. Has a doctor ever said that you have angina?

No 0  GO TO QUESTION 3b

Yes 1

3a. At what age were you first told this?

Age in years

Has a doctor ever said that these relatives had angina?

3b. Mother No or Don’t know 0 Yes 1

3c. Father No or Don’t know 0 Yes 1

3d. Brother(s) or sister(s) No or Don’t know 0 Yes 1

4. Has a doctor ever said that you had a heart attack?

No 0  GO TO QUESTION 4b

Yes 1

4a. At what age were you first told this?

Age in years

Has a doctor ever said that these relatives had a heart attack?

4b. Mother No or Don’t know 0 Yes 1 Age

4c. Father No or Don’t know 0 Yes 1 Age

4d. Brother(s) or sister(s) No or Don’t know 0 Yes 1 Age

5. Has a doctor ever said that you had heart failure?

No 0

Yes 1

Has a doctor ever said that these relatives had heart failure?

5b. Mother No or Don’t know 0 Yes 1

5c. Father No or Don’t know 0 Yes 1

5d. Brother(s) or sister(s) No or Don’t know 0 Yes 1

6. Has a doctor ever said that you had rheumatic heart disease?

No 0

Yes 1

Has a doctor ever said that these relatives had rheumatic heart disease?

6b. Mother No or Don’t know 0 Yes 1

6c. Father No or Don’t know 0 Yes 1

6d. Brother(s) or sister(s) No or Don’t know 0 Yes 1

7. Has a doctor ever told you that you had atrial fibrillation?

No 0

Yes 1

8. Has a doctor ever said that you had some other kind of heart problem?

No 0

Yes 1

If yes, please specify: _________________________

9. Have you had a balloon angioplasty, a stent, or bypass surgery to the arteries in your heart to improve the blood flow to your heart?

No 0

Yes 1

Have these relatives had a balloon angioplasty or bypass surgery to the arteries in their heart to improve the blood flow to the heart?

9a. Mother No or Don’t know 0 Yes 1

9b. Father No or Don’t know 0 Yes 1

9c. Brother(s) or sister(s) No or Don’t know 0 Yes 1

10. Has a doctor ever said that you had a stroke?

No 0

Yes 1

Has a doctor ever said that these relatives had a stroke?

10a. Mother No or Don’t know 0 Yes 1

10b. Father No or Don’t know 0 Yes 1

10c. Brother(s) or sister(s) No or Don’t know 0 Yes 1

11. Has a doctor ever said that you had a mini-stroke or TIA (transient ischemic attack)?

No 0

Yes 1

12. Have you had a balloon angioplasty or surgery to the arteries of your neck to prevent or correct a stroke?

No 0

Yes 1

13. Has a doctor ever said that you have an aortic aneurysm, an AAA, or ballooning of your aorta?

No 0

Yes 1

Has a doctor ever said that these relatives had an aortic aneurysm, an AAA, or ballooning of their aorta?

13a. Mother No or Don’t know 0 Yes 1

13b. Father No or Don’t know 0 Yes 1

13c. Brother(s) or sister(s) No or Don’t know 0 Yes 1

14. Has a doctor ever said that you have peripheral arterial disease (problems with circulation, blocked arteries to the legs)?

No 0

Yes 1

Has a doctor ever said that these relatives had peripheral arterial disease?

14a. Mother No or Don’t know 0 Yes 1

14b. Father No or Don’t know 0 Yes 1

14c. Brother(s) or sister(s) No or Don’t know 0 Yes 1

15. Have you had an operation, a balloon angioplasty, a stent, or an amputation for this condition?

No 0

Yes 1

16. Has a doctor ever said that you have diabetes (high sugar in blood or urine)?

No 0  GO TO QUESTION 16e

Yes 1

16a. At what age were you first told this?

Age in years

16b. FOR WOMEN: Was this during pregnancy only?

No 0

Yes 1

16c. Are you being treated with insulin?

No 0  GO TO QUESTION 16e

Yes 1

16d. Was insulin the first medicine used for diabetes?

No 0

Yes 1

Has a doctor ever said that these relatives had diabetes?

16e. Mother No or Don’t know 0 Yes 1

16f. Father No or Don’t know 0 Yes 1

16g. Brother(s) or sister(s) No or Don’t know 0 Yes 1

17. Has a doctor ever said that you have kidney problems?

No 0

Yes 1

18. Has a doctor ever said that you have liver disease?

No 0  GO TO QUESTION 19

Yes 1

What type of liver disease?

18a. Hepatitis No 0  GO TO QUESTION 18c

Yes 1

18b. What type? Type A 1

Type B 2

Type C 3

Don’t know 4

18c. Cirrhosis No 0

Yes 1

18d. Other No 0

Yes 1

19. Have you had heartburn (a burning pain or discomfort behind the breast bone in your chest) in the past year?

No 0  GO TO QUESTION 20

Yes 1

19a. How often have you had heartburn in the past year?

Less than once per month 1

About once per month 2

About once per week 3

Several times per week 4

Daily 5

20. Have you had acid regurgitation (a bitter or sour-tasting fluid coming into your throat or mouth) in the past year?

No 0  GO TO QUESTION 21

Yes 1

20a. How often have you had acid regurgitation in the past year?

Less than once per month 1

About once per month 2

About once per week 3

Several times per week 4

Daily 5

21. Has a doctor ever said that you have migraine headaches (with or without an aura)?

No 0

Yes 1

Has a doctor ever said that these relatives had migraine headaches?

21a. Mother No or Don’t know 0 Yes 1

21b. Father No or Don’t know 0 Yes 1

21c. Brother(s) or sister(s) No or Don’t know 0 Yes 1

22. Has a doctor ever said that you have a blood clot in your leg vein or lung requiring blood thinning medicine?

No 0

Yes 1

23. Do you have painful inflammation or swelling of your joints that limits your activities?

No 0

Yes 1

Has a doctor ever said that these relatives had painful inflammation or swelling of their joints that limits activities?

23a. Mother No or Don’t know 0 Yes 1

23b. Father No or Don’t know 0 Yes 1

23c. Brother(s) or sister(s) No or Don’t know 0 Yes 1

24. Have you ever been told by a doctor that you have a sleep disorder?

No 0  GO TO QUESTION 27

Yes 1

Don’t know 9  GO TO QUESTION 27

25. Which sleep disorder(s)? (Mark all that apply)

a. Insomnia

b. Restless legs

c. Narcolepsy

d. Apnea

e. Other

If other, please specify: ______________

26. Have you been prescribed a CPAP or BIPAP machine, or a device to wear in your mouth to treat your sleep apnea?

No 0

Yes 1

27. Has a doctor ever said that you have cancer or a malignant tumor?

No 0  GO TO QUESTION 27b

Yes 1

27a. What type? (Mark all that apply)

a. Lung

b. Breast

c. Cervical

d. Blood/lymph glands

e. Testes/scrotum

f. Bone

g. Melanoma

h. Skin (not melanoma)

i. Brain

j. Stomach

k. Colon

l. Uterine

m. Prostate

n. Other

Has a doctor ever said that these relatives had cancer or a malignant tumor?

27b. Mother No or Don’t know 0 Yes 1

27c. Father No or Don’t know 0 Yes 1

27d. Brother(s) or sister(s) No or Don’t know 0 Yes 1

MEN  STOP, END QUESTIONNAIRE

WOMEN  GO TO QUESTION 28

FOR WOMEN ONLY

28. Have you ever taken birth control pills or other birth control medication?

No 0

Yes 1

29. At what age did your menses begin?

Age in years

30. Do you currently have menstrual periods?

No 0

Yes 1

Uncertain 9

31. Have you ever been pregnant?

No 0  GO TO QUESTION 35

Yes 1

Uncertain 9

32. How many times have you been pregnant? Number of pregnancies

33. How many live births have you had? Number of live births

34. Are you currently pregnant?

No 0

Yes 1

Uncertain 9

35. Have you reached menopause (change of life)?

No 0  GO TO QUESTION 37

Yes, natural 1

Yes, surgical 2

Uncertain 9  GO TO QUESTION 37

36. At what age? Age in years

37. Have you had a hysterectomy?

No 0  GO TO QUESTION 39 Yes, with removal of both ovaries 1

Yes, without removal of both ovaries 2

Yes, uncertain if ovaries removed 3

38. Age at surgery? Age in years

39. Are you currently taking hormones other than birth control pills?

No 0  END QUESTIONNAIRE

Yes 1

Not sure 9  END QUESTIONNAIRE

40. Are those hormone supplements…? (Give examples if needed)

Estrogen alone 1

Estrogen + progestin 2

Other hormone combination 3

If other hormone combination, please specify:________________

Medical History (MHE) 0 of 10