Form 3A Health Status Questionnaire (Male-HSQ)
Prostate, Lung, Colorectal and Ovarian Cancer Screening Trial (PLCO) (NCI)
Attach_03A_HSQ-Male9_24_12
Health Status Questionnaire (HSQ) for PLCO
OMB: 0925-0407
Version No: 3/05 Form Approved OMB No.: 0925-0407
Expiration Date: xx/xx/xxxx
Prostate, Lung, Colorectal and Ovarian Cancer Screening Trial
Collection of this information is authorized by the Public Health Services ACT, Section 412 (42 USC 285 a-1). Rights of study participants are protected by the Privacy Act of 1974. Participation is voluntary, and there are no penalties for not participating or withdrawing from the study at any time. Refusal to participate will not affect your benefits in any way. The information collected in this study will be kept private under the Privacy Act. Names and other identifiers will be separated from information provided and will not appear in any report of the study. Information provided will be combined for all study participants and reported as statistical summaries. Public Reporting Burden for this collection of information is estimated to average 5 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 Officer, 6701 Rockledge Drive, MSC 7730, Bethesda, MD 20892-7730. Attention: PRA (0925-0407). Do not return the completed form to this address. |
Men's Health Status Questionnaire (HSM) |
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*HSM*
HSM-C |
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1. What is your date of birth? |
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PHYSICAL EXAMINATIONS Please complete each question by placing a ( √ ) in the box next to the answer that best fits your situation. (Mark only one answer for each question.) |
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2a. Have you ever had an eye examination for glaucoma or cataracts? |
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2b. When did you have your most recent eye examination for glaucoma or cataracts? |
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2c. What was the main reason you had this eye examination for glaucoma or cataracts? |
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Men's Health Status Questionnaire (HSM) |
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3a. Have you ever had a chest x-ray? |
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3b. When did you have your most recent chest x-ray? |
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3c. What was the main reason you had this chest x‑ray? |
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4a. Have you ever had a Spiral CT (Computed Tomography) of your chest?
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4b. When did you have your most recent Spiral CT of your chest? |
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4c. What was the main reason you had this Spiral CT of your chest? |
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5a. Have you ever had a digital rectal examination of the prostate? |
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5b. When did you have your most recent digital rectal examination of the prostate? |
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5c. What was the main reason you had this digital rectal examination of the prostate? |
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6a. Have you ever had a barium enema to examine your colon and rectum? |
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6b. When did you have your most recent barium enema to examine your colon and rectum? |
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6c. What was the main reason you had this barium enema to examine your colon and rectum? |
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7a. Have you ever had a flexible sigmoidoscopy examination of your colon and rectum? |
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7b. When did you have your most recent flexible sigmoidoscopy examination of your colon and rectum? |
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7c. What was the main reason you had this flexible sigmoidoscopy examination of your colon and rectum? |
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Men's Health Status Questionnaire (HSM) |
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8a. Have you ever had a colonoscopic examination of your colon and rectum? |
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8b. When did you have your most recent colonoscopic examination of your colon and rectum? |
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8c. What was the main reason you had this colonoscopic examination of your colon and rectum? |
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9a. Have you ever had a test for blood in the stool?
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9b. When did you have your most recent test for blood in the stool?
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9c. What was the main reason you had this test for blood in the stool?
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10a. Have you ever had your blood pressure checked? |
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10b. When did you have your most recent blood pressure check?
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10c. What was the main reason you had this blood pressure check? |
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Men's Health Status Questionnaire (HSM) |
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BLOOD TESTS Please complete each question by placing a (√) in the box next to the answer that best fits your situation. (Mark only one answer for each question.) |
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11a. Have you ever had a test to check your blood cholesterol level? |
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11b. When did you have your most recent test to check your blood cholesterol level? |
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11c. What was the main reason you had this test to check your blood cholesterol level? |
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12a. Have you ever had a test to check your blood glucose (sugar) level? |
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12b. When did you have your most recent test to check your blood glucose (sugar) level? |
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12c. What was the main reason you had this test to check your blood glucose (sugar) level? |
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Men's Health Status Questionnaire (HSM) |
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13a. Have you ever had a PSA blood test for prostate cancer? |
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13b. When did you have your most recent PSA blood test for prostate cancer? |
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13c. What was the main reason you had this PSA blood test for prostate cancer?
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14. Today's Date:
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Thank you for completing this questionnaire. Please return this form to:
SC Name
Address
-
FOR OFFICE USE ONLY
1. Method of Administration:
1 Self-Administered
2 Self-Administered with Assistance
3 Telephone Administered
4 In-person Interview
2. If Completion Date was estimated, check: 1
| File Type | application/msword |
| File Title | Form Approved OMB No.: 0925-0407 |
| Author | Debra Reames |
| Last Modified By | Vivian Horovitch-Kelley |
| File Modified | 2012-09-27 |
| File Created | 2012-09-17 |
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