Year 1 Personal Habits and Lifestyles

Participant ID #  

These questions ask about habits (smoking, caffeine, alcohol use, diet, and exercise) that may affect your health. Please answer each question as accurately as possible. There are no right or wrong answers.

Smoking

1. During your entire life, have you smoked at least 100 cigarettes?
Yes
No (Skip to Question 2)
Not Answered
 
How old were you when you first started smoking cigarettes regularly? (Give your best guess)
 
1.1 Do you smoke cigarettes now? No
Yes (Skip to Question 1.2)
Not Answered
 
How old were you when you quit smoking regularly?
 
Did you quit smoking because you had a health problem that was caused by or made worse by smoking? No
Yes
Not Answered
 
1.2 On the average, how many cigarettes do you (did you) usually smoke each day?
 
1.3 How many years have you been (were you) a regular smoker? Do not count the times you stayed off cigarettes.
 
1.4 Have you ever smoked to keep from gaining weight or to lose weight? No
Yes
Not Answered
 
2. Have you ever worked in a space where people smoked cigarettes?
Yes
No (Skip to Question 3)
Not Answered
 
2.1 How many total years have you worked in a space where people smoked cigarettes?
 
2.2 Do you now work in a space where people smoke? No
Yes
Not Answered
 
3. As a child/adolescent, how many years did you live with someone who smoked regularly?
 
4. As an adult, how many years have you lived with someone who smoked regularly?
 

Breast Exams and Breast Disease

5. Have you ever done a breast self-examination (a breast exam on yourself)?
Yes
No (Skip to Question 6)
Not Answered
 
5a. How many times have you done a breast self-exam in the last 12 months?
 
6. Have you ever had a breast physical exam done by a doctor, nurse, or physician assistant?
Yes
No (Skip to Question 7)
Not Answered
 
6.1 How many of these exams have you had in the last 5 years?
 
6.2 How long ago did you last have a breast exam by a doctor, nurse, or physician assistant?
 
7. Has a doctor ever told you that you had benign breast disease or fibrocystic disease in your breasts?
No
Yes
Not Answered
 
8. Have you had a mammogram (x-ray of the breast to look for cancer or other breast problems) in the last 5 years?
Yes
No (Skip to question 9)
Not Answered
 
8.1 How many mammograms have you had in the last 5 years?
 

Use of powders (talc, baby powder, deodorant powder)

9. Have you ever used powder on your private parts (genital areas)?
Yes
No (Skip to question 10)
Not Answered
 
9.1 For how many years?
 
10. Did you ever use a diaphragm (a birth control device that fits over the opening of your womb?
Yes
No (Skip to question 11)
Not Answered
 
10.1 Did you ever use powder on your diaphragm? Yes
No (Skip to question 11)
Not Answered
 
10.2 For how many years did you use powder on your diaphragm?
 
11. Did you ever use powder on a sanitary napkin or pad?
Yes
No (Skip to question 12)
Not Answered
 
11.1 For how many years?
 

Use of electric blankets

12. Have you ever used an electric blanket, electric mattress pad, or heated water bed on at least half the days in any one month period?
Yes
No (Skip to question 13)
Not Answered
 
12.1 For how many years total did you use an electric blanket, electric mattress pad, or heated water bed?
 
12.2 In those years, how many months per year did you use an electric blanket, electric mattress pad, or heated water bed on at least half the days of the month?
 
12.3 When you used the electric blanket, electric mattress pad, or heated water bed, did you leave it turned on most of the time while you were sleeping, or did you use it only to warm the bed before you went to sleep?
 
12.4 Have you used an electric blanket, electric mattress pad, or heated water bed during the past year? No
Yes
Not Answered
 

Sun exposure

13. As a child or adolescent, once you had been exposed to the sun several times, what kind of reaction would your skin have after two or more hours in the sun on a bright day?
practically none
some redness only
burn
painful burn
painful burn with blisters
not answered
 
14. As a child or adolescent, after repeated sun exposures (e.g., two weeks playing in the sun), what kind of tan would you get?
practically none
light tan
average tan
deep tan
other
not answered
 
15. How often have you had a severe and painful sunburn at each of these areas on the body?
 
Never 1-2 times 3-5 times 6 or more times Not answered
back and shoulders
lower limbs
face or arms
"all over"
 
16. What percentage of your time in the sun now do you apply sunscreen?
none
25%
50%
75%
100%
not answered
 
17. What sun protection factor (SPF) of sunscreen do you usually use?
none
SPF 3 or below
SPF 4-7
SPF 8-14
SPF 15-24
Above SPF 24
not answered
 

Coffee, tea and soft drink habits

18. Do you usually drink coffee each day?
Yes
No (Skip to question 19)
Not Answered
 
18.1 How many cups of regular coffee (not decaf) do you usually drink each day? (Count tall [12 oz. or more] cups and espresso drinks made with double shots of espresso as 2 cups)
 
18.2 How many cups of decaf coffee do you usually drink each day? (Count tall [12 oz. or more] cups and espresso drinks made with double shots of espresso as 2 cups)
 
18.3 How is the coffee usually made? (Mark one or two answers) Drip
Espresso
Instant		 Boiled
Percolated
French Press
 
19. Do you usually drink tea each day? (Do not include decaf or herbal tea)
Yes
No (Skip to question 20)
Not Answered
 
How many cups of tea do you usually drink each day? (Do not include decaf or herbal tea)
 
20. Do you usually drink soft drinks each day? (Do not include decaffeinated drinks)
Yes
No (Skip to question 21)
Not Answered
 
How many soft drinks do you usually drink each day? (One can equals 12 oz.)
 

Alcohol

Alcohol may affect a person's health. We would like to know about the alcohol you have drunk over your lifetime. (For the questions below, one drink of alcohol is equal to one can of beer, one glass of wine, or one shot of liquor)

21. During your entire life, have you had at least 12 drinks of any kind of alcoholic beverage?
Yes
No (Skip to question 22)
Not Answered
 
21.1 Do you still drink alcohol? No
Yes (Skip to question 21.3)
Not Answered
 
21.2 Why did you stop or quit drinking alcohol?
 
21.3 When you were between 14 and 17 years old, how many drinks of alcohol did you usually have?
 
21.4 When you were between 18 and 22 years old, how many drinks of alcohol did you usually have?
 
21.5 When you were between 23 and 29 years old, how many drinks of alcohol did you usually have?
 
21.5 When you were between 30 and 49 years old, how many drinks of alcohol did you usually have?
 
21.5 When you were about 50 years old, how many drinks of alcohol did you usually have?
 

Height and Weight

22. Women's weight changes during their adult lies. Select the one answer that best describes you during your adult life. Please do not include times when you were pregnant or sick.
Weight has stayed about the same (within 10 pounds) (Skip to question 23)
Steady gain in weight (Skip to question 23)
Lost weight as an adult and kept it off (Skip to question 23)
Weight has gone up and down again by more than 10 pounds
Not answered
 
22.1 About how many times did your weight go up and down again by more than 10 pounds? Please don't include times when you were pregnant or sick?
 
The next set of questions asks about your height and weight at different ages since age 18. If you don't remember exactly, give your best guess.

23. How tall were you (without shoes on) at about age 18 (your tallest adult height)?
feet    inches (you may enter up to 2 decimal places)
 
24. What was your weight at about age 18 (when you were not pregnant)?
pounds
 
25. What was your weight at about age 35 (when you were not pregnant)?
pounds
 
26. What was your weight at about age 50 (when you were not pregnant)?
pounds
 
27. What was your maximum adult weight (the most you ever weighed since you were 18 years old) when you were not pregnant?
pounds
 
28. How old were you when you were at your maximum adult weight? (Mark all that apply)
18-29 years old
30-39 years old		 40-49 years old
50-59 years old		 60-69 years old
70 years old or older
 
29. What was your minimum adult weight (the least you ever weighed since you were 18 years old) when you were not pregnant?
pounds
 
30. How old were you when you were at your minimum adult weight? (Mark all that apply)
18-29 years old
30-39 years old		 40-49 years old
50-59 years old		 60-69 years old
70 years old or older
 

Weight Loss

31. Within the last 20 years, when you were not pregnant or sick, did you ever lose 10 pounds or more on purpose?
Yes
No (Skip to question 32)
Not Answered
 
31.1 How many times did you lose 50 pounds or more?
 
31.2 How many times did you lose at least 20 pounds, but not more than 49 pounds?
 
31.3 How many times did you lose at least 10 pounds, but not more than 19 pounds?
 
32. How long have you been within 10 pounds of your current weight (do not count times when you were pregnant or sick)?
years
 
The next set of questions is about special diets or types of foods women may choose or may be told to eat by the doctors.

33. Are you now on any of the following special diets?
 
No Yes Not answered
A low-calorie diet?
A low-fat or low-cholesterol diet?
A low salt (low-sodium) diet?
A high-fiber diet?
A diabetic or ADA diet?
A lactose-free (no milk or dairy foods) diet?
Any other diet?

Usual activities

34. During a usual day and night, about how many hours do you spend sitting? Be sure to include the time you spend sitting at work, sitting at the table eating, driving or riding in a car or bus, and sitting up watching TV or talking.
 
35. During a usual day and night, about how many hours do you spend sleeping or lying down with your feet up? Be sure to include the time you spend sleeping or trying to sleep at night, resting or napping, and lying down watching TV.
 

Sexually transmitted diseases

Sexual behavior may affect a woman's health. The next set of questions asks about sexually transmitted diseases.

36. How do you protect yourself from sexually transmitted diseases? (Mark all that apply)
I am not sexually active
I don't engage in sexual intercourse
I am in a monogamous relationship
My partner(s) and I use condoms (male or female)
     sometimes
     every time
     not answered
My partner(s) and I use dental dams
     sometimes
     every time
     not answered
My partner(s) and I use spermicide with nonoxyl-9
     sometimes
     every time
     not answered
My partner(s) and I discuss our sexual histories
I perform a visual inspection of my partner
Prefer not to answer
 
37. Of the following sexually transmitted diseases, which have you been diagnosed as having? (Mark all that apply)
Does not apply, I have never been diagnosed with a sexually transmitted disease
I do not know
Herpes Simplex II
genital warts (also known as HPV or condyloma)
chlamydia
syphilis
gonorrhea
HIV or AIDS
Other
Prefer not to answer

Work and Jobs

38. Did you ever live or work on a farm?
Yes
No (Skip to Question 39)
Not Answered
 
38.1 For how many years?
 
39. Did you ever work for one year or more as a hairdresser, beautician, or cosmetologist where you worked with hair dyes?
Yes
No (Skip to Question 40)
Not Answered
 
39.1 For how many years?
 
40. Did you ever have a job where you worked with hazardous chemicals?
Yes
No (Skip to Question 41)
Not Answered
 
40.1 For how many years?
 
41. Have you ever had a job for which you were paid?
Yes
No (Skip the rest of this question)
Not Answered
 
41.1 What are the 3 full-time or part-time jobs that you have held the longest length of time since you were 18 years old? Please start with your most recent job. (If you worked less than one year at a job, write "1" in the boxes for total years worked)
Your job
What did the company
make or do?
Age started
this job
Total number of years worked at this job

Places you have lived

42. How many years have you lived in the state you now live in?
 
If in the U.S., which state? or If not in the U.S., which country?
 
43. Where were you born?
44. Where did you live at age 15?
45. Where did you live at age 35?
46. Where did you live at age 50?
47. In what state or country have you lived the longest?
 
 
What is the date you finished this form?

THE END

Thank you very much!