Black Women's Health Study 00 PLEASE USE BLUE OR BLACK BALLPOINT PEN. How old are you? Age. Please write in your date of birth. (This information is helpful for identification) MONTH (example: January = 0) 3. Please write in your current weight. DAY 9 YEAR 4. Between March 999 and March 00, did you use birth control pills? Yes No Go to Question 5 4a. How many s did you use them between March 999 and March 00? less than 6 s 5. Between March 999 and March 00 did you use any of these forms of birth control? (Mark all that apply) Norplant Depo-Provera (injections) tubes tied (tubal ligation) hysterectomy vasectomy 6- s -7 s 8 or s WEIGHT (Pounds) 4b. Please give the name of the last birth control pill that you used since March 999. 6. How many cigarettes do you currently smoke each? None 5-4 5-34 Less than 5 7. On average, in the last year how many alcoholic beverages did you drink each? None - 3 7-3 - 7 Less than 4-6 5-4 4-0 35 or 8 or 8. Women whose iods have stopped manently (at least s) are considered to have gone through menopause, even if they have not exienced any symptoms (hot flashes, etc.) Which of the following statements best describes your current situation? I still have my usual menstrual iods I am currently going through menopause My menstrual iods have stopped manently My iods stopped but I have iods now due to use of female hormones. I don't know if my iods have stopped because I began taking female hormones when I still had iods. Uncertain (please describe) Age iods stopped Reason iods stopped Natural menopause Chemotherapy/radiation Surgery Other 9. Have you had surgery to remove your ovaries or uterus? (Mark all that apply) No Age at removal Both ovaries removed One ovary only removed Uterus removed 0. Between March 999 and March 00, have you taken female hormones (like estrogen) for menopause? Yes No Go to question 0a. Between March 999 and March 00, how long did you take female hormones? less than 6 s 6 - s - 7 s 8 or s 0b. Type of hormone supplement used most recently? Premarin or other estrogen pills alone Progesterone (Provera etc.) pills alone Estrogen and progesterone pills Patch estrogen with or without progesterone Estrogen vaginal cream Birth control pill (for menopause) of medication. Have you had a mammogram between March 999 and March 00? Yes No Page
. Between March 999 and March 00, if you were diagnosed for the first time with any of the following conditions, please fill in the circle for yes and write in the year it was first diagnosed. (e.g. 999= 9 9 ; 000= 0 0 ) Yes Year Yes Year 7. Gallstones. Heart attack 8. Kidney Stones. Stroke 9. Colon or rectal polyp(benign) 3. Diabetes 30. Depression (treated with medication) Yes Year 4. Breast cancer 3. Glaucoma 5. Lung Cancer 3a. treated with laser surgery? 3b. treated with other surgery? 6. Colon Cancer 7. Rectal Cancer 8. Uterine Cancer 3. Other serious illness 9. 9. Other type cancer (specify) 3. Do you take any of the following medications or vitamins at least 3 s a? FIll in the circle for YES, leave blank for NO. Yes Year Aspirin (Anacin, Bufferin, Bayer, Excedrin, etc.) 0. Coronary bypass surgery or angioplasty Acetaminophen (Tylenol, Anacin-3, Panadol,etc.). Angina (chest pain). Blood clot (lungs or legs) Injections for diabetes 3. Hytension (high blood pressure) Pills for diabetes 4. High cholesterol 5. 6. 7. 8. 9. Fibroids in womb 5a. confirmed by pelvic exam? 5b. confirmed by ultrasound or laparoscopy? Polycystic ovarian syndrome Endometriosis 7a. confirmed by laparoscopy Hydatidiform mole (molar pregnancy) Cyst in breast 9a. confirmed by biopsy? 0. Lupus (systemic lupus erythematosus). Discoid Lupus. Rheumatoid arthritis 3. 4. Osteoarthritis Asthma 5. Sarcoidosis 6. Ulcer (gastric or duodenal) Yes Yes Year Year Diuretics (water pills) for high blood pressure or other reasons (Diuril, Hydrodiuril, etc.) Other blood pressure medication (Vasotec, Minipres, Calan, etc.) Antidepressants (Prozac, Zoloft, Elavil, etc.) Inhalers or pills for asthma Pills to lower cholesterol Medication for weight reduction Eye drops for glaucoma Multi-Vitamins Folic acid by itself Please list all other medications or supplements that you currently take at least 3 s a : Page
4. On average, during the past year, how many hours each did you spend: None less than hr 3-4 hours - hours 5 or hrs Watching TV, videos, home computer Sitting at work or at home during the Walking as part of your job No job 5. On average, during the past year, how many hours each did you spend: Walking to and from church, store, school, work Walking for exercise. Between March 999 and March 00, have you been pregnant? Yes No Go to page 5. Mark the number of times between March 999 and March 00 that you had any of the following: Birth of single child 3 Birth of twins or triplets 3 Miscarriage 3 Abortion 3 Currently pregnant Other None less than - 3-4 5-6 7-9 0 or hr hrs hrs hrs hrs hours Moderate activity (such as housework, childcare, gardening, bowling) Vigorous activity (such as basketball, swimming, running, aerobics) 6. In your opinion, what are the five most important things you do for your health?.. 3. 7. Have you ever been told by a doctor that you had sleep apnea (a condition in which breathing stops briefly during sleep)? Yes No Don't know 8. How often do you snore? never less than night - nights 3-5 nights always / almost always don't know 9. What is the chance that you would doze off or fall asleep while reading or watching TV? (not including at bedtime) no chance slight chance moderate chance high chance 0. What is the chance that you would doze off or fall asleep while talking to someone, or in a car while stopped in traffic for a few minutes? no chance slight chance moderate chance high chance 4. 5. 3 - Between March 999 and March 00, if you gave birth to a single child, either liveborn or stillborn, please answer the following questions. - If no births between March 999 and March 00, please skip this section and go to page 5. 3. What was your due date? (If you had than birth during this iod please answer only about the most recent) MONTH DAY YEAR 999 00 4. What was the child's birth date? MONTH DAY YEAR 999 00 000 00 000 00 Page 3
5. Did this pregnancy result from: IVF (in-vitro fertilization) GIFT (gamete intrafallopian transfer) 6. How much weight did you gain during this pregnancy? less than 0 lbs 0-4 lbs 8. Did you breast feed the baby? Yes No Go to question 9 8a. How long did you breast feed? No less than 3 s 3-5 s 6 s or 9. Did you take multi-vitamins during this pregnancy? Yes No Go to question 30 9a. When did you take them? (Mark all that apply) Before the pregnancy During st trimester During nd trimester During 3rd trimester 30. Did you use vaginal douching during this pregnancy or in the 6 s before it? (Mark all that apply) Yes, in the 6 s before this pregnancy 3. Did you smoke during this pregnancy or just before it? Yes, during this pregnancy less then 5 times Yes, during this pregnancy 5 or times Yes No Go to question 3 3a. When did you smoke? (Mark all that apply) Before the pregnancy During st trimester During nd trimester During 3rd trimester 3b. How many cigarettes did you smoke on average during or just before this pregnancy? Less then 5 5-4 5-4 5 or 3. When did you first see a doctor or nurse for prenatal care? During st trimester During nd trimester During 3rd trimester 33. How much did this baby weigh at birth? Please write in the child's weight in pounds and ounces. If not certain, give approximate weight. POUNDS OUNCES 5-9 lbs 0-4 lbs Other assisted reproductive technology None of these 5-9 lbs 30-34 lbs 35-39 lbs than 39 lbs 7. Since the birth, how much of the pregnancy weight gain have you lost? Almost all About half About a quarter Almost none 34. Did the doctor say this child was born at least 3 s early (premature / preterm)? Yes No Go to question 35 34a. How early? 3 s 5 s 7 s 9 s 4 s 6 s 8 s 0 s or 34b. Were you told that the birth was early for any of the following reasons? labor began early for no known reason membranes ruptured (water broke) early and baby was delivered to prevent infection labor was induced or had c-section because (mark all that apply): blood pressure was too high (preeclampsia, toxemia) baby was too big placenta detached or in wrong position (bleeding) breech birth baby too small or not growing proly (or had defect) some other reason Don't know 35. Did this child stay in a neonatal intensive care unit before going home? Yes, less than Yes, - 4 s Yes, 5-9 s Yes, 0 or s No Page 4
The next questions are about your usual diet during the past year. Mark the column to show how often, on average, you ate each food during the past year. Mark whether your usual size is small, medium, large, or su. Please DO NOT OMIT size unless you never ate the food or ate it less than once a. - a small size is about half the medium size or less. - a large size is about one and a half times the medium size. - a su size is than times the size of a medium size. Please do not skip any foods. If you never eat a food, mark "never or < " Example: During the past year, you ate a su of rice ( cups) about twice a, medium apples and medium pear each (3 ), and sausage less than once a (< ). Apples, pears EXAMPLE TYPE OF FOOD or < or < - 3 or Your size small medium large su medium Rice Regular bacon or regular sausage pieces TYPE OF FOOD or < - 3 or Your Your size size small medium large su 36. FRUIT AND JUICES Apples, pears medium Bananas medium Cantaloupe /4 medium Canned fruit, fruit cocktail, applesauce Oranges, tangerines, grapefruit medium Other fruit (strawberries,grapes,etc) Orange or grapefruit juice Other fruit juices, fortified fruit drinks, kool-ade 37. BREAKFAST FOODS High fiber,bran or granola cereals,shredded shredded wheat Highly fortified cereals, such as Product 9 or Total Other cereals, such Corn Flakes, Rice Krispies Other cooked cereals, or grits 6 ounce glass 6 ounce glass medium bowl medium bowl medium bowl medium bowl Eggs, including egg sandwich eggs Regular bacon or regular sausage pieces Turkey bacon or turkey sausage pieces Page 5
TYPE OF FOOD 38. VEGETABLES or < - 3 or Your size small med large su Beans such as baked, pintos, kidney, lentil, black eyed peas Chili with beans Tomatoes or tomato juice Red chili sauce, taco sauce, salsa picante medium or 6 oz glass tablespoons Broccoli Spinach Collard greens, mustard greens, turnip greens Cole slaw, cabbage, sauerkraut Carrots or mixed vegetables containing carrots Corn canned or on the cob or cob Green beans or string beans Green peas Green salad medium bowl Regular salad dressing or mayonnaise (including on sandwiches, in potato salad etc) tablespoons Lowfat salad dressing or mayonnaise tablespoons French fries, fried potatoes Sweet potatoes, yams Other potatoes including boiled, mashed, and potato salad Rice or dishes made with rice Any other vegetables including in stir fry Tofu Butter,margarine or other fat on vegetables, potatoes,etc. 39. MEAT, FISH, POULTRY, LUNCH ITEMS Hamburger,cheeseburger meatloaf, beef burritos, or tacos Soyburgers or garden burgers Beef (steaks, roasts, etc including in sandwiches) Beef stew or pot pie with carrots or other vegetables Liver, including chicken livers Pork, including chops, roasts, dinner ham Fried chicken, chicken nuggets Mixed dishes with chicken or turkey including tacos, burritos potpie and stir fry Other chicken or turkey (roasted, stewed, or broiled, including in sandwiches). medium or pats medium or 4ozs medium or 4ozs 4 ozs. cup 4 ozs chops or 4 ozs small or large piece small or large piece Page 6
TYPE OF FOOD Dark meat fish, including sardines, mackerel, salmon, bluefish or < - 3 or 4 ounces Your size small med large su Fried fish or fish sandwich 4 ozs or sandwich Other fish (broiled or baked) 4 ounces Shellfish(shrimp, crab, lobster,etc) 4 ounces Tuna fish (in sandwiches salad or casserole) Spaghetti, lasagna, other pasta with tomato sauce Cheese dishes without tomato sauce, like macaroni & cheese Pizza, including takeout cup cup slices Hot dogs, polish sausage pieces Ham, bologna, salami & other lunch meats slices or ounces Vegetable/tomato soup, minestrone, vegetable beef soup medium bowl 40. SWEETS Regular ice cream Lowfat ice cream Doughnuts, cake, cookies, pastry Pies Chocolate candy 4. BREADS,SNACK,SPREADS SNACK, SPREADS scoop or scoop or piece or 3 cookies medium slice small bar or oz. Biscuits, muffins (including fast food) White bread (including sandwiches, bagels, burger rolls, French or Italian bread) Dark breads, such as wheat, rye, pumnickel (including sandwiches) Corn bread, corn muffins, corn tortillas Snacks such as potato chips, corn chips, buttered popcorn medium slices slices medium piece handfuls or cup Peanuts, peanut butter tablespoons Cheese and cheese spreads (not cottage cheese) slices or ounces Yogurt 8 ounces Frozen yogurt scoop Butter on bread or rolls pats Margarine on bread or roll What form or type of margarine do you usually use? None pats FORM? Stick Tub Spray Squeeze (liquid) TYPE? Reg Light Extra Light Nonfat Page 7
TYPE OF FOOD or < -3-4 4. BEVERAGES (please note that the categories for these columns are different from previous page) Milk and Whole milk 8 oz glass beverages % milk 8 oz glass with milk (not % or skim/nonfat 8 oz glass including on Soy milk 8 oz glass cereal) Regular soft drinks Diet soft drinks Decaffeinated coffee Coffee with caffeine Tea, hot or iced (not herbal) Milk or cream in coffee or tea Sugar in coffee or tea oz can or bottle oz can or bottle medium cup medium cup medium cup tablespoon teaspoons Water 8 oz glass 5-6 -3 4-5 6 or Your size small med large su 43. Please list any foods that you ate once a or, that were not asked about above.. Food:. Food: Number of s : Number of s : 44. What kinds of fat do you usually add to your vegetables, potatoes, etc.? (Mark only or ). don't add fat margarine oil lard, drippings, bacon fat butter crisco pam or no fat 45. What kinds of fat do you usually use in cooking (to fry, stir-fry or saute?)(mark only or ). margarine oil lard, drippings, bacon fat butter crisco pam or no fat don't add fat 46. If you use oil in cooking, what kind do you usually use? (Mark only or ). don't use corn oil olive oil sesame oil soybean oil coconut oil vegetable oil sunflower oil canola oil don't know safflower oil blend of oils peanut oil other 47. SUMMARY QUESTIONS A. How many times did you use fat or oil in cooking each or? Less than - 3 4 or B. Not counting salad or potatoes, how many s of vegetables did you eat each or Diet? soft drinks C. Not counting juices, how many s of fruit did you eat each or? D. How many s of cold cereal did you eat each or? 48. How often did you: Seldom or Sometimes A. eat the skin on chicken B. eat the fat on meat? C. add salt to your food? Often or Always 49. In the past year, how often did you eat the following types of food from a fast food, takeout or other restaurant? AVERAGE USE in past year LAST YEAR Fried chicken Burgers Pizza Chinese food Mexican food Fried fish Other foods - 4 times past year 5 - times past year - 3 times a Once a - 4 times a About every Page 8