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RES11078 CONTROL PATIENTS Book: Blank Case Report Blank Case Report Form for Study: RES11078 Book: CONTROL PATIENTS Page 1 Blank Case Report Form for Study RES11078 PT: _ _ INVSITE:: INV: Visit_Name : CSA Visit_Date: COMMON SUBJECT ASSESSMENT (CSA) Date of completion ___________ Participant: (CASE= Case, CNTL= Control, FAM= Family Member) CRF Version _ Complete by site staff before handing to study participant for Items 1-15 Page 2 Blank Case Report Form for Study RES11078 PT: ____________________ INVSITE: INV: Visit_Name : CSA Visit_Date: COMMON SUBJECT ASSESSMENT Continued Medical and Family History These questions are about you and your health. There are no right or wrong answers. You can put 'Don't Know'. Most people take 5 to 15 minutes to complete, but take as much time as you need. Feel free to ask the study staff if you need help or have questions. Section 1 - Your Information Please fill in boxes: 1. Date of birth ___________ 2. Please put your sex. __ (M= Male , F= Female) 3. Are you adopted? __ (Y= Yes, N= No, K= Don't know) Page 3 Blank Case Report Form for Study RES11078 PT: ____________ INVSITE: INV: Visit_Name : CSA Visit_Date: COMMON SUBJECT ASSESSMENT Continued Section 2 - You and Your Family's Origins The following is about you, your parents and grandparents if related by blood (for example, your biological parents, but NOT your step-parents). 4. For You SL SELF Race _ (W= White, B= Black, A= Asian, X= Other). Other, specify ____________________ Your first Language(s) 1. __ ____________________ (EN= English, FR= French, GE= German, 2. __ ____________________ HL= Dutch, IT= Italian, X= Other). 'Asian', here, means from India, Pakistan, Far east, Southeast Asia, Pacific Rim. 'Other', here, means your group is not shown above, or is a combination of groups. Please put your group on the text field. Page 4 Blank Case Report Form for Study RES11078 PT: __ ____ INVSITE: INV: Visit_N ame : CSA Visit_Date: COMMON SUBJECT ASSESSMENT Continued 5. For each of your 2 parents, tick box The following groups have some genetic importance or boxes if relevant and fill in the blank. in understanding disease. If your parents are from any of these groups, please tick 1 or more boxes Your Parents Race Other, specify First language? Other, specify Ethnic Group M BIOLOGICAL MOTHER _ ______ _________________ ____ F BIOLOGICAL FATHER _ _________________ __ _________________ ____ (W=White, B=Black, A=Asian, (EN= English, FR= French, (FN= Finnish, FRCD= French Canadian, K= Don't Know, X= Other) HNSA= Hispanic from North, South or Central America, ASJW= Ashkenazi Jewish, M= North America 'Asian', here, means from India, Pakistan, Far East, Southeast Asia, Pacific Rim. 'Original Peoples' or First Nation) 'Other', here, means the group of your parents is not show above, or is a combination of groups. Page 5 Blank Case Report Form for Study RES11078 PT:__ ___ INVSITE: INV: Visit : Visit Date: _Name CSA _ COMMON SUBJECT ASSESSMENT Continued 6. For each of your 4 grandparents, tick box or boxes if relevant and fill in the blank. The following groups have some genetic importance in understanding disease If your grandparents are from any of these groups, please tick 1 or more boxes Your Biological Grandparents Race Other, specify First language? Other, specify Ethnic group MGM MATERNAL GRANDMOTHER _ _________________ __ ________________ ____ MGF MATERNAL GRANDFATHER ______ __ ____ ___ ____ PGM PATERNAL GRANDMOTHER _ _________________ __ ________________ ____ PGF PATERNAL GRANDFATHER _ _________________ __ ________________ ____ (W- White, B= Black, A=Asian, (EN= English, (FN= Finnish, FRCD= French Canadian K=Don't Know, X= Other) FR= French, HNSA= Hispanic from North, South or Central America, ASJW= Ashkenazi Jewish, M= North American 'Original Peoples' or First Nation) Page 6 Blank Case Report Form for Study RES11078 PT: _ ___ INVSITE: INV: Visit_Name : CSA Visit_Date: COMMON SUBJECT ASSESSMENT Continued 7. Have you, or your immediate family (parents, brothers, sisters or children) ever been told by a doctor about having the following illnesses? Please tick for each illness, one box under the column labelled 'You' and one under the column labelled 'Your Parents, Brothers, Sisters or Children? Your Parents, Brothers, If so, how Sisters or MANY had Illness You Children the illness? Allergies * ARHF HAYFEVER _ _ __ ALDR DRUG ALLERGY _ _ __ Bone or Joint Problems ODB OSTEOPOROSIS OR 'THIN' BONES _ _ __ OSA OSTEOARTHRITIS _ _ __ RART RHEUMATOID ARTHRITIS _ _ __ ARTO OTHER ARTHRITIS _ _ __ Lung or Breathing ATH ASTHMA _ _ __ Problems ECB EMPHYSEMA OR CHRONIC BRONCHITIS _ _ __ Heart or Circulation MIAN HEART ATTACK, ANGINA _ _ __ Problems HCL HIGH BLOOD CHOLESTEROL _ _ __ HBP HIGH BLOOD PRESSURE _ _ __ ST STROKE _ _ __ (Y= Yes, N= No) (Y= Yes, N= No K= Don't Know) * Drugs causing allergies ____________________ Page 7 Blank Case Report Form for Study RES11078 PT: _________ ____ INVSITE: INV: Visit_Name : CSA Visit_Date: COMMON SUBJECT ASSESSMENT Continued 7. Have you, or your immediate family (parents, brothers, sisters or children) ever been told by a doctor about having the following illnesses? Please tick for each illness, one box under the column labelled 'You' and one under the column labelled 'Your Parents, Brothers, Sisters or Children? Your Parents, If so, how Brothers, Sisters MANY had Illness You or Children the illness? Digestive Problems IB INFLAMMATORY BOWEL DISORDER (CROHNS, ULCERATIVE COLITIS) _ _ __ Diabetes DB1 DIABETES TYPE 1 (EARLY ONSET) _ _ __ DB2 DIABETES TYPE 2 (LATE ONSET) _ _ __ DBNR PAIN DUE TO DIABETES (DIABETIC NEUROPATHY) _ _ __ PHN PAIN DUE TO VIRUS (POST HERPETIC NEURALGIA) _ _ __ Mood Disorders ANX ANXIETY OR PANIC DISORDER _ _ __ BPD MANIC DEPRESSION OR BIPOLAR DISORDER _ _ __ OCB OBSESSIVE/COMPULSIVE DISORDER _ _ __ DLM DEPRESSION THAT NEEDS TREATMENT _ _ __ DLMP DEPRESSION AFTER PREGNANCY (POST-PARTUM DEPRESSION) _ _ __ Nervous System EPCV EPILEPSY OR CONVULSIONS _ _ __ Problems MGR MIGRAINE HEADACHES _ _ __ MS MULTIPLE SCLEROSIS _ _ __ PD PARKINSON'S DISEASE _ _ __ MEML SEVERE MEMORY LOSS (LIKE ALZHEIMER'S DISEASE) _ _ __ SCH SCHIZOPHRENIA _ _ __ (Y=Yes, (Y=Yes, N=No, N=No) K=Don't Know) Page 8 Blank Case Report Form for Study RES11078 PT: ____________________ INVSITE:: INV: Visit_Name : CSA Visit_Date: COMMON SUBJECT ASSESSMENT Continued 7. Have you, or your immediate family (parents, brothers, sisters or children) ever been told by a doctor about having the following Brothers, Sisters or Children? Your Parents, Brothers, If so, how Sisters or MANY had Illness You Children the illness? Cancer BRCN BREAST CANCER _ _ __ LCNR LUNG CANCER _ _ __ SC STOMACH CANCER _ _ __ CC COLON CANCER _ _ __ UC UTERUS CANCER _ _ __ PCNR PROSTATE CANCER _ _ __ Skin Diseases PSOR PSORIASIS _ _ __ Put Other X OTHER _ _ __ Illness NOT X OTHER _ _ __ Listed above X OTHER _ _ __ Specify other illnesses 1. __________________________________________________________________ 2. __________________________________________________________________ 3. __________________________________________________________________ Page 9 Blank Case Report Form for Study RES11078 P : _ _ : I : T INVSITE: NV Visit_Name : CSA Visit_Date: COMMON SUBJECT ASSESSMENT Continued 8. Did you ever in your life drink 5 or more drinks of any kind of alcohol almost every day? _ (Y=Yes, N=NO, K= Don't know) 8a. Do you drink alcohol now? (Y= Yes, N= No) If NO, go to question 9 8b. During the past 30 days, on how many days did you have at least one alcohol drink? ( NONE= [None], 1B5D [1 to 5 days ], 5B10D [ 5 to 10 days ], >10D [ more than 10 days ] ) 'One drink' means a bottle of beer, or a large glass of wine, or a single spirit measure of liquor. 8c. Over the last 30 days, what is the average number of drinks you had PER DAY: ___ 9. Tick the box that best descr be you: _ (S= I smoke now, If F "I don't smoke now', then F= I don't smoke now. I have stopped smoking for ____ Years N= I have never smoked) If N, go to question 10 9a. About how many cigarettes do you or did you smoke per day? _____ (CD= Cigarettes per day, PD= Packs per day) __ 9b. Put the number of years you have smoked ____ Years Page 10 Blank Case Report Form for Study RES11078 P : ____________________ INV: T INVSITE: Visit_Name : CSA Visit_Date: COMMON SUBJECT ASSESSMENT Continued 12. How many cups (or cans) of drinks with caffeine do you have per day? ( NONE [None], 1B3 [1 to 3], 4B6 [4 to 6], >6 [more than 6] ) 13. Has the doctor ever told you that you were overweight? _ (Do not include times during pregnancy) (Y= Yes, N= No, K= Don't know) If yes, then put what ages (in years) that you were overweight? You can tick more than one box. (Y= Yes, N= No) <10Y YOUNG CHILD, 10 YEARS OR LESS _ 11B19Y TEENAGER, 11 TO 19 YEARS _ 20B30Y YOUNG ADULT, 20 TO 30 YEARS 31B50Y ADULT, 31 TO 50 YEARS _ >50Y OLDER ADULT, MORE THAN 50 YEARS 14. Are you concerned about your memory because it affects how you work or the way you live from day to day? If yes, has your memory problem gotten worse in the last year? _ (Y= Yes, N= No, K= Don't know) 15. How many years did you go to school? ____ ( <4Y [Less than or equal to 4 years], 5B10Y [5 to 10 years], 11B15Y [11 to 15 years], >15Y [more than 15 years] ) Page 11 Blank Case Report Form for Study RES11078 PT: ____________________ INVSITE:: INV: Visit_Name : ELIGIBILITY Visit_Date: METHOD OF ASCERTAINMENT Recruitment through a clinic visit? _ (Y=Yes, N=No) If YES, choose one from either the Specialty clinic OR General clinic ___ Specialty clinic Prospective (new patient to this specialty clinic) (SP) Retrospective (return patient
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