PLEASE do not write anything on this page. This page is for OFFICE USE ONLY.
Date Data Entered / Initials _____________________ Date Verified / Initials _____________________
MAILED QUESTIONNAIRE
ANNUAL FOLLOW-UP
Study of Women's Health Across the Nation
SECTION A. GENERAL INFORMATION
AFFIX ID LABEL HERE
A1. RESPONDENT ID:
A2. SWAN STUDY VISIT # 09
A3. FORM VERSION: 05/15/2005
A4. INTERVIEWER’S INITIALS: ___ ___ ___
A5. RESPONDENT’S DOB: ___ ___ / ___ ___ / 1 9 ___ ___
M M D D Y Y Y Y
A6. INTERVIEW COMPLETED IN:
RESPONDENT’S HOME / VIA MAIL ................................................................ 1
CLINIC / OFFICE .............................................................................................. 2
RESPONDENT’S HOME W/ PROXY ............................................................... 3
CLINIC/OFFICE W/ PROXY ............................................................................. 4
TELEPHONE..................................................................................................... 5
TELEPHONE BY PROXY ................................................................................. 6
A7. INTERVIEW LANGUAGE:
ENGLISH........................................................................................................... 1
SPANISH........................................................................................................... 2
CANTONESE .................................................................................................... 3
JAPANESE........................................................................................................ 4
A8. INTERVIEWER-ADMINISTERED?
NO ..................................................................................................................... 1
YES ................................................................................................................... 2
PLEASE do not write anything on this page. This page is for OFFICE USE ONLY.
MAILED QUESTIONNAIRE VERSION 2.0 05/15/2005 Page 1 of 28
ANNUAL FOLLOW-UP 9
MAIL
L:\swan\forms\follow9\09\mail.doc
We are interested in learning more about women’s health during their 40’s, 50’s and 60’s. The following
questions will help to further the knowledge about this crucial time period in a woman’s health. Please
answer the following questions as completely as possible. Thank you for your dedication and
commitment to the SWAN study.
We last interviewed you on [DATE]. We would like to ask you a few questions about what’s
happened to you since then.
B1. Please enter today’s date: ___ ___ / ___ ___ / ___ ___ ___ ___
M M D D Y Y Y Y
B2. In general, would you say your health is excellent, very good, good, fair or poor?
(PLEASE CIRCLE ONE RESPONSE.)
Excellent ......................................................................................................1
Very good.....................................................................................................2
Good .............................................................................................................3
Fair ...............................................................................................................4
Poor ..............................................................................................................5
Don’t know ............................................................................................... -8
The next questions ask about your menstrual periods. Please complete these questions even if you may
have indicated in a previous visit that you have not had any menstrual bleeding “since your last study
visit.”
B3. Did you have any menstrual bleeding since your last study visit?
NO ................................................................................................................1 (GO TO C1)
YES ..............................................................................................................2 (GO TO B3a)
B3a. What was the date that you started your most recent menstrual bleeding? [IF YOU DO NOT
KNOW THE EXACT DAY, ENTER THE MONTH AND YEAR.]
___ ___ / ___ ___ / ___ ___ ___ ___
M M D D Y Y Y Y
MAILED QUESTIONNAIRE VERSION 2.0 05/15/2005 Page 2 of 28
ANNUAL FOLLOW-UP 9
MAIL
L:\swan\forms\follow9\09\mail.doc
The next few questions focus on some other personal aspects of your life.
C1. Thinking about your quality of life at the present time, we’d like you to give it a rating where 0 represents
the worst possible quality for you and 10 represents the best possible quality for you. How would you rate
your overall quality of life at the present time? (PLEASE CIRCLE ONLY ONE NUMBER.)
0 1 2 3 4 5 6 7 8 9 10
Worst Best
possible possible
quality quality
C2. People experience a variety of feelings or thoughts. How often you have felt or thought the following in
the past two weeks? (CIRCLE ONE RESPONSE FOR EACH QUESTION.)
Never Almost Sometimes Fairly Very
Never Often Often
a. In the past two weeks have you felt unable
1 2 3 4 5
to control important things in your life?
b. In the past two weeks have you felt
confident about your ability to handle 1 2 3 4 5
your personal problems?
c. In the past two weeks have you felt that
1 2 3 4 5
things were going your way?
d. In the past two weeks have you felt that
difficulties were piling so high that you 1 2 3 4 5
could not overcome them?
MAILED QUESTIONNAIRE VERSION 2.0 05/15/2005 Page 3 of 28
ANNUAL FOLLOW-UP 9
MAIL
L:\swan\forms\follow9\09\mail.doc
The next two questions describe some general attitudes and feeling that women your age may have.
C3. Please indicate the extent to which you personally agree or disagree with the following statements about
yourself. (CIRCLE ONE RESPONSE FOR EACH QUESTION.)
Agree Neutral Disagree Don’t
Know
a. The older a woman is, the more valued she is. 1 2 3 -8
b. A woman is less attractive after menopause. 1 2 3 -8
c. Women who no longer have menstrual periods 1 2 3 -8
feel free and independent.
d. Menopause is a mid-life change that generally 1 2 3 -8
does not need medical attention.
e. Women with little free time hardly notice the 1 2 3 -8
menopause.
C4. Please indicate the extent to which you personally agree or disagree with the following statements about
your self. (CIRCLE ONE RESPONSE FOR EACH QUESTION.)
Agree Neutral Disagree Don’t
Know
a. Overall, going through the menopause or 1 2 3 -8
change of life will be, or was, a positive
experience for me.
b. As I age I feel worse about myself. 1 2 3 -8
c. During the menopause or the change of life, I 1 2 3 -8
became, or expect to become, irritable or
depressed.
d. I will feel, or felt, regret when my periods 1 2 3 -8
stopped for the last time.
e. I don’t, or didn’t know, what to expect with 1 2 3 -8
the menopause.
MAILED QUESTIONNAIRE VERSION 2.0 05/15/2005 Page 4 of 28
ANNUAL FOLLOW-UP 9
MAIL
L:\swan\forms\follow9\09\mail.doc
The following questions will help us to better understand your responses to our SWAN study questions.
Please remember that this information will remain confidential.
C5. What is your current marital status?
Single/never married ....................................................................................1
Currently married or living as married ........................................................2
Separated ......................................................................................................3
Widowed ......................................................................................................4
Divorced.......................................................................................................5
Don’t know ................................................................................................ -8
C6. How hard is it for you to pay for the very basics like food, housing, medical care, and heating? Would
you say it is… (CIRCLE ONE NUMBER.)
Very hard .....................................................................................................1
Somewhat hard.............................................................................................2
Not hard at all ..............................................................................................3
Don’t know ............................................................................................... -8
C7. Since your last study visit, have you smoked cigarettes regularly (at least one cigarette a day)?
No...........................................................................................................1 (GO TO D1, PAGE 6)
Yes .........................................................................................................2
C7a. How many cigarettes, on average, do you smoke per day now?
(IF NONE, please indicate with a (0) zero and answer C7b.)
________ CIGARETTES PER DAY
C7b. If you stopped smoking since your last study visit, what was the last month and year you
smoked? (CHECK BOX IF UNKNOWN.)
___ ___ / ___ ___ ___ ___ Don’t Know (-8)
M M Y Y Y Y
MAILED QUESTIONNAIRE VERSION 2.0 05/15/2005 Page 5 of 28
ANNUAL FOLLOW-UP 9
MAIL
L:\swan\forms\follow9\09\mail.doc
The next set of questions ask about your health and medical conditions.
D1. Since your last study visit, has a doctor, nurse practitioner or other health care provider told you that you
had any of the following conditions or treated you for them?
NO YES DON’T KNOW
a. Anemia? 1 2 -8
b. Diabetes? 1 2 -8
c. High blood pressure or hypertension? 1 2 -8
d. High cholesterol? 1 2 -8
e. Migraines? 1 2 -8
f. Stroke? 1 2 -8
g. Arthritis or osteoarthritis (degenerative joint 1 2 -8
disease)?
h. Overactive or under-active thyroid? 1 2 -8
i. Heart attack? 1 2 -8
j. Angina? 1 2 -8
k. Osteoporosis (brittle or thinning bones)? 1 2 -8
l. Skin cancer? 1 (GO TO D2) 2 -8 (GO TO D2)
l.1 If yes, what type of cancer were you told .
you had?
a. Melanoma? 1 2 -8
b. Non melanoma skin cancer? 1 2 -8
MAILED QUESTIONNAIRE VERSION 2.0 05/15/2005 Page 6 of 28
ANNUAL FOLLOW-UP 9
MAIL
L:\swan\forms\follow9\09\mail.doc
D2. Since your last study visit, has a doctor, nurse practitioner or other health care provider told you
that you had cancer, other than skin cancer?
NO ....................................................................................................................1 (GO TO D3)
YES ..................................................................................................................2
DON’T KNOW ............................................................................................. -8 (GO TO D3)
D2a. If YES to cancer, have you received chemotherapy and/or radiation treatment for this cancer?
NO ....................................................................................................................1
YES ..................................................................................................................2
DON’T KNOW ............................................................................................. -8
D2b. If YES to cancer, what is/was the primary site of the cancer?
(CIRCLE ONE ANSWER.)
D2c. If BREAST CANCER: Have
you taken Tamoxifen?
ONE BREAST ....................................................1 NO ................................ 1
BOTH BREASTS ...............................................2 YES .............................. 2
DON’T KNOW .......... -8
OVARY ..............................................................3 (GO TO D3)
UTERUS.............................................................4
CERVIX .............................................................5
LEUKEMIA .......................................................6
LUNG .................................................................7
COLON ..............................................................8
RECTUM ...........................................................9
THROAT ............................................................10
VULVA ..............................................................12
RENAL CELL ....................................................13
NONE OF THE ABOVE / OTHER ...................11
SPECIFY:_________________________
DON’T KNOW ................................................. -8
MAILED QUESTIONNAIRE VERSION 2.0 05/15/2005 Page 7 of 28
ANNUAL FOLLOW-UP 9
MAIL
L:\swan\forms\follow9\09\mail.doc
D3. How many times have you broken or fractured one or more bones since your last study visit?
(If more than one bone was broken during the same event count as one time.)
_________ # of events where bone(s) were broken or fractured
If you reported that you broke or fractured any bones, we’d like to know more about those events. You may
get a call from one of the study representatives at your SWAN site to ask you more questions.
D4. How much do you weigh? pounds
D5. Since your last study visit, have you had a D and C (a scraping of the uterus) for any reason?
No.................................................................................................................1 (GO TO D6)
Yes ...............................................................................................................2
Don’t know ................................................................................................ -8 (GO TO D6)
D5a. IF YES, since your last study visit, how many times have you had a D and C? ___ ___ # TIMES
D6. Since your last study visit, have you had a hysterectomy (an operation to remove your uterus or womb
only)?
No.................................................................................................................1 (GO TO D7)
Yes ...............................................................................................................2
Don’t know ................................................................................................ -8 (GO TO D7)
D6a. IF YES, when was this hysterectomy performed? (CHECK BOX IF UNKNOWN.)
___ ___ / ___ ___ ___ ___ Don’t Know (-8)
M M Y Y Y Y
If you reported a hysterectomy, we’re interested in knowing more about your experience. You may get a
call from one of the study representatives at your SWAN site to ask you more questions.
D7. Since your last study visit, did you have one or both ovaries removed (an oophorectomy)?
No.................................................................................................................1 (GO TO D8)
Yes ...............................................................................................................2
Don’t know ................................................................................................ -8 (GO TO D8)
D7a. IF YES, was one ovary removed or were both ovaries removed?
One ovary removed ..............................................................1
Both ovaries removed ..........................................................2
Don’t know ........................................................................ -8
MAILED QUESTIONNAIRE VERSION 2.0 05/15/2005 Page 8 of 28
ANNUAL FOLLOW-UP 9
MAIL
L:\swan\forms\follow9\09\mail.doc
D8. Since your last study visit, did you have an endometrial ablation (a procedure to reduce or eliminate
menstrual periods by partially or completely destroying the lining of the uterus)?
No.................................................................................................................1
Yes ...............................................................................................................2
Don’t know ................................................................................................ -8
D9. Since your last study visit, did you have any other uterine procedures (procedures not mentioned in
Questions D5 -D8), for example: IUD insertion, fibroid removal or endometrial biopsy?
No.................................................................................................................1
Yes ...............................................................................................................2
Don’t know ................................................................................................ -8
D10. Since your last study visit, did you have your thyroid gland removed?
No.................................................................................................................1
Yes ...............................................................................................................2
Don’t know ................................................................................................ -8
D11. Since your last study visit, have you had any of the following conditions?
DON’T
NO YES
KNOW
a. Since your last study visit, have you had endometriosis diagnosed by
a physician (abnormal growths in lining of uterus)? 1 2 -8
b. Since your last study visit, have you had pelvic pain (pain in the
lowest part of the abdomen)? 1 2 -8
c. Since your last study visit, have you had pelvic prolapse or relaxation
(the uterus, bladder, or rectum drops, sometimes bulging out of 1 2 -8
vagina)?
d. Since your last study visit, have you had abnormal vaginal bleeding
(bleeding from the vagina that is different enough from your normal 1 2 -8
pattern to be a concern: irregular, heavy, or long in duration)?
e. Since your last study visit, have you had fibroids (benign growths in
the uterus or womb)? 1 2 -8
MAILED QUESTIONNAIRE VERSION 2.0 05/15/2005 Page 9 of 28
ANNUAL FOLLOW-UP 9
MAIL
L:\swan\forms\follow9\09\mail.doc
The following questions are about specific health problems you may have had over the past two weeks.
E1. Over the past two weeks, how often have you had hot flashes or flushes?
(CHECK ONE BOX AND ANSWER THE NEXT QUESTIONS AS INSTRUCTED.)
Not at all (1) (GO TO E2)
1-5 days (2)
6-8 days (3) E1a. On the days that you have hot flashes or flushes, how many times
each day do you usually have them?
9-13 days (4)
Every day (5) NUMBER OF TIMES PER DAY ___ ___ (GO TO E1b)
E1b. How much are you usually bothered by hot flashes or flushes?
(CIRCLE ONE NUMBER.)
Not at all ................................................... 1
Very little ................................................. 2
Moderately ............................................... 3
A lot.......................................................... 4
E2. Over the past two weeks, how often have you had cold sweats?
(CHECK ONE BOX AND ANSWER THE NEXT QUESTIONS AS INSTRUCTED.)
Not at all (1) (GO TO E3)
1-5 days (2)
E2a. On the days that you have cold sweats, how many times each day
6-8 days (3) do you usually have them?
9-13 days (4)
Every day (5) NUMBER OF TIMES PER DAY ___ ___ (GO TO E2b)
E2b. How much are you usually bothered by cold sweats?
(CIRCLE ONE NUMBER.)
Not at all ................................................... 1
Very little ................................................. 2
Moderately ............................................... 3
A lot.......................................................... 4
MAILED QUESTIONNAIRE VERSION 2.0 05/15/2005 Page 10 of 28
ANNUAL FOLLOW-UP 9
MAIL
L:\swan\forms\follow9\09\mail.doc
E3. Over the past two weeks, how often have you had night sweats?
(CHECK ONE BOX AND ANSWER THE NEXT QUESTIONS AS INSTRUCTED.)
Not at all (1) (GO TO E4)
1-5 days (2)
6-8 days (3) E3a. On the days that you have night sweats, how many times each
night do you usually have them?
9-13 days (4)
Every day (5) NUMBER OF TIMES PER NIGHT ___ ___ (GO TO E3b)
E3b. How much are you usually bothered by night sweats?
(CIRCLE ONE NUMBER.)
Not at all ................................................... 1
Very little ................................................. 2
Moderately ............................................... 3
A lot.......................................................... 4
E4. Over the past two weeks, how often have you had stiffness or soreness in joints, neck or shoulders?
(CHECK ONE BOX AND ANSWER THE NEXT QUESTION AS INSTRUCTED.)
Not at all (1) (GO TO E5)
1-5 days (2)
E4a. How much are you usually bothered by stiffness or soreness in
6-8 days (3) joints, neck or shoulders? (CIRCLE ONE NUMBER.)
9-13 days (4) Not at all ................................................... 1
Every day (5) Very little ................................................. 2
Moderately ............................................... 3
A lot.......................................................... 4
E5. Over the past two weeks, how often have you had irritability or grouchiness?
(CHECK ONE BOX AND ANSWER THE NEXT QUESTION AS INSTRUCTED.)
Not at all (1) (GO TO E6)
1-5 days (2)
E5a. How much are you usually bothered by irritability or grouchiness?
6-8 days (3) (CIRCLE ONE NUMBER.)
9-13 days (4) Not at all ................................................... 1
Very little ................................................. 2
Every day (5)
Moderately ............................................... 3
A lot.......................................................... 4
MAILED QUESTIONNAIRE VERSION 2.0 05/15/2005 Page 11 of 28
ANNUAL FOLLOW-UP 9
MAIL
L:\swan\forms\follow9\09\mail.doc
E6. Over the past two weeks, how often have you felt tense or nervous?
(CHECK ONE BOX AND ANSWER THE NEXT QUESTION AS INSTRUCTED.)
Not at all (1) (GO TO E7)
1-5 days (2)
6-8 days (3) E6a. How much are you usually bothered by feeling tense or nervous?
(CIRCLE ONE NUMBER.)
9-13 days (4)
Not at all ................................................... 1
Every day (5) Very little ................................................. 2
Moderately ............................................... 3
A lot.......................................................... 4
E7. Below is a list of common problems which affect us from time to time in our daily lives.
Thinking back over the past two weeks, how often have you experienced any of the following:
(PLEASE CIRCLE ONE NUMBER FOR EACH QUESTION.)
Not at all 1-5 days 6-8 days 9-13 days Every day
a. In the past two weeks how often
have you had back aches or 1 2 3 4 5
pains?
b. In the past two weeks how often
1 2 3 4 5
have you had vaginal dryness?
c. In the past two weeks how often
have you had felt blue or 1 2 3 4 5
depressed?
d. In the past two weeks how often
1 2 3 4 5
have you had dizzy spells?
e. In the past two weeks how often
1 2 3 4 5
have you had forgetfulness?
f. In the past two weeks how often
have you had frequent mood 1 2 3 4 5
changes?
g. In the past two weeks how often
have you had heart pounding or 1 2 3 4 5
racing?
MAILED QUESTIONNAIRE VERSION 2.0 05/15/2005 Page 12 of 28
ANNUAL FOLLOW-UP 9
MAIL
L:\swan\forms\follow9\09\mail.doc
Question E7 continued:
Not at all 1-5 days 6-8 days 9-13 days Every day
h. In the past two weeks how often
have you felt fearful for no 1 2 3 4 5
reason?
i. In the past two weeks how often
1 2 3 4 5
have you had headaches?
j. In the past two weeks how often
have you had breast 1 2 3 4 5
pain/tenderness?
k. In the past two weeks how often
have you had vaginal 1 2 3 4 5
irritation/itching?
l. In the past two weeks how often
1 2 3 4 5
have you had vaginal discharge?
m. In the past two weeks how often
have you had vaginal 1 2 3 4 5
soreness/pain?
E8. The following questions (a - c) are about your sleep habits over the past two weeks. Pick the answer that
best describes how often you experienced the situation in the past 2 weeks. (CIRCLE ONE RESPONSE
FOR EACH QUESTION.)
No, Yes, Yes, Yes, Yes,
not in the less than 1 or 2 3 or 4 5 or more
past 2 once a times a times per times a
weeks week week week week
a. In the past two weeks, did you have
trouble falling asleep? 1 2 3 4 5
b. In the past two weeks, did you
wake up several times a night? 1 2 3 4 5
c. In the past two weeks, did you
wake up earlier than you had
1 2 3 4 5
planned to, and were unable to fall
asleep again?
MAILED QUESTIONNAIRE VERSION 2.0 05/15/2005 Page 13 of 28
ANNUAL FOLLOW-UP 9
MAIL
L:\swan\forms\follow9\09\mail.doc
The next questions are about your general feelings and attitudes that women your age may have.
F1. This question deals with how you respond to your physical senses. For each item please indicate the degree to
which each statement is TRUE OF YOU in general. (CIRCLE ONE RESPONSE FOR EACH QUESTION.)
Not at all A little bit Moderately Quite a bit Extremely
TRUE TRUE TRUE TRUE TRUE
a. I am often aware of various things 1 2 3 4 5
happening within my body.
b. Sudden loud noises really bother 1 2 3 4 5
me.
c. I hate to be too hot or too cold. 1 2 3 4 5
d. I am quick to sense the hunger 1 2 3 4 5
contractions in my stomach.
e. I can’t stand pain. 1 2 3 4 5
F2. Please indicate the extent to which you personally agree or disagree with the following statements about
yourself. (CIRCLE ONE NUMBER ON EACH LINE.)
Strongly Agree Neither Disagree Strongly
Agree Agree nor Disagree
Disagree
a. I have never dreaded the day I 1 2 3 4 5
would look in the mirror and see
gray hairs.
b. It doesn’t bother me at all to imagine 1 2 3 4 5
myself being old.
c. When I look in the mirror, it doesn’t 1 2 3 4 5
bother me to see how my looks have
changed with age.
d. I expect to feel good about life when 1 2 3 4 5
I am old.
e. I fear it will be very hard for me to 1 2 3 4 5
find contentment in old age.
f. I will have plenty to occupy my time 1 2 3 4 5
when I am old.
MAILED QUESTIONNAIRE VERSION 2.0 05/15/2005 Page 14 of 28
ANNUAL FOLLOW-UP 9
MAIL
L:\swan\forms\follow9\09\mail.doc
g. As I age I feel worse about myself. 1 2 3 4 5
The next questions ask about your physical activity during the past year.
F3. During the past year, did you watch television? (CIRCLE ONE RESPONSE.)
Never or less than 1 hour a week .................................................................1
At least 1 hour/week but less than 1 hour per day .......................................2
1 – 2 hours a day ..........................................................................................3
2 – 4 hours a day ..........................................................................................4
More than 4 hours a day ..............................................................................5
F4. During the past year, did you walk or bike to and from work, school or errands?
(CIRCLE ONE RESPONSE.)
Never or less than 5 minutes per day ...........................................................1
5 – 15 minutes per day .................................................................................2
16 – 30 minutes per day ...............................................................................3
31 – 45 minutes per day ...............................................................................4
More than 45 minutes per day .....................................................................5
A common complaint among women is having to urinate a lot or the involuntary loss of urine.
G1. Since your last study visit, have you leaked urine, even a small amount, beyond your control?
No...................................................................................................................1 (GO TO H1)
Yes .................................................................................................................2
G2. In the last month, about how many days have you lost any urine, even a small amount, beyond your
control when you are coughing, laughing, sneezing, jogging, picking up an object from the floor or
similar type of activity? (CIRCLE ONLY ONE ANSWER.)
Never ............................................................................................................1
About once in the last month .......................................................................2
At least once per week to several times per week .......................................3
Almost daily / daily......................................................................................4
G3. In the last month, about how many days have you lost any urine, even a small amount, beyond your
control when you have the urge to urinate and can’t get to the toilet fast enough?
(CIRCLE ONLY ONE ANSWER.)
Never ............................................................................................................1
About once in the last month .......................................................................2
At least once per week to several times per week .......................................3
Almost daily / daily......................................................................................4
MAILED QUESTIONNAIRE VERSION 2.0 05/15/2005 Page 15 of 28
ANNUAL FOLLOW-UP 9
MAIL
L:\swan\forms\follow9\09\mail.doc
H1. These next questions ask about events that we sometimes experience in our lives. Since your last study
visit, have you experienced any of the following: If you have not, circle 1 (NO). If you have, indicate
how upsetting it was by circling 2, 3, 4 or 5. (CIRCLE ONE ANSWER FOR EACH QUESTION.)
NO YES YES YES YES
Not at all Somewhat Very Very
upsetting upsetting upsetting upsetting and
still upsetting
a. Since your last study visit, have you started
1 2 3 4 5
school, a training program, or new job?
b. Since your last study visit, have you had
trouble with a boss or conditions at work got 1 2 3 4 5
worse?
c. Since your last study visit, have you quit, got
1 2 3 4 5
fired or laid off from a job?
d. Since your last study visit, have you taken on
1 2 3 4 5
a greatly increased work load at your job?
e. Since your last study visit, has your
1 2 3 4 5
husband/partner become unemployed?
f. Since your last study visit, have you had
1 2 3 4 5
major money problems?
g. Since your last study visit, have your relations
with husband/partner changed for the worse 1 2 3 4 5
but without separation or divorce?
h. Since your last study visit, were you separated
or divorced or was a long-term relationship 1 2 3 4 5
ended?
i. Since your last study visit, have you had a
serious problem with child or family member
1 2 3 4 5
(other than husband/partner) or with a close
friend?
j. Since your last study visit, has your child
1 2 3 4 5
moved out of the house or left the area?
MAILED QUESTIONNAIRE VERSION 2.0 05/15/2005 Page 16 of 28
ANNUAL FOLLOW-UP 9
MAIL
L:\swan\forms\follow9\09\mail.doc
Question H1 continued
NO YES YES YES YES
Not at all Somewhat Very Very
upsetting upsetting upsetting upsetting and
still upsetting
k. Since your last study visit, have you taken on
responsibility for the care of another child,
1 2 3 4 5
grandchild, parent, other family member or
friend?
l. Since your last study visit, has a family
member had legal problems or a problem with 1 2 3 4 5
police?
m. Since your last study visit, has a close relative
1 2 3 4 5
(husband/partner, child or parent) died?
n. Since your last study visit, has a close friend
or family member other than a 1 2 3 4 5
husband/partner, child or parent died?
o. Since your last study visit, has a major
accident, assault, disaster, robbery or other 1 2 3 4 5
violent event happened to you?
p. Since your last study visit, has a major
accident, assault, disaster, robbery or other 1 2 3 4 5
violent event happened to a family member?
q. Since your last study visit, has a serious
physical illness, injury or drug/alcohol 1 2 3 4 5
problem happened to a family member,
partner or close friend?
r. Since your last study visit, have you had a 1 2 3 4 5
major event not included above? If YES,
SPECIFY:
MAILED QUESTIONNAIRE VERSION 2.0 05/15/2005 Page 17 of 28
ANNUAL FOLLOW-UP 9
MAIL
L:\swan\forms\follow9\09\mail.doc
The next questions ask about hormone usage.
I1. Did you start using any prescription medications containing estrogen or progestin since the time of your
last study visit? (CIRCLE “YES” EVEN IF YOU STOPPED AND/OR STARTED ONE OR MORE
TIMES.)
No .....................................................................................................................1 (GO TO I3)
Yes ....................................................................................................................2
Don't know ...................................................................................................... -8 (GO TO I3)
I2. Below is a list of some reasons why women start taking hormones, not including birth control pills. For
each one, please indicate if it is a reason why you started taking hormones.
(PLEASE CIRCLE ONE RESPONSE FOR EACH REASON.)
NO YES
a. Did you start taking hormones to reduce the risk of heart disease?
1 2
b. Did you start taking hormones to reduce the risk of osteoporosis (brittle
1 2
or thinning bones)?
c. Did you start taking hormones to relieve menopausal symptoms?
1 2
d. Did you start taking hormones to stay young-looking?
1 2
e. Did you start taking hormones because a health care provider advised
1 2
you to take them?
f. Did you start taking hormones because a friend or relative advised you
1 2
to take them?
g. Did you start taking hormones to improve your memory?
1 2
h. Did you start taking hormones to regulate periods?
1 2
i. Any other reason you started taking hormones? Please, specify:
1 2
MAILED QUESTIONNAIRE VERSION 2.0 05/15/2005 Page 18 of 28
ANNUAL FOLLOW-UP 9
MAIL
L:\swan\forms\follow9\09\mail.doc
I3. Have you stopped taking any prescription medications containing estrogen or progestin since your last
study visit? (CIRCLE “YES” EVEN IF YOU STARTED AGAIN AFTER STOPPING.)
No ..................................................................................................................1 (GO TO I5)
Yes .................................................................................................................2
Don’t Know ................................................................................................. -8 (GO TO I5)
I3a. In what month and year did you last take hormones? (CHECK BOX IF UNKNOWN.)
___ ___ / ___ ___ ___ ___ Don’t know (-8)
M M Y Y Y Y
I4. Below is a list of some reasons why women stop taking hormones, not including birth control pills. For
each one, please indicate if it is a reason why you stopped taking hormones.
(PLEASE CIRCLE ONE RESPONSE FOR EACH REASON.)
NO YES
a. I stopped taking hormones because of problems with bleeding. 1 2
b. I stopped taking hormones because I didn’t like having periods. 1 2
c. I stopped taking hormones because I didn’t like how I felt on them. 1 2
d. I stopped taking hormones because I worried about possible side
1 2
effects.
e. I stopped taking hormones because I worried about cancer. 1 2
f. I stopped taking hormones because my health care provider advised
me to stop (for medical reasons). 1 2
g. I stopped taking hormones because they were too expensive. 1 2
h. I stopped taking hormones because I don’t like to take any
1 2
medications.
i. I stopped taking hormones because I couldn’t remember to take them. 1 2
j. I stopped taking hormones because of news / media reports about
1 2
women who took hormones as part of a research study (like WHI).
k. Any other reason you stopped? Please specify: _________________
1 2
MAILED QUESTIONNAIRE VERSION 2.0 05/15/2005 Page 19 of 28
ANNUAL FOLLOW-UP 9
MAIL
L:\swan\forms\follow9\09\mail.doc
The next questions ask about vitamins and supplements.
I5. During the past year have you used any supplements containing soy protein or phytoestrogen powders or
pills?
No.................................................................................................................1 (GO TO I6)
Yes ...............................................................................................................2
Don’t know ................................................................................................ -8 (GO TO I6)
I5a. IF YES, how many times per week?
Don't take any now or take less than once per week ...................................1
1-3 days per week ........................................................................................2
4-6 days per week ........................................................................................3
Every day .....................................................................................................4
Don’t know ................................................................................................ -8
I6. During the past year have you used any single vitamin (not part of a multi-vitamin) that is mostly calcium
or taken Tums pills?
No.................................................................................................................1 (GO TO I7)
Yes ...............................................................................................................2
Don’t know ................................................................................................ -8 (GO TO I7)
I6a. IF YES, how many times per week?
Don't take any now or take less than once per week ...................................1
1-3 days per week ........................................................................................2
4-6 days per week ........................................................................................3
Every day .....................................................................................................4
Don’t know ................................................................................................ -8
MAILED QUESTIONNAIRE VERSION 2.0 05/15/2005 Page 20 of 28
ANNUAL FOLLOW-UP 9
MAIL
L:\swan\forms\follow9\09\mail.doc
I7. How many bowls of cereal do you eat per week where the label of the cereal box says that it is high in
calcium?
None or fewer than one a week....................................................................1
1 per week ....................................................................................................2
2 per week ....................................................................................................3
3-4 per week.................................................................................................4
5-6 per week.................................................................................................5
7 or more per week ......................................................................................6
Don’t know ................................................................................................ -8
I8. How many slices of bread do you eat per week where the bread wrapper says the loaf is high in calcium?
None or fewer than one a week....................................................................1
1 per week ....................................................................................................2
2 per week ....................................................................................................3
3-4 per week.................................................................................................4
5-6 per week.................................................................................................5
7 or more per week ......................................................................................6
Don't know ................................................................................................. -8
I9. Some brands of fortified juice have extra calcium added. How many glasses of fruit juice or fruit drink
containing extra calcium do you drink per week?
None or fewer than one a week....................................................................1
1 per week ....................................................................................................2
2 per week ....................................................................................................3
3-4 per week.................................................................................................4
5-6 per week.................................................................................................5
7 or more per week ......................................................................................6
Don't know ................................................................................................. -8
MAILED QUESTIONNAIRE VERSION 2.0 05/15/2005 Page 21 of 28
ANNUAL FOLLOW-UP 9
MAIL
L:\swan\forms\follow9\09\mail.doc
We are interested in prescription medications women take. As you answer these questions, it would be helpful
to have all of the medications you have taken in front of you so that you can read exactly what is written on the
bottles and other containers.
We will ask about any pills or medicines, including patches, suppositories, injections, creams and ointments
which are prescribed by your doctor or other health care provider, that you have taken since your last study
visit.
Please record medication name in the spaces provided and answer whether you’ve taken that medication at least
two times per week for the last month (you will notice that, for hormone medications, we simply ask if you
have taken them in the last month). There are two lines provided for each type of medication, in case you have
taken more than one of that type of medication. If you have taken more than two medications of a particular
type, please list them in the space for Question J19 (page 27). Question J19 provides blank lines where all other
prescription medications that are not specified in the questions can be listed.
PLEASE PRINT CAREFULLY, AS MANY MEDICATIONS HAVE SIMILAR NAMES. Copy the name
exactly as it appears on the container; you do not need to write down the dosage.
PRESCRIPTION MEDICATION
b. Have you been taking
a. If YES, what is the name of the it at least two times
medication? per week for the last
month?
Since your last study visit did you take…
NO YES NO YES
J1. Any medication, pills or 1 2 1 2
other medicine to thin your
blood (anticoagulants)? 1 2
J2. Anything for your heart or 1 2 1 2
heart beat, including pills or
patches? 1 2
J3. Any medications for 1 2 1 2
cholesterol or fats in your
blood? 1 2
J4. Blood pressure pills? 1 2 1 2
1 2
MAILED QUESTIONNAIRE VERSION 2.0 05/15/2005 Page 22 of 28
ANNUAL FOLLOW-UP 9
MAIL
L:\swan\forms\follow9\09\mail.doc
PRESCRIPTION MEDICATION
b. Have you been taking
a. If YES, what is the name it at least two times
of the medication? per week for the last
month?
Since your last study visit, have you taken....
NO YES NO YES
J5. Diuretics for water retention? 1 2 1 2
1 2
J6. Thyroid pills? 1 2 1 2
1 2
J7. Insulin or pills for sugar in 1 2 1 2
your blood?
1 2
J8. Any medications for a 1 2 1 2
nervous condition such as
tranquilizers, sedatives, 1 2
sleeping pills or anti-
depression medicine?
J9. Steroid pills such as 1 2 1 2
Prednisone, or cortisone?
1 2
J10. Prescribed medications for 1 2 1 2
arthritis?
1 2
MAILED QUESTIONNAIRE VERSION 2.0 05/15/2005 Page 23 of 28
ANNUAL FOLLOW-UP 9
MAIL
L:\swan\forms\follow9\09\mail.doc
PRESCRIPTION HORMONE MEDICATION
a. If YES, what is the name of the b. Have you been taking it
medication? in the last month?
Since your last study visit, did you take....
NO YES NO YES
J11. Birth Control pills? 1 2 1 2
1 2
J11.c If you are using birth control pills, what was the primary reason for taking birth control pills?
(CIRCLE ONE ANSWER)
To prevent pregnancy ....................................................................................1
To help control pre-menstrual symptoms......................................................2
To help control menopausal symptoms .........................................................3
To control other symptoms............................................................................4
To regulate periods ........................................................................................5
To prevent osteoporosis ................................................................................6
To reduce bleeding ........................................................................................7
Other, Specify________________________________________________8
Don't know .................................................................................................. -8
Since your last study visit did you take…
NO YES NO YES
J12. Estrogen pills (such as 1 2 1 2
Premarin, Estrace, Ogen, etc)?
1 2
J12.c If taking estrogen pills, how often does/did your most recent prescription have you taking the
estrogen pills? (ANSWER “Off and On” IF YOUR PRESCRIPTION IS FOR ANYTHING
OTHER THAN DAILY.)
Every day .................................................... 1
Off and on ................................................... 2
Don’t know ................................................ -8
Since your last study visit did you take…
NO YES NO YES
J13. Estrogen by injection or 1 2 1 2
patch (such as Estraderm)?
1 2
J14. Combination 1 2 1 2
estrogen/progestin
(such as Premphase or 1 2
Prempo)?
MAILED QUESTIONNAIRE VERSION 2.0 05/15/2005 Page 24 of 28
ANNUAL FOLLOW-UP 9
MAIL
L:\swan\forms\follow9\09\mail.doc
PRESCRIPTION HORMONE MEDICATION
a. If YES, what is the name of the b. Have you been taking it
medication? in the last month?
Since your last study visit did you take...
NO YES NO YES
J15. Progestin pills (such as 1 2 1 2
Provera)?
1 2
J15.c If taking progestin pills how often does/did your most recent prescription have you take the
progestin pills? (ANSWER “Off and On” IF YOUR PRESCRIPTION IS FOR ANYTHING
OTHER THAN DAILY.)
Every day ...................................................... 1
Off and on ..................................................... 2
Don’t know ................................................... -8
PRESCRIPTION HORMONE MEDICATION
a. If YES, what is the name of the b. Have you been taking it
medication? in the last month?
Since your last study visit, have you taken...
NO YES NO YES
J16. Any other prescription 1 2 1 2
hormones that you
haven’t mentioned, 1 2
for example vaginal
rings (such as 1 2
Femring), progestin
1 2
injections (such as
DepoProvera),
estrogen/testosterone
combinations (such as
Estratest), or vaginal
creams?
MAILED QUESTIONNAIRE VERSION 2.0 05/15/2005 Page 25 of 28
ANNUAL FOLLOW-UP 9
MAIL
L:\swan\forms\follow9\09\mail.doc
PRESCRIPTION OSTEOPOROSIS MEDICATION
NO YES
J17. Since your last study visit have you taken, IV (into the vein) medication to prevent
1 2
or treat osteoporosis (brittle or thinning bones) such as IV bisphosphonates?
PRESCRIPTION OSTEOPOROSIS MEDICATION (continued)
If YES, what is the
a. b. Have you been c. Have you been
name of the taking it at least two taking it once a
medication? times per week for week for the last
the last month? month?
Since your last study visit, have you taken…
NO YES NO YES NO YES
J18. Non IV Medications
to prevent or treat 1 2 1 2 1 2
osteoporosis (brittle
or thinning bones) 1 2 1 2
such as Fosamax,
Didronel, Evista,
Miacalcin, Rocaltrol,
Actonel, Forteo
(PTH)?
MAILED QUESTIONNAIRE VERSION 2.0 05/15/2005 Page 26 of 28
ANNUAL FOLLOW-UP 9
MAIL
L:\swan\forms\follow9\09\mail.doc
OTHER PRESCRIPTION MEDICATION
b. Have you been
a. If YES, what is the name of the taking it at least
medication? two times per
week for the last
month?
Since your last study visit....
NO YES NO YES
J19. Are there any other prescription 1 2 1 2
pills or medications that you
have taken, that we haven’t 1 2
asked you about? Please list them
all and tell us whether you’ve 1 2
taken them at least twice a week
in the last month. If you have 1 2
not taken any other prescription
medication, CIRCLE “NO.” 1 2
1 2
1 2
1 2
1 2
1 2
1 2
1 2
1 2
1 2
1 2
MAILED QUESTIONNAIRE VERSION 1.0 01/15/2005 Page 27 of 28
ANNUAL FOLLOW-UP 9
MAIL
L:\swan\forms\follow9\09\mail.doc
Thank you for your time.
Please put this in the envelope provided and mail it to the
SWAN study office.
We look forward to seeing you again next year!
MAILED QUESTIONNAIRE VERSION 1.0 01/15/2005 Page 28 of 28
ANNUAL FOLLOW-UP 9
MAIL
L:\swan\forms\follow9\09\mail.doc