| 2 | 1 | / | 0 | 6 | / | 1 | 9 | 4 | 5 | age | 6 | 2 |
day month year 1. What is your date of birth? / /
SAX 45 and Up Study Male Scanning.qxd:Layout 1 20/6/08 2:27 PM Page 3
research to improve health and wellbeing
Your answers and experiences are important to us. To help us read your answers, please write as clearly as possible using a BLACK or BLUE pen, and be sure to complete the questionnaire as shown: Please put a cross in the appropriate box(es) Yes No OR put numbers in the appropriate box, e.g. 21st June 1945
General questions about you
2 1 / 0 6 / 1 9 4 5 age 6 2 day month year 2. What is today's date? / /day month year 1. What is your date of birth? / /
3. How tall are you without shoes? cm OR feet inches (please give to the nearest cm or inch)
4. About how much do you weigh? kg OR stone lbs
5. What is the highest qualification you have completed? (please put a cross in the most appropriate box) no school certificate or other qualifications school or intermediate certificate (or equivalent) higher school or leaving certificate (or equivalent) trade/apprenticeship (e.g. hairdresser, chef) certificate/diploma (e.g. child care, technician) university degree or higher
6. Are you of Aboriginal or Torres Strait Islander origin? (you can cross more than one box) No Yes, Aboriginal Yes, Torres Strait Islander
7. In which country were you born? Australia ----->please go to question 9 UK Ireland Italy China Greece New Zealand Germany Lebanon Philippines Netherlands Vietnam Malta Poland other (please specify)______________ 8. What year did you first come to live in Australia for one year or more?(e.g. 1970)
9. What is your ancestry? (please cross up to 2 boxes) Australian English Irish Chinese Italian Greek Scottish German Lebanese Dutch Maltese Polish Filipino Indian Croatian Vietnamese other (please specify)___________________________________
10.Do you speak a language other than English at home? Yes No
11.Have you ever been a regular smoker? Yes . No If No -please go to question 12 How old were you when you started smoking regularly? years old Are you a regular smoker now? Yes No If No – how old were you when you stopped smoking regularly? years old About how much do you/did you smoke on average each day? (If you are an ex-smoker, how much did you smoke on average when you smoked?) cigarettes per day pipes and cigars per day
12.About how many alcoholic drinks do you have each week? one drink = a glass of wine, middy of beer or nip of spirits (put “0" if you do not drink, or have less than one drink each week) number of alcoholic drinks each week 13.On how many days each week do you usually drink alcohol? days each week
14. What best describes your current situation? (please cross one box) single married de facto/living with a partner widowed divorced separated
15. What best describes your current housing? (please cross one box) house flat, unit, apartment house on farm hostel for the aged mobile home other nursing home retirement village, self care unit
16. How many TIMES did you do each of these times in the activities LAST WEEK? last week (put "0" if you did not do this activity) Walking continuously, for at least 10 minutes (for recreation or exercise or to get to or from places) Vigorous physical activity (that made you breathe harder or puff and pant, like jogging, cycling, aerobics, competitive tennis, but not household chores or gardening) Moderate physical activity (like gentle swimming, social tennis, vigorous gardening or work around the house) 17. If you add up all the time you spent doing each activity LAST WEEK, how much time did you spend ALTOGETHER doing each type of activity? (put "0" if you did not do this activity) hours minutes Walking continuously, for at least 10 minutes : (for recreation or exercise or to get to or from places) Vigorous physical activity : (that made you breathe harder or puff and pant, like jogging, cycling, aerobics, competitive tennis, but not household chores or gardening) Moderate physical activity : (like gentle swimming, social tennis, vigorous gardening or work around the house)
18. Have your mother, father, brother(s) or sister(s) ever had: (blood relatives only: please put a cross in the appropriate box(es))
| mother | father | brother/ sister | motehr | father | brother/ sister | ||
| heart disease | breast cancer | ||||||
| high blood pressure | bowel cancer | ||||||
| stroke | lung cancer | ||||||
| diabetes | melanoma | ||||||
| dementia/Alzheimer's | prostate cancer | ||||||
| Parkinson's disease | ovarian cancer | ||||||
| severe depression | osteoporosis | ||||||
| severe arthritis | hip fracture | ||||||
| do not know |
19. How many children have you given birth to? Children (please include stillbirths but do not include miscarriages, please write "0" if you have not had any children) How old were you when you gave birthr to your FIRST child? years old How old were you when yougave birth to your LAST child? years old For how many months, in total, have you breastfed? months (please add together all the time you spent breastfeeding all of your children; put "0"if you never breastfed)
20.About how many hours a week are you exposed
to someone else's tobacco smoke.
hours per week hours per week
at home in other places
(e.g. work, going out, cars)
21. Have you ever used the pill or other hormonal contraceptives?
(e.g. the combined pill, mini pill, contraceptive implant or injections)
Yes No
If Yes, for how long altogether have you
used hormonal contraceptives? years
(please write '0' if you used them for less than a year in total)
If Yes, how old were you when you LAST
used hormonal contraceptives? age
(please write your current age if you are still using them)
Which type of pill or other hormonal contraceptive
did you use MOST RECENTLY?
"the pill", combined pill (e.g. Microgynon, Levlen)
progesterone-only pill ("mini pill") (e.g. Micronor, Noriday, Microval)
Depo Provera
contraceptive implant (e.g. Implanon, Norplant)
do not know
22. Have you ever used hormone replacement therapy (HRT)?
Yes No
If Yes, for how long altogether have you
used HRT? years
(please write '0' if you used HRT for less than a year in total)
Are you currently taking HRT? Yes No
If No, at what age did you stop? age
23.Have you taken any medications, vitamins or supplements for most of the last 4 weeks? Yes No If Yes, was it: multivitamins + minerals multivitamins alone fish oil glucosamine omega 3 paracetamol aspirin for the heart aspirin for other reasons Lipitor Avapro, Karvea warfarin, Coumadin Pravachol Coversyl, Coversyl Plus Lasix, frusemide Zocor, Lipex Cardizem, Vasocordol Micardis Nexium Norvasc Fosamax Somac Tritace Caltrate Losec, Acimax Noten, Tenormin Oroxine omeprazole atenolol thyroxine Ventolin Zyloprim, Progout 300 Diabex, Diaformin salbutamol allopurinol metformin Zoloft Cipramil Efexor sertraline citaloprim venlafaxine
24. Has a doctor EVER told you that you have: (If YES, please cross the box and give your age when the condition was first found) Age when condition Yes was first found skin cancer (not melanoma) age melanoma age Breast cancer age other cancer age heart disease age high blood pressure age stroke age diabetes age blood clot (thrombosis) age enlarged prostate age asthma age hayfever age depression age anxiety age Parkinson's disease age none of these
25. In the last month have you been treated for: (If YES, please cross the box and give your age when the treatment started) Age started Yes treatment cancer age heart attack or angina age other heart disease age high blood pressure age high blood cholesterol age blood clotting problems age asthma age osteoarthritis age thyroid problems age osteoporosis or low bone density age depression age anxiety age none of these
26.Are you NOW suffering from any other important illness?
Yes No
27.Do you regularly need help with daily tasks because of long-term illness or disability? (e.g. personal care, getting around, preparing meals) Yes No 28.Does your health now LIMIT YOU yes, yes, no,no in any of the following activities? limited limited limited a lot a lot a lot VIGOROUS activities (e.g. running, strenuous sports) MODERATE activities (e.g. pushing a vacuum cleaner, playing golf) lifting or carrying shopping climbing several flights of stairs climbing one flight of stairs walking one kilometre walking half a kilometre walking 100 metres bending, kneeling or stooping bathing or dressing yourself
29.Have you ever had any of the following operations? (If YES, please cross the box and give your age when you had the operation; give your age at the most recent operation if you Age when have had more than one) Yes had operation removal of skin cancer age hysterectomy age part of prostate removed age both ovaries removed age sterilisation (tubes tied) age knee replacement age hip replacement age gallbladder removed age heart or coronary bypass surgery age (include stents and balloons)
30. Do you regularly care for a sick or disabled family member or friend? Yes . No If Yes, about how much time each week do you usually spend caring for this person? full time OR hours/wk
31. In general, how would you rate your: excellent very good fair poor good overall health? quality of life? eyesight?(with glasses or contact lenses, if you wear them) memory? teeth and gums?
32. Do you feel you have a hearing loss? Yes No
33. How many of your own teeth do you have left? None - all of my teeth are missing 1-9 teeth left 10-19 teeth left 20 or more teeth left
34. During the past 12 months, how many times have you fallen to the floor or ground? (put "0" if you haven't fallen in this time) times 35. Have you had a broken/fractured bone in the last 5 years? Yes . No If No- please go to question 12 If Yes, which bones were broken? wrist arm hip ankle rib finger/toe other______________________________ How old were you when it happene? (give age at most recent fracture if more than one) years old
36. About how many times a week are you usually troubled by leaking urine? never once a week or less 2-3 times 4-6 times every day
37. Have you been through menopause? No Not sure (because hysterectomy, taking HRT, etc.) My periods have become irregular Yes - How old were you when you went through menopause? years old
38. Have you ever been for a breast screening mammogram? Yes . No If No - please go to question 12 If Yes, what year did you have your last mammogram? (e.g. 2005) How many times have you been for breast screening altogether? times
39. Have you ever been screened for colorectal (bowel) cancer? Yes . No If No - please go to question 12 If Yes, please indicate which test(s) you had: faecal occult blood test (test for blood in the stool/faeces) sigmoidoscopy (a tube is used to examine the lower bowel: this is usually done in a doctor's office without pain relief) colonoscopy (a long tube is used to examine the whole large bowel; you would usually have to have an enema or drink large amounts of special liquid to prepare the bowel for this) What year did you have the most recent one of these tests? (e.g. 2005)
40.About how many times each week do you eat: number of (please count all meals and snacks. put '0' if never eaten times eaten or eaten less than once a week) each week beef, lamb or pork chicken, turkey or duck processed meat (include bacon, sausages, salami, devon, burgers, etc) fish or seafood cheese
41.About how many of the following do you usually eat: slices or pieces of brown/wholemeal bread each week (also include multigrain, rye bread, etc.) bowls of breakfast cereal each wee If you eat breakfast cereal is it usually: (please cross) bran cereal (allbran, branflakes, etc.) muesli biscuit cereal (weetbix, other (cornflakes, shredded wheat, etc.) rice bubbles,etc.) oat cereal (porridge, etc.)
42.Which type of milk do you mostly have? whole milk reduced fat milk skim milk soy milk other milk I don't drink milk
43.About how many serves of vegetables do you usually eat each day? A serve is half a cup of cooked vegetables or one cup of salad (please include potatoes and put “0" if less than one a day) number of serves of cooked vegetables each day number of serves of raw vegetables each day (e.g. salad) I don't eat vegetables 44.About how many serves of fruit or glasses of fruit juice do you usually have each day? A serve is 1 medium piece or 2 small pieces or 1 cup of diced or canned fruit pieces (put “0" if you eat less than one serve a day) number of serves of fruit each day number of glasses of fruit juice each day I don't eat fruit
45.Please put a cross in the box if you NEVER eat: red meat chicken/poultry pork/ham dairy products any meat eggs sugar wheat products fish seafood cream cheese
46.What is your usual yearly HOUSEHOLD income before tax, from all sources? (please include benefits, pensions, superannuation, etc) less than $5,000 per year $30,000-$39,999 per year $5,000-$9,999 per year $40,000-$49,999 per year $10,000-$19,999 per year $50,000-$69,999 per year $20,000-$29,999 per year $70,000 or more per year I would rather not answer this question
47. What is your current work status? (you can cross more than one box) in full time paid wor self-employed in part time paid work doing unpaid work completely retired/pensioner studying partially retired looking after home/family disabled/sick unemployed other 48. If you are partially or completely retired, how old were you when you retired? years old Why did you retire? (you can cross more than one box) reached usual retirement age lifestyle reasons to care for family member/friend ill health made redundant could not find a job other 49. About how many HOURS each WEEK do you usually spend doing the following? (please put"0" if you do not spend any time doing it) hours per week hours per week paid work voluntary/unpaid work
50. Which of the following do you have? (excluding Medicare) Private health insurance- with extras Private health insurance- without extras Department of Veterans' Affairs white or gold card Health care concession card none of these
51. What best describes the colour of the skin on the inside of your upper arm, that is your skin colour without any tanning? very fair light olive brown fair dark olive black 52. What would happen if your skin was repeatedly exposed to bright sunlight during summer without any protection? Would it: Get very tanned? Get mildly or occasionally tanned? Get moderately tanned? Never tan, or only get freckled?
53. About how many hours a DAY would you usually spend outdoors on a weekday and on the weekend? hours per day hours per day weekday weekend
54.About how many HOURS in each 24 hour DAY do you usually spend doing the following? (please put "0" if you do not spend any time doing it) hours per day hours per day sleeping (including sitting at night & naps) watching television standing or using a computer
55.How many TIMES in the LAST WEEK did you: times in the (please put "0" if you did not spend any time doing it)
last week spend time with friends or family who do not live with you? talk to someone (friends, relatives or others) on the telephone? go to meetings of social clubs, religious groups or other groups you belong to?
56. How many people outside your home, but within one hour of travel, do you feel you can depend on or feel very close to? people 57.During the past 4 weeks, none a little some most all about how often did you feel: of the of the of the of the of the time time time time time tired out for no good reason? nervous? so nervous that nothing could calm you down? hopeless? restless or fidgety? so restless that you could not sit still? depressed? that everything was an effort? so sad that nothing could cheer you up? worthless? 58.During the past 4 weeks, have you had any of the following problems with your work or daily activities because of any emotional problems (such as being depressed or anxious)? cut down on the amount of time you spent on work or other activities Yes No achieved less than you would have liked to Yes No did work or other activities less carefully than usual Yes No
Thank you very much for filling in the questionnaire DON'T FORGET TO SIGN THE CONSENT FORM OVERLEAF SAX 45 and Up Study Male Scanning.qxd:Layout 1 20/6/08 2:27 PM Page 2 Consent formThe 45 and Up Study relies on the willingness of people in New South Wales to share information about their lives and experiences and to have their health followed over time. By signing this form you are agreeing to take part in the 45 and Up Study and for the Study team to follow your health over time. Participation is completely voluntary, and you are free to ask questions or to withdraw from the Study at any time, by calling the Study helpline on 1300 45 11 45. More information on the Study can be found at www.45andup.org.auresearch to improve health and wellbeing I agree to have my health followed over time through: the 45 and Up Study team following health and other records relating to me, including NSW hospital records, cancer records, death records and other health-related records, as outlined in the Study leaflet: The 45 and Up Study: Information for participants; Medicare Australia releasing to the 45 and Up Study my enrolment details, including Medicare number, and information concerning services provided to me under Medicare, the Department of Veterans' Affairs, the Pharmaceutical Benefits Scheme and the Repatriation Pharmaceutical Benefits Scheme, including past information, until the end of the Study or for the duration of my involvement in the Study; being contacted in the future to provide information on changes to my health and lifestyle. I may also be asked to provide further information including questionnaire responses or biological samples; my participation in any of these would be completely voluntary. I give my consent on the understanding that: my information will only be used for the purposes outlined in the Study leafletentitled The 45 and Up Study: Information for participants, of which I have a copy; my information will be kept strictly confidential and will be used for health research only; reports and publications from the Study will be based on de-identified information and will not identify any individual taking part; my participation in this Study is entirely voluntary and my consent will continue to be valid following death or disablement unless withdrawn by my next of kin or other person responsible. I am free to withdraw from the Study at any time by calling the Study helpline on 1300 45 11 45; my decision on whether or not to take part in the Study or in any additional research will not disadvantage me or affect my future health care in any way. I have been provided with information about the 45 and Up Study including how it will gather, store, use and disclose information about me, in the Study leaflet. I have been given an opportunity to ask questions and have been fully informed about the Study. Name (Print): ____________________________________________________________________________ day month year Signature: ____________________________________ Date today: / / Extra contact details It would be very helpful and reduce Study costs if we could contact you in future by email. If you are happy for us to do this, please write your email address here: Email address: Sometimes we find that people have moved when we try to contact them again. It would be very helpful if you could give us your mobile phone number and/or the contact details of someone close to you (such as a relative or friend) who would be happy for us to contact them if we are unable to reach you. We would only get in touch with that person if we were unable to contact you directly and we would need to tell them our reason for contacting you. Please leave this section blank if you do not wish to provide these extra contact details. Your home Your mobile phone number: ( ) phone number: ( ) Full name of contact person: Phone number of contact person: ( )
| If you have any questions about the Study, please ring the Study helpline on 1300 45 11 45. You can also write to or send your questionnaire (no stamp required) directly to: Associate Professor Emily Banks, Scientific Director, The 45 and Up Study, Reply paid 5289, Sydney NSW 2001. |