Eligibility Questionnaire for the Alberta Lung Cancer Screening Program

Transcription

1 Eligibility Questionnaire for the Alberta Lung Cancer Screening Program Please complete this questionnaire IN FULL and mail it back to the study office along with your signed consent form to: Alberta Lung Cancer Screening Program Attention: Rommy Koetzler Heritage Medical Research Building 3330 Hospital Drive NW Calgary, AB, T2N 4N1 Note: We cannot accept ed consent forms. Please, use the address above to mail the documents back to the study office. If you have any questions about this component of the research project or wish to complete this questionnaire by phone, please contact the main study office at or Alberta Lung Cancer Screening Program - Eligibility Questionnaire Please enter today's date What is your first (given) name? What is your middle name? What is your last name? Date of Birth What is your Alberta Health Card Number (PHN) How old are you as of today? (yyyy-mm-dd) (yyyy-mm-dd) (9 digits) What is your gender? Male Female Education (Please select your highest level of education) Less than high school graduation High school grad Post high school training Some college College grad Postgrad Professional 1

2 What is your race or ethnicity? White / Caucasian Black / African American Hispanic Asian Native Hawaiian / Pacific Islander Native American / First Nations Cancer history Have you had a CT scan of your chest in the last 2 years? Were any of your blood relatives, mother, father, siblings, children, including half-sisters and halfbrothers, ever diagnosed with lung cancer? Yes No If you have answered YES to the above question, which relative(s) have had lung cancer? Mother or Father Daughter or Son Sister or Brother Half-sister or Half-brother Do you have a history of any type of cancer? If your answer is no, please skip to the next page (Section General health history) Do you have a history of lung cancer? If you have had cancer, has a cancer been present or have you received any treatment for it in the past 5 years? If a cancer has been present or treated in the past five years, was this cancer one of the following? -non melanoma skin cancer -CIS or "in-situ" cervical cancer -Localized bladder (not requiring removal of the bladder) -Localized prostate cancer (not spread outside of the prostate) If your cancer was one of those listed above, has this cancer been present or have you received any treatment for it in the past 6 months? 2

3 General health history Have you been told by physician that you have COPD, emphysema or chronic bronchitis? Do you have any major medical problem, such as severe heart disease (e.g. unstable angina, chronic congestive heart failure), acute or chronic respiratory failure, use of home oxygen, bleeding disorder or solid organ transplant? Do you have a history of depression or anxiety disorder? Can you tell us which statement best describes your current physical function level? Fully active, able to carry on all pre-disease performance without restriction Restricted in physically strenuous activity but ambulatory and able to carry out work of a light or sedentary nature, e.g., light house work, office work Ambulatory and capable of all self-care but unable to carry out any work activities. Up and about more than 50% of waking hours Capable of only limited self-care, confined to bed or chair more than 50% of waking hours Completely disabled. Cannot carry on any self-care. Totally confined to bed or chair If female, are you currently pregnant? How tall are you? In centimeters or in feet and inches What is your weight in kilograms? In Kilograms or in pounds 3

4 Symptoms Do you currently have any symptoms related to your chest that you think a doctor should evaluate? Yes No Don't know/not sure If yes, please answer the 2 questions below (leave blank if not applicable and proceed to the next page): -Has a doctor evaluated you for these symptoms in the past or recently? Yes No Don't know/not sure -If everything else about you were the same, except you did not have any of these symptoms, would you still have enrolled in this lung screening study? Definitely not Probably not Probably yes Definitely yes Don't know/not sure 4

5 Have you had any of the following symptoms in the last 12 months? Yes No Shortness of breath Cough Coughing up phlegm Coughing up blood Hoarseness or loss of voice Wheeze Chest pain Poor appetite Fatigue or tiredness Unintentional weight loss If you have experienced an unintentional weight loss, please provide details below: How many months ago did you start losing weight? How much weight have you lost? In Kilograms or in pounds Alcohol and Tobacco How often do you have a drink containing alcohol? (A drink is defined as 12 oz. of beer, 4 oz. of wine, or 1 oz. of hard liquor) Never Monthly or less 2-4 times a month 2-3 times a week 4+ times a week If you do drink, how many drinks containing alcohol do you have on a typical day when you are drinking? (A drink is defined as 12 oz. of beer, 4 oz. of wine, or 1 oz. of hard liquor)

6 What is your smoking history? Current smoker Ex-smoker (You are considered an ex-smoker if you have smoked at least 100 cigarettes in your lifetime and have not smoked at all during the past 30 days) Never smoker (You are considered a never smoker if you have smoked less than 100 cigarettes in your lifetime) Do you currently live with someone who smokes in your home? Did either of your parents smoke cigarettes when you were a child? Are any of your siblings current or past smokers? I have no siblings or I do not know Do you or have you used other tobacco products or smoked anything else rather than cigarettes on a regular basis? If you have smoked other products on a regular basis, what else (do/did) you smoke? Currently In the past only (In past 30 days) Cigars Pipe Menthol cigarettes E-cigarettes Smokeless (chewing) tobacco Cigarillos or tiparillos Marijuana or pot Other If you have selected OTHER, what was the other product that you smoked? If you are a Never smoker, your questionnaire is complete you do not need to answer the remaining questions. If you are a current smoker or an ex-smoker, please, proceed to the next section. How old were you when you started smoking regularly (More than 1 cigarette per day)? If you have quit smoking, how many years ago did you quit smoking? How many years in total have you smoked? How many cigarettes do or did you smoke per day, on average? During the time period in your life when you smoked the most, how many cigarettes per day did you smoke? If you are an ex-smoker, your questionnaire is complete you do not need to answer the remaining questions. If you are a current smoker, please proceed to the next page. 6

7 In the past 30 days, how many cigarettes per day did you smoke? How many days did you smoke out of the last 30? Do you smoke at home? How often do you smoke at home? Daily Weekly Less than weekly Do you smoke at work? Not applicable / not working Do you smoke in public places? How soon after you wake up do you smoke your first cigarette? After 60 minutes minutes 6-30 minutes Within 5 minutes Do you find it difficult to refrain from smoking in places where it is forbidden? Which cigarette would you hate most to give up? The first one in the morning Any other How many cigarettes per day do you smoke? 10 or less or more Do you smoke more frequently during the first hours after awakening than during the rest of the day? Do you smoke even if you are so ill that you are in bed most of the day? 7

8 Motivation to quit (smokers only) Do you want to stop smoking for good? Are you interested in making a serious attempt to stop smoking in the near future? Are you considering quitting smoking during the next 6 months? Do you plan to quit smoking in the next 30 days? Are you interested in receiving help with your quit attempt? What is the ONE MOST IMPORTANT reason you want to quit using tobacco? Please, select only one. Health Money Family Work Smells Bad Social Acceptability Other If you have selected OTHER, what was the other reason you want to quit using tobacco? Quit attempts Have you tried to quit smoking in the last 12 months? If yes, what was the longest length of time you stopped smoking because you were trying to quit in the past 12 months? Are you currently participating in a smoking cessation program? Are you currently on smoking cessation therapy in the form of a nicotine replacement therapy (such as patch, gum, inhaler) to help you quit? Are you currently on smoking cessation therapy in the form of a prescription drug (such as Zyban (bupropion) or Champix (varenicline)) to help you quit? 8

9 Quit attempts Please tell us about any previous attempts to quit I have used I was able to quit this method smoking for at least 24 hours using this method Cold turkey (stopped smoking on your own without assistance) How long did you stay quit using the cold turkey approach? Self-help program (booklets and/or audiotapes) How long did you stay quit using the self-help program approach? Self-help Internet program How long did you stay quit using the self-help Internet program approach? Participating in a stop smoking program over the telephone How long did you stay quit using the telephone program approach? A text messaging program which gives encouragement for quitting How long did you stay quit using the text messaging program approach? Stop smoking counseling conducted in person with a health professional How long did you stay quit using the health professional counseling program approach? Group counseling? How long did you stay quit using the group counseling program approach? Nicotine replacement therapy (gum, patch, lozenge, inhaler, or spray) How long did you stay quit using the nicotine replacement approach? Zyban (also called bupropion)- a purple pill to help people stop smoking) How long did you stay quit using the Zyban / buproprion approach? Champix (also called varenicline) How long did you stay quit using the Champix / varenicline approach? E-cigarettes How long did you stay quit using the e-cigarette approach? Other What was the other quitting method used? How long did you stay quit using this approach? 9

10 Would you try the following approaches to quit smoking in the future? Cold turkey? Self-help programs (such as booklets or audiotapes)? A self-help Internet program? Participating in a stop smoking program over the phone? A text messaging program which gives encouragement for quitting? Stop smoking counseling with a health professional (such as a doctor, a nurse)? Group counseling? Nicotine replacement therapy (such as gum, patch, inhaler, or spray)? Zyban (bupropion), (prescribed by a doctor)? Champix (varenicline), (medication prescribed by a doctor)? E-cigarettes? Other methods (hypnosis, acupuncture)? Yes No Thank you for completing the questionnaire for the Alberta Lung Cancer Screening Study. Please return to the study office along with your signed consent form to: Alberta Lung Cancer Screening Program Attention: Rommy Koetzler Heritage Medical Research Building 3330 Hospital Drive NW Calgary, AB, T2N 4N1 Note: We cannot accept ed consent forms. Please, use the address above to mail the documents back to the study office. If you have any questions about this component of the research project or wish to complete this questionnaire by phone, please contact the main study office at or If you are still smoking, we encourage you to visit the Albertaquits.ca website to get access to a variety of resources to help you quit. 10