Mdc9391.pdf

DFCI US E ONLY:
DFCI MRN #_____________
Protocol ID # _____________
Medical Questionnaire and Tissue Banking for Multiple Myeloma, Waldenström
Macroglobulinemia, and Related Disorders
DFCI Protocol Number: 09-233 Principal Investigator: Irene M. Ghobrial, MD Please complete and return in enclosed envelope to Irene Ghobrial at: Dana-
Farber Cancer Institute,
450 Brookline Avenue, LG-LC, Boston, MA 02115.
OR fax to 617-582-7153 OR email to DFCItissuebank@gmail.com
Male Female
D.O.B (mm/dd/yyyy):
Today’s Date (mm/dd/yyyy):
We invite you to participate in a research project that is being organized by Dana- Farber/Harvard Cancer Center. We are studying the molecular characteristics of Multiple Myeloma (MM), Waldenström M acroglobulinemia (WM ), M onoclonal Gammopathy of Undetermined Significance (M GUS), smoldering MM (sMM) and other lymphoplasmacytic lymphomas (LPL). Your participation in this study will help us understand the causes and help us move toward prevention and improved treatment. As part of the study, we will ask you to complete a medical questionnaire. Research participation is voluntary, and a decision not to participate will not affect your care. All information that contains personal identifiers will be held in strict confidence and will not be released Have you signed informed consent? No
If no, please sign the informed consent document before completing this questionnaire. Are you willing to complete this questionnaire? No
If no, please mark your response and mail back, and we will not contact you again. If yes, please provide the contact information identified below. Mailing Address:______________________________________________ Telephone Number: ___________________________________________ Email Address:_______________________________________________ DFCI US E ONLY:
DFCI MRN #_____________
Protocol ID # _____________
Medical Questionnaire and Tissue Banking for Multiple Myeloma, Waldenström
Macroglobulinemia, and Related Disorders
DFCI Protocol Number: 09-233 Principal Investigator: Irene M. Ghobrial, MD CANCER HISTORY

1.) Were you ever diagnosed by a physician with any of the following types of cancer listed below?
Select all that apply.
Other (Please specify_____________________) Test on your blood Test on your urine Other (Please specify_____________________) Test on your blood Test on your urine Other (Please specify_____________________) Test on your blood Test on your urine Other (Please specify_____________________) Other (Please specify_____________________) If you are a patient diagnosed with any of the cancers listed above, please provide the following
related to your care:
Primary Oncologist Name ___________________________________________________________
Primary Oncologist Address: ________________________________________________________
Primary Oncologist Telephone: ______________________________________________________
I am not a patient diagnosed with any of the cancers listed above. I am one of the following: Family member of: Patient Name: _____________________________ Non-family acquaintance of: Patient Date of Birth: ____________________________ (i.e., neighbor or friend who has not ever DFCI US E ONLY:
DFCI MRN #_____________
Protocol ID # _____________
Medical Questionnaire and Tissue Banking for Multiple Myeloma, Waldenström
Macroglobulinemia, and Related Disorders
DFCI Protocol Number: 09-233 Principal Investigator: Irene M. Ghobrial, MD PATIENT BACKGROUND INFORMATION

2.) How would you describe your racial background? Select all that apply.
Arab/West Asian (e.g. Armenian, Egyptian, Iranian, Lebanese, M oroccan) Black Caucasian Chinese Filipino Japanese Korean Latin American Native/aboriginal people of North America South Asian (e.g. East Indian, Pakistani, Punjabi, Sri Lankan) South East Asian (e.g. Cambodian, Indonesian, Laotian, Vietnamese) Other (Please specify: )
3.) Were you born in the US? Yes
No, I was born in ______________________ (country)
4.) In what religion were you raised?
None
(Please specify_______________________)

5.) What best describes your educational status? Select one.
Some grade school
College degree (bachelor’s or equivalent) DFCI US E ONLY:
DFCI MRN #_____________
Protocol ID # _____________
Medical Questionnaire and Tissue Banking for Multiple Myeloma, Waldenström
Macroglobulinemia, and Related Disorders
DFCI Protocol Number: 09-233 Principal Investigator: Irene M. Ghobrial, MD PATIENT BACKGROUND INFORMATION, continued

6.) What is your current employment status?

7.) In which of the following locations have you lived the longest?
On a farm Rural area, but not a farm City or town, population under 10,000 City or town, population 10,000 to 100,000
8.) Have you ever lived in a residence situated within one kilometer (~6 blocks) of the following?

Airport………………….For approximately _____ years Railroad Station……….For approximately _____ years Railroad Track……………For approximately _____ years Industrial Site…………….For approximately _____ years M ulti-Lane Highway…….For approximately _____ years
9.) What is your current marital status?
Married
Widowed Separated Divorced Never married Living with someone in a marriage-like relationship DFCI US E ONLY:
DFCI MRN #_____________
Protocol ID # _____________
Medical Questionnaire and Tissue Banking for Multiple Myeloma, Waldenström
Macroglobulinemia, and Related Disorders
DFCI Protocol Number: 09-233 Principal Investigator: Irene M. Ghobrial, MD PATIENT BACKGROUND INFORMATION, continued

10.) What is your current weight?

11.) What was your weight 6 months ago?

12.) Have you lost any weight in the past year? No
a.) If yes, approximately how much weight have you lost?
13.) During the past two years, did you intentionally lose weight? No
a.) If yes, approximately how much have you lost? Pounds
14.) What is your current height?
DFCI US E ONLY:
DFCI MRN #_____________
Protocol ID # _____________
Medical Questionnaire and Tissue Banking for Multiple Myeloma, Waldenström
Macroglobulinemia, and Related Disorders
DFCI Protocol Number: 09-233 Principal Investigator: Irene M. Ghobrial, MD PAST CANCER HISTORY, continued
15.) In the past, have you ever had any of the following types of cancer listed below? If yes, please
specify the type of treatment you received for it. Check all that apply (do not include basal cell skin cancer, MGUS,
MM, Smoldering Myeloma, Lymphoplasmacytic lymphoma or WM).

DFCI US E ONLY:
DFCI MRN #_____________
Protocol ID # _____________
Medical Questionnaire and Tissue Banking for Multiple Myeloma, Waldenström
Macroglobulinemia, and Related Disorders
DFCI Protocol Number: 09-233 Principal Investigator: Irene M. Ghobrial, MD MEDICAL HISTORY
16.) Has a doctor e ver diagnosed you with any of the following conditions?
Inflammatory bowel disease (ulcerative colitis/ Crohn’s disease) Infectious mononucleosis (i.e. mono) (please specify___________________________)

TOBACCO HISTORY
17.) Have you smoked more than five standard packs of cigarettes (i.e., more than 100 cigarettes) in
your lifetime? No
If Yes… a.) How old were you when you started smoking cigarettes? b.) Throughout the time that you smoked cigarettes, what is the average number of cigarettes per day that you DFCI US E ONLY:
DFCI MRN #_____________
Protocol ID # _____________
Medical Questionnaire and Tissue Banking for Multiple Myeloma, Waldenström
Macroglobulinemia, and Related Disorders
DFCI Protocol Number: 09-233 Principal Investigator: Irene M. Ghobrial, MD TOBACCO HISTORY, continued
d.) What age were you when you stopped smoking cigarettes?

18.) Have you ever been exposed to someone else’s tobacco smoke?
a.) If yes, for how long were you exposed? b.) If yes, on average how many hours per week were you exposed?

19.) Please indicate where you typically experienced exposure to someone else’s smoke.
Select all that apply.
Home
Work Other (please specify_______________________)

20.) Have you ever used any of the other tobacco or related products listed below? If yes, please
indicate the number of times per day and number of years used.
Chewing tobacco
Yes Number of times per day ________ Number of years_________ Yes Number of times per day ________ Number of years_________ Yes Number of times per day ________ Number of years_________ Yes Number of times per day ________ Number of years_________ Yes Number of times per day ________ Number of years_________

SOCIAL HISTORY
21.) Have you ever or do you currently drink alcohol?

Yes, but only in the past. Yes, currently. DFCI US E ONLY:
DFCI MRN #_____________
Protocol ID # _____________
Medical Questionnaire and Tissue Banking for Multiple Myeloma, Waldenström
Macroglobulinemia, and Related Disorders
DFCI Protocol Number: 09-233 Principal Investigator: Irene M. Ghobrial, MD SOCIAL HISTORY, continued
a.) If yes, at what age did you FIRST start drinking alcohol at least once per week for a period of 6 months or longer? b.) For how many years total have you consumed alcohol at least once per week? c.) If you have stopped, at what age did you stop drinking alcohol at least
22.) For each type of alcohol listed below, please list the average number of drinks per week.


23.) If your alcohol intake in the past was different from now, for each type of alcohol listed below,
please list the average number of drinks per week.

DFCI US E ONLY:
DFCI MRN #_____________
Protocol ID # _____________
Medical Questionnaire and Tissue Banking for Multiple Myeloma, Waldenström Macroglobulinemia, and Related Disorders
DFCI Protocol Number: 09-233 Principal Investigator: Irene M. Ghobrial, MD FAMILY HISTORY
24.) Please provide information about your immediate family: parents, grandparents, uncles, aunts, siblings and children as well as their
history of cancer. These questions only apply to full biological or blood relatives. Do not include relativ es through marriage or adoption, and do
not include step- or half-brothers or sisters.
If you are unsure about or do not know the information for a relative, please put “DK” in the space provided.

**Cancer Types
DFCI US E ONLY:
DFCI MRN #_____________
Protocol ID # _____________
Medical Questionnaire and Tissue Banking for Multiple Myeloma, Waldenström Macroglobulinemia, and Related Disorders
DFCI Protocol Number: 09-233 Principal Investigator: Irene M. Ghobrial, MD FAMILY HISTORY, continued
Note: Please complete this section only for blood relatives diagnosed with cancer. If you have more than one relative of a particular type who has
been diagnosed with cancer, please assign each a number in the relative column (e.g. Sister 1, Sister 2).
Maternal
Cancer Type**
Age at diagnosis
If deceased, at
(M)/ Paternal
estimated to
what age?
(P)/ Both (B)
DFCI US E ONLY:
DFCI MRN #_____________
Protocol ID # _____________
Medical Questionnaire and Tissue Banking for Multiple Myeloma, Waldenström
Macroglobulinemia, and Related Disorders
DFCI Protocol Number: 09-233 Principal Investigator: Irene M. Ghobrial, MD OB/GYN HISTORY (If Male, please skip to Question 30)
25.) At what age did you have your first menstrual period?
Younger than 11


26.) Have you ever been pregnant?
a.) How many times have you been pregnant? b.) How many miscarriages have you had? e.) If you have children, what was your age at your first live birth? i.)If you had/ have children, did / do you breastfeed? ii.) How many of your children did you breastfeed? iii.) What was the total number of months you spent breastfeeding? iv.) Did you ever experience mastitis (an infection of the breast)?
27.) Have you had a menstrual period within the last six months?
Yes; have menstrual periods on hormone replacement therapy Yes; natural menstrual periods or menstrual periods on birth control pills Not sure DFCI US E ONLY:
DFCI MRN #_____________
Protocol ID # _____________
Medical Questionnaire and Tissue Banking for Multiple Myeloma, Waldenström
Macroglobulinemia, and Related Disorders
DFCI Protocol Number: 09-233 Principal Investigator: Irene M. Ghobrial, MD OB/GYN HISTORY, continued
(Please specify _______________________)
28.) Have you ever used estrogen or estrogen replacement therapy?
a.) If yes, what form of estrogen do/did you use? Select all that apply


OTHER MEDICATIONS and/or TREATMENTS

29.) Outside of a multivitamin do you REGULARLY use other complementary/nontraditional/
alternative therapies?
a.) If yes, which therapies? Select all that apply
DFCI US E ONLY:
DFCI MRN #_____________
Protocol ID # _____________
Medical Questionnaire and Tissue Banking for Multiple Myeloma, Waldenström
Macroglobulinemia, and Related Disorders
DFCI Protocol Number: 09-233 Principal Investigator: Irene M. Ghobrial, MD OTHER MEDICATIONS and/or TREATMENTS, continued

30.) Please complete the table below by indicating average use for the following:

Aspirin (including regular Anacin, Bufferin, etc. but NOT aspirin-free products or Tylenol or
Non-Steroidal Anti-Inflammatory Drugs (including Ibuprofen, Advil, M otrin, Aleve, Nuprin,
Naprosyn, Anaprox, Relafen, Clinoril, Indocin, Feldene, Keptoprofen, Celebrex, Vioxx but NOT aspirin-free products or Tylenol or Acetaminophen). Non-Steroidal
Anti-Inflammatory
Acetaminophen/
DFCI US E ONLY:
DFCI MRN #_____________
Protocol ID # _____________
Medical Questionnaire and Tissue Banking for Multiple Myeloma, Waldenström
Macroglobulinemia, and Related Disorders
DFCI Protocol Number: 09-233 Principal Investigator: Irene M. Ghobrial, MD OTHER MEDICATIONS and/or TREATMENTS, continued
31.) Please complete the table below by indicating average use for the medications listed.
Multivitamin
Folate Supplement
Antacids
Metformin
DFCI US E ONLY:
DFCI MRN #_____________
Protocol ID # _____________
Medical Questionnaire and Tissue Banking for Multiple Myeloma, Waldenström
Macroglobulinemia, and Related Disorders
DFCI Protocol Number: 09-233 Principal Investigator: Irene M. Ghobrial, MD OTHER MEDICATIONS and/or TREATMENTS, continued
32.) Not counting multivitamins, do you take any of the following individual vitamin supplements?



33.) Are there any other supplements that you take on a regular basis?



ACTIVITY HISTORY
34.) What is your normal walking pace outdoors? Select one
Very brisk / Striding (4 mph or faster) Normal, average (2 to 2.9 miles per hour)
35.) How many flights or sets of stairs (NOT steps) do you climb daily? Select one
DFCI US E ONLY:
DFCI MRN #_____________
Protocol ID # _____________
Medical Questionnaire and Tissue Banking for Multiple Myeloma, Waldenström
Macroglobulinemia, and Related Disorders
DFCI Protocol Number: 09-233 Principal Investigator: Irene M. Ghobrial, MD ACTIVITY HISTORY, continued

36.) During the PAST 2 MONTHS, what was your average time PER WEEK s pent doing each of the
following recreational activities?

stationary machine) Jogging (slower than 10 (yoga, stretching, toning) Other aerobic exercise (calisthenics, ski or stair machine, etc.) Other vigorous activities walking to work (including golf without a cart) Weight training DFCI US E ONLY:
DFCI MRN #_____________
Protocol ID # _____________
Medical Questionnaire and Tissue Banking for Multiple Myeloma, Waldenström
Macroglobulinemia, and Related Disorders
DFCI Protocol Number: 09-233 Principal Investigator: Irene M. Ghobrial, MD EMPLOYMENT HISTORY
37.) Have you ever worked for more than 6 months in any of the following jobs? If your work in any of
these industries is primarily office or administrative related, please indicate this by checking the appropriate
box below.
DFCI US E ONLY:
DFCI MRN #_____________
Protocol ID # _____________
Medical Questionnaire and Tissue Banking for Multiple Myeloma, Waldenström
Macroglobulinemia, and Related Disorders
DFCI Protocol Number: 09-233 Principal Investigator: Irene M. Ghobrial, MD EMPLOYMENT HISTORY, continued
38.) Have you ever performed any of the following tasks in the context of your work? If so,
please specify the approximate number of months.

ENVIRONMENTAL HISTORY
39.) Have you ever used permanent hair dye for more than one year? No
a.) If yes, approximately what year did you begin using it? b.) If yes, approximately how many years total have you used it? DFCI US E ONLY:
DFCI MRN #_____________
Protocol ID # _____________
Medical Questionnaire and Tissue Banking for Multiple Myeloma, Waldenström
Macroglobulinemia, and Related Disorders
DFCI Protocol Number: 09-233 Principal Investigator: Irene M. Ghobrial, MD ENVIRONMENTAL HISTORY, continued

40.) Have you ever been exposed to any of the substances listed below for at least 8 hours per week for
1 year or more, either on a job or while working on a hobby?

DFCI US E ONLY:
DFCI MRN #_____________
Protocol ID # _____________
Medical Questionnaire and Tissue Banking for Multiple Myeloma, Waldenström
Macroglobulinemia, and Related Disorders
DFCI Protocol Number: 09-233 Principal Investigator: Irene M. Ghobrial, MD Thank you for completing this questionnaire. We would like to invite you to complete the optional dietary questionnaire

Source: http://www.junkfax.org/skirsch.com/wm/dfci/questions.pdf