Proxy questionnaire, patient alive

A_I. What is your relationship with [PT NAME]?

1 Spouse

2 Child

3 Other relative

4 Friend

A_II. How long have you known [PT NAME]?

[text answer] units=Weeks

A_III. Do you or did you ever live in the same house?

1 Yes

2 No

A_IV. How long did you live/have you lived in the same house?

[text answer] units=Weeks

A1. What is [PT NAME]’s date of birth?

[text answer]

A2. Is [PT NAME]…?

1 Female

2 Male

A3. Is he/she of Hispanic or Latino origin?

1 Yes

2 No

A4. What racial or ethnic group best describes him/her?

1 African-American/Black

2 Asian

3 Caucasian/White

4 American Indian or Alaskan native

5 Native Hawaiian or other Pacific Islander

6 Unknown

7 Other:

A5. Was [PT NAME] born in the United States?

1 Yes

2 No

A6. In what part of the world was [PT NAME] born?

1 North America (outside the US)

2 Middle East

3 South America

4 Asia/India/Pacific Island

5 Caribbean

6 Europe

7 Africa

8 Australia/New Zealand

A7. Is he/she presently:

1 Married

2 Separated

3 Divorced

4 Widowed

5 Single or never married

6 Living as married

A8. Which best describes [PT NAME]’s current living situation?

1 Living alone in a house or apartment

2 Living with others in a house or apartment

3 Living in a group or assisted living facility or nursing home

4 Homeless or homeless shelter

5 Other:

A9. What is the highest grade or year of school [PT NAME] completed?

1 Never attended school or only kindergarten

2 Grades 1 through 8 (elementary)

3 Grades 9 through 11 (some high school)

4 Grade 12 or GED (high school graduate)

5 College 1 year to 3 years (some college or technical school)

6 College graduate or graduate school (4 or more years)

A10. To the best of your knowledge, what was [PT NAME]’s approximate total household income for the last year?

1 Less than $10.000

2 $10,001 - $20,000

3 $20,001 - $30,000

4 $30,001 - $40,000

5 $40,001 - $50,000

6 $50,001 - $60,000

7 $60,001 - $70,000

8 $70,001 - $90,000

9 More than $90,000

10 Currently no income

B1. Which of the following categories best describes the usual type of paid work [PT NAME] has done?

1 Farmer, farm worker

2 Service worker or laborer

3 Craftsworker, factory worker, mechanic

4 Clerical worker, salesperson, technician

5 Professional, administrator, executive

6 Other

7 Never worked [Did not work for at least 6 months]

B2. For the job that [PT NAME] held longest, did he/she regularly work in dusty conditions?

1 Yes

2 No

B3. Was the dust from?

1 Sand or rock

2 Concrete, brick or mortar

3 Soil

4 Grains, animal bedding or manure

5 Flour

6 Clay, ceramics or enamel

7 Wood dust

8 Rubber or plastic

9 Metals

10 Other materials

B4. For the job that [PT NAME] held longest, did he/she regularly breathe in chemical vapors or fumes?

1 Yes

2 No

B5. Did [PT NAME] regularly get chemicals or oils on their skin or clothing?

1 Yes

2 No

B6. Did [PT NAME] regularly come in contact with solvents or degreasers?

1 Yes

2 No

B7. Did [PT NAME] regularly come in contact with metal chips, metal dust or metal fumes?

1 Yes

2 No

B8. Has [PT NAME] served in the military?

1 Yes

2 No

B9. Where was [PT NAME] stationed when he/she served?

1 USA/Canada

2 Africa

3 Asia/South Pacific

4 Caribbean

5 Mexico

6 Middle East

7 Northern/Central Europe/Mediterranean

8 Other

9 Don't know

B10. What was [PT NAME]’s primary or longest military occupational specialty (MOS)?

[text answer]

B11. In what branches of the military did [PT NAME] serve?

1 Army

2 Navy

3 Air Force

4 Marine Corps

5 Coast Guard

B12. Did [PT NAME] ever serve a tour of duty that included combat operations?

1 Yes

2 No

C1. Did a doctor ever tell [PT NAME] that he/she had:

1 Arthritis (including rheumatoid arthritis)

2 Hypertension (high blood pressure)

3 Depression

4 Heart attack, heart problems, or stroke

5 Asthma, chronic bronchitis, emphysema

6 High cholesterol

7 High triglycerides

8 Neurological problems like seizures, epilepsy, or migraines

9 None of the above

C2. Did a doctor ever tell [PT NAME] that he/she had diabetes (high blood sugar)?

1 Yes

2 No

C3. When did [PT NAME]’s doctor first tell him/her that he/she had diabetes?

[text answer] units=Age

C4. Did [PT NAME] ever take pills for his/her diabetes?

1 Yes

2 No

C5. When did [PT NAME] start taking pills for his/her diabetes?

[text answer] units=Age

C6. How long did [PT NAME] take pills for his/her diabetes?

[text answer] units=Months

C7. Did [PT NAME] ever take Avandia or Actos for his/her diabetes?

1 Yes

2 No

C8. When did [PT NAME] start taking Avandia or Actos for his/her diabetes?

[text answer] units=Age

C9. Did [PT NAME] ever take glipizide (GLUCOTROL) for their diabetes?

1 Yes

2 No

C10. When did [PT NAME] start taking glipizide (GLUCOTROL) for their diabetes?

[text answer] units=Age

C11. Did [PT NAME] ever take glyburide (DIABETA, GLYCRON, GLYNASE, MICRONASE) for their diabetes?

1 Yes

2 No

C12. When did [PT NAME] start taking glyburide (DIABETA, GLYCRON, GLYNASE, MICRONASE) for their diabetes?

[text answer] units=Age

C13. Did [PT NAME] ever take metformin (Fortamet, Glucophage, Gulmetza, Riomet) for their diabetes?

1 Yes

2 No

C14. When did [PT NAME] start taking metformin (Fortamet, Glucophage, Gulmetza, Riomet) for their diabetes?

[text answer] units=Age

C15. Did [PT NAME] ever take insulin for their diabetes?

1 Yes

2 No

C16. When did [PT NAME] start taking insulin for their diabetes?

[text answer] units=Age

C17. Did [PT NAME] ever take any other medications for their diabetes?

1 Yes

2 No

C18A. What is the name of another medication [PT NAME] took for their diabetes?

[text answer]

C18B. When did [PT NAME] start taking this for their diabetes?

[text answer] units=Age

C18C. Did [PT NAME] take any other medications for their diabetes?

1 Yes

2 No

C18D. What is the name of another medication [PT NAME] took for their diabetes?

[text answer]

C18E. When did [PT NAME] start taking this for their diabetes?

[text answer] units=Age

C18F. Did [PT NAME] take any other medications for their diabetes?

1 Yes

2 No

C18G. What is the name of another medication [PT NAME] took for their diabetes?

[text answer]

C18H. When did [PT NAME] start taking this for their diabetes?

[text answer] units=Age

C19. Was [PT NAME] ever told he/she had hepatitis?

1 Yes

2 No

C20. Was [PT NAME] ever told he/she had hepatitis C?

1 Yes

2 No

C21. Did [PT NAME] ever receive treatment for hepatitis C?

1 Yes

2 No

C22. Was [PT NAME] treated with interferon (the shot)?

1 Yes

2 No

C23. How many times per week did [PT NAME] receive interferon (the shot)?

[text answer]

C24. Was [PT NAME] treated with ribavirin (the pills)?

1 Yes

2 No

C25. How many times per day did [PT NAME] take ribavirin (the pills)?

[text answer]

C26. Was [PT NAME] treated with sylimarin (milk thistle)?

1 Yes

2 No

C27. How many times per day did [PT NAME] take sylimarin (milk thistle)?

[text answer]

C28. Was [PT NAME] treated with any other medications for Hepatitis C?

1 Yes

2 No

C29A. What was the name of one of the other medications [PT NAME] took for Hepatitis C?

[text answer]

C29B. How many time per day did [PT NAME] take it?

[text answer]

C29C. Was [PT NAME] treated with any other medications for Hepatitis C?

1 Yes

2 No

C29D. What was one of the other medications [PT NAME] took for Hepatitis C?

[text answer]

C29E. How many time per day did [PT NAME] take it?

[text answer]

C29F. Was [PT NAME] treated with any other medications for Hepatitis C?

1 Yes

2 No

C29G. What was one of the other medications [PT NAME] took for Hepatitis C?

[text answer]

C29H. How many times per day did [PT NAME] take it?

[text answer]

C30. In total, how many weeks/months/years did [PT NAME] take hepatitis C treatment?

[text answer] units=Weeks

C31. Does [PT NAME] know if the hepatitis C treatment was successful or not?

1 Yes

2 No

C32. Has [PT NAME] ever been told he/she had Hepatitis B?

1 Yes

2 No

C33. Did [PT NAME] receive treatment for hepatitis B?

1 Yes

2 No

C34. Was [PT NAME] treated with Lamivudine?

1 Yes

2 No

C35. Was [PT NAME] treated with Adefovir?

1 Yes

2 No

C36. Was [PT NAME] treated with Entecavir?

1 Yes

2 No

C37. Was [PT NAME] treated with tenofovir?

1 Yes

2 No

C38. Were you treated with any other medications for Hepatitis B?

1 Yes

2 No

C39. What other medications did [PT NAME] take?

[text answer]

C40. In total, how many weeks/months/years did [PT NAME] take hepatitis B treatment?

[text answer] units=Weeks

C41A. Did [PT NAME] ever take atorvastatin (Lipitor, Caduet)?

1 Yes

2 No

C41B. Did [PT NAME] ever take fluvastatin (Lescol)?

1 Yes

2 No

C41C. Did [PT NAME] ever take lovastatin (Mevacor, Advicor, and Altoprev)?

1 Yes

2 No

C41D. Did [PT NAME] ever take pravastatin (Pravachol, Pravigard PAC)?

1 Yes

2 No

C41E. Did [PT NAME] ever take rosuvastatin (Crestor)?

1 Yes

2 No

C41F. Did [PT NAME] ever take simvastatin (Zocor, Vytorin)?

1 Yes

2 No

C41G. Did [PT NAME] ever take Baychol?

1 Yes

2 No

C42. In total, how many weeks/months/years did [PT NAME] take these medications?

[text answer] units=Weeks

C43A. Did he/she take any colesevelam (WelChol) to lower cholesterol?

1 Yes

2 No

C43B. Did he/she take any colestipol (Colestid)?

1 Yes

2 No

C43C. Did he/she take any cholestyramine (Locholest, Questran)?

1 Yes

2 No

C43D. Did he/she take any niacin obtained over the counter or by prescription (Nicotinic acid, Advicor)?

1 Yes

2 No

C43E. Did [PT NAME] take any gemfibrozel (Lopid)?

1 Yes

2 No

C43F. Did [PT NAME] take any fenofibrate (TriCor, Antara, Lofibra, Triglide)?

1 Yes

2 No

C43G. Did [PT NAME] take any ezetimibe (Zetia, Vytorin)?

1 Yes

2 No

C44. In total, how many weeks/months/years did [PT NAME] take these medications?

[text answer] units=Weeks

D1. Has [PT NAME] ever drunk coffee on a regular basis?

1 Yes

2 No

D1A. For how many years have you been aware of how much coffee he/she drinks?

[text answer]

D1C. During the years that you have been aware of his/her coffee intake, about how often did he/she drink an 8 oz. cup of coffee? Do not include the 12 months before he/she was diagnosed with cancer.

[text answer] units=Per day

D2. How often was the coffee that [PT NAME] drank during that time regular coffee; that is, it contained caffeine?

1 Almost always

2 Often

3 Sometimes

4 Seldom

5 Never

D3. Did [DECEDENT] drink coffee during the year before he/she was diagnosed with liver cancer?

1 Yes

2 No

E1. During the year before [PT NAME] was diagnosed with liver cancer, did he/she ever drink an 8 oz cup of coffee with caffeine?

1 Yes

2 No

E1A. How often did he/she drink caffeinated coffee during the year before he/she was diagnosed?

[text answer] units=Per day

E2. During the year before he/she was diagnosed with liver cancer, did he/she ever drink an 8 oz cup of decaffeinated coffee ?

1 Yes

2 No

E2A. How often did he/she drink an 8 oz cup of decaffeinated coffee during the year before he/she was diagnosed?

[text answer] units=Per day

E3. During the year before [PT NAME]’s diagnosis, did he/she drink any other type of coffee?

1 Yes

2 No

3 DK/REF

E4. How often did he/she drink an 8 oz. cup of [OTHER TYPE OF] coffee during the year before their diagnosis?

[text answer] units=Per day

E5. Which of the following did he/she usually add to coffee?

1 Creamer, half & half

2 Nondairy creamer

3 Milk

4 None of these

5 Did not drink coffee

E6. Did he/she usually add sugar (or honey) to coffee?

1 Yes

2 No

E7. How many teaspoons per cup?

[text answer]

E8. Did he/she usually add artificial sweetener to coffee?

1 Yes

2 No

E9. How many teaspoons or packets per cup?

[text answer] units=teaspoons per cup

E10. What type of artificial sweetener did he/she usually use?

1 Pink pack/Sweet and Low

2 Blue pack/Nutra Sweet

3 Yellow pack/Splenda

4 Other

E11. During the year before [PT NAME] was diagnosed with liver cancer, did he/she drink iced or hot tea with caffeine (NOT including herbal tea or green tea)?

1 Yes

2 No

E11A. How often did he/she drink an 8 oz. cup of iced or hot tea with caffeine (NOT including herbal tea or green tea)?

[text answer] units=Per day

E12. During the year before he/she was diagnosed with liver cancer, did he/she drink decaffeinated iced or hot tea (NOT including herbal tea or green tea)?

1 Yes

2 No

E12A. How often did he/she drink an 8 oz. cup of decaffeinated iced or hot tea (NOT including herbal tea or green tea)?

[text answer] units=Per day

E13. During the year before he/she was diagnosed with liver cancer, did he/she drink green tea?

1 Yes

2 No

E13A. How often did he/she drink an 8 oz. cup of green tea?

[text answer] units=Per day

E14. During the year before he/she was diagnosed with liver cancer, did he/she drink herbal tea?

1 Yes

2 No

E14A. About how often did he/she drink an 8 oz. cup of herbal tea?

[text answer] units=Per day

E15. During the year before their diagnosis, did he/she drink any other type of tea?

1 Yes

2 No

E16. How often did he/she drink an 8 oz. cup of tea during the year before your diagnosis?

[text answer] units=Per day

E17. Which of the following did he/she usually add to tea?

1 Creamer, half & half

2 Nondairy creamer

3 Milk

4 None of these

E18. Did he/she usually add sugar (or honey) to tea?

1 Yes

2 No

E19. How many teaspoons per each cup?

[text answer]

E20. Did he/she usually add artificial sweetener to tea?

1 Yes

2 No

E21. How many teaspoons or packets per cup?

[text answer] units=teaspoons per cup

E22. What type of artificial sweetener Does he/she usually use?

1 Pink pack/Sweet and Low

2 Blue pack/NutraSweet

3 Yellow pack/Splenda

4 Other

F1. During the year before [PT NAME]’s diagnosis, did he/she drink regular or diet soft drinks with caffeine (Coke, Pepsi, Mountain Dew, Mello Yello, SunDrop, Dr. Pepper, Red Bull)?

1 Yes

2 No

F1A. How often did he/she drink regular or diet soft drinks with caffeine (Coke, Pepsi, Mountain Dew, Mello Yello, SunDrop, Dr. Pepper, Red Bull)?

[text answer] units=Per day

F2. During the year before [PT NAME]’s diagnosis, did he/she drink regular or diet soft drinks that were caffeine-free? (Caffeine-free Coke, Pepsi or Diet Coke, Sprite, Fresca, 7-Up, Ginger Ale)?

1 Yes

2 No

F2A. How often did he/she drink regular or diet soft drinks that were caffeine-free? (Caffeine-free Coke, Pepsi or Diet Coke, Sprite, Fresca, 7-Up, Ginger Ale)

[text answer] units=Per day

G1. Before [PT NAME]’s liver cancer diagnosis, did a doctor ever tell him/her that he/she had a cancer other than liver cancer?

1 Yes

2 No

G1A. What other type of cancer was that?

[text answer]

G1B. How old was he/she when he/she was diagnosed with this cancer?

[text answer]

G2. Did a doctor ever tell him/her that he/she had an other cancer type besides liver cancer and the one you mentioned?

1 Yes

2 No

G2A. What other type of cancer was that?

[text answer]

G2B. How old was he/she when he/she was diagnosed with this other cancer?

[text answer]

G3. Did a doctor ever tell him/her that he/she had an other cancer type besides liver cancer and the other two you mentioned?

1 Yes

2 No

G3A. What other type of cancer was that?

[text answer]

G3B. How old was he/she when he/she was diagnosed with this other cancer?

[text answer]

G3C. Did a doctor ever tell him/her that he/she had an other cancer type besides liver cancer and the other three you mentioned?

1 Yes

2 No

G3D. What other type of cancer was that?

[text answer]

G3E. How old was he/she when he/she was diagnosed with this other cancer?

[text answer]

G4. [ONLY ASK IF PROSTATE CANCER WAS REPORTED] What kind of treatment did he receive for prostate cancer?

1 Radical surgery (prostatectomy)

2 Minimally invasive surgery (laparoscopic or robotic)

3 Radiation therapy

4 Hormone therapy

5 Other

6 Did not receive any treatment

H1. Before we begin asking about family history, was [PT NAME] adopted?

1 Yes

2 No

H2. Do you have medical information about any of your biological family members (parents or full siblings)?

1 Yes

2 No

II2. Was she ever pregnant? Pease include miscarriages, stillbirths, tubal pregnancies, and abortions.

1 Yes

2 No

I3. How many times was she been pregnant?

[text answer]

I4. How many of [PT NAME]’s pregnancies lasted 6 months or longer?

[text answer]

I5. How many of [PT NAME]’s pregnancies resulted in live births?

[text answer]

I6. How old was she at the first live birth?

[text answer]

I7. How old was she at the last live birth?

[text answer]

J1. What was [PT NAME]’s approximate weight one year before he/she was diagnosed with cancer?

[text answer]

J4. What is the most he/she ever weighed since age 18?

[text answer]

J5. How old were they when they first weighed this amount?

[text answer]

J6. What's your best estimate for his/her current weight?

[text answer]

J7. How tall is he/she?

[text answer]

KK1. Has he/she ever consumed alcohol on a regular basis? By regular, I mean at least once a week for 6 months or longer?

1 Yes

2 No

K2. How many of the years that [PT NAME] drank alcohol on a regular basis were you aware of how much alcohol he/she consumed?

[text answer]

K3. Would you say that during those years he/she was a…

1 Heavy drinker

2 Moderate drinker

3 Light drinker

K4. During the time that you were aware of his/her alcohol consumption, what type of alcohol did he/she consume most of the time?

1 Beer

2 Hard cider

3 Wine

4 Sake

5 Liquor

6 Spirits

7 Mixed drinks

8 Cocktails

L1. Has [PT NAME] ever smoked cigarettes on a regular basis? By 'regular', I mean at least one cigarette a day for 3 months or longer.

1 Yes

2 No

L2. In total, how long [did/have] he/she smoked cigarettes regularly?

[text answer] units=Weeks

L3. During the periods when he/she smoked regularly, how many cigarettes did they typically smoked in a day?