Health And Dietary

1

Dateentered (officeuse onlY)

mm

BONERESEARCH OF MELBOURNE THEUNIVERSITY PROGRAM of Medicine Department

of General Department

Royal Melbourne Hospital

practice and public Health

centrefor Genetic Epidemiology

WITH WHETHERREGULARTABLETENNISACTIVITYIS ASSOCIATED BALANCE AND IMPROVED BONEAND MUSCLESTRENGTH INCREASED IN OLDERASIANMENANDWOMEN

HEALTHAND DIETARYQUESTIONNAIRE

as bestyou can andanyproblems we wouldlikeyouto fill in thesequestionnaires can be discussedduringyourinterview. Pleasecompletein the weekpriorto yourvisit. in thisproject. Thankyoufor participating

Dateof Visit:O"y lTl

Month

of Medicine, BoneResearchProgram,Department VIC3050. Parkville, Hospital, Melbourne Royal 93482254. Fax: 03 83446882. Ph: 03

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Thisquestionnaire is designedto covervariousage groups.Somequestionsmay not seemrelevantto you,but pleasedo attemptto answereachrelevantsection.

A). PERSONALDATA A3. Dateof Birth: Months

Years

A.4 CurrentAge:

A.5 Education: Howold wereyouwhenyou leftschoolor othereducation? Howmanyyearsdid you spendin school: Primaryand Secondary? TechnicalCollege? University?

m m ul m

B). EthnicityData: 8.1 Placeof birth:

Country

State

Self: Father: Mother: B.3 Year of Migrationto Australia(if not born in Australia): Self: Father: Mother: 8.4 Gitizenship Self:

Father: Mother:

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City/Province

3 What do you consider to be your ethnic origin?

n tl

tr speciry:

Other A.9

Main LanguageSpoken:

Firstlanguage:

Secondlanguage:

At Home

At work/school

c). FAMTLYDATA Cl. Do any of your close relativeshave a tendencyto breaktheir bones easily? GO TO QUESTIONC3

zNo

I

GO TO QUESTION C3

| . Don'tknow

I rY es

+

G2. Which of your relativeshave brokentheir bones easily?

n

Mother

I

Father

I

sister

|-]

Brother

n

Aunt

I

Uncte

I

Grandfather

I

other

tl

Grandmother

C3. Has a doctor ever diagnoseda family member(blood relative)with osteoporosis? r Yes:

l-l, r'ro

E

. Don'tknow

FORRESEARCHERS USEONLY

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D). MEDTCAL HTSTORY DI. Pleaselist any presentor past operations,illnessesor accidents(and datesthey occurred).

USEONLY FORRESEARCHERS

D2. Haveyou broken any bonesin the past?

T

n n

zN o

GO TO SECTIONE

3 Don't know

GO TO SECTIONE

1 Yes

+

Tick the boxes correspondingto the sites that any fracturesoccurredin your life.

AGE(s)

SITE FOREARM / WRIST FI N G ER LEG HI P ANKLE TOE BACK OTHER:-

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E E E E E tr

RIGHT LEFT RIGHT LEFT RIGHT LEFT R IGH T LEFT R IGH T LEFT

tr

n

How was it broken

SMOKINGHABITS

Haveyou ever been a regularsmoker ie. smoked on averageat least seven cigarettesper week for at feast ayear ?

ruo'

L

Go to SECTIONF

I,

one year? at least"=s

Howold wereyou whenyou first smokedat leastsevencigarettesa weekfor

m

Years

Pleasefill out the followingtable. Startat the 10 -19 yr age range and continue until your current age. Just write "0" if yotr smokednone or less than 7 cigarettesper week.

Age range

How manyyears did you smokeregularly (ie.Smokedon averageat leastsevencigarettesper week?)

Duringthoseyears,on average,how many cigarettesper did you smoke?

10- 19years

Years

ru

Cigarettes/day

/ \ /

20 - 29 years

Years

ilI

Cigarettes/day

\

30 - 39 years

Years

t=

Cigarettes/day

/ \

40 - 49 years

Years

E;

Cigarettes/day

/

50 - 59 years

Years

[:

Cigarettes/day

60 - 69 years

Years

==

Cigarettes/day

a

70 - 79 years

Years

il

Cigarettes/day

\

80 - 89 years

Years

CI

Cigarettes/day

/ \

90 - 99 years

Years

Y a Y

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Frr.lrl

I

I Cigarettes/day

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HISTORY D. MENSTRUALREPRODUCTIVE Fl. Haveyou had your first menstrualperiod?

[-l , *o [l , ""r +

GO TO SECTIONG

F2. How old were you when you had your first menstrualperiod ?

vears

II

m

months

F3. What was the date of your !!!gg!_fece$ menstrual period (does not include spotting, breakthroughbleedingor bleedingwhile using HormoneReplacementTherapy(HRT))?

Year:

Month: m

Day:m

F4. How old were you when you last had a period?

vears

t]]

months

m

F5. Haveyour periods changedin frequencyor stopped?

T l I

GO TO F7

l\ln

Yes (changedin frequency) Yes (ceased)

+

GO TO F6 GO TO F6

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I

F6. Give the reason(s)why you believeyour periods have changedin trequencyor stopped. ,i

l-] ll

(changeof life) Menopause

ll

T T

Weightloss/stress/travel

n l

Whatwasit called?

Medicalcondition

Removalof bothovaries,withouthysterectomy Wereovariesremovedat the time of hysterectomy?

-+ Hysterectomy (date:__l-J----)

Ll

fl

on" ovaryremoved

No ovariesremoved

I

t*o ovariesremoved n

Unsureof ovarystatus

use Medication I

V

thatcausedyourperiodsto stop?.. Whatis the nameof the medication Howold wereyouwhenyou beganusingit?

I

Howtonghaveyoubeenusingit for,intotal? m

|

| years I

weeks tI

|

| months

ton,r*lTl

years

for? Whatwas it prescribed

n ll

due to menopause symptoms/menstrualirregularities Treatmentof menopausal

[-]

contraception Otherreason(pleasespecifY):

Don'tknow tl

l-J

: ............. Otherreason(pleasespecify)

F7 GO TO QUESTION

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OVERTHE LAST YEAR lf your last period was more than 12 months ago, you do not need to completethis section. Go to F16

NOTE:

F7. Over the last year,what was the averagetime betweenthe first day of one period and the first day of next period?

I

I

I

ld a Y s

F8. Over the last year, what was the maximumtime betweenthe first day of one period and the first day of the next period?

F9. Over the last year,what was the minimumtime betweenthe first day of one period and the first day of the next period? daYs F10.Over the tast year,what was the averageamountof bleeding?

t small

I

moderatel-lt

[-],

heavy/clots

usedper period? Fl1. Overthe last year, whatwasthe averagenumberof pads/tampons

pads

II

|

|

I

tampons

F12.Over the tast year,what was the averagenumberof days each period lasted?

davs

m

F13.Howmanyperiodshaveyou hadin the past year? tI F14.Over the past year, have you taken any medication,which would affect the reqularitvol you periods?

|__] No

[-]

Yes,HRr

l-l

pill v"r, contraceptive

l-l

Yes,other

F15. Over the last year, have your periodsbeenregularor similar to previousyears? Yes

GO TO F22 GO TO F24

Juststartedgettingperiods No

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GOTO Fl6

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THINKING ABOUTTHEYEARSDURINGWHICHYOU HAVEHADPERIODS

F16. What was the gyre period?

time between the first day of one period and the first day of next

l-I-[l

o"u.

F17. What was the maximumtime betweenthe first day of one period and the first day of the next period? days F18. What was the minimum time betweenthe first day of one period and the first day of the next period? days Fl9. Whatwas the averageamountof bleeding? r small

I,

moderate I

. heavy/clots

F20. What was the averagenumber of pads/tamponsused per period?

Inpads

tI

tampons

F21. What was the averagenumber of day each period lasts?

Inegufarperiodsorecotnffionaffion7youttguofilen arufwuaffy [o nat*rpt! any abnonno.fity F22. Has there ever been a time when you had less than five periods in one year (excluding pregnancy,breastfeedingor menopause)?

t--t 1_l

a No o rD o n 'tkn o #

GOTOF2S

r Yesl Y

F22a. How many periods,on averagedid you haveeach year? F22b. For how manyyears did you have less than 5 periods?

m m

F22c. What was the reason?

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r' 10

F23. Have your periods ever stopped for more than 2 months when you were breastfeedingor going through menopause?

tll [l

I,

, No

co ro F24

s Don'tknow -)

GO TO F24

t"tJ times

manytimesdid this occur? m F23a.How

months

howlongdid eachepisodelast? Il F23b.on average, F23c.What do you think was the reason(s)?

l_l

menopause oooroaching l-|

l_l ,os orweisht

n

stress/ travel

Medication

lllness/medicalcondition Don'tknow

Otherreason

F24. Haveyou ever used the contraceptivepill ?

Ll

zNo

GO TO F25

3 Don'tknow

GOTOF25

1 Yes: brand(s)

I

F24a.At whatagedid you first usethe pitt?

years

m

F24b.Intotat,ror how longhaveyou takenthe pitt? m pill? F24c.Areyou currenttvusingthe contraceptive

I

months

m

years t]] Yes

I

months No

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11

Haveyou ever used HormoneReplacementTherapy(HRT)?

ll

z N o#GOTOF26

Ll

g Don'tknow ---4 r Yes

GO TO F26

brand(s):

J

F25a. At what age did you first use HRT? F25b. What was the reasonyou commencedHRT?

F25c. In total, for how long have you taken HRT? F25d. Are you eurrentlvusing HRT?

|

| V".

F26. Have you ever been pregnant? GO TO SECTIONG

zN o

I

I r Don'tknow

GO TO SECTIONG

E , Ye s l 20weeks? ru ,Jgn"n"i"shaveyouhadthatlastedbeyond F26b.Howmanychitdrenhaveyou had? m

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F27.Pleasefill in the followingtable about eachof your children. Dateof birth of child

Calciumsupplements Numberof duringyour pregnancy? months breast fed

Yes

No

Don't know

Galciumsupplements while you were breast feeding?

Yes

No

Don't Know

1st CHILD 2nd CHILD

(_t_t_)

3rd CHILD

(J-r-7

4th cHtLD

(_t_t_)

sth cHtLD

(_/_/_)

(_tJ_) 7th cHtLD (JJ-\ 8th CHILD (JJ-) gth CHILD (_tJ_) 1othcHtLD (_t_t__) 6rh GHILD

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G. MEDICALHISTORY GI. Pleasethink aboutany currentor past medicalconditionsyou may havehad. We will ask you to give details (such as when it was diagnosedand any treatmentreceived)at the interview. G2. Haveyou ever beentreatedfor bone disease?

T T T

No Don't know Whatwas the diseasecalled?

YES

G3. Are you currently,or haveyou ever taken any of the following medications?(pleasetick)

Currently

Medication Yes

No

Don't Know

Ever Yes

No

Comment Don't know

Thyroidhormone (femalehormone, otherthan Oestrogens pill). the contraceptive Brand: Dose: Duration: CombinedOestrogen& Progestogen (otherthan the contraceptive pill) Brand: Dose: Duration: Progestogenalone Brand:

Dose: Duration: OralContraceptive Pill: Brand: Dose:

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medication Cortisone-like lin h a l e d I topical- cream Itablets AnabolicSteroid(to buildup bone/muscle) Androgens(sexhormones) Calcitonin(hormonetreatmentfor bone disease e.q. Paqet'sdisease

Anti-convulsants Thiazidediuretics(wateror fluidtablets) Tick if for hypertension use Non{hiazidediuretics Tick if for hvpertension use (not Anti-hypertension medication (otherthanfor CalciumSupplement pregnancyor breastfeeding)

(treatment Bisphosphonate for bone diseasee.o. Paoet'sdisease

Minerals(e.9.iron,zinc,magnesium):

Asthmamedication: Brand:

Non-steroidalanti-inflammatory medication Warfarin/Heparin Version4

Medication eg: herbal, Overthe counterremedies, promensil

Traditional medicine

(brand/dose/duration) OtherMedications

H. OCCUPATIONAL HISTORY Hl. Areyou currentlyin paidemployment?YESff 9-

*oI

yourcurrentmainoccupation lf yes,pleasedescribe : ............

SeeH1.a .....Goto H2.

Hl.a Pleasedescribeyour husband'sor parents'mainoccupations(see below). lf they are retired,pleasedescribetheir main occupationprior to retirement. lf no +

-+

lf you are a housewife, whatis yourhusband'smainoccupation?

If you are under18 yearsof age,whatare yourparents'mainoccupations? Father's occupation...... Mother's occupation......

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(lncl. volunteerwork) / DAILYACTIVITIES BELOWARE3 GROUPSOF OCCUPATIONAL Group 1: Group 2: Group 3:

Predominantlysitting e.g. desk work, factory work (mainlysitting),reception, (sitting),student,volunteer(mainlysitting)etc. cashier,computerprogrammer Predominantlystanding, some walking e.g. bank teller,generaloffice work, physiotherapist, factoryworkwithstandingandsomelifting,houseduties,etc. Predominantlyactivee.g.aerobicsteacher,domesticcleaner,nurse(patientcare), work involvingheavy lifting,waiter, dancer,caring for children(active),volunteer (active),etc.

H2. Pleasefill in the following table referringto your CURRENToccupation/dailyactivity. AGEat start (vears)

DURATION (months)

GROUP

COMMENTS (hrs/week)

Current (a) Pleaseelaborateon the type of activity currently performed(e.9.how much lifting/walking):

ul

H3. What is yourtotalnumberof workingyearsin yourlife up untilnow? Pleasecomplete the following table about your !l\$ occupations/dailyactivity of more than two years duration: JOB

AGE at start DURATION TYPEof job (years) (months)

GROUF ( 1.2or 3)

COMMENTS (hrs/week)

1 tt 2nd

3"t 4th

5t^ 6th 7th

gtn gth

H4. On average,how many hours per week do you do householdwork activities? hangingoutwashing,lawnmowing, e.g.vacuuming, scrubbing bathrooms, gardening, cookingandironingetc.

ul

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r.)DrET 1.1. Are you CURRENTLY or haveyou EVERfollowed any specialdiet for medicalreasons (eg. Diabetes,allergy,high cholesterol)? No - Go to question1.3

!

- Goto nextquestion. "".

a.2. lF you are CURRENTLY, or have EVERbeen on a specialdiet for medicalreasons(eg. Diabetes,allergyor high cholesterol)OR in order to slim, OR if you are vegetarian,please give the following information. Reasonfor diet

Dietarychangesmade

1.3 Pleaserank your use of the following milks in increasinqorder with "1" denotingthe most frequentlyused milk, "2" denotingthe second most frequentlyused milk, etc. Mark any milks not used at all with a "0".

I

wholemitk I

Revmitk I

I

soymilk

other(please specify):

I

Physical

1.5Pleasestateyour reasons,lf you do not drink milk?

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Skimmilk

I.6 MILKINTAKE The followingquestionsrelateto yourpastintakeof milk. Placea lineon the scaleof CUPSOF MILKPERDAY(onecup is 250 mL). lndicateby placinga stroke throughthe lineto indicatethe DAILYTOTALestimatedamountof milktakenduringdifferentperiodsof yourlife. (lt can helpif youtry to visualiseyourdayto day lifeas it wasthen,the placeyou wereliving, andwhereyouwereworkingor wentto school).

1.7

At the presenttime

I 'l'l 'l 1.8

'l

'l

'l

'l'l

78 cups of milk/day

Two years ago

l 'l' l'l'l'l'l'l' l 0123 4 5 6 7 8 cupsof milk/day r.g

rf aged over 30, 10 years ago

I 'l' l'l'l'l'l, l' l

78 cups of milk/day

1.10 lf you havehad children,during pregnancy

l , l' l'l'l'l

'l'l, l

78 cups of milk/day

1.11 lf you havebreastfedchildren,during breastfeeding

l'l'l 'l 'l 'l ,l 'l ' l 78 cups of milk/day

1.12 lf agedover 30, during adolescence(whilst at high school)

l' l' l'l'l'l'l'l ,l 012345678 c'upsof milk/day

1.13 Duringchildhood(whilstat primaryschool)

l' l,l'l'l'l'l

'l'l

78 cups of milk/day

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L9

you had at least12 drinks ol any kind of alcoholicbeveragesin your entirelife?

lf yes,pleasefill in this table: DURINGTHEPAST12 MONTHS Did you have at least 12 drinks of any kind of alcoholic beverageduring the last 12 months?

fill in this table:

ALCOHOLINTAKEDURINGTHE LAST12 MONTHS Beer Wine Spirits (7oz) (4oz) (mixeddrinks) -120m -210m

Have there been times in your life sincethe age of your first socialdrinkwhen your alcohol consumption hasbeengreatlydifferentthanthe past 12 months? Yes

T

No

r

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DO NOT COMPLETE - OFFICB USE ONLY

MEDICALCONDITIONS GastrectomylPart of stomachremoved Malabsorption Syndrome/ chronicboweldisease Otherboweldisease: Diabetes/ Sugarin the urine(NIDDM/ IDDM) Diabetes Gestational Rheumatoid arthritis Osteo-arthritis Otherarthritis: Asthma Osteoporosis Osteomalacia / Rickets(softbones) SecondaryAmenorrhoea Cushing's Syndrome (overactive thyroid) Hyperthyroidism (underactive thyroid) Hypothyroidism (highbloodcalcium) PrimaryHyperparathyroidism Kidneydiseaseor kidneystones: Liverdisease: Spinalsurgeryor chronicspinedisease problem backor neckmusculo-skeletal Significant eletalproblemaffectingpartof Significantmusculo-sk the legI arm: Cancer: Epilepsy: Hypertension hypertension Gestational HeartDisease: (highcholesterol) Hypercholesterolemia Prolongedperiodof immobilization:-

Under-nutritionorsignificant|ossofweight:problems Neurological / braindamage Stroke/ Hemiplegia Other

Yes

No

Don't know

Gomments (age,etc)

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22

A). PERSONALDATA A1. Name: (Othernames)

(Surname) A2. HomeAddress:

Postcode: Evening:(_)_

ContactPhoneNo. Daytime:(-)

THE FOLLOWING:lF UNDER18 YEARSOF AGE PLEASECOMPLETE C4. Mother'sName:

(Surname)

(Othernames)

C5. HomeAddress: Postcode: Evening:

ContactPhoneNo. Daytime: G6. Father'sName:

(Surname)

(Othernames)

G7. HomeAddress: Postcode: ContactPhoneNo.Daytime:

Evening: (lf it's the same put "as before")

THEHEALTHQUESTIONNAIRE. FORCOMPLETING THANK-YOU

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