Are you:
* must provide value
An NYU Women's Health Study participant
Completing the questionnaire on behalf of an NYU Women's Health Study participant
Is the NYU Women's Health Study participant:
* must provide value
Alive but unable to complete the questionnaire
Deceased
NYU Women's Health Study Participant's Information
First name
* must provide value
Last name
* must provide value
What was the cause of the study member's death?
What was the date of her death?
In what city did she die?
Did she die in a hospital?
No
Yes
Have you ever had any of the following conditions? (Please check NO or YES for every question. IF YES, please give the date of first diagnosis.)
Has she ever had any of the following conditions? (Please check NO or YES for every question. IF YES, please give the date of first diagnosis.)
Did she ever have any of the following conditions? (Please check NO or YES for every question. IF YES, please give the date of first diagnosis or surgery.)
No
Yes
Was the breast cancer detected by a routine breast cancer screening?
No
Yes
Cancer of the uterus (womb)?
No
Yes
Hysterectomy (uterus removed)?
No
Yes
No
Yes
No
Yes
Basal or squamous cell skin cancer?
No
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
Yes
Other cancer 1: Month of diagnosis
Other cancer 1: Year of diagnosis
Other cancer 1: Type of cancer
Other cancer 2: Month of diagnosis
Other cancer 2: Year of diagnosis
Other cancer 2: Type of cancer
Did a doctor ever tell you that you had any of the medical problems listed below?
Did a doctor ever tell her that she had any of the medical problems listed below?
Did she ever have any of the medical problems listed below?
Heart attack or myocardial infarction?
No
Yes
Year first heart attack diagnosed
Year second heart attack diagnosed
No
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
Yes
Year first stroke diagnosed
Year second stroke diagnosed
No
Yes
No
Yes
TIA (small stroke or mini-stroke)?
No
Yes
Year second TIA diagnosed
No
Yes
No
Yes
Congestive heart failure?
No
Yes
No
Yes
No
Yes
Chronic Obstructive Pulmonary Disease?
No
Yes
No
Yes
Diabetes (sugar disease)?
No
Yes
No
Yes
No
Yes
No
Yes
No
Yes
How did the fracture(s) happen? (Check all that apply.)
Did you ever have any of the following?
Did she ever have any of the following?
Did she ever have any of the following?
No
Yes
Balloon or other angioplasty?
No
Yes
Year of first angioplasty
Year of second angioplasty
Year of third angioplasty
No
Yes
Year of first carotid artery surgery
Year of second carotid artery surgery
Year of third carotid artery surgery
Are you currently taking any of the following medicines?
Is she currently  taking any of the following medicines?
No
Yes
No
Yes
No
Yes
Medicine to lower your cholesterol?
No
Yes
Anticoagulant medications or blood thinners (Coumadin, Pradaxa, Eliquis, Xarelto)?
No
Yes
Low-dose aspirin (baby aspirin, 81mg daily aspirin)?
No
Yes
Prescription medicine to treat depression?
No
Yes
In the past month, how often have you been feeling down, depressed or hopeless?
Not at all
Several days
More than half the days
Nearly every day
In the past month, how often has she been feeling down, depressed or hopeless?
Not at all
Several days
More than half the days
Nearly every day
Has a healthcare provider ever told you that you had, or likely had, COVID-19?
No
Yes
Has a healthcare provider ever told her that she had, or likely had, COVID-19?
No
Yes
Did a healthcare provider ever tell her that she had, or likely had, COVID-19?
No
Yes
Date the healthcare provider told you that you had, or likely had, COVID-19
MM/DD/YY
Date the healthcare provider told her that she had, or likely had, COVID-19
MM/DD/YY
No
Yes
No
Yes
Date you were hospitalized:
MM/DD/YY
Date she was hospitalized:
MM/DD/YY
Which of the following COVID-19 symptoms have you had in 2020? (Mark all that apply.)
Which of the following COVID-19 symptoms have you had in 2020? (Mark all that apply.)
Which of the following COVID-19 symptoms has she had in 2020? (Mark all that apply.)
Which of the following COVID-19 symptoms has she had in 2020? (Mark all that apply.)
Did you ever have a nasal swab or saliva test for active COVID-19 infection?
No
Yes
Did she ever have a nasal swab or saliva test for active COVID-19 infection?
No
Yes
Was your swab/saliva test ever positive?
No
Yes
Was her swab/saliva test ever positive?
No
Yes
Date of 1st  positive swab/saliva test:
MM/DD/YY
Was your swab/saliva test ever negative?
No
Yes
Was her swab/saliva test ever negative?
No
Yes
Date of most recent negative swab/saliva test:
MM/DD/YY
Did you ever have an antibody (blood) test for COVID-19?
No
Yes
Did she ever have an antibody (blood) test for COVID-19?
No
Yes
Was your antibody test ever positive?
No
Yes
Was her antibody test ever positive?
No
Yes
Date of 1st  positive antibody test:
MM/DD/YY
Was your antibody test ever negative?
No
Yes
Was her antibody test ever negative?
No
Yes
Date of most recent  negative antibody test:
MM/DD/YY
Between March and June 2020 (during the 1st stay-at-home order), about how many times per week did you go outside the home? (for example, to stores or parks)
times per week
Between March and June 2020 (during the 1st stay-at-home order), about how many times per week did she go outside the home? (for example, to stores or parks)
times per week
Between March and June 2020 (during the 1st stay-at-home order), about how much did you usually walk outdoors in a week (including walking to work, shopping, or to other activities)? (If you did not walk outdoors, please write '0'.)
Between March and June 2020 (during the 1st stay-at-home order), about how much did she usually walk outdoors in a week (including walking to work, shopping, or to other activities)? (If she did not walk outdoors, please write '0'.)
miles per week
blocks per week
minutes per week
Since the end  of the 1st stay-at-home order, approximately how many hours per week did you spend in the following types of exercise? (Please only include activities you did on a regular basis. If you didn't do a particular type of exercise, please write '0'.)
Since the end  of the 1st stay-at-home order, approximately how many hours per week did she spend in the following types of exercise? (Please only include activities she did on a regular basis. If she didn't do a particular type of exercise, please write '0'.)
Strenuous exercise (heart beats rapidly)?
(Examples: running, jogging, vigorous bicycling, vigorous swimming, vigorous gym aerobics)
# of hours per week
Moderate exercise (not exhausting)?
(Examples: fast walking, doubles tennis, moderate bicycling, moderate swimming, moderate gym aerobics, dancing)
# of hours per week
Mild exercise? (Examples: gentle yoga, bowling, golf, light gardening, easy walking)
# of hours per week
What is your usual walking pace?
Slow
Average
Brisk
Unable to walk
What is her usual walking pace?
Slow
Average
Brisk
Unable to walk
Do you usually use a cane, walker, or wheelchair/scooter? (Check all that apply.)
Does she usually use a cane, walker, or wheelchair/scooter? (Check all that apply.)
The following questions ask about your memory.
The following questions ask about her memory.
Have you recently experienced any change in your ability to remember things?
No
Yes
Has she recently experienced any change in her ability to remember things?
No
Yes
Do you have more trouble than usual remembering recent events?
No
Yes
Does she have more trouble than usual remembering recent events?
No
Yes
Do you have more trouble than usual remembering a short list of items, such as a shopping list?
No
Yes
Does she have more trouble than usual remembering a short list of items, such as a shopping list?
No
Yes
Do you have any difficulty understanding or following spoken instructions?
No
Yes
Does she have any difficulty understanding or following spoken instructions?
No
Yes
Do you have more trouble than usual following a group conversation or a plot in a TV program due to your memory ?
No
Yes
Does she have more trouble than usual following a group conversation or a plot in a TV program due to her memory ?
No
Yes
Do you have trouble finding your way around familiar streets?
No
Yes
Does she have trouble finding her way around familiar streets?
No
Yes
In the past month, how many hours of actual sleep did you get most nights?
hours
In the past month, how many hours of actual sleep did she get most nights?
hours
In the past month, how would you rate your sleep quality overall?
Very good
Fairly good
Fairly bad
Very bad
In the past month, how would she rate her sleep quality overall?
Very good
Fairly good
Fairly bad
Very bad
In the past month, how often have you taken medicine to help you sleep? (prescribed or over-the-counter)
Not in the past month
Less than once a week
1 or 2 times a week
3 or more times a week
In the past month, how often has she taken medicine to help her sleep? (prescribed or over-the-counter)
Not in the past month
Less than once a week
1 or 2 times a week
3 or more times a week
In the past month, how lonely were you?
Not lonely
Slightly lonely
Moderately lonely
Very lonely
Extremely lonely
In the past month, how lonely was she?
Not lonely
Slightly lonely
Moderately lonely
Very lonely
Extremely lonely
In the past year, have you had any falls to the ground?
No
Yes
In the past year, has she had any falls to the ground?
No
Yes
In the last year, have you lost more than 10 pounds unintentionally? (not due to dieting or exercise)
No
Yes
In the last year, has she lost more than 10 pounds unintentionally? (not due to dieting or exercise)
No
Yes
How much do you currently weigh?
pounds
How much does she currently weigh?
pounds
Do you currently smoke cigarettes?
No
Yes
Does she currently smoke cigarettes?
No
Yes
Did she ever (at any age) smoke cigarettes on a regular basis, meaning at least one cigarette a day on average?
No
Yes
At about what age did she start smoking regularly?
Age started
Did she continue smoking for the rest of her life?
No
Yes
How old was she when she stopped smoking?
Age stopped
How many alcoholic drinks do you currently consume in a week? (By one drink, we mean 12 oz of beer, 5 oz of wine, or 1½ ounces of liquor)
drinks per week
How many alcoholic drinks does she currently consume in a week? (By one drink, we mean 12 oz of beer, 5 oz of wine, or 1½ ounces of liquor)
drinks per week
Do you have a hearing problem?
Not at all
Mild
Moderate
Severe
Does she have a hearing problem?
Not at all
Mild
Moderate
Severe
How old were you when you first noticed the problem?
years old
How old was she when she first noticed the problem?
years old
Do you wear a hearing aid?
No
Yes
Does she wear a hearing aid?
No
Yes
The following questions are about her biological relatives.
Did her biological mother have cancer?
No
Yes
(Report only mother's first cancer.)
Breast cancer Endometrial cancer Cancer of the ovary Colon or rectal cancer Basal or squamous cell skin cancer Melanoma Lymphoma Leukemia Lung cancer Other cancer
Did any of her sisters have breast cancer ?
No
Yes
Age at breast cancer diagnosis (sister 1):
Age at breast cancer diagnosis (sister 2):
Age at breast cancer diagnosis (sister 3):
Do you live in any of the following residential settings?
Nursing home
Assisted living facility
Senior/retirement housing
None of these
Does she live in any of the following residential settings?
Nursing home
Assisted living facility
Senior/retirement housing
None of these
Which of the following best describes the group to which she belonged?
White or European Descent
Black or African American
Asian or Pacific Islander
Hispanic or Latina
Native American
Other
NYU Women's Health Study Participant Information
Is there someone that we could contact if we are unable to contact you?
Yes
No
Contact person street address
Contact person home phone #
Contact person cell phone #
What is your relationship to the study member?
her husband, daughter, etc.
Is there someone better able than you to provide medical information about our study member?
Yes
No
Please name this person below
The following questions ask you for your feedback about this questionnaire
QA1 Is the lettering large enough?
Yes
No
QA2 Are any questions confusing?
Yes
No
QA3 Please write the question number that was confusing
QA4 Please tell us what makes the question you wrote above unclear or difficult.
QA3 Please write the question number that was confusing
QA4 Please tell us what makes the question you wrote above unclear or difficult.
QA3 Please write the question number that was confusing
QA4 Please tell us what makes the question you wrote above unclear or difficult.