NS-LIJ Tissue Donation Program
Endometriosis Specimen Bank Data Collection Form
Name:
Affix Subject ID
SUBJECT ID: TB1302
Address: Street
City, State, Zip Code
Phone: Home:
Cell:
Other:
Date of birth:
Gender:
Female
Male
Email:
Are any of your blood relatives already in this study?
yes
no
If yes:
DOB
Name
Relationship
Office use:
Assigned family ID:
Assigned Family Position ID:
Family history:
Do you have any relatives with endometriosis?
If yes, provide details
Relationship
yes
Comment
Do you have any other relatives with history of cancer?
If yes, provide details
Relationship
04/10/14
no
yes
Cancer Type
no
Comment
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NS-LIJ Tissue Donation Program
Endometriosis Specimen Bank Data Collection Form
Affix Subject ID
Gynecological History:
How old are you when you had your first menstrual period? ________
Are your periods regular?
Extremely regular (no more than 1-2 days before or after expected)
Very regular (within 3-4 days of expected)
Regular (within 5-7 days of expected)
Usually irregular
Always irregular
If regular, how many days in a cycle? (number of days between the first day of one period and the first
day of the next (on average)? _______
How many days of bleeding? ___________
In the past three months have you had any of the following symptoms with your periods:
О No periods in the past three months
Pain: Yes
No
If yes, please describe the pain:
Very Painful Cramping
Discomfort
Aching
Other (please describe) ________________
Heavy bleeding?
Yes
No
Clotting?
Yes
No
Pain with bowel movement?
Yes
No
Leg pain with period? Yes
No
Pain during ovulation? Yes
No
Pain with intercourse? Yes
No
Abdominal or pelvic pain when not menstruating?
Yes
No
Other symptoms (Please describe): ___________________________________________
From the time of your first period to age 20 did you have any of the following symptoms with your periods:
О No periods in this age range
Pain: Yes
No
If yes, please describe the pain:
Very Painful Cramping
Discomfort
Aching
Other (please describe) ________________
Heavy bleeding?
Yes
No
Clotting?
Yes
No
Pain with bowel movement?
Yes
No
Leg pain with period? Yes
No
Pain during ovulation? Yes
No
Pain with intercourse? Yes
No
Abdominal or pelvic pain when not menstruating?
Yes
No
Other symptoms (Please describe):___________________________________________
04/10/14
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NS-LIJ Tissue Donation Program
Endometriosis Specimen Bank Data Collection Form
Affix Subject ID
From the age of 20 to the age of 30 did you have any of the following symptoms with your periods:
О No periods in this age range
Pain: Yes
No
If yes, please describe the pain:
Very Painful Cramping
Discomfort
Aching
Other (please describe) ________________
Heavy bleeding?
Yes
No
Clotting?
Yes
No
Pain with bowel movement?
Yes
No
Leg pain with period? Yes
No
Pain during ovulation? Yes
No
Pain with intercourse? Yes
No
Abdominal or pelvic pain when not menstruating?
Yes
No
Other symptoms (Please describe): ___________________________________________
From the age of 30 to the age of 40 did you have any of the following symptoms with your periods:
О No periods in this age range
Pain: Yes
No
If yes, please describe the pain:
Very Painful Cramping
Discomfort
Aching
Other (please describe) ________________
Heavy bleeding?
Yes
No
Clotting?
Yes
No
Pain with bowel movement?
Yes
No
Leg pain with period? Yes
No
Pain during ovulation? Yes
No
Pain with intercourse? Yes
No
Abdominal or pelvic pain when not menstruating?
Yes
No
Other symptoms (Please describe): ___________________________________________
After the age of 40 did you have any of the following symptoms with your periods:
О No periods in this age range
Pain: Yes
No
If yes, please describe the pain:
Very Painful Cramping
Discomfort
Aching
Other (please describe) ________________
Heavy bleeding?
Yes
No
Clotting?
Yes
No
Pain with bowel movement?
Yes
No
Leg pain with period? Yes
No
Pain during ovulation? Yes
No
Pain with intercourse? Yes
No
Abdominal or pelvic pain when not menstruating?
Yes
No
Other symptoms (Please describe): ___________________________________________
04/10/14
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NS-LIJ Tissue Donation Program
Endometriosis Specimen Bank Data Collection Form
Fertility:
Have you ever been pregnant?
Yes
Affix Subject ID
No
If you have been pregnant,
How many times have you been pregnant? _______
How many live deliveries have you had? _______
Have you ever had a miscarriage or termination of pregnancy?
If yes, how many? ________
Yes
No
If you have been pregnant, did you have difficulty conceiving?
Yes No
If yes, did you have any fertility treatment? Yes No
What treatments? ________________________________________________________
If you have not been pregnant, have you ever tried to conceive?
Yes No
If yes, have you ever had fertility treatments?
Yes No
What treatments? _______________________________________________
Have you had a tubal ligation (sterilization/tubes tied)?
Yes
No
If yes, how old were you at the time of ligation? _______
Have you ever used oral contraceptives? Yes No
If yes, are you currently using oral contraceptives?
Yes
No
If yes, what is the name and dosage of the pill you use now? _________________________
How many years in total have you taken oral contraceptives? ________
Have you ever used a birth control patch? Yes No
If yes, are you currently using a birth control patch?
Yes
No
If yes, what is the name and dosage of the birth control patch you use now? _________________________
How many years in total have you used a birth control patch? ________
Have you ever used an internal birth control device, such as a coil or IUD? Yes
If yes, are you currently using a coil or IUD?
Yes
No
If yes, what type are you using now? _________________________
How many years in total have you used a coil or IUD? ________
No
Have you ever used an internal hormone releasing birth control ring such as NuvaRing? Yes No
If yes, are you currently using an internal hormone releasing birth control device?
Yes
No
If yes, what type are you using now? _________________________
How many years in total have you used an internal hormone releasing birth control device? ________
Have you ever used hormonal injections/shots? Yes No
If yes, are you currently using hormonal injections/shots?
Yes
No
If yes, what is the name and dosage you are using now? _________________________
How many years in total have you used hormonal injections/shots? ________
If you are not currently being treated with hormonal injections, but have used these in the past, please tell
us the names and dosages of the drugs you were treated with and the total number of years you used them.
_______________________________________________________________________________
_______________________________________________________________________________
Have you ever used hormonal implants such as Implanon/ Nexplanon? Yes No
If yes, are you currently using a hormonal implant?
Yes
No
If yes, what type and dosage are you using? _________________________
How many years in total have you used a hormonal implant? ________
04/10/14
Page 4 of 6
NS-LIJ Tissue Donation Program
Endometriosis Specimen Bank Data Collection Form
Affix Subject ID
Have you ever used hormone replacement therapy? Yes No
If yes, are you currently using hormone replacement therapy?
Yes
No
If yes, what type and dosage are you using? _________________________
How many years in total have you used hormone replacement therapy? ________
Have you ever used any other hormone treatments? Yes No
If yes, what type?_________________________________________________________________________
Total years used: _______
Have you completed menopause? Yes
No Perimenopausal
Age at menopause? ____________
Was menopause natural or surgically induced? ________________________
Surgical history:
Have you ever had surgery for diagnosis or treatment of endometriosis:
If yes, please complete:
Date
Surgeon
Yes
No
Hospital
Procedure
_________________________________________________________________________________________
_________________________________________________________________________________________
_________________________________________________________________________________________
_________________________________________________________________________________________
Have you ever had abdominal or pelvic surgery for any other reason:
If yes, please complete:
Date
Surgeon
Hospital
Yes
No
Procedure
_________________________________________________________________________________________
_________________________________________________________________________________________
_________________________________________________________________________________________
________________________________________________________________________________________
If available, please provide copies of Pathology and Operative Reports.
Please complete ethnicity questionnaire on next page.
04/10/14
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NS-LIJ Tissue Donation Program
Endometriosis Specimen Bank
Data Collection Form
Affix Subject ID
Ethnicity:
American Indian/Alaska Native
North America
South America (includes Central America)
Asian
Chinese
Korean
Filipino
Pakistani
Vietnamese
Cambodian
Japanese
Malaysian
Thai
Indian
Black/African-American
African-American
West Indian
African heritage
Jewish
Ashkenazi Jewish
Sephardic Jewish
Other or Unknown
Latino/Hispanic
Mexican
Central American
South American
Dominican
Puerto Rican
Cuban
West Indian
Native Hawaiian/Pacific Islander
Hawaiian
Samoan
Guamanian or Chamorro
Pacific Islands
White
Northern European (England, Scotland, Wales, Ireland, N. France, Holland, Belgium, Switzerland)
Scandinavian (Denmark, Norway, Sweden, Finland)
Southern European (Spain, Portugal, Italy, S. France)
Central European (Germany, Austria, Hungary)
Eastern European (Russia, Poland, Romania, Ukraine, Lithuania, Latvia, Estonia, Czech Republic)
East Mediterranean (Greece, Turkey, Croatia, Bosnia,Yugoslavia, Albania)
Northern Africa
Middle East
French Canada
South America
Unknown
04/10/14
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