Initial Reproductive History Form and Dictionary
| Initial Reproductive History | ||
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| Variable / Field Name | Field Label | Choices, Calculations, OR Slider Labels |
|---|---|---|
| rep_hist_adcid | Site: 39 ADCID | rep_hist_ptid | Subject ID: PTID | rep_hist_visitdate | Form Date: (Y-M-D) | rep_hist_visitnum | Visit Number: 1 Initial visit | rep_hist_initials | Examiner's initials: INITIALS | rep_hist_ent_date | Data Entry Date: (Y-M-D) | rep_hist_ent_by | Data Entry By: | initial_repro_admin_sts | Administered Status | 1, 1 Yes | 95, 95 - No, Physical Problem | 96, 96 - No, Cognitive/Behavior Program | 97, 97 - No, Other Problem | 98, 98 - No, Verbal Refusal | 99, 99 - Not Administered | rep_hist_text00 | Reproductive History (women only), initial visit | rep_hist_q1 | 1. How old were you when you had your first menstrual period? (nearest 6 months; e.g. 11 1/2 or 12 or 12 1/2 years old, coded as 11.5, 12.0, or 12.5 years) | rep_hist_q2 | 2. How many pregnancies have you had? (0/ 1/ 2/ 3/ 4/ 5 or more) (Do not include induced abortions or spontaneous abortions (miscarriages) during the first or second trimester.) (If the answer to #2 is 0 pregnancies, mark 0 for question #3 and skip to question #4.) | 0, 0 | 1, 1 | 2, 2 | 3, 3 | 4, 4 | 5, 5 or more | rep_hist_q3 | 3. How many live-born children have you had? (0/ 1/ 2/ 3/ 4/ 5 or more) | 0, 0 | 1, 1 | 2, 2 | 3, 3 | 4, 4 | 5, 5 or more | rep_hist_q4 | 4. Have you ever had one or both ovaries removed? (Y/N/DK) | 0, 0 No | 1, 1 Yes | 9, 9 Don't Know | rep_hist_q4a | 4a. If YES, one or both? (one/two/DK) | 1, 1 | 2, 2 | 9, 9 Don't Know | rep_hist_q4ai | 4ai. If ONE or DON'T KNOW, what was your age when your ovary was removed? (years) | rep_hist_q4aii | 4aii. If TWO, both at the same time? (Y/N/DK) | 0, 0 No | 1, 1 Yes | 9, 9 Don't Know | rep_hist_q4aiia | 4aii(A). If YES or DON'T KNOW, what was your age when your ovaries were removed? (years) | rep_hist_q4aiib1 | 4aii(B1). If NO, what was your age when your first ovary was removed? (years) | rep_hist_q4aiib2 | 4aii(B2). If NO, what was your age when your second ovary was removed? (years) | rep_hist_q5 | 5. Have you ever had a hysterectomy (partial hysterectomy or total hysterectomy)? / (or, Have you ever had your uterus removed?) (Y/N/DK) | 0, 0 No | 1, 1 Yes | 9, 9 Don't Know | rep_hist_q5a | 5a. If YES, how old were you when you had a hysterectomy? (years) | rep_hist_q5b | 5b. (For women who answered YES to question #4 and question #5): If YES, was this at the same time that (your ovary was removed)/ (your ovaries were removed)? (Y/N/DK) | 0, 0 No | 1, 1 Yes | 9, 9 Don't Know | rep_hist_q6 | 6. Are you currently using (hormonal) birth control? (Y/N/DK) (Hormonal birth control refers to an estrogen or a progestin or both. These can be taken or delivered by mouth, by injection, by transdermal patch, by a vaginal ring, or by a subcutaneous implant. It does not include intrauterine devices or other forms of contraception. OK to assume "NO" for ages 60+.) | 0, 0 No | 1, 1 Yes | 9, 9 Don't Know | rep_hist_q7 | 7. Have you ever taken hormone therapy (menopausal hormone therapy)? (Y/N/DK) (Hormone therapy is an estrogen, with or without a progestogen, taken by mouth, or delivered by injection or transdermal patch. Include estrogen prescribed for migraine headache. Do not include vaginal (topical) estrogen.) | 0, 0 No | 1, 1 Yes | 9, 9 Don't Know | rep_hist_q7a | 7a. If YES, are you currently taking hormone therapy? (Y/N/DK) | 0, 0 No | 1, 1 Yes | 9, 9 Don't Know | rep_hist_q7b | 7b. If YES, how old were you when you most recently started (or most recently restarted) hormone therapy? (years) | rep_hist_q8 | 8. Are you still menstruating?/ (or, Have you had a menstrual period within the past 12 months?) (Y/N/DK) (DON'T KNOW may apply when a woman started hormone therapy prior to a final menstrual period.) | 0, 0 No | 1, 1 Yes | 9, 9 Don't Know | rep_hist_q8a | 8a. If YES, have you had a menstrual period within the past 60 days? (Y/N/DK) | 0, 0 No | 1, 1 Yes | 9, 9 Don't Know | rep_hist_q8b | 8b. If YES, would you describe your current menstrual cycle (menstrual periods) as 1) regular without a change in flow or length, 2) regular but with mild changes in flow or length, or 3) variable with a persistent, 7 or more day difference in the length of consecutive cycles (periods)? (Regular/ Mild changes/ Variable) | 1, 1 Regular: regular without a change in flow or length | 2, 2 Mild changes: regular but with mild changes in flow or length | 3, 3 Variable: variable with a persistent 7 or more day difference in the length of consecutive cycles | rep_hist_q8c | 8c. If NO, how old were you when you had your last period? (years) (This age must be at least 1 year less than the current age.) |