Genomics Research Centre General Questionnaire

General Family History

Surname
First Name                              
Year of Birth
Country of Birth                              
Sex
Male Female
    
Occupation(if retired Previous Occupation)
 
                         
Mothers Name
        
Mothers maiden name (if known)
        
Mothers Date of Birth
        
Mothers Country of Birth
                         
If your mother is deceased, her Year of Death
                        
Fathers Name
                      
Fathers Date of Birth
                    
Fathers Country of Birth
                  
If your father is deceased, his year of death
                
What country was your maternal grandmother (MGM) born?
              
What country was your maternal grandfather (MGM) born?
            
What country was your paternal grandmother (PGM) born?
          
What country was your paternal grandfather (PGF) born?
        
Are you a twin?
Yes  
No
If yes, Are you Identical or Non-Identical?
Identical
Non-Identical
Unknown
 
Do you have any other brothers or sisters?
Yes
No




If yes Please enter their sex and year of birth

      
     
1. Sex Birth Year
Male Female
   
2. Sex Birth Year
Male Female
3. Sex Birth Year
Male Female
   
4. Sex Birth Year
Male Female
5. Sex Birth Year
Male Female
6. Sex Birth Year
Male Female
7. Sex Birth Year
Male Female
8. Sex Birth Year
Male Female
9. Sex Birth Year
Male Female
10. Sex Birth Year
Male Female
 
Do you have any Children?
Yes
No



If yes Please enter their sex and year of birth

 
1. Sex Birth Year
Male Female

 
2. Sex Birth Year
Male Female

 
3. Sex Birth Year
Male Female

 
4. Sex Birth Year
Male Female
5. Sex Birth Year
Male Female
6. Sex Birth Year
Male Female
7. Sex Birth Year
Male Female
Your Address
  
Height(in cms)
  
Weight (in kgs.)
  
Waist Circumference (in cms.)
  
Hip Circumference (in cms.)
  
Waist/Hip Ratio
  
Body Mass Index (BMI)
  
Blood Pressure (in mm or Hg)
        
Have you ever smoked cigarettes, cigars or a pipe?
Never Smoked
Yes, Current Smoker
Yes, Ex Smoker
                         
If yes, as what age did you start smoking?
  
Do you smoke at all now?
Yes
No
   
If you were an ex-smoker, at what age did you quit?
  
How many cigarette/cigars do/did you smoke on average each day?
  
Are you regularly exposed to someone else's smoke at work, school or home?
  
What is your current Alcohol consumption?
Never
Social Occasions only
1-5 standard drinks/week
6-10 standard drinks/week
11-15 standard drinks/week
16-20 standard drinks/week
21-30 standard drinks/week
31-40 standard drinks/week
More than 40 standard drink/week
     
Do you exercise?
Never
Less than once/month
Less than once/fortnight
Less than once/week
1-2 times/week
2-3 times/week
4-5 times/week
> 6 times/week
                     
If you answered yes, what type of exercise do you participate in?
  
On an average, how much time would you spend exercising per session?
< 20 minutes
20 - 30 minutes
30 - 45 minutes
45 min -1hr
1 - 1.5 hrs.
1.5 - 2 hrs.
2 - 2.5 hrs.
2.5 - 3 hrs.
> 3 hrs.
       
Females Only (How old were you when you had your first period?
  
Are you still having regular periods?
Yes
No
                                         
If not, how old were you when you had your last regular period?
  
What is your menopausal status?
Definitely Pre-Menopausal (Definitely Post-Menopausal (Menstruating regularly)
Definitely Post-Menopausal (Ceased menstruating)
Menstruating, but not regularly
       
How many pregnancies have you had (including miscarriages, stillbirths and terminations)?
        

How many children did you breast-feed?

  
Have you ever taken the oral contraceptive pill?
No
Yes, Current
Yes, ex-user
                                     
If YES, how old were you when you started on the pill?
  
How long have you been or were you on the pill? (in Months)
  
Have you ever had hormone replacement therapy (HRT)?
No
Don't know
Yes, Current
Yes, ex-user
                                     
If YES, how old were you when you went on to HRT?
 
Have you ever had severe menstrual problems?
Yes
No