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 FEMALE QUESTIONNAIRE - PAGE 6 

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SYMPTOMS: REPRODUCTIVE

Some of the questions below are personal in nature. If you are unwilling to answer a question, skip it by leaving the default "don't know" response.
541.  At what age did you become sexually active?
Not applicable / never active / don't know
Before age 15
15 to 19
20 to 25
Over 25
542.  What is the approximate number of sexual partners that you have had during your lifetime?
Unwilling to answer / don't know
One or fewer
2 to 5
6 to 20
Over 20
543.  Is your sexual desire (libido)... ?
Totally absent
Reduced
Normal / don't know
Increased
Very strong
544.  Have you had endometriosis?
Never had it / don't know
Probably had it/minor episode(s) now resolved
Major episode(s) now resolved
Current minor problem
Current major problem
545.  Have you had Pap smear tests?
Don't know
Never had one
No, not within the last year
Yes, within last year, cells normal
Yes, within last year, cells abnormal
546.  Cervical Dysplasia. Have irregular, but non-cancerous, cells been found on a PAP smear? (Class 1 = Slightly abnormal, Class 2 = Abnormal, Class 3 = Severely abnormal. Class 4 would be cancer.)
Not applicable / don't know
Abnormal cells in the past only - class 1 or 2
Very abnormal cells in the past only - class 3
Current abnormal cells - class 1 or 2
Current very abnormal cells - class 3
547.  Do you have difficulty achieving an orgasm?
Don't know
No
Occasionally
Often
Always
548.  When you have tried, how difficult in general has it been for you to conceive children?
Not applicable / I have not tried / don't know
It has not been difficult
There was some difficulty
It was very difficult
I am infertile / unable to have children
549.  Is there a chance of your becoming pregnant within the next six months?
Don't know
No, definitely not
Yes, a fair chance
Yes - in fact I think I may be already
I am currently pregnant
550.  Have you ever been pregnant, now or in the past?
Don't know
No
Yes, but not currently pregnant
More questions later...
Currently pregnant with first child
More questions later...
Pregnant now but this is not my first time
More questions later...
551.  Have you had uterine fibroids?
Never had them / don't know
Probably had them/minor episode(s) now resolved
Major episode(s) now resolved
Current minor problem
Current major problem
552.  Have you had ovarian cysts?
Never had one / don't know
Probably had one/minor episode(s) now resolved,
Major episode(s) now resolved
Current minor problem
Current major problem
553.  Do you find that deep penetration during sexual intercourse is particularly painful?
Not applicable / don't know
No
Occasionally / moderately
Often / severely
554.  Do you ever experience a vaginal burning sensation?
Occasionally / don't know
No, never
Yes, even without sexual activity
Only with sex, but even without semen contact
Only after contact with semen
555.  Do you have any unusual vaginal discharge or bleeding? An unusual discharge may be heavier/thicker than usual, puslike, grayish, greenish, yellowish, blood-tinged, foul-smelling, with possible itching/burning/rash/soreness.
Don't know
No
Occasional slight discharge
More questions later...
Regular minor discharge / occasional significant
More questions later...
Constant significant discharge
More questions later...
556.  Do you have vaginal itching?
No / don't know
Occasionally / moderate
Often / severe
557.  Do you experience any discomfort in the vulvar area (labia and opening to the vagina)?
Don't know
No
Mild irritation / burning - stinging
Moderate pain
Very painful / sensitive to any contact
558.  Do you experience vaginal dryness? It is usually associated with itching, burning and pain during sexual intercourse.
Never had it / don't know
Probably had it/minor episode(s) now resolved
Major episode(s) now resolved
Current minor problem
Current major problem
559.  Do you have any genital sores or lesions?
No / don't know
One or two, minor
Numerous, minor
One or two, worrying
Numerous, worrying
560.  Do you have any wart-like fleshy bumps in or around the vagina or anus, or groin? They may bleed when irritated, and may occur individually or merge to form small cauliflower-like clusters.
Don't know
No
Yes, one or two
Yes, a few
Yes, many / cluster(s)
561.  What is your current menstrual status? If unsure, answer Premenopausal if aged under 45 or Perimenopausal if 45-52. Only answer Postmenopausal if you have passed through menopause. Answering Don't know will present all menstrual questions.
Not applicable / don't know
More questions later...
Premenopausal - I still have regular periods
More questions later...
Perimenopausal - periods are changing
More questions later...
Menopausal - having menopausal symptoms
More questions later...
Postmenopausal, either naturally or surgically
More questions later...
562.  What is your HIV/AIDS risk/status?
I am not at risk and have tested negative
I am not at risk, but have not been tested
Don't know
I am at risk
I have been diagnosed with it
563.  Other than AIDS, have you had any form of sexually-transmitted disease (STD)?
Don't know
No
Yes / probably    More questions later...

Add any additional information here for the questions above:

Please mention the question number(s) if possible.

 
SYMPTOMS: RESPIRATORY
564.  Do you have a cough that produces mucus?
Don't know
No
Recent problem for less than a month
Problem for over a month but less than a year
Problem for more than a year
565.  Do you have a cough that does not produce mucus (a 'dry cough')?
Don't know
No
Recent problem for less than a month
Problem for over a month but less than a year
Problem for more than a year
566.  Do you have Chronic Obstructive Pulmonary Disease (COPD), also known as Emphysema or chronic Bronchitis?
Don't know
No - definitely not
Mildly
Moderately
Severely
567.  Do you have a history of Acute Infectious Bronchitis? Symptoms may include chest pain on coughing, difficulty breathing, mild fever and a cough with mucus produced later in the course of the infection.
Don't know
No
Recurrent problem, but no symptoms now
Recurrent problem with current symptoms
Current problem for the first time
568.  Do you feel worse when in moldy or musty places?
No / don't know
Somewhat
Very much
569.  Pneumonia
Never had it / don't know
Probably/minor episode(s) now resolved
Major episode(s) now resolved
Current minor problem
Current major problem
570.  Do you ever have shortness of breath that is not associated with significant exertion? In other words, do you experience a sensation of difficult or uncomfortable breathing or a feeling of not getting enough air?
Don't know
No
Mildly / occasionally
Moderately / often
Serious sudden unexplained onset
571.  How easily do you become short of breath?
Don't know
Only with great exertion, for example sprinting
With moderate exertion such as jogging
Even with mild activity, such as walking
Always/often - even when not active
572.  Asthma
Never had it / don't know
Probably had it/minor episode(s) now resolved
Major episode(s) now resolved
Current minor problem
Current major problem
573.  Do you wheeze? If you are using respiratory medication (e.g. for asthma), tell us if you wheeze when you are not using it.
Don't know
No, not at all
Only after exercise
Occasionally / slightly
Much of the time / severely
574.  Sore throat / tonsillitis. How many times per year do you suffer from this?
Never / rarely
About once a year / average / don't know
2-3 times, mildly
2-3 times severely or more than 3 times mildly
More than 3 times, severely
575.  Tuberculosis
Never had it / don't know
Probably/minor episode now resolved
Major episode now resolved
Current minor problem
Current major problem
576.  Have you experienced any kind of chest pain, burning, tightness, pressure or discomfort within the past year?
Don't know
No
Yes    More questions later...

Add any additional information here for the questions above:

Please mention the question number(s) if possible.

 
SYMPTOMS: SLEEP
577.  How often do you take a nap outside of normal sleeping hours?
Never / don't know
Once a month or less
Once a week or less
A few times per week
Daily or almost daily
578.  Roughly how often do you yawn, on average?
Never / a few times per year perhaps
I'd say less than average
Average / a few times per day / don't know
Many times during the day
Several times every hour
579.  Drowsiness. Not including after meals, do you find yourself often falling asleep in situations such as boring meetings, watching TV or while driving?
Never / don't know
Once a month or less
Once a week or less
A few times per week
At least daily
580.  Do you generally become sleepy after eating?
Rarely / don't know
No
Occasionally
Often
581.  Do you have difficulty staying awake after midnight?
Yes, always
Usually / I only stay up for special occasions
Sometimes / I'm about average / don't know
No, I regularly stay up into the small hours
Not at all, I'm a real "night person"
582.  How is your quality of sleep when you are able to sleep without interruption or pain?
Usually broken up / difficult
Sometimes broken up / difficult
Average/sound / don't know
Generally deep
Always deep
583.  Sleep. On average, how many hours of sleep do you get per night?
Fewer than 6
6 to 7
8 / don't know
9
10 or more
584.  Do you sweat at night? Only include sweating that is not the result of an overly warm environment or too many bed covers.
Don't know
No
Only slightly
Moderately, sheets are damp or moist
Profusely, sheets are soaked
585.  If you suffer from night sweats (severe/drenching sweating that is not due to heat or humidity), for how long has it been a problem?
Not applicable / don't know
Recent onset only - less than 2 weeks' duration
2 weeks to 2 months
2 to 6 months
Longer than 6 months
586.  Do you experience bizarre, vivid or nightmarish dreams?
Never / don't know
Occasionally
Quite often, quite bad
Often and awful/recurring nightmares
587.  Do you remember your dreams when you wake up?
I almost always remember my dreams clearly
Average - sometimes I remember / don't know
I almost always forget them quickly
588.  Do you have any other sleep problems? Examples include insomnia, restless legs, snoring, apnea, other sleep disorders, grogginess and problems that are present upon waking up.
Don't know
No
Yes    More questions later...

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SYMPTOMS: CARDIOVASCULAR
589.  Atherosclerosis.
Never had it / don't know
Probably had it/minor symptoms now resolved
Significant symptoms now resolved
Current problem
Current major problem
590.  Have you had an enlarged artery called an aneurysm or experienced a ruptured aneurysm? Sometimes cerebral aneurysms are the cause of stroke, although most strokes are caused by clotting rather than by a rupturing aneurysm.
Don't know
No
Possible enlargement being watched for progression
Yes, may require surgery
Yes, ruptured or required surgery
591.  Do you have Raynaud's phenomenon (extreme loss of circulation to fingers and/or toes)?
No / don't know
Probably had it / minor episode(s) now resolved
Major episode(s) now resolved
Current minor problem
Current major problem
592.  Have you been diagnosed with vasculitis?
Don't know
No
Yes, in the past, but it is not a current problem
Yes, it is a minor recurring problem
Yes, it is a serious recurring problem
593.  Have you been diagnosed with phlebitis or thrombophlebitis?
Don't know
No, I do not have this condition
Yes, but in the past only - not a current problem
Yes, superficial phlebitis
Yes, deep vein - thrombophlebitis
594.  Do you suffer from occasional and unusual pain that is in your chest, upper left arm, or left side of neck?
No / don't know
Occasionally / moderate
Often / severe
595.  Does your heart sometimes race or palpitate such that you can feel it beating?
No / don't know
Occasionally / moderately
Often / severely
596.  Have you had any kind of heart problem not mentioned above? Examples include heart attack, valve damage, enlargement, weakness, failure, pain, etc.
Don't know
No
Yes / probably    More questions later...
597.  Do you have varicose veins?
No / don't know
Minor - first signs
Moderate - a few, small instances
Serious - many minor instances or a few major
Severe - many major instances
598.  Have you had any kind of anemia?
Don't know
No
Yes    More questions later...

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Please mention the question number(s) if possible.

 
SYMPTOMS: IMMUNE SYSTEM
599.  Have you suffered from boils, abscesses or carbuncles?
Never had one / don't know
Probably had one/minor episode(s) now resolved
Major episode(s) now resolved
Current minor/occasional problem
Current major/frequent problem
600.  Have you ever been diagnosed with cytomegalovirus (CMV)?
No / don't know
Yes
601.  Have you ever been diagnosed with Epstein-Barr virus (EBV)?
Don't know
No, tests were negative
Yes, doctor suggested it but no testing was done
Yes, tests confirmed previous infection only
Yes, tests confirmed current active infection
602.  Have you had vaginal yeast infections? Symptoms may include itching, burning or a "cottage cheese" discharge.
Don't know
No
In the past, but none for at least a year
Currently 1 to 3 per year
Chronic problem / more than 3 per year
603.  Have you been diagnosed with Candida infection anywhere in your body other than the vagina?
Never had it / don't know
Probably had it/minor episode(s) now resolved
Major episode(s) now resolved
Current minor problem
Current major problem
604.  Have you had vaginal infections that were NOT caused by yeast? Symptoms, if any, may include discharge, irritation and itching.
Don't know
No
In the past, but none for at least a year
Currently 1 to 3 per year
Chronic problem / more than 3 per year
605.  Have you had fungal or yeast infections anywhere OTHER THAN the vagina?
No / don't know
Minor in the past only, now resolved
Major in the past only, now resolved
Current minor problem
Current major problem
606.  Have you had Coccidioidomycosis (Valley Fever)?
Don't know
No, tested negative
In the past only
Current problem, only lungs involved
Current problem, disseminated
607.  Do you have a history of infections, for example skin, ear, bladder, respiratory etc.?
No / almost never
Average - occasionally / don't know
Often - one or two per year
Very often - more than two per year
608.  Have you ever been diagnosed with Lupus (SLE, Systemic Lupus Erythromatosis)?
No / don't know
Minor episode(s) now resolved
Major episode(s) now resolved
Current minor problem
Current major problem
609.  Have you ever been diagnosed with Lyme disease?
No / don't know
Minor episode now resolved
Major episode now resolved
Current minor problem
Current major problem
610.  Do you generally have poor wound healing?
No / don't know
Moderate - healing takes longer than it should
Severe - healing takes weeks/months
611.  Blood clotting problems. When you start to bleed, does it take a long time to stop?
Don't know
No, bleeding stops quickly (normal)
It takes quite a long time
Yes, definitely
I have von Willebrand disease or hemophilia
612.  Have you suffered from Postviral Syndrome - a viral infection where symptoms persist for a long time?
Never had it / don't know
Probably/minor episode now resolved
Major episode now resolved
Current minor problem
Current major problem
613.  Have you been diagnosed with scleroderma?
Never had it / don't know
Probably/minor episode now resolved
Major episode now resolved
Current minor problem
Current major problem
614.  Have you had Shingles, also known as Varicella Zoster?
Never had it / don't know
Probably/minor episode now resolved
Major episode now resolved
Current minor problem
Current major problem
615.  Have you been diagnosed with chronic thyroiditis (Hashimoto's disease)?
Never had it / don't know
Probably/minor episode now resolved
Major episode now resolved
Current minor problem
Current major problem
616.  Have you had tumors that were benign, or non-ovarian cysts?
Never had any / don't know
Probably/minor episode now resolved
Major episode now resolved
Current minor problem
Current major problem
617.  Do you have Multiple Sclerosis? Details can be entered into box below.
Never had it / don't know
Probably had it/minor episode now in remission
Significant problem in remission for some time
Current problem
Current major problem
618.  Have you ever had from any form of cancer?
No / don't know
Yes    More questions later...

Add any additional information here for the questions above:

Please mention the question number(s) if possible.

 


 


GLOSSARY

Acute
An illness or symptom of sudden onset, which generally has a short duration.

AIDS
Acquired Immune Deficiency Syndrome. An immune system deficiency disorder that suddenly alters the body's ability to defend itself. The AIDS virus invades the T4 helper/inducer lymphocytes and multiplies, causing a breakdown in the body's immune system, eventually leading to overwhelming infection and/or cancer, with ultimate death.

Anemia (Anaemia, Anemias)
A condition resulting from an unusually low number of red blood cells or too little hemoglobin in the red blood cells. The most common type is iron-deficiency anemia in which the red blood cells are reduced in size and number, and hemoglobin levels are low. Clinical symptoms include shortness of breath, lethargy and heart palpitations.

Aneurysm
Localized enlargement of an artery.

Apnea
Cessation of breathing.

Arterial (Arteries, Artery)
Blood that leaves the heart. When it leaves the right ventricle, it is venous blood; and when it leaves the left ventricle, through the aorta, it is fresh and oxygenated. After it has passed out to the capillaries and started to return, it is venous blood.

Asthma (Asthmatic)
A lung disorder marked by attacks of breathing difficulty, wheezing, coughing, and thick mucus coming from the lungs. The episodes may be triggered by breathing foreign substances (allergens) or pollutants, infection, vigorous exercise, or emotional stress. Extrinsic Asthma is triggered by pollen, chemicals or some other external agent; Intrinsic Asthma is triggered by boggy membranes, congested tissues, or other native causes… even adrenalin stress or exertion.

Atherosclerosis
Common form of arteriosclerosis associated with the formation of atheromas which are deposits of yellow plaques containing cholesterol, lipids, and lipophages within the intima and inner media of arteries. This results in a narrowing of the arteries, which reduces the blood and oxygen flow to the heart and brain as well as to other parts of the body and can lead to a heart attack, stroke, or loss of function or gangrene of other tissues.

Benign
Literally: innocent; not malignant. Often used to refer to cells that are not cancerous; they tend to grow slowly and don't spread (metastasize) like cancer tumors do.

Boil (Abscess, Abscesses, Boils, Carbuncle, Carbuncles, Cystic Acne, Furuncle, Furuncles, Hidradenitis Suppurativa, Pilonidal Cyst, Pilonidal Cysts)
A localized infection deep in the skin. A boil generally starts as a reddened, tender area. Over time, the area becomes firm and hard. Eventually, the center of the abscess softens and becomes filled with white cells that the body sends to fight the infection (pus). Finally, the pus forms a "head" and drains out through the skin. A furuncle or carbuncle is an abscess in the skin caused by the bacteria Staphylococcus aureus. It can have one or more op