To be filled out by your doctor
Today M-D-Y
2. First Name
* must provide value
3. Last Name
* must provide value
4. Gender
* must provide value
Female
Male
5. Date of Birth
* must provide value
Today M-D-Y
6. Ethnicity
* must provide value
Check all that apply.
7. Marital Status
* must provide value
Married
Previously Married
Widowed
Single
8. Mailing Address - Street Name
* must provide value
9. Mailing Address - City
* must provide value
10. Mailing Address - State
* must provide value
11. Mailing Address - Zip Code
* must provide value
12. Phone Number
* must provide value
Include Area Code
13. Email Address
* must provide value
14. Weight (pounds)
* must provide value
15. Height (in inches)
* must provide value
For example, if you are 5 feet 2 inches, this value would be 62.
16. Are you a flight attendant, including current or past employment with the airlines?
* must provide value
Yes
No
17. Have you smoked more than 100 cigarettes in your lifetime?
* must provide value
Yes
No
18. Were you exposed to secondhand tobacco smoke for at least one year while working on the aircrafts?
* must provide value
Yes
No
19. Do you want to refer a friend?
Yes
No
If you would like to refer a friend please email us at famri@ucsf.edu or call us at 415-412-0872
Part II
Secondhand Smoke Exposure Questionnaire
i. Airline Related Occupational History
1. Have you ever been employed as an airline flight attendant?
* must provide value
Yes
No
2. Have you flown domestically?
* must provide value
Yes
No
a. How many years have you flown domestically?
b. How many hours a month did you fly domestically?
0-20
20-40
40-60
60-80
80+
c. Please list the range of years that you flew domestically
example: 1967-1998
3. Have you flown internationally?
* must provide value
Yes
No
a. How many years have you flown internationally?
b. How many hours a month did you fly internationally?
0-20
20-40
40-60
60-80
80+
c. Please list the range of years you flew internationally
example 1963-1977
a. Did you fly both domestic and international routes at the same time during a period of your employment?
* must provide value
Yes
No
b. How many years have you flown domestically and internationally at the same time?
* must provide value
c. During this period approximately what percentage of your routes were domestic?
d. d. How many years did you fly before the smoking ban?
d. e. How many hours did you fly before the smoking ban?
4. Please select all former occupations, only those lasting at least one year apply.
How many years did you work as a business executive?
How many years did you work as a health care worker?
How many years did you work as a bar or restaurant employee?
How many years did you work as a teacher?
What was your other profession(s)?
How many years did you work in another profession?
How many hours per week did you work as a business executive?
How many hours per week did you work as a health care worker?
How many hours per week did you work as a bar or restaurant employee?
How many hours per week did you work as a student?
How many hours per week did you work as a teacher?
How many hours per week did you work in another profession?
Were there any smokers around you while working as a business executive?
Yes
No
Were there any smokers around you while working in healthcare?
Yes
No
Were there any smokers around you while working as a bar or restaurant employee?
Yes
No
Were there any smokers around you while you were a student?
Yes
No
Were there any smokers around you while working as a teacher?
Yes
No
Were there any smokers around you while working in another position?
Yes
No
Please estimate the number of smokers in the room with you during your work week as a business executive.
Please estimate the number of smokers in the room with you during your work week as a healthcare worker.
Please estimate the number of smokers in the room with you during your hours working in a bar or restaurant.
Please estimate the number of smokers in the room with you during your school week as a student
Please estimate the number of smokers in the room with you during your work week as a teacher.
Please estimate the number of smokers in the room with you during your work week in another job.
Please estimate the average number of hours per day you smelled or observed smoke while you worked as a business executive?
Please estimate the average number of hours per day you smelled or observed smoke as a student?
Please estimate the average number of hours per day you smelled or observed smoke while working as a healthcare worker?
Please estimate the average number of hours per day you smelled or observed smoke while working in a bar or restaurant?
Please estimate the average number of hours per day you smelled or observed smoke while working as a teacher?
Please estimate the average number of hours per day you smelled or observed smoke while working at another job?
5. Did you retire early from your job (airline or non-airline) due to health problems?
* must provide value
Yes
No
5a. Please explain what health problems you experienced that caused you to retire early.
6. Has a doctor ever told you that you have any of the following medical problems?
Age when diagnosed with high blood pressure
Age when diagnosed with diabetes
Age during heart bypass surgery
Age during coronary angioplasty or stent
Age when diagnosed with congestive heart failure
Age when diagnosed with asthma
Age when diagnosed with chronic bronchitis
Age when diagnosed with emphysema
Age when diagnosed with sleep apnea
Age when diagnosed with lung cancer
Age when diagnosed with breast cancer
Age when diagnosed with thyroid disorder
Age when diagnosed with sinus problems
Age when diagnosed with ear infections
Age when diagnosed with high cholesterol
Age when diagnosed with peripheral vascular disease
List "other" medical condition and age when diagnosed
7. Do you take any medications?
* must provide value
Yes
No
7a. Please list: 1) the names of any medications you are currently, 2) the approximate dates you started the medications, and 3) the average dosage of each medication.
In order to avoid confusion, please skip lines between each medication you list.
8. Do you ever experience chest pain or discomfort with exertion:
* must provide value
Yes
No
a. Have you ever had a stress test done?
Yes
No
i. What was the result of the stress test?
Normal
Abnormal
b. Do you ever experience chest pain or discomfort with emotional stress?
Yes
No
c. In the past 6 weeks, how often have you had chest discomfort (per week)?
9. Do you ever experience shortness of breath?
* must provide value
Yes
No
9a. Do you experience shortness of breath in bed at night?
* must provide value
Yes
No
9b. Do you experience shortness of breath with regular activity?
* must provide value
Yes
No
10. Are you able to perform less physical activity than other healthy people your age?
* must provide value
Yes
No
10a. Please explain the reason you are unable perform the same level of physical activity as other healthy people your age.
11. Please choose the best description of your usual level of activity based on the following definitions:
VERY ACTIVE: Running, fast walking, or other cardiovascular exercise at least once a week for 30 minutes at a time.
ACTIVE: Standing or walking most of the day; lifting groceries, heavy housework, care of young children, or similar activities.
SEDENTARY: Sitting for most of the day without regular physical activity, and does not include minor household or office tasks.
LIMITED: Often staying in bed for part of the day; performs physical activity only when necessary or require assistance with household tasks.
Very active
Active
Sedentary
Limited
12. Do you have a cough?
* must provide value
Daily
Monthly
Rarely (2-3 times per year)
Never
13. Do you have nasal congestion, throat, or eye irritation, not related to a cold or hay fever?
* must provide value
Daily
Monthly
Rarely (2-3 times per year)
Never
14. Have you previously been exposed to vapors, dust, gases, or fumes (OTHER than tobacco smoke) at your workplace?
* must provide value
Yes
No
14a. What were you exposed to?
14b. How many years were you exposed to this agent?
14c. Please list the type of vapor, dust, gas, or fume you were exposed to
15. Are you currently exposed, for at least one hour daily, to vapors, dust, gas or fumes (other than tobacco smoke) at your workplace?
* must provide value
Yes
No
16. Have you ever smoked cigarettes regularly (at least 1 cigarette per day and a total of 100 cigarettes in your lifetime?)
* must provide value
Yes
No
16a. On average, how many cigarettes per day did you smoke when you were smoking at your heaviest?
16b. How old were you when you started to smoke cigarettes regularly?
* must provide value
16c. How old were you when you last smoked cigarettes regularly?
17. Do you smoke cigarettes now?
* must provide value
DAILY
SOME DAYS
NO
17a. On average, how many cigarettes per day do you smoke? (One pack = 20 cigarettes)
* must provide value
17a. On average, how many cigarettes per week do you smoke? (One pack = 20 cigarettes)
* must provide value
18. When your mother was pregnant with you, did either of your parents smoke?
* must provide value
Mother
Father
Both
Neither
Don't know
19. Growing up (until age 18), did anyone regularly smoke indoors in your home?
Yes
No
19a. Age range (example: 13-16)
19b. Please specify the smoker you lived with.
i. Hours per week that you spent time with other smokers? (e.g. babysitter, friends, relatives)
19c. Number of hours per week in a car with a smoker?
20. After age 18, have you ever lived with anyone who smoked cigarettes indoors in your home?
* must provide value
Yes
No
20a. Age Range (example: 19-24)
20b. Please list the number of people who smoked indoors in your home
20c. How many packs of cigarettes did they smoke per day altogether?
Less than one
One
Two
More than two
21. Have you spent time in locations other than home or work where smoking occurred around you (after age 18)?
If the answer is yes, please select the specific location(s).
21a. Hours per week in friends' home with smoke
21b. Age range while in friends' homes
21c. Hours per week in a car with smoke
21d. Age range in car with smoke
21e. Hours per week in restaurants with smoke
21f. Age range while in restaurants with smoke
21g. Hours per week in bars/lounges with smoke
21h. Age range while in bars/lounges with smoke
21i. Please list any other locations where you have been exposed to smoke over the age of 18
21j. Hours per week in other locations with smoke
21k. Age range while in other locations with smoke
22. Over the past 12 months, how often have you gone to places other than your home or work where people smoked around you indoors, close enough to see or smell the smoke?
* must provide value
More than once a week
More than once a month
Less than once a month
Never
23. Have you experienced irritation of your eyes or throat from other people's smoke at home?
* must provide value
More than once a week
More than once a month
Less than once a month
Never
24. Have you experienced irritation of your eyes or throat from other people's smoke at work?
* must provide value
More than once a week
More than once a month
Less than once a month
Never
25. Have you experienced irritation of your eyes or throat from other people's smoke in other places?
* must provide value
More than once a week
More than once a month
Less than once a month
Never
Please tell us more about the respiratory symptoms you have experienced
26. Have you ever used of oral contraceptives?
Yes
No
26a. How long have you taken oral contraceptives?
Under one year
1-2 years
2-5 years
5-10 years
10-15 years
More than 15 years
27. Have you ever been pregnant?
Yes
No
27a. How many times have you been pregnant?
(including miscarriages, abortions, stillbirths, and live births)
27b. Have you ever had a spontaneous miscarriage?
Yes
No
If yes, how many miscarriages have you had?
27c. Have you ever had an abortion?
Yes
No
If yes, how many abortions have you had?
27d. Have you ever had a stillbirth?
Yes
No
If yes, did you learn the cause of the stillbirth?
28. Have you ever given birth?
Yes
No
28a. Have you ever had a baby prematurely?
(prematurely is defined as less than 37 weeks)
Yes
No
If yes, how many premature (<37 weeks) babies have you given birth to?
28b. How many times have you given birth?
One
Two
Three
Four
Five or more
Was your first baby full term, preterm (premature), or stillbirth at the time of delivery?
Full term
Preterm
Stillbirth
At how many weeks and days was your first baby born?
For example: 38 weeks and 5 days
How much did your first baby weigh at birth?
For example: 7 pounds and 6 ounces
Please enter the type of delivery for your first birth.
Vaginal
Cesarean section
How old were you at the birth of your first child?
For example: 35 years old
Did you have any of the following complications during your first pregnancy?
If you selected "Other," please describe the complication for your first birth.
Was your first baby born with any congenital defects?
Yes
No
Was your second baby full term, preterm (premature), or stillbirth at the time of delivery?
Full term
Preterm
Stillbirth
At how many weeks and days was your second baby born?
For example: 38 weeks and 5 days
How much did your second baby weigh at birth?
For example: 7 pounds and 6 ounces
Please enter the type of delivery for your second birth.
Vaginal
Cesarean section
How old were you at the birth of your second child?
For example: 35 years old
Did you have any of the following complications during your second pregnancy?
If you selected "Other", please describe the complication for your second birth.
Was your second baby born with any congenital defects?
Yes
No
Was your third baby full term, preterm (premature), or stillbirth at the time of delivery?
Full term
Preterm
Stillbirth
At how many weeks and days was your third baby born?
For example: 38 weeks and 5 days
How much did your third baby weigh at birth?
For example: 7 pounds and 6 ounces
Please enter the type of delivery for your third birth.
Vaginal
Cesarean section
How old were you at the birth of your third child?
For example: 35 years old
Did you have any of the following complications during your third pregnancy?
If you selected "Other", please describe the complication for your third birth.
Was your fourth baby full term, preterm (premature), or stillbirth at the time of delivery?
Full term
Preterm
Stillbirth
Was your third baby born with any congenital defects?
Yes
No
At how many weeks and days was your fourth baby born?
For example: 38 weeks and 5 days
How much did your fourth baby weigh at birth?
For example: 7 pounds and 6 ounces
Please enter the type of delivery for your fourth birth.
Vaginal
Cesarean section
How old were you at the birth of your fourth child?
For example: 35 years old
Did you have any of the following complications during your fourth pregnancy?
If you selected "Other", please describe the complication for your fourth birth.
Was your fourth baby born with any congenital defects?
Yes
No
Was your fifth baby full term, preterm (premature), or stillbirth at the time of delivery?
Full term
Preterm
Stillbirth
At how many weeks and days was your fifth baby born?
For example: 38 weeks and 5 days
How much did your fifth baby weigh at birth?
For example: 7 pounds and 6 ounces
Please enter the type of delivery for your fifth birth.
Vaginal
Cesarean section
How old were you at the birth of your fifth child?
For example: 35 years old
Did you have any of the following complications during your fifth pregnancy?
If you selected "Other", please describe the complication for your fifth birth.
Was your fifth baby born with any congenital defects?
Yes
No
29a. Have you ever tried to conceive for more than 1 year without becoming pregnant?
Yes
No
Don't know
29b. Did you visit a doctor or clinic because you didn't get pregnant?
Yes
No
29c. Was a reason found for why you did not become pregnant?
Yes
No
29d. What was the reason you did not become pregnant?
Please specify the "Other" reason.
29e. Have you ever been diagnosed with polycystic ovarian syndrome?
Yes
No
29f. Did you receive any of the following treatments for infertility?
30. Has it been more than one year since you had your last menstrual cycle?
Yes
No
Please disregard if you are male.
30a. How old were you when you had your last menstrual cycle?
30b. Have you taken hormone replacement therapy orally for menopause?
Please state "no" if you are a male.
30c. What was the dose of your estrogen oral replacement therapy medication?
30d. What was the dose of your progesterone oral replacement therapy medication?
30e. What was the dose and type of the oral replacement therapy you listed as "other"?
30f. Did you take hormone replacement therapy as a patch for menopause?
Please state "no" if you are a male.
30g. What was the dose of your estrogen replacement therapy patch?
30h. What was the dose of your progesterone replacement therapy patch?
30i. What was the dose and type of the patch replacement therapy you listed as "other"?
30j. Did you take any topical hormone replacement therapy for menopause?
Please state "none" if you are a male.
31. Did you ever fly when you were pregnant?
Yes
No
How often did you fly while pregnant?
Once per month
Twice per month
Three times per month
More than three times per month
Please tell us more about your experience flying while pregnant.
By selecting the "Submit" button, you are signing this agreement electronically. You agree your electronic signature is the legal equivalent of your manual signature for research purposes with FAMRI at UCSF.
* must provide value
Submit
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