| CDE ID | CDE Description | | * 421 | EDRN Participant ID (Go To: 773) |
| * 773 | Visit code (Go To: 423) |
| | | Permissible Values (value): | BLN1 (1) |
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| * 423 | EDRN Protocol ID (Go To: 422) |
| * 422 | EDRN Site ID (Go To: 807) |
| * 807 | Date of baseline visit: (Go To: 929) |
| * 929 | EDRN Staff ID of the person who collected the data: (Go To: 799) |
| 799 | Height [in inches] (What is your total current height in inches?) (Go To: 440) |
| 440 | Weight [in pounds] (What is your current weight [in pounds]? (Go To: 435) |
| 435 | Hispanic or Latino (Are you Hispanic or Latino?) (Go To: 436) |
| | | Permissible Values (value): | No (0) |
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| 436 | Race (What is your race? Check all that apply.) (Go To: 434) |
| | | Permissible Values (value): | White (1) |
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| | | | Black or African-American (2) |
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| | | | American Indian or Alaska Native (3) |
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| | | | Native Hawaiian or other Pacific Islander (7) |
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| | | | Other, specify: (97) (Go To: 793) |
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| 793 | Race (Other,specify) (Go To: 434) |
| 434 | Gender (What is your gender?) (Go To: 441) |
| | | Permissible Values (value): | Male (1) |
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| 459 | Have menstrual periods stopped due to natural menopause, hysterectomy, the removal of both ovaries, or radiation or chemotherapy treatment? (Have your menstrual periods stopped due to natural menopause, hysterectomy, the removal of both ovaries, or radiation or chemotherapy treatment?) (Go To: 458) |
| | | Permissible Values (value): | No (0) |
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| 460 | Age when menstrual periods stopped (How old were you when your menstrual periods stopped?) (Go To: 458) |
| 458 | Age of first menstrual period? (How old were you when you first started having menstrual periods?) (Go To: 441) |
| 441 | Ever smoke cigarettes regularly, at least one a day for a year or more? (Did you ever smoke cigarettes regularly, at least one a day for a year or more?) (Go To: 443) |
| | | Permissible Values (value): | No (0) (Go To: 1036) |
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| 443 | Currently smoke at least one cigarette a day? (Do you currently smoke cigarettes regularly, at least one a day?) (Go To: 445) |
| | | Permissible Values (value): | No (0) (Go To: 444) |
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| | | | Unknown/refused (9) (Go To: 1036) |
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| 444 | Age quit smoking cigarettes? (How old were you when you permanently quit smoking cigarettes?) (Go To: 445) |
| 445 | Average number of cigarettes smoked per day? (During the time you have smoked, on average, how many cigarettes did you smoke per day?) (Go To: 442) |
| 442 | Age first began smoking cigarettes regularly, at least one a day? (How old were you when you began smoking cigarettes regularly, at least one a day?) (Go To: 1039) |
| 1039 | Total number of years smoked? (How many years total have you smoked?) (Go To: 1036) |
| 1036 | Has participant ever taken any of the following statin medications? (Have you ever taken any of the following statin medications?) (Go To: 1037) |
| | | Permissible Values (value): | Atorvastatin (Lipitor) (1) |
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| | | | Pravastatin (Pravachol) (4) |
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| 1037 | Has participant ever taken any of the following antiviral medications or therapies used to treat liver disease? (Have you ever taken any of the following antiviral medications or therapies used to treat liver disease?) (Go To: 1045) |
| | | Permissible Values (value): | Adefovir (1) (Go To: 1038) |
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| | | | Interferon (2) (Go To: 1038) |
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| | | | Lamivudine (3) (Go To: 1038) |
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| | | | Peginterferon (4) (Go To: 1038) |
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| | | | Ribavirin (5) (Go To: 1038) |
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| | | | Tenofovir (6) (Go To: 1038) |
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| 1038 | Is participant currently taking any of the following antiviral medications or therapies used to treat liver disease? (Are you currently taking any of the following antiviral medications or therapies used to treat liver disease?) (Go To: 1045) |
| | | Permissible Values (value): | Adefovir (1) |
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| 1045 | Performance status (Which of the following options would you say describes your current performance status?) (Go To: 819) |
| | | Permissible Values (value): | Fully active, able to carry on all pre-disease performance without restriction (0) |
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| | | | Restricted in physically strenuous activity but ambulatory and able to carry out work of a light or sedentary nature, e.g., light house work, office work (1) |
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| | | | Ambulatory and capable of all selfcare but unable to carry out any work activities. Up and about more than 50% of waking hours (2) |
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| | | | Capable of only limited selfcare, confined to bed or chair more than 50% of waking hours (3) |
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| | | | Completely disabled. Cannot carry on any selfcare. Totally confined to bed or chair (4) |
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| 819 | Number of living and deceased blood-related daughters: (How many living and deceased blood-related daughters do you have? [Not including adopted, foster, or step-daughters] (Go To: 818) |
| 818 | Number of living and deceased blood-related sons: (How many living and deceased blood-related sons do you have? [Not including adopted, foster, or step-sons] (Go To: 821) |
| 821 | Number of living and deceased first-degree blood sisters: (How many living and deceased blood-related sisters do you have? [Not including adopted, foster, half-sisters or step-sisters] (Go To: 820) |
| 820 | Number of living and deceased first-degree blood brothers: (How many living and deceased blood-related brothers do you have? [Not including adopted, foster, half-brothers or step-brothers] (Go To: 1085) |
| 1085 | Have any of the participant´s living and deceased first degree blood relatives been diagnosed with cancer [other than basal/squamous cell skin cancer]? (Have any of your living and deceased first degree blood relatives (biological parents, siblings, children) been diagnosed with cancer [other than basal/squamous cell skin cancer]? [Not including half-siblings, step-siblings, step-parents, or step-children]. (Go To: 1040) |
| | | Permissible Values (value): | No (0) |
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| 1084 | How many of the participant´s living and deceased first degree blood relatives have been diagnosed with cancer [other than basal/squamous cell skin cancer]? (How many of your living and deceased first degree blood relatives (biological parents, siblings, children) have been diagnosed with cancer [other than basal/squamous cell skin cancer]? [Not including half-siblings, step-siblings, step-parents, or step-children].) (Go To: 1200) |
| * 1200 | Relative type (mother, brother, etc) (Go To: 850) |
| | | Permissible Values (value): | Brother (1) |
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| * 850 | First primary cancer: (Go To: 798) |
| | | Permissible Values (value): | Bladder (1) |
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| | | | Head & neck (mouth, nose, and throat) (8) |
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| | | | Lymphoma, including Hodgkins (13) |
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| | | | Skin (melanoma, no basal or squamous) (18) |
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| * 798 | Age at which family member's first cancer was diagnosed: (Go To: 851) |
| * 851 | Subsequent primary cancer(s): (Go To: 1040) |
| | | Permissible Values (value): | Bladder (1) |
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| | | | Head & neck (mouth, nose, and throat) (8) |
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| | | | Lymphoma, including Hodgkins (13) |
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| | | | Skin (melanoma, no basal or squamous) (18) |
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| 1040 | Have any of the participant's living and deceased first degree blood relatives been diagnosed with liver disease? (Have any of your living and deceased first degree blood relatives (parents, siblings, children) been diagnosed with liver disease? [Not including half-siblings, step-siblings, or step-children.]) (Go To: 997) |
| | | Permissible Values (value): | No (0) |
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| 1041 | How many of the participant's living and deceased first-degree blood relatives have been diagnosed with liver disease? (How many of your living and deceased first degree blood relatives (parents, siblings, children) have been diagnosed with liver disease? [Not including half-siblings, step-siblings, or step-children.]) (Go To: 1202) |
| * 1202 | Relative type (mother, brother, etc) (Go To: 1043) |
| | | Permissible Values (value): | Brother (1) |
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| * 1043 | What type(s) of liver disease? (Check all that apply) (Go To: 1044) |
| | | Permissible Values (value): | Alcoholic liver disease (1) |
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| | | | Alpha-1 antitrypsin deficiency (2) |
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| | | | Non-alcoholic fatty liver (7) |
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| | | | Primary biliary cirrhosis (8) |
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| | | | Primary sclerosing cholangitis (9) |
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| * 1044 | Age at which family member's first liver disease was diagnosed: (Go To: 997) |
| 997 | Has participant ever had at least one drink of alcohol [beer, liquor, wine, or wine coolers] per month during a twelve-month period? (Have you ever had at least one drink of alcohol [beer, liquor, wine, or wine coolers] per month during a twelve-month period?) (Go To: 1097) |
| | | Permissible Values (value): | No (0) |
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| 998 | Average number of drinks (beer, wine, liquor, or wine coolers) participant drank per week during his/her teens: (Average number of drinks (beer, wine, liquor, or wine coolers) you drank per week during your teens:) (Go To: 1000) |
| 1000 | Average number of drinks (beer, wine, liquor, or wine coolers) participant drank per week during his/her twenties: (Average number of drinks [beer, wine, liquor, or wine coolers] you drank per week during your twenties:) (Go To: 1001) |
| 1001 | Average number of drinks (beer, wine, liquor, or wine coolers) participant drank per week during his/her thirties: (Average number of drinks [beer, wine, liquor, or wine coolers] you drank per week during your thirties:) (Go To: 999) |
| 999 | Average number of drinks (beer, wine, liquor, or wine coolers) participant drank per week during his/her forties: (Average number of drinks [beer, wine, liquor, or wine coolers] you drank per week during your forties:) (Go To: 1002) |
| 1002 | Average number of drinks (beer, wine, liquor, or wine coolers) participant drank per week during his/her fifties and older:Average number of drinks [beer, wine, liquor, or wine coolers] you drank per week during your fifties and older:) (Go To: 1097) |
| 1097 | Comments (do not include any participant identifiers) (Go To: End of Form) |