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FOR FUTURE STUDIES
1. Can we contact you to inform you of future studies
(such as clinical trials on new therapy)?
Yes
No
Please fill out all or preferred contact information:
2. In future studies, would you be willing to participate
in the following ways (check all that apply):
Fill out surveys
Give
blood
Give
household water samples
Give
residential soil samples
Be on new treatment regimens
None of the above
A. BACKGROUND
1. Date of birth (month-day-year):
2. Gender:
Male
Female
3. Race:
White
Asian / Pacific
Islander
Black / African
Hispanic
Native
American
Other
4. Highest Education level:
Less
than High School
High
school graduate
Some college
College degree
Advanced degree
5. Are you currently employed?
Yes
No
6. Main occupation (current, or past if not currently employed):
a. Was this work environment a (check one):
Indoor office
Indoor factory
Indoor non-factory with machinery
Outdoors without heavy equipment
Outdoors with heavy equipment
b. Did this environment have:
Airborne dust
Water aerosol
Chemicals
None
of the above
7. Birthplace:
City, State:
8. Where did you live for the longest time (complete table
for the top 3 residences)?
City, State:
Years in
residence:
City, State:
Years in
residence:
City, State:
Years in
residence:
9. Residence when symptoms began:
City, State:
a. How long had you lived there when your symptoms began?
Years (approx):
b. Type of area:
Agricultural
/ Rural
Industrial /
Urban
c. Age of the residence:
years
old
d. Did this residence have (check all that
apply):
Central air conditioning
Forced air heating
Copper household pipe
Zinc household pipe
PVC household pipes
Carpeting
None of the above
e. Water source of this residence:
Utility
Well
Other
f. Was the water treated?
Yes
No
Unknown
If yes, which disinfectants were used?
g. Was the residence near a (check all that apply):
Pond
Lake
Ocean
Farm
None of the Above
10. Current residence:
Address:
City:
State:
Zip:
B. MEDICAL HISTORY
1. When was your first onset of symptoms
(month-year)?
2. Initial symptoms (check all that apply):
None
Hemoptysis
(coughing up blood)
Cough
Weight
loss
Loss of appetite
Fatigue
Shortness of breath
Fever
Depression
Other
Please specify:
3. When did a doctor first tell you that you have NTM (month-year)?
4. What type of doctor was the one who first
told you that you have NTM:
Primary care doctor
Infectious disease dosctor
Pulmonary doctor
Unknown
Other
Please specify:
5. How was the respiratory sample obtained
for this first diagnosis:
Coughed up sputum
Induced sputum (inhaled mist)
Bronchoscopy
Lung biopsy
Not done
Other
Please specify:
6. Which type of NTM did your doctor first
tell you that you have (check all that apply)?
M.
avium-intracellulare complex (i.e., MAC or MAI)
M. abscessus
M. kansasii
M. fortuitum
M. chelonae
M. gordonae
Unknown
Other
Please specify:
7. Before your first NTM diagnosis, had you ever tested positive on a skin
test for TB?
Yes
No
Unknown
8. Before your first NTM diagnosis, did a doctor ever tell you that you
had TB?
Yes
No
Unknown
a. Were you treated for TB?
Yes
No
Unknown
b. Did you complete your treatment for TB?
Yes
No
Unknown
9. Do you have a family history of any of
the following lung conditions (check all that apply)?
No lung disease in family
TB
NTM disease
Cystic Fibrosis
Unknown
Other lung disease:
Please specify:
10. Do you have a personal history of any of the following conditions (check
all that apply)?
Cystic Fibrosis
Hypersensitivity Pneumonitis
Bronchiectasis
COPD
Emphysema
Bronchitis
Sinusitis
Recurrent pneumonia
Childhood pneumonia
Pulmonary fibrosis
Pulmonary embolus
Pneumothorax
Cancer
Gastroesophageal reflux
Diverticulitis
Chronic diarrhea
Chronic constipation
Mitral valve prolapse
Scoliosis
Protruding breast bone
Sunken breast bone
Other non-NTM conditions
Please specify:
11. Current symptoms (check all that apply):
None
Hemoptysis
(coughing up blood)
Cough
Weight
loss
Loss of appetite
Fatigue
Shortness of breath
Fever
Depression
Other
Please specify:
12. Do your symptoms worsen with changes
in weather?
Yes
No
Unknown
a. If yes, are you affected by (check all
that apply):
Increase in temperature
Decrease in temperature
Increase in humidity
Decrease in humidity
Other weather
changes:
Please specify:
b. How have you coped with weather changes?
13. Weight before symptoms began (fill numbers
in blanks):
pounds
14. Current weight (fill numbers in blanks):
pounds
15. Current height (fill numbers in blanks):
feet,
inches
16. What is your current energy level?
Very low
Low
Medium
High
Very high
energy level
17. Have you had vaccinations?
Yes
No
Unknown
a. TB (or BCG) shot:
Yes
No
Unknown
If yes, what year:
b. Pneumonia (Pneumovax) shot:
Yes
No
Unknown
If yes, what year:
b. Flu (Influenza) shot:
Yes
No
Unknown
If yes, what year:
C. MEDICAL CARE
AND TREATMENT
1. In the last 12 months, how many times
were you hospitalized?
(approximate number of times)
2. In the last 12 months, how many times did you visit your doctor (not
counting hospital stays) for NTM infection or lung troubles?
(approximate number of times)
3. Have you ever taken medications for NTM infection?
Yes
No
Unknown
If yes, complete table and questions below. If no, skip to Question 5c.
Medication:
Year - Month (mm/yy) started:
Year - Month (mm/yy) stopped:
Medication:
Year - Month (mm/yy) started:
Year - Month (mm/yy) stopped:
Medication:
Year - Month (mm/yy) started:
Year - Month (mm/yy) stopped:
Medication:
Year - Month (mm/yy) started:
Year - Month (mm/yy) stopped:
Medication:
Year - Month (mm/yy) started:
Year - Month (mm/yy) stopped:
Medication:
Year - Month (mm/yy) started:
Year - Month (mm/yy) stopped:
4. If you have taken medications, how many
courses or cycles of therapy have you had?
cycles
a. Did you take the medications as directed
by your doctor or pharmacist?
Yes
No
b. If you had multiple cycles of therapy, did you have recurrence of symptoms
after a previous therapy cycle was stopped?
Yes
No
Unknown
5. Are you currently treated for NTM infection?
Yes
No -
(If no, skip to 5c.)
Unknown
If you are currently treated for NTM infection:
a. How long have you been under the current
treatment regimen?
months
or
years
b. How have your current conditions changed
compared to your conditions before you started the current treatment?
(1) Cough:
Worsened
Unchanged
Improved
Resolved
N/A
(2) Hemoptysis:
Worsened
Unchanged
Improved
Resolved
N/A
(3) Weight loss:
Worsened
Unchanged
Improved
Resolved
N/A
(4) Loss of appetite:
Worsened
Unchanged
Improved
Resolved
N/A
(5) Fatigue:
Worsened
Unchanged
Improved
Resolved
N/A
(6) Short of breath:
Worsened
Unchanged
Improved
Resolved
N/A
(7) Fever:
Worsened
Unchanged
Improved
Resolved
N/A
(8) Depression:
Worsened
Unchanged
Improved
Resolved
N/A
(9) X-ray/ CT results:
Worsened
Unchanged
Improved
Resolved
N/A
(10) Culture results:
Still positive
Converted to negative
Unknown
c. How have your current conditions changed
compared to your conditions 12 months ago?
(1) Cough:
Worsened
Unchanged
Improved
Resolved
N/A
(2) Hemoptysis:
Worsened
Unchanged
Improved
Resolved
N/A
(3) Weight loss:
Worsened
Unchanged
Improved
Resolved
N/A
(4) Loss of appetite:
Worsened
Unchanged
Improved
Resolved
N/A
(5) Fatigue:
Worsened
Unchanged
Improved
Resolved
N/A
(6) Short of breath:
Worsened
Unchanged
Improved
Resolved
N/A
(7) Fever:
Worsened
Unchanged
Improved
Resolved
N/A
(8) Depression:
Worsened
Unchanged
Improved
Resolved
N/A
(9) X-ray/ CT results:
Worsened
Unchanged
Improved
Resolved
N/A
(10) Culture results:
Still positive
Converted to negative
Unknown
6. Are you taking medications for medical
conditions other than NTM infection? (Include over-the-counter medications,
herbal medicines, and supplements)
Yes
No
Unknown
(Fill in names of other medications)
Medication:
Year - Month (mm/yy) started:
Year - Month (mm/yy) stopped:
Medication:
Year - Month (mm/yy) started:
Year - Month (mm/yy) stopped:
Medication:
Year - Month (mm/yy) started:
Year - Month (mm/yy) stopped:
Medication:
Year - Month (mm/yy) started:
Year - Month (mm/yy) stopped:
Medication:
Year - Month (mm/yy) started:
Year - Month (mm/yy) stopped:
Medication:
Year - Month (mm/yy) started:
Year - Month (mm/yy) stopped:
Medication:
Year - Month (mm/yy) started:
Year - Month (mm/yy) stopped:
Medication:
Year - Month (mm/yy) started:
Year - Month (mm/yy) stopped:
Medication:
Year - Month (mm/yy) started:
Year - Month (mm/yy) stopped:
7. Are you receiving any of the following
therapy other than medications (check all that apply)?
Rehabilitation
Holistic treatment
Respiratory therapy (Flutter valve, Acapella, postural drainage, chest percussion)
None of the above
Other
Please specify:
8. Have you undergone:
Corticosteroid therapy (e.g., prednisone)
Cancer chemotherapy
Radiation
to breast/ chest
Lung surgery
None of
the above
D. LIFESTYLE
HABITS
1. Have you ever smoked cigarettes?
Yes
No
a. At what age did you start smoking?
years
old
b. At what age did you stop smoking?
years old,
OR Still
smoking
c. When you smoked, how many cigarettes did
you smoke?
cigarettes
per day, OR
cigarettes per week
2. In your lifetime, have you been around
smokers while they were smoking?
Yes
No
Unknown
a. For how many years of your life were you
around anyone who was smoking?
years
b. During these years, how much time on average
did you spend with them?
Occasionally
hours per day, or
hours per week
c. In the last 12 months, have you been around
anyone who was smoking?
Yes
No
If yes, how much time on average were you around others while they were
smoking?
Occasionally
hours per day, or
hours per week
3. Have you ever taken calcium supplements?
Yes
No
a. At what age did you start taking calcium
supplements?
years old
b. At what age did you stop?
years old, OR
Still taking calcium
c. How often did you take calcium supplements?
Occasionally
Once daily
Twice daily
3 times daily
d. What was the dose of a single calcium supplement that you took?
mg
4. In the last 12 months, did you consume
the following foods (fill in for each item)?
None below
Servings per week OR per month
a. Milk
glasses per week
glasses per month
b. Yogurt
cups per week
cups per month
c. Cheese
servings (1 oz./serving) per week
servings (1 oz./serving) per month
d. Green leafy vegetables
cups per week
cups per month
e. Calcium fortified food:
cups per week
cups per month
5. How often did you take baths or showers
in the time before or after your first NTM diagnosis?
Before your first NTM diagnosis
a. Baths
times
per week
times
per month
b. Showers
times
per week
times
per month
In last 12 months
a. Baths
times per week
times per month
b. Showers
times per week
times per month
6. Have you ever used hottubs?
Yes
No
a. At what age did you start using hottubs?
years old
b. At what age did you stop?
years old, OR
Still using hottubs
c. When you used hottubs, how often did you use them in a 12-month period?
Occasionally
times per month, or
times per year
7. Do you ever swim?
Yes
No
a. At what age did you start swimming?
years old
b. At what age did you stop?
years old, OR
Still swimming
c. When you swam, where and how often did you swim in a 12-month period?
Indoor pool:
Occasionally
times per month, or
times per year
Outdoor pool:
Occasionally
times per month, or
times per year
8. Have you had any hydrotherapy?
Yes
No
9. Have you had a pedicure?
Yes
No
10. Do you regularly use a hair dryer?
Yes
No
11. Have you ever gardened?
Yes
No
a. At what age did you start gardening?
years old
b. At what age did you stop?
years old, OR
Still using gardening
c. When you gardened, where and how often did you do this in a 12-month
period?
Indoors:
Occasionally
times per month, or
times per year
Outdoors:
Occasionally
times per month, or
times per year
d. Planting material used:
Potting soil
Peat
moss Other
12. Have you ever had pets?
Yes
No
If yes, complete the table for each type of pet you
had.
When you last had this type of pet?
a. Birds
years
ago Still
has pet
years
in total
b. Dogs
years ago
Still has
pet
years
in total
c. Cats
years ago
Still has
pet
years
in total
d. Other
years
ago
Still has pet
years in total
e. Other
years ago
Still
has pet
years in total
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