| Age (years) |
| Gender |
|
(1) Female |
|
(2) Male |
| Height (cm) |
| Weight (kg) |
| Zip code |
| Time in actual residence (years) |
| Residence area |
|
(1) Urban |
|
(2) Rural |
| Level of completed studies |
|
(1) No studies or incomplete primary studies |
|
(2) Primary studies |
|
(3) Secondary studies |
|
(4) Higher education |
| Current occupation |
| Time of performance in the current occupation (years) |
|
Section 2: Consumptions habits and lifestyle
|
| Exposure, with consent, to chemical products at work |
|
(1) Yes |
|
(2) No |
| Frequency of food intake of each one of the of the following (dairy products, coffee, tea, eggs, fresh vegetables, canned vegetables, fresh fruit/natural juices, canned fruit, soft drinks, organic food, fast-food, poultry meat, red meat, fresh/frozen fish, canned fish, shellfish, grilled food, smoked food and bottled water) |
|
(1) Never |
|
(2) 1-3x/month |
|
(3) 1-3x/week |
|
(4) 4-6x/week |
|
(5) Every day |
| Smoker |
|
(1) Yes |
|
(2) No |
|
If yes, number of cigarettes per day? |
|
If stopped smoking, how long ago did it happened? |
| Alcoholic beverages intake |
|
(1) Yes |
|
(2) No |
| If yes, number of glasses per day? |
| Physical exercise practice |
|
(1) Yes |
|
(2) No |
|
If yes, how often? |
|
|
(1) 1-3x/month |
|
|
(2) 1-3x/week |
|
|
(3) 4-6x/week |
|
|
(4) Every day |
| Regular medication |
|
(1) Yes |
|
(2) No |
|
If yes, which one? |
|
Section 3: Examination and endocrine history
|
| Endocrine system pathology |
|
(1) Yes |
|
(2) No |
|
If yes, which one? |
| Conditions that may influence the Endocrine System |
|
(1) Yes |
|
(2) No |
|
If yes, which one? |
| Drug/supplement/mineral salt intake for hormonal normalization |
|
(1) Yes |
|
(2) No |
|
If yes, which one? |
| Family member with history of thyroid disorders |
|
(1) Yes |
|
(2) No |
|
If yes, which one? |
|
|
Family degree? |
|
|
Age? |
|
Did some treatment? |
|
|
(1) Yes |
|
|
(2) No |
|
If yes, which one? |
| Hoarse feeling in the last year? |
|
(1) Yes |
|
(2) No |
|
If yes, how much interfered with daily life? |
|
|
(1) Absolutely nothing |
|
|
(2) Little |
|
|
(3) Moderately |
|
|
(4) Considerable |
|
|
(5) Greatly |
| Swallowing difficulty in the last year? |
|
(1) Yes |
|
(2) No |
|
If yes, how much interfered with daily life? |
|
|
(1) Absolutely nothing |
|
|
(2) Little |
|
|
(3) Moderately |
|
|
(4) Considerable |
|
|
(5) Greatly |
| Breathing difficulty in the last year? |
|
(1) Yes |
|
(2) No |
|
If yes, how much interfered with daily life? |
|
|
(1) Absolutely nothing |
|
|
(2) Little |
|
|
(3) Moderately |
|
|
(4) Considerable |
|
|
(5) Greatly |
|
Section 4: Family predisposition
|
| Have you ever had genetic testing? |
|
(1) Yes |
|
(2) No |
|
If yes, and if was obtained a positive result, which was the mutation/syndrome identified? |
|
Section 4: Family predisposition
|
| Family members with a history of cancer |
|
(1) Yes |
|
(2) No |
|
If yes: |
|
|
Family degree? |
|
|
Age at diagnosis? |
|
|
Gender? |
|
|
Cancer location? |
| Diagnosed cancer |
|
|
(1) Yes |
|
|
(2) No |
|
|
If yes, what is the type and location of cancer? |
| Cancer screenings |
|
|
(1) Yes |
|
|
(2) No |
|
|
If yes, how often? |
|
Section 5: Endocrine history (only for female patients)
|
| Endocrinology appointment arise after pregnancy? |
|
|
(1) Yes |
|
|
(2) No |
| Take oral contraceptive? |
|
|
(1) Yes |
|
|
(2) No |
| If already in menopause, do any hormone replacement treatment? |
|
|
(1) Yes |
|
|
(2) No |
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