NS-LIJ Tissue Donation Program
Endometriosis Specimen Bank Data Collection Form
Name: SUBJECT ID: TB1302Address: Street
City, State, Zip Code
Phone: Home:
Cell:
Other:
Date of birth:
Gender: Female Male
Email:
Are any of your blood relatives already in this study? yes no
If yes:
Name / DOB / Relationship
Office use:
Assigned family ID: Assigned Family Position ID:
Family history:
Do you have any relatives with endometriosis? yes no
If yes, provide details
Relationship / Comment
Do you have any other relatives with history of cancer? yes no
If yes, provide details
Relationship / Cancer Type / Comment
Gynecological History:
How old are you when you had your first menstrual period? ______
Are your periods regular? Extremely regular (no more than 1-2 days before or after expected)
Very regular (within 3-4 days of expected)
Regular (within 5-7 days of expected)
Usually irregular
Always irregular
If regular, how many days in a cycle? (number of days between the first day of one period and the first
day of the next (on average)? ______
How many days of bleeding? ______
In the past three months have you had any of the following symptoms with your periods:
О No periods in the past three months
Pain: Yes No
If yes, please describe the pain: Very Painful Cramping
Discomfort
Aching
Other (please describe) ______
Heavy bleeding? Yes No
Clotting? Yes No
Pain with bowel movement? Yes No
Leg pain with period? Yes No
Pain during ovulation? Yes No
Pain with intercourse? Yes No
Abdominal or pelvic pain when not menstruating? Yes No
Other symptoms (Please describe): ______
From the time of your first period to age 20 did you have any of the following symptoms with your periods:
О No periods in this age range
Pain: Yes No
If yes, please describe the pain: Very Painful Cramping
Discomfort
Aching
Other (please describe) ______
Heavy bleeding? Yes No
Clotting? Yes No
Pain with bowel movement? Yes No
Leg pain with period? Yes No
Pain during ovulation? Yes No
Pain with intercourse? Yes No
Abdominal or pelvic pain when not menstruating? Yes No
Other symptoms (Please describe):______
From the age of 20 to the age of 30 did you have any of the following symptoms with your periods:
О No periods in this age range
Pain: Yes No
If yes, please describe the pain: Very Painful Cramping
Discomfort
Aching
Other (please describe) ______
Heavy bleeding? Yes No
Clotting? Yes No
Pain with bowel movement? Yes No
Leg pain with period? Yes No
Pain during ovulation? Yes No
Pain with intercourse? Yes No
Abdominal or pelvic pain when not menstruating? Yes No
Other symptoms (Please describe): ______
From the age of 30 to the age of 40 did you have any of the following symptoms with your periods:
О No periods in this age range
Pain: Yes No
If yes, please describe the pain: Very Painful Cramping
Discomfort
Aching
Other (please describe) ______
Heavy bleeding? Yes No
Clotting? Yes No
Pain with bowel movement? Yes No
Leg pain with period? Yes No
Pain during ovulation? Yes No
Pain with intercourse? Yes No
Abdominal or pelvic pain when not menstruating? Yes No
Other symptoms (Please describe): ______
After the age of 40 did you have any of the following symptoms with your periods:
О No periods in this age range
Pain: Yes No
If yes, please describe the pain: Very Painful Cramping
Discomfort
Aching
Other (please describe) ______
Heavy bleeding? Yes No
Clotting? Yes No
Pain with bowel movement? Yes No
Leg pain with period? Yes No
Pain during ovulation? Yes No
Pain with intercourse? Yes No
Abdominal or pelvic pain when not menstruating? Yes No
Other symptoms (Please describe): ______
Fertility:
Have you ever been pregnant? Yes No
If you have been pregnant,
How many times have you been pregnant? ______
How many live deliveries have you had? ______
Have you ever had a miscarriage or termination of pregnancy? Yes No
If yes, how many? ______
If you have been pregnant, did you have difficulty conceiving? Yes No
If yes, did you have any fertility treatment? Yes No
What treatments? ______
If you have not been pregnant, have you ever tried to conceive? Yes No
If yes, have you ever had fertility treatments? Yes No
What treatments? ______
Have you had a tubal ligation (sterilization/tubes tied)? Yes No
If yes, how old were you at the time of ligation? ______
Have you ever used oral contraceptives? Yes No
If yes, are you currently using oral contraceptives? Yes No
If yes, what is the name and dosage of the pill you use now? ______
How many years in total have you taken oral contraceptives? ______
Have you ever used a birth control patch? Yes No
If yes, are you currently using a birth control patch? Yes No
If yes, what is the name and dosage of the birth control patch you use now? ______
How many years in total have you used a birth control patch? ______
Have you ever used an internal birth control device, such as a coil or IUD? Yes No
If yes, are you currently using a coil or IUD? Yes No
If yes, what type are you using now? ______
How many years in total have you used a coil or IUD? ______
Have you ever used an internal hormone releasing birth control ring such as NuvaRing? Yes No
If yes, are you currently using an internal hormone releasing birth control device? Yes No
If yes, what type are you using now? ______
How many years in total have you used an internal hormone releasing birth control device? ______
Have you ever used hormonal injections/shots? Yes No
If yes, are you currently using hormonal injections/shots? Yes No
If yes, what is the name and dosage you are using now? ______
How many years in total have you used hormonal injections/shots? ______
If you are not currently being treated with hormonal injections, but have used these in the past, please tell
us the names and dosages of the drugs you were treated with and the total number of years you used them.
______
______
Have you ever used hormonal implants such as Implanon/ Nexplanon? Yes No
If yes, are you currently using a hormonal implant? Yes No
If yes, what type and dosage are you using? ______
How many years in total have you used a hormonal implant? ______
Have you ever used hormone replacement therapy? Yes No
If yes, are you currently using hormone replacement therapy? Yes No
If yes, what type and dosage are you using? ______
How many years in total have you used hormone replacement therapy? ______
Have you ever used any other hormone treatments? Yes No
If yes, what type?______
Total years used: ______
Have you completed menopause? Yes No Perimenopausal
Age at menopause? ______
Was menopause natural or surgically induced? ______
Surgical history:
Have you ever had surgery for diagnosis or treatment of endometriosis: Yes No
If yes, please complete:
Date Surgeon Hospital Procedure
______
______
______
______
Have you ever had abdominal or pelvic surgery for any other reason: Yes No
If yes, please complete:
Date Surgeon Hospital Procedure
______
______
______
______
If available, please provide copies of Pathology and Operative Reports.
Please complete ethnicity questionnaire on next page.
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NS-LIJ Tissue Donation Program
Endometriosis Specimen Bank
Data Collection Form
Ethnicity: American Indian/Alaska Native North AmericaSouth America (includes Central America)
Asian
Chinese
Korean
Filipino
Pakistani
Vietnamese
Cambodian
Japanese
Malaysian
Thai
Indian
Black/African-American
African-American
West Indian
African heritage
Jewish
Ashkenazi Jewish
Sephardic Jewish
Other or Unknown
Latino/HispanicMexican
Central American
South American
Dominican
Puerto Rican
Cuban
West Indian
Native Hawaiian/Pacific Islander Hawaiian
Samoan
Guamanian or Chamorro
Pacific Islands
White
Northern European (England, Scotland, Wales, Ireland, N. France, Holland, Belgium, Switzerland)
Scandinavian (Denmark, Norway, Sweden, Finland)
Southern European (Spain, Portugal, Italy, S. France)
Central European (Germany, Austria, Hungary)
Eastern European (Russia, Poland, Romania, Ukraine, Lithuania, Latvia, Estonia, Czech Republic)
East Mediterranean (Greece, Turkey, Croatia, Bosnia,Yugoslavia, Albania)
Northern Africa
Middle East
French Canada
South America
Unknown
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