Protocol - Personal History of Gastrointestinal Conditions

1. In the past 2 years, have you had a…

1a. upper endoscopy (esophagus/stomach)?

[ ] No

[ ] Yes

1b. a (Virtual) CT colonoscopy?

[ ] No

[ ] Yes

1b1. a colonoscopy?

[ ] No

[ ] Yes

1b2. a sigmoidoscopy?

[ ] No

[ ] Yes

If Yes to 1b1 or 1b2:

1c. Initial reason(s) you had a colonoscopy/sigmoidoscopy?

[ ] visible blood

[ ] family history of colon cancer

[ ] Virtual (CT) colonography

[ ] occult fecal blood

[ ] diarrhea/constipation

[ ] prior polyps

[ ] abdominal pain

[ ] barium enema

[ ] asymptomatic or routine screening

2. Have you had any of the following clinician diagnosed conditions?*

2a. Diverticulitis or Diverticulosis

[ ] No

[ ] Yes

If Yes, year of diagnosis ________

2b. Colon or rectal polyp

[ ] No

[ ] Yes

If Yes, year of diagnosis ________

2c. Cancer of colon or rectum

[ ] No

[ ] Yes

If Yes, year of diagnosis ________

2d. Gall bladder removal

[ ] No

[ ] Yes

If Yes, year of diagnosis ________

2e. Gastric or duodenal ulcer

[ ] No

[ ] Yes

If Yes, year of diagnosis ________

2f. Barretts esophagus

[ ] No

[ ] Yes

If Yes, year of diagnosis ________

2g. Ulcerative colitis/Crohns disease

[ ] No

[ ] Yes

If Yes, year of diagnosis ________

3. Have you ever had gastrointestinal bleeding that required hospitalization or a transfusion?

[ ] Yes

[ ] No

If Yes

3a. What was the site of the bleeding? (Mark all that apply.)

[ ] Esophagus

[ ] Stomach

[ ] Duodenum

[ ] Colon/Rectum

[ ] Other

[ ] Site unknown

3b. What year(s) did this happen? (Mark all that apply.)

[ ] Before 1993

[ ] 1993–1997

[ ] 1998–1999

[ ] 2000–2001

[ ] 2002–2003

[ ] 2004–2005

2006[ ]+

*Editors Note: The Gastrointestinal Working Group (WG) slightly modified this question from the original protocol text. The original protocol obtains year of diagnosis by asking respondents to choose between four choices (Before 2006, 2006, 2007, or 2008). The Gastrointestinal WG removed the phrase "Since January 1, 2006" to allow collection of diagnoses that occurred prior to that time. The original response options were deleted and respondents are now asked to write in the four-digit year of diagnosis if they respond "Yes."