Orthomolecular Oncology

Questionnaire

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Multiple Myeloma Questionnaire

Orthomolecular Oncology is pioneering a special study of Multiple Myeloma which may lead, in the near future, to a radical new approach to this cancer. If you wish to be included in this study, and its possible benefits, we would be most grateful if you could complete the following questionnaire. We hope to be in touch with you within a matter of months, when Part I of the study - the epidemiological, or information-gathering part - is complete.

As Multiple Myeloma is still a relatively rare cancer (although the incidence is increasing), and still one of the most difficult blood cancers in terms of finding a cure, pooling any information together is of great value. Orthomolecular Oncology undertakes to treat your personal details with total confidentiality. Thank you for your help. If you do not feel well enough to do this, perhaps a close friend or relative could do it for you.


There are two options for filling out the questionnaire.

  • Use the on-line form on this page, which will automatically e-mail your replies to us.
  • If your browser cannot send the form as an e-mail, or if you prefer not to submit it as e-mail, you can fill in the details on-screen and then print out the page (it will require about 14 sheets of A4), then send it by post. (Should any of your replies exceed the space available in the text boxes, please use an extra sheet of paper. Thank you)

If you choose to use the on-line form, please remember that e-mail is not very secure. Due to the number of questions we would recommend that, once the page has fully opened in your browser, you disconnect from the Internet whilst composing your answers. The compiled replies will be present as an e-mail in your "Out" folder in your e-mail programme, and will be sent the next time you log on. If you remain on-line it will be sent immediately.

Postal address:

Orthomolecular Oncology
The Estate Office,
Ashton,
Nr Oundle,
Northamptonshire,
PE8 5LE,
United Kingdom.



Section 1: About you

Name:


Address: (for contact purposes only)


Telephone: (for contact purposes only)


E-mail: (for contact purposes only)


Sex: Male Female

Date of birth:


Marital status: Single Married or equivalent Divorced or separated Widowed

How many children do you have? None 1 2 3 4 5 6 or more

At what age did you have your first child?

Age at diagnosis:

Ethnic Origin (please be specific, eg country of origin of parents/grandparents):


Religion, if applicable:


Height:
Metres Feet

Weight before diagnosis:

Current weight:
Kilograms Stones Pounds

Where do you live now? (Please give location - exact address not essential)


How long have you lived there?

What proportion of your life has been spent in towns: % and countryside: %

Current occupation / work:


Previous occupation / work:


Do you have any hobbies & special pursuits (please be specific, and indicate how much time you devote to each):

How much of the following exercise do you take (average hours per week)?

Exercise 0-1 1-5 5-10 10+
Walking
Cycling
Running
Swimming
Strenuous sports

What do you do to relax?

Do you travel much? No Yes

If so, where have you been, and how often?

To the best of your knowledge, have you ever caught any rare diseases or parasites whilst travelling?



Section 2: About your myeloma

Do you know the TYPE of your myeloma? Ig A Ig E Ig G Kappa Lambda Bence Jones

Stage at diagnosis: I II III IV

Current stage: I II III IV

What (conventional) treatment have you had for your myeloma to date?

How well are you responding?
In remission Condition improving No change Poorly Too early to judge

Where are you being treated? (Please give hospital name and location)

Do you intend to continue conventional treatment? Yes No

Have you tried any alternative approaches alongside your conventional therapy? If so, please specify.

Do you believe any of these approaches have been helpful? Please specify.

Do you connect your diagnosis of myeloma with anything in particular in your life, whether medical, psychological, physical or otherwise, or do you have any "gut feeling" about any causal connections with your myeloma? Please be as specific as possible.

If you have used any alternative therapies in the past, what were they, for what condition, and with what outcome?

Please describe the circumstances leading up to your myeloma diagnosis



Section 3: About your medical history

If there is any history of myeloma in your family, please give details:

If there is any history of other blood or immune system cancers in your family (eg leukaemias, lymphomas, Hodgkin's disease), please give details:

If there is any history of other cancers in your family (eg solid tumours), please give details:

If there is any history of other blood disorders in your family (eg inherited or non-inherited anaemias), please give details:

Are your parents still alive? Yes No

If not, what caused their death(s), and at what age?

Prior to your myeloma diagnosis, had you been diagnosed with Monoclonal Gammopathy of Unknown Significance (MGUS) or Benign Monoclonal Gammopathy (BMG)? (MGUS and BMG are both the same condition)
No Yes

If so, how long did you have MGUS/BMG before your myeloma diagnosis?

Has anyone else in your family had MGUS/BMG? No Yes

If so, did they also develop myeloma? No Yes

Prior to your myeloma diagnosis, did you suffer from any other blood disorder? If so, please give details, including its duration.

If you have ever been anaemic, please specify the type of anaemia, and how long you suffered before diagnosis.

What treatment were you given for your blood disorder?

Was the treatment successful? No Yes

Did your blood disorder recur at any time? No Yes

Please give the major features of your medical history to date (include minor items if they have occured more than two or three times), and specify whether you have any current medical problems NOT related to your myeloma.


Have you ever suffered from depression? No Yes

If so, how often?

What vaccinations have you had over the course of your life?

Vaccination No Yes
Smallpox (BCG)
Mumps, measles, rubella (MMR)
Whooping Cough
Polio
Rabies
Tetanus
Other (specify below)

Details of other vaccinations

Please indicate how many times you have used the following medicines prior to your myeloma diagnosis (ie total number of standard "doses").

Medicine Never 1+ 10+ 100+ 1000+
Aspirin
Paracetamol
Ibuprofen
Opiates (codeine, morphine, DF118 etc)
Other painkiller (specify below)
Tranquilisers/sleeping pills (specify below)
Antibiotics (specify below)
Cardiac drugs: to control cholesterol
Cardiac drugs: cardiac glycosides (eg digoxin)
Cardiac drugs: beta blockers (eg propranolol)
Diuretics / other cardiac drugs (specify below)
Antacid preparations (eg milk of magnesia)
Anti-ulcer drugs (eg Zantac, cimetidine)
Anti-epileptic/antispasmodic drugs
Anti-asthma drugs
Anti-histamines
Chemotherapy for past solid tumours
Other (specify below)

Please specify here any other drugs from the above

How would you describe your energy levels in the ten years prior to your myeloma diagnosis?
High Medium Low Very Low

How would you rate your stress levels over the same period?
High Medium Low Very Low

Do you cope well with stress?Yes No

If "no", what symptoms do you get?

Symptom No Yes
Headache
Anxiety
Stomach upsets
Insomnia
Inability to concentrate
Other (specify below)

Please specify here any other symptoms

Is there anything to which you are allergic?



Section 4: about your diet

Are you: Omnivorous Vegetarian Vegan Following any special diet (please specify)



Prior to diagnosis, did you take any vitamin, mineral or other dietary supplements of any kind? If so, please specify which, and for how long.



From the following list of foods, please indicate those that you have regularly consumed over the last 15-20 years, in large or small amounts. Please be as honest as you can.

Foodstuff None Low Med. High
Sugar
Cakes/biscuits
Sweets
Puddings
Jam
Honey
Jellies/mousses
Chocolate
Ice cream
Red Meat
Raw Meat
Hamburgers
Sausages
Patés
Poultry
Game
Fish
Raw Fish
Shellfish
Salted or cured fish or meat
Eggs
Cheese
Milk
Cream
Yoghurt
Other dairy products
Water: mineral
Water: tap
Water: well
Fruit juices
Fizzy, canned drinks
Vegetable juices
Fruit
Vegetables: raw
Vegetables: cooked
Soups
Oils: olive
Oils: fish
Oils: flax (linseed)
Oils: sunflower
Oils: canola (rapeseed or "vegetable" oil)
Oils: peanut
Oils: soya
Oils: sesame
Oils: walnut
Oils: hazelnut
Oils: lard/animal fat
Oils: margerine
Oils: soya spread
Nuts: almonds
Nuts: peanuts (salted)
Nuts: peanuts (plain)
Nuts: brazils
Nuts: cashews (salted)
Nuts: cashews (plain)
Nuts: pistacchios
Nuts: walnuts
Nuts: chestnuts
Nuts: macadamia
Nuts: hazelnuts
Nuts: tigernuts
Nuts: pinenuts
Nuts: other
Halva/turron nut products
Pasta: white
Pasta: wholemeal
Pulses: chickpeas
Pulses: lentils
Pulses: beans of all kinds
Pulses: sprouted beans or pulses
Soya products: tofu, tempeh, miso, soy sauce
Seeds: eg sesame, pumpkin, sunflower
Rice: brown
Rice: white
Rice: red
Rice: wild
Corn (maize/sweetcorn)
Wheat
Rye
Barley
Oats
Bread: white
Bread: wholemeal
Crackers: white
Crackers: wholemeal
Salt
Crisps & salted/fried snacks (US: chips)
Chips (US: fries)
Alcohol: beer
Alcohol: wine
Alcohol: spirits
Spices: chilli
Spices: pepper
Spices: cayenne
Spices: nutmeg
Spices: mace
Spices: curry mix
Spices: turmeric
Spices: coriander
Spices: saffron
Spices: liquorice
Spices: cinnamon
Herbs: parsley
Herbs: basil
Herbs: mint
Herbs: chives
Herbs: oregano/marjoram
Herbs: thyme
Herbs: garlic
Herbs: onions
Herbs: other
Smoked foods
Fermented foods
Pickles
Tea: green
Tea: standard
Tea: herbal
Tea: other
Coffee: fresh
Coffee: instant
Coffee: decaffeinated

Are there any other items of food or drink not listed above which you have regularly consumed in the past?


Which are your favourite fruit and vegetables?


How much of the food you eat falls into the following categories?

Category None Low Med. High
Fresh
Homegrown
Organic
Processed, with additives
Tinned
Frozen
Refrigerated
Over a week old

How often do you use the following cooking methods?

Method Never Rarely Often Always
Grill
Steam
Fry
Boil
Roast
Microwave



Section 5: About your environmental exposure

Do you have any contact with animals? (Please include pets, any animals you work with, and household pests like mice or cockroaches etc)

Do you smoke?
No
No, but I live/work with smokers
No, but I used to
Yes, less than 5 per day
Yes, up to 20 per day
Yes, more than 20 per day

If yes, for how long? years

If you have quit smoking, how long ago? years

Are you aware of having been exposed to any radiation (eg medical X-rays, fallout, living in high-Radon areas, etc)?
No Yes

Are you aware of having been exposed to any dangerous chemicals (eg insecticides, organophosphates, herbicides etc) in the workplace or elsewhere? Please specify.

Do you regularly use any strong chemicals at home (eg for cleaning)? Please specify.

Have you ever had a positive test for any of the following?
Cytomegalovirus No Yes
Epstein-Barr virus No Yes
Herpes No Yes

Do you have any dental fillings?
Filling type No Yes
Mercury alloy
Gold
Quartz
Amalgam
Other (specify below)

Specify other filling type

Thank you very much for taking the time to answer this questionnaire. Please be assured that all of your personal information will be dealt with in the strictest confidence, and that only statistical data will be made available to help promote understanding of this condition.

Press "Send" below to e-mail your reply, or "Redo" to start again - this will erase ALL of the information you have entered. Due to the size of the questionnaire, it will take a few minutes to compile and send the mail.




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