Microsoft word - flaxfx screening-questionnaire v1.doc

A research study of the effects
of flaxseed lignans on colon health
Initial Questionnaire
Please note: your participation is voluntary and any information you give us will be kept confidential. Your answers to this questionnaire will determine if you are eligible to participate in the study. Thank you for your time and interest. There are some characteristics, every day habits and medical treatments that could affect this research. Unfortunately, if any of the following is true, you will not be able take part in the study:  Younger than 20 years of age or older than 45 years of age.  Taking prescription medications every day (this includes women taking birth-control pills or shots, or those who have a hormone-secreting IUD).  Currently pregnant or breastfeeding or planning on becoming pregnant in the next 12 months.  Tobacco use now or any time within the past year (smoking and chewing tobacco).  Using any type of recreational drug now or any time within the past year.  Drinking 2 or more cans of beer OR 2 or more glasses of wine OR 3 or more ounces of hard  Taking or have taken antibiotics within the past 3 months. Again… if any of the above is true for you, please do not return this questionnaire. Otherwise, please complete the following questions. __________________ ____ ______________________________ MAILING ADDRESS: _______________________________________________________________ City: __________________________________ State: WA Zip:______________________ E-MAIL: _________________________________________________ (PLEAS PRINT CLEARLY)
For the following questions, please check the appropriate box or enter the information requested
Yes, to which foods: ___________________________________ Yes, please describe: ____________________________________ 6. Are you currently taking or have you taken at any time during the past 3 months, any type of prescription medication on a regular basis, including birth control (pill, shot, patch or IUD with hormones? (for longer than 2 days at a time) _____________________________ ______________ _____________________________ ______________ _____________________________ ______________ 7. Do you regularly use any medication(s) that can be purchased over-the-counter? (without a prescription _____________________________ ______________ _____________________________ ______________ _____________________________ ______________ 8. During the study, would you be willing to not take medication(s) that can be purchased over-the-counter 9. Do you use any type of laxative or enema more than once a month (like Dulcolax, Fleetlax, etc.)? 10. Have you ever had surgery for removal of all or part of your stomach, intestines, colon or rectum? 11. Have you taken antibiotics in the past 3 months? 12. Has a doctor ever told you that you had any of the following? Please check Yes or No for each Peptic ulcer disease (ulcers of stomach or Kidney disease, problems with kidney function Liver disease, elevated liver enzymes, chronic Chronic bowel diseases, such as Ulcerative 13. Please think about your eating habits over the past year or so. About how often do you eat each of the following foods? Remember breakfast, lunch, dinner, snacks and eating out. Less than
2-3 times a 4-6 times a
Fruit juice, like orange, apple, grape,
fresh, frozen or canned.

(not sodas or other drinks)
Any fruit, fresh or canned (not
counting juice)

Vegetable juice, like tomato juice,
V-8, carrot

Green salad
Potatoes, any kind, including baked,
mashed or french fried

Vegetable soup, or stew with

Any other vegetables, including string
beans, peas, corn, broccoli, carrots, or

any other kind
Fiber cereals like Raisin Bran,
Shredded Wheat or Fruit-n-Fiber

Beans such as baked beans, pinto,
kidney, or lentils (not green beans)

Dark bread such as whole wheat or rye
14. Do you consume flax seeds or flax meal (not flax seed oil) on a regular basis? 15. Do you take any dietary supplements including: multi-vitamins, individual vitamin/mineral supplements, protein powders, herbal extracts, teas/infusions? If yes, would you be willing to not take them or any other dietary supplement for the duration of the study? 16. Do you smoke now, or have you smoked in the past year? (cigarettes, cigars, pipes, etc) 17. Do you drink 2 or more cans of beer OR 2 or more glasses of wine OR 3 or more ounces of hard 18. Do you plan to be in the Seattle area for the next 12 months? 19. May we contact you about other studies related to genetics and their influence on metabolism? Only: Are you currently pregnant or planning on becoming pregnant in the next year? Only: Do you use any medications specifically to prevent pregnancy? This includes pills (oral contraceptives), capsules, patches, shots or injections (e.g. DepoProvera), hormone-secreting IUDs and implants (e.g. Norplant). Thank you for completing this questionnaire. Please send to:
Or scan and email to:
Seattle, WA 98109
We will contact you soon.
If you are eligible for the study,
we will set up an appointment for an informational meeting.


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