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)?

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: MGUS Indolent Smouldering I II III IV

Current stage: MGUS Indolent Smouldering I II III IV

Do you know your current paraprotein level? If so, please state:

Have you had a bone-marrow aspirate? If so, do you know the percentage of "plasma cells" infiltrating your marrow?

How recently was this done?

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)

Physician in charge of your case?

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?

Are your grandparents 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, how long you suffered before diagnosis, and whether you are anaemic now.

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?

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").

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?

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.

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?

How often do you use the following cooking methods?

About your digestion

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
Silver Amalgam
White Amalgam
Porcelain
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.

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