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The Brain Tumor Center Meningioma Questionnaire for Women
Thank you for your interest in Meningioma research.
The purpose of this research study is to determine what
role hormones and/or environmental factors play in the
growth of meningiomas. Our preliminary data suggests
that women with specific types of meningiomas have
several unrelated conditions that are signs of high
levels of estrogen throughout their bodies. our study
seeks to definitively determine if this observation is
scientifically significant. Some of the data obtained
by the questionnaire study suggests that further exposure
to pesticides and/or fertilizers may also play some role
in the growth of meningiomas. Further, we would like to
determine what, if any role genetic changes within the
tumor cells play in these tumors.
Please either mail, fax or email your completed
questionnaire to:
Nancy Conn-Levin
Box 634
Oakhurst, NJ 07755
Fax (732) 922-4364
or email
Meningioma Questionnaire for Women
Please answer the following questions by indicating your
answers according to this scale:
(fill in the space next to the answer you choose)
[] 1 = none
[] 2 = less than 1 year
[] 3 = 1 to 5 years
[] 4 = 5 to 10 years
[] 5 = more than 10 years
For the following items, please indicate your
estimated lifetime exposure (from birth to
present day).
1. allergy shots
[] 1 [] 2 [] 3 [] 4 [] 5
2. cellular telephone
[] 1 [] 2 [] 3 [] 4 [] 5
3. color TV
[] 1 [] 2 [] 3 [] 4 [] 5
4. computer
[] 1 [] 2 [] 3 [] 4 [] 5
5. cordless telephone
[] 1 [] 2 [] 3 [] 4 [] 5
6. electric blanket
[] 1 [] 2 [] 3 [] 4 [] 5
7. frequent air travel (5 + times per year)
[] 1 [] 2 [] 3 [] 4 [] 5
8. hair coloring
[] 1 [] 2 [] 3 [] 4 [] 5
9. insecticides (interior, monthly use)
[] 1 [] 2 [] 3 [] 4 [] 5
10. insecticides (occasional use)
[] 1 [] 2 [] 3 [] 4 [] 5
11. overhead high voltage lines
[] 1 [] 2 [] 3 [] 4 [] 5
12. pesticides (outdoor application)
[] 1 [] 2 [] 3 [] 4 [] 5
13. second hand tobacco smoke (home)
[] 1 [] 2 [] 3 [] 4 [] 5
14. second hand smoke (at work)
[] 1 [] 2 [] 3 [] 4 [] 5
15. water bed heater (electric)
[] 1 [] 2 [] 3 [] 4 [] 5
16. well water (home water supply)
[] 1 [] 2 [] 3 [] 4 [] 5
Please estimate the total number of years that
you lived less than 5 miles from:
17.cellular or radio antenna tower
[] 1 [] 2 [] 3 [] 4 [] 5
18. chemical manufacturing
[] 1 [] 2 [] 3 [] 4 [] 5
19. coal or oil refinery
[] 1 [] 2 [] 3 [] 4 [] 5
20. commercial airport
[] 1 [] 2 [] 3 [] 4 [] 5
21. farm (less than 30 acres)
[] 1 [] 2 [] 3 [] 4 [] 5
22. farm (greater than 30 acres)
[] 1 [] 2 [] 3 [] 4 [] 5
23. fresh water lake
[] 1 [] 2 [] 3 [] 4 [] 5
24. fresh water stream or river
[] 1 [] 2 [] 3 [] 4 [] 5
25. industrial manufacturing
[] 1 [] 2 [] 3 [] 4 [] 5
26. interstate highway
[] 1 [] 2 [] 3 [] 4 [] 5
27. landfill
[] 1 [] 2 [] 3 [] 4 [] 5
28. military installation
[] 1 [] 2 [] 3 [] 4 [] 5
29. nuclear power plant
[] 1 [] 2 [] 3 [] 4 [] 5
30. ocean or salt water lake
[] 1 [] 2 [] 3 [] 4 [] 5
31. toxic waste disposal area
[] 1 [] 2 [] 3 [] 4 [] 5
Using the same scale as before, please
estimate your use of the following:
32. alcohol (less than 1 drink per week)
[] 1 [] 2 [] 3 [] 4 [] 5
33. alcohol (2 to 5 drinks per week)
[] 1 [] 2 [] 3 [] 4 [] 5
34. alcohol (more than 5 drinks per week)
[] 1 [] 2 [] 3 [] 4 [] 5
35. birth control pills
[] 1 [] 2 [] 3 [] 4 [] 5
36. cigarette smoking (less than 1 pack)
[] 1 [] 2 [] 3 [] 4 [] 5
37. cigarette smoking (1 to 2 packs/day)
[] 1 [] 2 [] 3 [] 4 [] 5
38. cigarette smoking (2 + packs/day)
[] 1 [] 2 [] 3 [] 4 [] 5
39. daily use of other prescription drugs
[] 1 [] 2 [] 3 [] 4 [] 5
40. daily use of recreational drugs
[] 1 [] 2 [] 3 [] 4 [] 5
41. estrogen (Premarin, etc.)
[] 1 [] 2 [] 3 [] 4 [] 5
42. hormone replacement therapy
[] 1 [] 2 [] 3 [] 4 [] 5
43. marijuana (occasional use)
[] 1 [] 2 [] 3 [] 4 [] 5
44. marijuana (daily use)
[] 1 [] 2 [] 3 [] 4 [] 5
45. progesterone (Provera, etc.)
[] 1 [] 2 [] 3 [] 4 [] 5
46. steroids (prednisone, etc.)
[] 1 [] 2 [] 3 [] 4 [] 5
47. thyroid hormones (Synthroid, etc.)
[] 1 [] 2 [] 3 [] 4 [] 5
48. Any other drug, medicine or chemical not
included in the lists above
(please print description in space below)
[] 1 [] 2 [] 3 [] 4 [] 5
For the following questions, leave blank
any areas that do not apply.
Please clearly print any hand written
answers throughout the remainder of the
questionnaire.
49. Age at first menstrual period
__________ years, ________ months
50. Age at last period (if applicable)
__________ years, ________ months
51. Typical length of cycle
[] less than 25 days
[] 26 to 27 days
[] 28 to 29 days
[] 30 to 31 days
[] 32 days or longer
[] irregular, no pattern
52. Have you had a full term pregnancy?
[] yes [] no
53. Age at first full term pregnancy
__________ years, ________ months
54. Number of full term pregnancies
[] 0 [] 1 [] 2 [] 3 [] 4 or more
55. Did you breastfeed?
[] yes [] no [] does not apply
56. If so, total number of months
(please combine for all children)
_________ months total of breastfeeding
57. Did you receive medication to inhibit
lactation (dry-up milk)?
[] yes [] no
58. Have you been diagnosed with uterine
fibroid tumors?
[] yes [] no
59. If so, age at time of diagnosis
__________ years, ________ months
60. Have you had treatment for fibroids?
[] yes [] no
61. Please describe below:
[] drugs [] surgery [] other
62. Have you been diagnosed with meningioma?
[] no
[] yes, cranial (skull)
[] yes, spinal
[] other (please describe)
63. Please indicate the date of your meningioma
diagnosis (if applicable)
________(month) ________ (year)
64. Please indicate today's date:
________ (month)______ (day) ______ (year)
65. Do you follow a special diet?
(check all that apply)
[] low calorie (less than 1200 cal. per day)
[] high protein
[] low fat (less than 25 g. fat per day)
[] vegetarian (lacto-ovo)
[] low carbohydrate
[] vegan
[] macrobiotic
[] kosher
[] semi-vegetarian (poultry, fish only)
[] other (please describe)
66. Has your diet changed since meningioma
diagnosis?
[] yes [] no [] N/A
67. If yes, in what way:
68. Please estimate your height:
________ inches
69. Please estimate your weight:
________ pounds
70. Is this where you feel healthy?
[] yes [] no
71. If no, would you like to:
[] gain less than 10 pounds
[] gain more than 10 pounds
[] lose less than 10 pounds
[] lose more than 10 pounds
72. Please indicate the body weight where you
feel most healthy: ________ pounds
73. Do you follow an exercise program?
[] yes [] no
74. If so, how often do you exercise?
[] daily
[] 4 to 6 times per week
[] 2 to 3 times per week
[] once a week or less
What kind of activity do you do?
(please list all exercise activities)
75. Has your exercise changed since meningioma
diagnosis? [] yes [] no [] N/A
76. If yes, in what ways? (please describe)
77. Is your health currently affected by brain
tumor symptoms or treatment effects?
(please describe if so, and leave blank if
not applicable)
78. What kinds of brain tumor treatment have
you had? (please check all that apply)
[] chemotherapy
[] hormonal therapy
[] radiation treatments
[] stereotactic radiation (Gamma Knife, etc.)
[] surgery (please describe what kind,
where it was performed)
[] other (please describe)
79. Have you had any of these diagnostic tests?
(please check all that apply)
[] MRI
[] CT (or CAT)
[] skull x-ray
[] EEG
[] cerebral angiogram
[] other (please describe)
80. What kind of follow-up testing was recommended?
Type:
[] MRI
[] CT
[] other (please describe)
Frequency:
[] every six months
[] every 12 months
[] every other year
[] more than 2 years
[] not recommended at all
[] other (please explain)
81. What size was your tumor when diagnosed?
[] less than 1 cm. [] 5 to 7 cm.
[] 1 to 2 cm. [] 7 to 9 cm.
[] 2 to 3 cm. [] greater than 9 cm.
[] 3 to 5 cm. [] do not know size of tumor
82. Do you have more than one brain tumor?
[] yes [] no [] N/A
83. If yes, please indicate how many, and
location of each below:
Please complete the following questions,
whether or not you have had any tumors.
84. Have you had a head injury?
[] no [] yes (please describe)
85. What is your occupation? (if not currently employed,
use former occupation)
86. Are you currently being treated by:
(please check all that apply)
[] neurosurgeon
[] neurologist
[] internist
[] gynecologist/obstetrician
[] physicianís assistant (P.A.)
[] nurse practitioner
[] chiropractor (D.C.)
[] other medical specialist (please describe)
87. Which of these health professionals is your primary
care provider? (please print)
88. How frequently do you receive medical "check-ups" ?
[] every 6 months
[] every 12 months
[] other (please describe)
89. Has anyone else in your family been diagnosed
with meningioma?
[] no
[] yes (please describe age, relation to you,
other details)
90. Has anyone else in your family been diagnosed
with another type of tumor?
[] no
[] yes (please describe age, relation to you,
other details)
91. Have you used any of the following complementary
therapies?
[] acupuncture
[] meditation
[] psychological counseling (individual)
[] support groups
[] therapeutic massage
[] other (please describe)
92. Have any of these complementary therapies been
helpful to you?
[] yes [] no [] N/A
93. Do you have a history of any of the following
illnesses:
(check all that apply)
[] allergies
[] anemia
[] arthritis
[] asthma
[] breast cancer
[] chronic fatigue syndrome (CFIDS)
[] diabetes
[] endometriosis
[] fibroid tumors (uterus)
[] heart disease
[] high blood pressure
[] high cholesterol (greater than 230)
[] lupus (SLE)
[] migraine headaches
[] ovarian cancer
[] severe sunburn (with blistering)
[] skin cancer
[] uterine cancer
[] viral infection (unusual symptoms or severity)
[] other chronic illness (please list)
94. Did you ever receive radiation therapy or
treatments to your neck or head?
(not including radiation for brain tumor)
[] yes [] no
95. If yes, please describe type of treatments,
length of time, your age when treated:
96. What is your current age?
__________ years, ________ months
97. Place of birth: (city or town, state or
province, country, postal code)
98. For each of the following ages, please indicate
the type of location where you lived:
age birth to 4
[] rural [] suburban [] small city [] large city
age 5 to 10
[] rural [] suburban [] small city [] large city
age 10 to 15
[] rural [] suburban [] small city [] large city
age 15 to 20
[] rura l[] suburban [] small city [] large city
age 20 to 25
[] rural [] suburban [] small city [] large city
age 25 to 30
[] rural [] suburban [] small city [] large city
age 30 to 35
[] rural [] suburban [] small city [] large city
age 35 to 40
[]rural [] suburban [] small city [] large city
age 40 to 45
[] rural [] suburban [] small city [] large city
age 45 to 50
[] rural [] suburban [] small city [] large city
over age 50
[] rural [] suburban [] small city [] large city
99. Please indicate your current residence:
(city or town, state or province, country)
100. Postal or zip code for your current residence:
____________________________
101. Any other comments about areas where you
currently or have previously lived:
102. Are you currently married or living with
another adult?
[] yes [] no
103. Has your spouse/partner been diagnosed with
any tumor?
[] yes [] no
104. Please write your date of birth below:
_______ (month) _______ (day) _______ (year)
105. Would you be available for any follow-up
questioning?
(check all that apply)
[] by mail
[] by telephone
[] by e-mail
[] by fax
[] not interested or available
If you indicated one of the means of follow-up
above, please provide whatever information we
need to contact you (i.e. mailing address,
telephone or fax number, etc.)
Please use the back of this page to
include any additional comments or
questions:
Online Support and Information
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