Document dYQ7bOYnRG1gRK9p6nRybMpyb

Study ID Number _ _ _ __ Name _ _ __ Part 3. Medical histories MHI Have you ever received a blood transfusion? [J NO [J Yes D Do not know MH2 If yes, how many times ?_ __ MH3a Date of first transfusion MH3b Reason (from List below) __ Reason list 1. Accident 2. Anemia 3. Leukemia 5. After childbirth 6. Other (specify) _ _ MH4a Date for last transfusion MH4b Reason (from list) _ _ _ __ Reason list 1. Accident 2. Anemia 3. Leukemia 5. After childbirth 6. Other (specify) _ _ 4. After surgery 4. After surgery MH5 Have you been diagnosed with any of the following diseases (if yes, give year and hospital): [J NO [J Yes D Do not know MH61 I Cancer (any type - specify if known): Cancer Year of diagnosis_ __ Hospital _______ MH 62 Diseases of the Blood System Check Diseases if yes Leukemia (specify type if known) Acute Myeloid Leukemia Chronic Myeloid Leukemia Acute Lymphocytic Leukemia Chronic Lymphocytic Leukemia Other leukemia, not known Aplastic anemia Anemia (other than aplastic) Myelodysplastic syndromes "Low blood count" If yes, type Non-Hodgkin's lymphoma Multiple myeloma Other blood disease, not known MH I Other Diseases Check Disease if yes Tuberculosis Hepatitis (circle type HAV, HEV, HCV) Arthritis Rheumatic fever Infectious mononeucleosis Diabetes HIV Year of Hospital diagnosis Year of Hospital diagnosis Version 24 February 2004 CC_DP Questionnaire 5 of 15 SH ELL-MCCLU RG-059283