Bd-steps

Birth Defects Study to Evaluate Pregnancy exposureS (BD-STEPS)

AttG_BDSTEPS_CATI_FullDraft_Nov8

Mother Questionnaire

OMB: 0920-0010

Document [docx]
Download: docx | pdf

Form Approved

OMB No. 0920-0010

Exp. Date: XX/XX/20XX

Centers for Birth Defects Research and Prevention

Birth Defects Study To Evaluate Pregnancy exposureS (BD-STEPS)

Computer-Assisted Telephone Interview







OPENING STATEMENT

In this interview we will be asking you questions about your family, health, and lifestyle. The questions cover many topics because we don’t know what causes most birth defects. We will study the answers from thousands of mothers hoping to learn something new about the causes of birth defects. Your individual responses are being collected with an assurance of confidentiality.





Section A: ESTABLISHING DATES

I’m going to ask many questions about the time before and during your pregnancy [with [NOIB]/ affected by a birth defect]. In order to do this, I need to start by asking you some dates.

  1. [TAB: What was [NOIB]’s date of birth; On what date did the affected pregnancy end]?

    1. MM/DD/YYYY

    2. Check if DK

      1. MM

      2. DD

      3. YYYY

    3. RF

  2. What date did the doctor give you as a due date for [TAB: [NOIB]’s birth; the affected pregnancy]? That is, when was [TAB: [NOIB]; the baby] expected to be born?

    1. MM/DD/YYYY

    2. Check if DK

      1. MM

      2. DD

      3. YYYY

    3. RF



IF NOIB IS TAB OR STILLBIRTH, SKIP TO QUESTION 6

  1. Is [NOIB] still living?

    1. YES Skip to Question 6

    2. NO Continue to Question 4

    3. DK Skip to Question 6

    4. RF Skip to Question 6

  2. What did s/he die of?

    1. Specify:__________

    2. DK

    3. RF

  3. How old was s/he when s/he died?

    1. AGE:__________

      1. UNITS:__________ (days, weeks, months, years)

    2. DK

    3. RF

    4. Note: If the baby lived less than 24 hours, the response can be recorded as 1 day

  4. What was your date of birth? (mother’s)

    1. MM/DD/YYYY

    2. Check if DK

      1. MM

      2. DD

      3. YYYY

    3. Check if RF

      1. MM

      2. DD

      3. YYYY

  5. I would like to ask about [TAB: [NOIB]’s; the baby’s] biologic or natural father. What was his date of birth? IF DK, PROBE: You don’t know the date of birth or you don’t know the biologic father?

    1. MM/DD/YYYY

    2. Check if DK

      1. MM

      2. DD

      3. YYYY

    3. Check if RF

      1. MM

      2. DD

      3. YYYY

    4. DK WHO FATHER IS

Section B: MULTIPLE GESTATION

  1. In [TAB: your pregnancy with [NOIB]; the affected pregnancy], how many babies were you carrying? PROBE: Were you carrying a single baby, twins, or more babies?

    1. Number:__________

      1. If 1 (single baby) Skip to next section

      2. If ≥2 (twins or higher order multiple) Continue to Question 2

      3. DK Skip to next section

      4. RF Skip to next section

  2. (Is the other baby/are the other babies) still living? [

    1. YES, ALL OTHER BABIES STILL LIVING

    2. SOME BABIES STILL LIVING, OTHERS ARE NOT

    3. NO, NO OTHER BABIES STILL LIVING

    4. DK

    5. RF

  3. What is/was [if deceased] the sex of the other baby/babies? [RECORD FOR EACH ADDITIONAL BABY (number reported in 1a-1)]

    1. Girl

    2. Boy

    3. Ambiguous

    4. DK

    5. RF

  4. Was the other baby/Were the other babies affected by a birth defect? [RECORD FOR EACH ADDITIONAL BABY]

    1. YES Continue to Question 5

    2. NO Skip to Question 6/next section

    3. DK Skip to Question 6/next section

    4. RF Skip to Question 6/next section

  5. What was it? / Anything else? [RECORD FOR EACH ADDITIONAL BABY]

    1. Response:___________________________

      1. See QxQ for list of prompts

    2. DK

    3. RF

  6. FOR SAME SEX TWINS ONLY: The next question is to see how similar your twins’ appearances are. There are three options. Would you say that your twins: [READ OPTIONS]

    1. Look/ed virtually the same, as physically alike as “two peas in a pod”; or

    2. As similar as typical brothers or sisters at the same age; or

    3. Do not look very much alike at all?

    4. DK

    5. RF





Section C: PREGNANCY HISTORY

Now I’m going to ask you about your previous pregnancy experiences.

  1. How many times have you been pregnant before [TAB: [NOIB]; the pregnancy that ended on [DOPT]], including pregnancies that may have ended in miscarriages, stillbirths, induced abortions, or other outcomes?

    1. NUMBER:__________

      1. If 0 Skip to the next section

      2. If >0 Continue to Question 2

    2. DK Skip to the next section

    3. RF Skip to the next section

  2. When did the last pregnancy before [TAB: [NOIB]; the pregnancy that ended on [DOPT]] end?

    1. MM/DD/YYYY or

    2. Time period ago:__________

      1. Years

      2. Months

      3. Weeks

  3. Did that pregnancy end with (a/an) (READ CATEGORIES: live birth, stillbirth, induced abortion, miscarriage, or some other outcome)?

    1. Live birth Skip to Question 5/next section

    2. Stillbirth Continue to Question 4

    3. Induced abortion Continue to Question 4

    4. Miscarriage Continue to Question 4

    5. Some other outcome (specify) Continue to Question 4

    6. DK Skip to Question 5/next section

    7. RF Skip to Question 5/next section

  4. IF REPORTING ANY OUTCOME BESIDES LIVE BIRTH: How far along were you in your pregnancy when the pregnancy ended? For example, the week, month, or trimester?

    1. AMOUNT:______________

      1. UNITS:___________(days, weeks, months)

    2. DK Skip to Question 5/next section

    3. RF Skip to Question 5/next section

  5. ASK ONLY IF RESPONSE TO QUESTION 1 ≥ 2: What was/were the outcome(s) of your [Answer to Question 1 – 1] pregnancy/pregnancies before that? (NUMBER OF EACH OPTION)

    1. Live birth?

    2. Stillbirth?

      1. (If any pregnancies ending in stillbirth reported): How far along were you in your pregnancy when the pregnancy ended?

        1. AMOUNT:__________

          1. UNITS:__________(days, weeks, months)

        2. DK

        3. RF

    3. Induced abortion?

      1. (If any induced abortions reported): How far along were you in your pregnancy when the pregnancy ended?

        1. AMOUNT:__________

          1. UNITS:__________(days, weeks, months)

        2. DK

        3. RF

    4. Miscarriage?

      1. (If any miscarriage reported): How far along were you in your pregnancy when the pregnancy ended?

        1. AMOUNT:__________

            1. UNITS:__________(days, weeks, months)

        2. DK

        3. RF

    5. Other outcome?





Section D: FAMILY HISTORY

  1. Did you have a health problem at birth or a birth defect that was diagnosed in childhood?

    1. YES Continue to Question 2

    2. NO Skip to Question 3

    3. DK Skip to Question 3

    4. RF Skip to Question 3

  2. What was it? / Anything else?

    1. Response:___________________________

      1. See QxQ for list of prompts

    2. DK

    3. RF

  3. IF FATHER UNKNOWN, SKIP TO QUESTION 5: Did [TAB: [NOIB]’s; the) biological or natural father have a health problem at birth or a birth defect that was diagnosed in childhood?

    1. YES Continue to Question 4

    2. NO Skip to Question 5/next section

    3. DK Skip to Question 5/next section

    4. RF Skip to Question 5/next section

  4. What was it? / Anything else? (J15a)

    1. Response:___________________________

      1. See QxQ for list of prompts

    2. DK

    3. RF

  5. IF PREVIOUS PREGNANCIES REPORTED: Did any of [TAB: [NOIB]’s; the) brothers or sisters have a health problem at birth or a birth defect that was diagnosed during pregnancy or in childhood? Please do not include half-siblings or step-siblings. Please do include full siblings who are not still living, including previous pregnancies that ended in a miscarriage, stillbirth, or induced abortion.

    1. YES Continue to Question 6

    2. NO Skip to next section

    3. DK Skip to next section

    4. RF Skip to next section

  6. What was it? / Anything else?

    1. Response:___________________________

      1. See QxQ for list of prompts

    2. DK

    3. RF





Section E: FERTILITY

Now I have some questions specific to your pregnancy [TAB: with [NOIB]; that ended on [DOPT]].

  1. How long were you trying to get pregnant with [TAB: [NOIB]; the pregnancy affected by a birth defect] before you became pregnant? [READ OPTIONS]

    1. We were not trying Skip to Question 14

    2. Less than 6 months

    3. 6 months or more, but less than a year

    4. A year or more, but less than 3 years

    5. 3 years or more, but less than 5 years

    6. 5 years or more, but less than 7 years

    7. 7 years or more

    8. DK

    9. RF

  2. In the two months before you became pregnant with [TAB: [NOIB]; the pregnancy that ended on [DOPT]] did you use any of the following procedures to help you become pregnant? [READ LIST, indicate all that apply]

    1. In-vitro fertilization, or IVF

      1. YES

      2. NO

      3. DK

      4. RF

    2. Intracytoplasmic sperm injection, or ICSI

      1. YES

      2. NO

      3. DK

      4. RF

    3. Artificial insemination

      1. YES

      2. NO

      3. DK

      4. RF

If YES to only one procedure Skip to Question 4

If YES to more than one procedure Continue to Question 3

If NO and/or DK and/or RF to all Skip to Question 9



  1. Which was the last procedure you used before getting pregnant with [TAB: [NOIB]; the affected pregnancy]?

    1. In-vitro fertilization, or IVF

    2. Intracytoplasmic sperm injection, or ICSI

    3. Artificial insemination

    4. DK

    5. RF

  2. What was the date of that procedure?

    1. MM/DD/YYYY

    2. Check if DK

      1. MM

      2. DD

      3. YYYY

    3. RF

  3. Were donor egg(s), donor sperm, or donor embryo(s) used on [DATE OF LAST PROCEDURE/during this last procedure (if date unknown)]?

    1. YES Continue to Question 6

    2. NO Skip to Question 7

    3. DK Skip to Question 7

    4. RF Skip to Question 7

  4. Which of these were used? [SELECT ALL THAT APPLY]?

    1. Donor eggs

    2. Donor sperm

    3. Donor embryos

    4. DK

    5. RF

  5. Were frozen egg(s), frozen sperm, or frozen embryo(s) used on [DATE OF LAST PROCEDURE]?

    1. YES Continue to Question 8

    2. NO Skip to Question 9

    3. DK Skip to Question 9

    4. RF Skip to Question 9

  6. Which of these were used? [SELECT ALL THAT APPLY]

    1. Frozen eggs

    2. Frozen sperm

    3. Frozen embryos

    4. DK

    5. RF

  7. In the two months before you became pregnant with [TAB: [NOIB]; the pregnancy that ended on [DOPT]] did you take any of the following medications to help you become pregnant? [READ LIST, indicate all that apply]

    1. Clomid or clomiphene citrate

      1. YES Ask Question 10

      2. NO

      3. DK

      4. RF

    2. Letrozole/Femara

      1. YES Ask Question 10

      2. NO

      3. DK

      4. RF

    3. Anything else (specify) IF CAN’T RECALL, READ LIST: Was it…?

      1. YES

        1. SPECIFY_____________________

        2. Bromocriptine

        3. Danazol

        4. Danocrine

        5. Depo-Provera

        6. Factrel

        7. Lupron

        8. Lutrepulse

        9. Metrodin

        10. Parlodel

        11. Pergonal

        12. Pregnyl

        13. Profasi HP

        14. Provera

        15. Serophene

        16. Synarel

      2. NO

      3. DK

      4. RF

  8. IF 9a or 9b=YES: How many pills per day did you take at your last cycle before getting pregnant?

    1. NUMBER:__________

    2. DK

    3. RF

  9. IF REPORT ANY FERTILITY PROCEDURES OR MEDICATIONS: How many menstrual cycles with fertility treatments (complete or incomplete) did you have before [TAB: you got pregnant with NOIB; the pregnancy that ended on [DOPT]]?

    1. 1 cycle

    2. 2-3 cycles

    3. 4-6 cycles

    4. ≥7 cycles

    5. DK

    6. RF

  10. IF REPORT ANY FERTILITY PROCEDURES OR MEDICATIONS: What was the reason(s) for fertility treatments? Was it…[READ OPTIONS; indicate all that apply]

    1. A female issue, such as blocked fallopian tubes or Polycystic Ovary Syndrome Continue to Question 13

    2. A male issue, such as low sperm count or low motility Skip to Question 14 if previous pregnancy reported/Question 15 if only one pregnancy reported

    3. No male partner Skip to Question 14/Question 15

    4. Unexplained Skip to Question 14/Question 15

    5. DK Skip to Question 14/Question 15

    6. RF Skip to Question 14/Question 15

  11. IF REPORT FEMALE FACTOR: What was the female issue? Was it…[READ OPTIONS; indicate all that apply]

    1. Blocked fallopian tubes

    2. Polycystic Ovary Syndrome (PCOS)

    3. Endometriosis

    4. Ovulation problems (irregular periods)

    5. Other (specify)

    6. DK

    7. RF

  12. IF PREVIOUS PREGNANCY REPORTED: Have you ever conceived a previous pregnancy using [READ ALL, indicate all that apply]…

    1. Ovulation stimulation pills, such as Clomid or Femara

      1. YES

      2. NO

      3. DK

      4. RF

    2. Artificial insemination

      1. YES

      2. NO

      3. DK

      4. RF

    3. In-vitro fertilization, or IVF; or

      1. YES

      2. NO

      3. DK

      4. RF

    4. Intracytoplasmic sperm injection, or ICSI?

      1. YES

      2. NO

      3. DK

      4. RF

  13. During the first trimester of your pregnancy with [TAB: [NOIB]/the pregnancy that ended on [DOPT]], did you take any medications to prevent pregnancy complications or pregnancy loss, such as hormones, steroids, or injections?

    1. YES Continue to Question 16

    2. NO Skip to next section

    3. DK Skip to next section

    4. RF Skip to next section

  14. What did you take? / Did you take anything else? LIST ALL. IF CAN’T RECALL, READ LIST: Was it…?

    1. Anti D Globulin

    2. Channel Blockers

    3. Depo-Provera

    4. Magnesium Sulfate

    5. Progesterone

    6. Rhogam

    7. Unknown Steroids

    8. Other

      1. Specify:________

    9. DK

    10. RF

  15. When in the first trimester did you start using [MEDICINE] to prevent complications or pregnancy loss?

    1. MM/DD/YYYY or

    2. Month of pregnancy (B1, P1, P2, P3)

    3. DK

    4. RF

  16. When did you stop using [MEDICINE] for the last time during this time period?

    1. MM/DD/YYYY or

    2. Month of pregnancy (B1, P1, P2, P3) If valid start and stop date, skip to Question 20

    3. DK

    4. RF

  17. How long did you take it? You can say the length of time in days, weeks or months.

    1. AMOUNT:__________

      1. Days

      2. Weeks

      3. Months

  18. How often did you use [MEDICINE] in the first three months of your pregnancy? You can say the number of times per day, per week, per month, or during the entire 3 month period.

    1. AMOUNT:__________

      1. Per day

      2. Per week

      3. Per month

      4. Per period



Maternal Health Introduction

At this time, and at other times during this interview, I will be asking you about illnesses you may have had and various kinds of medications or remedies you may have used. Please include medications prescribed by a health care practitioner and medications you might have obtained without a prescription from stores, pharmacies, friends or relatives, as well as herbal and home remedies. If you filled out the medication worksheet we included in your introductory packet, it will be helpful for you to have it in front of you for these questions. Now I have some questions about your health.



Section F: DIABETES

  1. Were you ever told by a doctor that you had diabetes (including gestational diabetes), sometimes called sugar diabetes or diabetes mellitus?

    1. YES Continue to Question 2

    2. NO Skip to next section

    3. DK Skip to next section

    4. RF Skip to next section

  2. What type of diabetes did you or do you currently have? Was it (READ LIST)?

    1. Gestational, that is, during pregnancy only

    2. Insulin-dependent diabetes, also called Type 1, or Juvenile

    3. Non-insulin-dependent diabetes, also called Type 2, or Adult onset

    4. DK

    5. RF

  3. When were you first diagnosed with diabetes? (READ LIST)

    1. Before this pregnancy and not during any other pregnancy?

    2. During a previous pregnancy?

    3. During your pregnancy with [TAB: [NOIB]; the affected pregnancy]?

    4. DK

    5. RF

IF Question 2=a, d, or e OR Question 3=b, c, d, e THEN SKIP TO QUESTION 7 [only ask Question 4 if Question 2 = b or c AND Question 3=a

  1. Either before or during your pregnancy, did you speak with a healthcare provider about your treatment options during pregnancy?

    1. YES Go to Question 5

    2. NO Skip to Question 7

    3. DK Skip to Question 7

    4. RF Skip to Question 7

  2. Did you discuss these options before your pregnancy began?

    1. YES Skip to Question 7

    2. NO Go to Question 6

    3. DK Skip to Question 7

    4. RF Skip to Question 7

  3. How far along were you in your pregnancy when you discussed treatment options with your provider?

    1. AMOUNT:__________

    2. UNITS:

      1. Days

      2. Weeks

      3. Months

      4. Trimester

    3. DK

    4. RF

  4. How did you manage your diabetes and its complications during the time between the month before your pregnancy and the end of the third month of your pregnancy? GIVE OPTIONS; INDICATE ALL THAT APPLY.

    1. Take medications or other remedies if YES, continue to Question 8 after querying 7b-7d

    2. Modify your eating habits if YES, ask Question 19

    3. Control your weight gain if YES, ask Question 19

    4. Do anything else if YES, ask Question 20

    5. If NO to all Skip to Question 22

    6. DK Skip to Question 22

    7. RF Skip to Question 22

  5. IF 7a=YES: What medications did you take?/Did you take anything else? LIST ALL. IF CAN’T RECALL, READ FROM DRUG LIST. Did you take…?

    1. Insulin

      1. Humalog

      2. Novolog

      3. Lantus

      4. Levemir

      5. Humulin N, Novolin N

      6. Humulin R, Novolin R

    2. Diabeta

    3. Glynase

    4. Glyburide [G]

    5. Diabinese

    6. Glucophage

    7. Actos

    8. Glumetza

    9. Metformin [G]

    10. Amaryl

    11. Precose

    12. Glucotrol

    13. Glucotrol XL

    14. Micronase

    15. Januvia

    16. Onglyza

    17. Prandin

    18. Starlix

    19. Byetta

    20. Victoza

    21. Other (specify)

    22. DK

    23. RF

  6. Did you use [MEDICATION] continuously throughout the month before your pregnancy through your third month of pregnancy, that is from [START DATE OF B1] to [END DATE OF P3]?

    1. YES Skip to Question 13

    2. NO Continue to Question 10

    3. DK Continue to Question 10

    4. RF Continue to Question 10

  7. When did you start using [MEDICATION] for diabetes for the first time during this period?

    1. MM/DD/YYYY or

    2. Month of pregnancy (B1, P1, P2, P3)

    3. DK

    4. RF

  8. When did you stop using [MEDICATION] for the last time during this time period?

    1. MM/DD/YYYY or

    2. Month of pregnancy (B1, P1, P2, P3) If valid response to Questions 10 and 11, skip Question 12

    3. DK

    4. RF

  9. How long did you take it?

    1. AMOUNT:__________

      1. Days

      2. Weeks

      3. Months

    2. DK

    3. RF

  10. How often did you use [MEDICINE] during the month before your pregnancy through the end of your third month of pregnancy? You can say the number of times per day, per week, per month, or during the entire 4 month period.

    1. AMOUNT = __________

      1. Per day

      2. Per week

      3. Per month

      4. Per period

    2. DK

    3. RF

  11. Did you take the same amount of medicine each time you took it throughout [START DATE OF B1] TO [END DATE OF P3]? That is, for example, the same number of milligrams of medicine in each dose.

    1. YES Continue to Question 15

    2. NO Skip to Question 16

    3. DK Continue to Question 15

    4. RF Continue to Question 15

  12. What amount of [MEDICINE] did you take each time you took it?

    1. AMOUNT:_______________ Skip to Question 19 (if 7b or 7c=YES) or Question 20 (if 7b and 7c=NO and 7d=YES) or Question 21 (if 7b, 7c, and 7d=NO)

      1. UNITS:__________

    2. DK Skip to Question 19 (if 7b or 7c=YES) or Question 20 (if 7b and 7c=NO and 7d=YES) or Question 21 (if 7b, 7c, and 7d=NO)

    3. RF Skip to Question 19 (if 7b or 7c=YES) or Question 20 (if 7b and 7c=NO and 7d=YES) or Question 21 (if 7b, 7c, and 7d=NO)

  13. What amount of [MEDICINE] did you take 1st/2nd/3rd/etc…?

    1. AMOUNT:__________

      1. UNITS:__________

    2. DK

    3. RF

  14. When did you begin taking that dose?

    1. MM/DD/YYYY or

    2. Month of pregnancy (B1, P1, P2, P3)

    3. DK

    4. RF

  15. When did you stop taking that dose?

    1. MM/DD/YYYY or Continue to Question 19 (if 7b or 7c=YES) or Question 20 (if 7b and 7c=NO and 7d=YES) or Question 21 (if 7b, 7c, and 7d=NO)

    2. Month of pregnancy (B1, P1, P2, P3) Continue to Question 19 (if 7b or 7c=YES) or Question 20 (if 7b and 7c=NO and 7d=YES) or Question 21 (if 7b, 7c, and 7d=NO)

    3. DK Continue to Question 19 (if 7b or 7c=YES) or Question 20 (if 7b and 7c=NO and 7d=YES) or Question 21 (if 7b, 7c, and 7d=NO)

    4. RF Continue to Question 19 (if 7b or 7c=YES) or Question 20 (if 7b and 7c=NO and 7d=YES) or Question 21 (if 7b, 7c, and 7d=NO)

  16. ASK IF 7b OR 7c=YES: In order to modify your eating habits or control your weight, did you…? READ OPTIONS. CHOOSE ALL THAT APPLY.

    1. Follow a diet specifically for diabetes?

    2. Eat healthier but no specific diabetes diet?

    3. Do physical exercise?

    4. Other? SPECIFY____________________________

    5. DK

    6. RF

  17. IF 7d=YES: What else did you do to manage your diabetes and its complications?/Anything else?

    1. SPECIFY:_____________________________

    2. DK

    3. RF

  18. How often did (this measure/these measures) work in controlling your diabetes? READ OPTIONS Needs to be asked separately for 7a, 7b, 7c, and 7d, if they report multiple control methods

    1. Always

    2. Most of the time

    3. Part of the time

    4. Never or rarely

    5. DK

    6. RF

  19. Glycosylated (GLY-CO-SYL-AT-ED) hemoglobin or the “A one C” test measures your average level of blood sugar for the past 3 months, and usually ranges between 5.0 and 13.9. At the time that you became pregnant with [TAB: [NOIB]; the pregnancy that ended on [DOPT]], had a doctor or other health professional ever checked your glycosylated hemoglobin or “A one C”?

    1. YES Continue to Question 23

    2. NO Skip to next section

    3. DK Skip to next section

    4. RF Skip to next section

  20. What was your “A one C” level at the time it was tested closest to when you became pregnant with [TAB: [NOIB]; the pregnancy that ended on [DOPT]]?

    1. AMOUNT:__________

    2. DK

    3. RF

  21. When was the “A one C” test conducted?

    1. MM/DD/YYYY or

    2. Time relative to pregnancy start

    3. DK

    4. RF





Section G: CANCER

  1. Have you ever been told by a doctor or other health professional that you had cancer or a malignancy of any kind?

    1. YES Continue to Question 2

    2. NO Skip to next section

    3. DK Skip to next section

    4. RF Skip to next section

  2. What kind of cancer was it (can enter multiple sites if applicable)?

    1. SPECIFY:__________

    2. DK

    3. RF

  3. How old were you when you were diagnosed with cancer?

    1. AGE:_______________________

    2. DK
      RF

  4. What is the current status of your cancer? (READ OPTIONS)

    1. Active Skip to next section

    2. In remission Continue to Question 5

    3. DK

    4. RF

  5. How long has it been in remission?

    1. TIME:__________

      1. Years

      2. Months

      3. Weeks

      4. Days

    2. DK

    3. RF





Section H: HEART PROBLEMS

  1. Do you have a heart problem that has been present since birth?

    1. YES Continue to Question 2

    2. NO Skip to Question 15

    3. DK Skip to Question 15

    4. RF Skip to Question 15

  2. What is it?

    1. SPECIFY:__________

    2. DK

    3. RF

  3. Did you take any medications or remedies for [HEART PROBLEM] during the month before your pregnancy through the third month of your (pregnancy with [TAB: [NOIB]; the pregnancy that ended on [DOPT]]?

    1. YES Continue to Question 4

    2. NO Skip to Question 15

    3. DK Skip to Question 15

    4. RF Skip to Question 15

  4. What did you take? / Did you take anything else?

    1. SPECIFY:__________

    2. DK

    3. RF

  5. Did you use [MEDICATION] continuously throughout the month before your pregnancy through your third month of pregnancy, that is from [START DATE OF B1] through [END DATE OF P3]?

    1. YES Skip to Question 9

    2. NO Continue to Question 6

    3. DK Continue to Question 6

    4. RF Continue to Question 6

  6. When did you start using [MEDICINE] for the first time during this period?

    1. MM/DD/YYYY or

    2. Month of pregnancy (B1, P1, P2, P3)

    3. DK

    4. RF

  7. When did you stop using [MEDICINE] for the last time during this time period?

    1. MM/DD/YYYY or

    2. Month of pregnancy (B1, P1, P2, P3) if valid response to Questions 6 and 7, skip Question 8

    3. DK

    4. RF

  8. How long did you take it?

    1. AMOUNT:__________

      1. Days

      2. Weeks

      3. Months

    2. DK

    3. RF

  9. How often did you use [MEDICINE] during the month before your pregnancy through the end of your third month of pregnancy? You can say the number of times per day, per week, per month, or during the entire 4 month period.

    1. AMOUNT:__________

      1. Per day

      2. Per week

      3. Per month

      4. Per period

    2. DK

    3. RF

  10. Did you take the same amount of medicine each time you took it throughout [START DATE OF B1] to [END DATE OF P3]? That is, for example, the same number of milligrams of medicine in each dose.

    1. YES Continue to Question 11

    2. NO Skip to Question 12

    3. DK Continue to Question 11

    4. RF Continue to Question 11

  11. What amount of [MEDICINE] did you take each time you took it?

    1. AMOUNT:__________ Skip to Question 15

      1. UNITS:__________

    2. DK Skip to Question 15

    3. RF Skip to Question 15

  12. What amount of [MEDICINE] did you take 1st/2nd/3rd, etc…?

    1. AMOUNT:__________

      1. UNITS:__________

    2. DK

    3. RF

  13. When did you begin taking that dose?

    1. MM/DD/YYYY or

    2. Month of pregnancy (B1, P1, P2, P3)

    3. DK

    4. RF

  14. When did you stop taking that dose?

    1. MM/DD/YYYY or

    2. Month of pregnancy (B1, P1, P2, P3)

    3. DK

    4. RF

  15. Have you ever been diagnosed with cardiac arrhythmias?

    1. YES Continue to Question 16

    2. NO Skip to Question 28

    3. DK Skip to Question 28

    4. RF Skip to Question 28

  16. Did you take any medication for arrhythmias during the month before your pregnancy through the third month of pregnancy?

    1. YES Continue to Question 17

    2. NO Skip to Question 28

    3. DK Skip to Question 28

    4. RF Skip to Question 28

  17. What did you take? / Did you take anything else? IF CAN’T RECALL, READ FROM DRUG LIST:

    1. Beta-blockers

      1. Atenolol

      2. Metoprolol (Toprol, Lopressor)

      3. Propranolol

      4. Labetolol

      5. Carvedilol

    2. Calcium channel blockers

      1. Diltiazem (Cardizem, Cartia)

      2. Verapamil

    3. Rythmol (Propafenone)

    4. Sotalol (Betapace)

    5. Amiodarone (Pacerone, Corderone)

    6. Other (specify)

    7. DK

    8. RF

  18. Did you use [MEDICATION] continuously throughout the month before your pregnancy through the third month of pregnancy, that is from [START DATE OF B1] to [END DATE OF P3]?

    1. YES Skip to Question 22

    2. NO Continue to Question 19

    3. DK Continue to Question 19

    4. RF Continue to Question 19

  19. When did you start using [MEDICINE] for arrhythmias for the first time during this period?

    1. MM/DD/YYYY or

    2. Month of pregnancy (B1, P1, P2, P3)

    3. DK

    4. RF

  20. When did you stop using [MEDICINE] for arrhythmias for the last time during this time period?

    1. MM/DD/YYYY or

    2. Month of pregnancy (B1, P1, P2, P3) If valid response to Questions 19 and 20, skip Question 21

    3. DK

    4. RF

  21. How long did you take it?

    1. AMOUNT:__________

      1. Days

      2. Weeks

      3. Months

    2. DK

    3. RF

  22. How often did you use [MEDICINE] during the month before your pregnancy through the end of your third month of pregnancy? You can say the number of times per day, per week, per month, or during the entire 4 month period.

    1. AMOUNT:__________

      1. Per day

      2. Per week

      3. Per month

      4. Per period

    2. DK

    3. RF

  23. Did you take the same amount of medicine each time you took it throughout [START DATE OF B1] to [END DATE OF P3]? That is, for example, the same number of milligrams of medicine in each dose.

    1. YES Continue to Question 24

    2. NO Skip to Question 25

    3. DK Continue to Question 24

    4. RF Continue to Question 24

  24. What amount of [MEDICINE] did you take each time you took it?

    1. AMOUNT:__________ Skip to Question 28

      1. UNITS:__________

    2. DK Skip to Question 28

    3. RF Skip to Question 28

  25. What amount of [MEDICINE] did you take 1st/2nd/3rd, etc…?

    1. AMOUNT:__________

      1. UNITS:__________

    2. DK

    3. RF

  26. When did you begin taking that dose?

    1. MM/DD/YYYY or

    2. Month of pregnancy (B1, P1, P2, P3)

    3. DK

    4. RF

  27. When did you stop taking that dose?

    1. MM/DD/YYYY or

    2. Month of pregnancy (B1, P1, P2, P3)

    3. DK

    4. RF

  28. Were you ever in your life told by a doctor that you had high blood pressure?

    1. YES Continue to Question 29

    2. NO Skip to next section

    3. DK Skip to next section

    4. RF Skip to next section

  29. What type of high blood pressure did you or do you have? Was it pregnancy-related – that is during pregnancy only? This might also be called pregnancy-induced toxemia or pre-eclampsia or eclampsia. Or is it chronic high blood pressure or chronic hypertension? This is high blood pressure that is not related to your pregnancy. This may have been diagnosed during pregnancy but did not go away after the pregnancy ended.

    1. Pregnancy related

    2. Chronic hypertension

    3. Both

    4. DK

    5. RF

IF Question 29=a, d, or e THEN SKIP TO Question 33 (only ask Question 30 if Question 29=b,c)

  1. Either before or during your pregnancy, did you speak with a healthcare provider about your treatment options during pregnancy?

    1. YES Go to Question 31

    2. NO Skip to Question 33

    3. DK Skip to Question 33

    4. RF Skip to Question 33

  2. Did you discuss these options before your pregnancy began?

    1. YES Skip to Question 33

    2. NO Go to Question 32

    3. DK Skip to Question 33

    4. RF Skip to Question 33

  3. How far along were you in your pregnancy when you discussed treatment options with your provider?

    1. AMOUNT:__________

    2. UNITS:

      1. Days

      2. Weeks

      3. Months

      4. Trimester

    3. DK

    4. RF

  4. Did you take any medications or remedies for high blood pressure during the month before your pregnancy through the third month of pregnancy?

    1. YES Continue to Question 34

    2. NO Skip to next section

    3. DK Skip to next section

    4. RF Skip to next section

  5. What did you take? / Did you take anything else? IF CAN’T RECALL, READ FROM DRUG LIST:

    1. Ace Inhibitor (NOS)

    2. Benazepril (Lotensin)

    3. Enalapril (Vasotec)

    4. Lisinopril (Prinivil, Zestril)

    5. Quinapril (Accupril)

    6. Ramipril (Altace)

    7. Beta Blocker (NOS)

    8. Atenolol (Tenormin)

    9. Metoprolol

    10. Propranolol (Inderal)

    11. Labetalol (Normodyne, Trandate)

    12. Calcium Channel Blocker (NOS)

    13. Amlodipine (Norvasc)

    14. Diltiazem (Cardizem, Tiazac)

    15. Nifedipine (Procardia, Adalat)

    16. Verapamil (Calan, Verelan, Covera)

    17. Diuretic or Water Pill (NOS)

    18. Hydrochlorothiazide [HCTZ] (Microzide)

    19. Angiotensin-converting enzyme inhibitors [ACE inhibitors] (NOS)

    20. Capoten

    21. Angiotensin Receptor Blockers (NOS)

    22. Losartan (Cozaar)

    23. Irbesartan (Avapro)

    24. Olmesartan (Benicar)

    25. Valsartan (Diovan)

    26. Antihypertensive (NOS)

    27. Methyldopa

    28. Hydralazine

    29. Other (specify):__________

    30. DK

    31. RF

  6. Did you use [MEDICATION] continuously throughout the month before your pregnancy through your third month of pregnancy, that is from [START DATE OF B1] to [END DATE OF P3]?

    1. YES Skip to Question 39

    2. NO Continue to Question 36

    3. DK Continue to Question 36

    4. RF Continue to Question 36

  7. When did you start using [MEDICINE] for high blood pressure for the first time during this period?

    1. MM/DD/YYYY or

    2. Month of pregnancy (B1, P1, P2, P3)

    3. DK

    4. RF

  8. When did you stop using [MEDICINE] for the last time during this time period?

    1. MM/DD/YYYY or

    2. Month of pregnancy (B1, P1, P2, P3) If valid response to Questions 36 and 37, skip Question 38

    3. DK

    4. RF

  9. How long did you take it?

    1. AMOUNT:__________

      1. Days

      2. Weeks

      3. Months

    2. DK

    3. RF

  10. How often did you use [MEDICINE] during the month before your pregnancy through the end of your third month of pregnancy? You can say the number of times per day, per week, per month, or during the entire 4 month period.

    1. AMOUNT:__________

      1. Per day

      2. Per week

      3. Per month

      4. Per period

    2. DK

    3. RF

  11. Did you take the same amount of medicine each time you took it throughout [START DATE OF B1] to [END DATE OF P3]? That is, for example, the same number of milligrams of medicine in each dose.

    1. YES Continue to Question 41

    2. NO Skip to Question 42

    3. DK Continue to Question 41

    4. RF Continue to Question 41

  12. What amount of [MEDICINE] did you take each time you took it?

    1. AMOUNT:__________ Skip to next section

      1. UNITS:__________

    2. DK Skip to next section

    3. RF Skip to next section

  13. What amount of [MEDICINE] did you take 1st/2nd/3rd/etc…?

    1. AMOUNT:__________

      1. UNITS:__________

    2. DK

    3. RF

  14. When did you begin taking that dose?

    1. MM/DD/YYYY or

    2. Month of pregnancy (B1, P1, P2, P3)

    3. DK

    4. RF

  15. When did you stop taking that dose?

    1. MM/DD/YYYY or

    2. Month of pregnancy (B1, P1, P2, P3)

    3. DK

    4. RF





Section I: THYROID DISEASE

  1. Have you ever been diagnosed with thyroid disease, not including thyroid cancer, which we have already talked about?

    1. YES Continue to Question 2

    2. NO Skip to next section

    3. DK Skip to next section

    4. RF Skip to next section

  2. What type of thyroid disease were you diagnosed with originally? Was it…[ask all options and allow multiple types]

    1. Hypothyroidism, also called having an “underactive” thyroid?

      1. YES

      2. NO

      3. DK

      4. RF

    2. Hashimoto’s Disease or autoimmune thyroiditis?

      1. YES

      2. NO

      3. DK

      4. RF

    3. Hyperthyroidism, also called having an “overactive” thyroid?

      1. YES

      2. NO

      3. DK

      4. RF

    4. Graves’ Disease?

      1. YES

      2. NO

      3. DK

      4. RF

    5. If a-d = NO/DK/RF (no YES): Was it another type of thyroid disease? Please specify

      1. Response:_______________________________________

      2. NOTE: CANCER, INCLUDING THYROID, WILL HAVE BEEN QUERIED IN AN EARLIER SECTION

      3. DK

      4. RF

  3. When was [thyroid disease specified above] first diagnosed [READ LIST]?

    1. More than 2 years before [TAB: your pregnancy with [NOIB]; the pregnancy that ended on [DOPT]]

    2. In the 2 years before [TAB: your pregnancy with [NOIB]; the affected pregnancy]

    3. During the first trimester of [TAB: your pregnancy with [NOIB]; the affected pregnancy]

    4. After the first trimester but still during pregnancy

    5. After [TAB: your pregnancy with [NOIB]; the affected pregnancy] ended

    6. RF

    7. DK

  4. [If reporting Hyperthyroidism/overactive thyroid/Graves’ Disease continue, otherwise, skip to 9]: Have you had surgery to remove all or part of your thyroid gland?

    1. YES Continue to Question 5

    2. NO Skip Question 7

    3. DK Skip Question 7

    4. RF Skip Question 7

  5. Did you have all or part of your thyroid gland removed?

    1. ALL

    2. PART

    3. DK

    4. RF

  6. When did you have this surgery?

    1. MM/DD/YYYY or

    2. AGE:__________ or

    3. Time period ago:__________

      1. Years

      2. Months

      3. Weeks

    4. DK

    5. RF

  7. Did you have treatment with radioactive iodine?

    1. YES

    2. NO

    3. DK

    4. RF

  8. When did you have this procedure?

    1. MM/DD/YYYY or

    2. AGE:__________ or

    3. Time period ago:__________

      1. Years

      2. Months

      3. Weeks

    4. DK

    5. RF

IF Question 3=c, d, e, f, or g THEN SKIP TO QUESTION 12 (only ask Question 9 if Question 3=a or b)

  1. Either before or during your pregnancy, did you speak with a healthcare provider about your treatment options during pregnancy?

    1. YES Go to Question 10

    2. NO Skip to Question 12

    3. DK Skip to Question 12

    4. RF Skip to Question 12

  2. Did you discuss these options before your pregnancy began?

    1. YES Skip to Question 12

    2. NO Go to Question 11

    3. DK Skip to Question 12

    4. RF Skip to Question 12

  3. How far along were you in your pregnancy when you discussed treatment options with your provider?

    1. AMOUNT:__________

    2. UNITS:

      1. Days

      2. Weeks

      3. Months

      4. Trimester

    3. DK

    4. RF

  4. Did you take any medications or remedies for [THYROID CONDITION] during the month before your pregnancy through the third month of pregnancy, that is from [START DATE OF B1] to [END DATE OF P3]?

    1. YES Continue to Question 13

    2. NO Skip to next section

    3. DK Skip to next section

    4. RF Skip to next section

  5. What did you take? / Did you take anything else?

    1. IF CAN’T RECALL, READ FROM LIST:

      1. Synthroid

      2. Levothyroxine

      3. Levothroid

      4. Levoxyl

      5. Tirosint

      6. Liothyronine

      7. Cytomel

      8. Unithroid

      9. Liotrix

      10. Thyrolar

      11. Desiccated natural thyroid, such as Armour Thyroid

      12. Methimazole/thiamazole

      13. Propylthiouracil (PTU)

      14. Carbimazole

      15. Other (specify):__________

      16. DK

      17. RF

  6. Did you use [MEDICATION] continuously throughout the month before your pregnancy through the third month of your pregnancy?

    1. YES Skip to Question 18

    2. NO Continue to Question 15

    3. DK Continue to Question 15

    4. RF Continue to Question 15

  7. When did you start using [MEDICATION] for [THYROID CONDITION] for the first time during this period?

    1. MM/DD/YYYY or

    2. Month of pregnancy (B1, P1, P2, P3)

    3. DK

    4. RF

  8. When did you stop using [MEDICATION] for [THYROID CONDITION] for the last time during this time period?

    1. MM/DD/YYYY or

    2. Month of pregnancy (B1, P1, P2, P3) If valid response to Questions 15 and 16, skip Question 17

    3. DK

    4. RF

  9. How long did you take it?

    1. AMOUNT:__________

      1. Days

      2. Weeks

      3. Months

    2. DK

    3. RF

  10. How often did you use [MEDICINE] during the month before your pregnancy through the end of your third month of pregnancy? You can say the number of times per day, per week, per month, or during the entire 4 month period.

    1. AMOUNT: ___________________

      1. Per Day

      2. Per Week

      3. Per Month

      4. Per Period

    2. DK

    3. RF

  11. Did you take the same amount of medicine each time you took it throughout [START DATE OF B1] to [END DATE OF P3]? That is, for example, the same number of milligrams of medicine in each dose.

    1. YES Continue to Question 20

    2. NO Skip to Question 21

    3. DK Continue to Question 20

    4. RF Continue to Question 20

  12. What amount of [MEDICINE] did you take each time you took it?

    1. AMOUNT:__________ Skip to next section

      1. UNITS:__________

    2. DK Skip to next section

    3. RF Skip to next section

  13. What amount of [MEDICINE] did you take 1st/2nd/3rd/etc…?

    1. AMOUNT:__________

      1. UNITS:__________

    2. DK

    3. RF

  14. When did you begin taking that dose?

    1. MM/DD/YYYY or

    2. Month of pregnancy (B1, P1, P2, P3)

    3. DK

    4. RF

  15. When did you stop taking that dose?

    1. MM/DD/YYYY or

    2. Month of pregnancy (B1, P1, P2, P3)

    3. DK

    4. RF





Section J: ASTHMA

  1. Have you ever been diagnosed with asthma or reactive airway disease?

    1. YES Continue to Question 2

    2. NO Skip to next section

    3. DK Skip to next section

    4. RF Skip to next section

  2. When was your [ASTHMA/REACTIVE AIRWAY DISEASE] first diagnosed? [READ LIST]

    1. More than 2 years before [TAB: your pregnancy with [NOIB]; the pregnancy that ended on [DOPT]]

    2. In the 2 years before [TAB: your pregnancy with [NOIB]/the affected pregnancy]

    3. During the first trimester of [TAB: your pregnancy with [NOIB]; the affected pregnancy]

    4. After the first trimester but still during pregnancy

    5. After [TAB: your pregnancy with [NOIB]; the affected pregnancy] ended

    6. RF

    7. DK

  3. Did you have any asthma symptoms in the month before your pregnancy through your third month of pregnancy, that is from [START DATE OF B1] to [END DATE OF P3]? These symptoms include shortness of breath, chest tightness or pain, coughing or wheezing, or low peak expiratory flow (PEF) readings.

    1. YES Continue to Question 4

    2. NO Skip to Question 5

    3. DK Skip to Question 5

    4. RF Skip to Question 5

  4. During that 4 month period did you miss any work, school, or normal daily activities because of your asthma?

    1. YES

    2. NO

    3. DK

    4. RF

  5. During that 4 month period how often did you wake up at night because of your asthma? [read options]

    1. Not at all

    2. Less than once per month

    3. Once or twice per month

    4. More than twice per month

    5. DK

    6. RF

IF Question 2=c, d, e, f, g THEN SKIP TO Question 8 (only ask Question 6 if Question 2=a, b)

  1. Either before or during your pregnancy, did you speak with a healthcare provider about your treatment options during pregnancy?

    1. YES Go to Question 7

    2. NO Skip to Question 9

    3. DK Skip to Question 9

    4. RF Skip to Question 9

  2. Did you discuss these options before your pregnancy began?

    1. YES Skip to Question 9

    2. NO Go to Question 8

    3. DK Skip to Question 9

    4. RF Skip to Question 9

  3. How far along were you in your pregnancy when you discussed treatment options with your provider?

    1. AMOUNT:__________

    2. UNITS:

      1. Days

      2. Weeks

      3. Months

      4. Trimester

    3. DK

    4. RF

Now I am going to ask about maintenance medications and remedies for long-term control of your asthma and then fast-acting, or “rescue”, medications for treatment of an asthma attack. First…

  1. Did you take any maintenance medications or remedies for long-term control of your asthma during the month before your pregnancy through the third month of pregnancy?

    1. YES Continue to Question 10

    2. NO Skip to Question 21

    3. DK Skip to Question 21

    4. RF Skip to Question 21

  2. What did you take? / Did you take anything else? IF CAN’T RECALL, READ FROM DRUG LIST:

    1. Fluticasone (G)

    2. Flovent

    3. Flonase

    4. Budesonide (G)

    5. Pulmicort

    6. Rhinocort

    7. Mometasone (G)

    8. Nasonex

    9. Asmanex

    10. Ciclesonide (G)

    11. Alvesco

    12. Omnaris

    13. Flunisolide (G)

    14. Aeorbid

    15. Aerospan

    16. Beclomethasone (G)

    17. Qvar

    18. Qnasl

    19. Montelukast (G)

    20. Singulair

    21. Zafirlukast (G)

    22. Accolate

    23. Zileuton (G)

    24. Zyflo

    25. Salmeterol (G)

    26. Serevent

    27. Formoterol (G)

    28. Foadil

    29. Perforomist

    30. Advair

    31. Symbicort

    32. Dulera

    33. Other (specify):__________

    34. DK

    35. RF

  3. How did you take [MEDICATION]? Was it [ASK EACH OPTION]:

    1. Breathed in through your mouth

    2. Breathed in through your nose

    3. Taken as a pill in your mouth

    4. Other (specify)

    5. DK

    6. RF

  4. Did you use [MEDICATION] continuously throughout the month before your pregnancy through your third month of pregnancy?

    1. YES Skip to Question 16

    2. NO Continue to Question 13

    3. DK Continue to Question 13

    4. RF Continue to Question 13

  5. When did you start using [MEDICATION] for [ASTHMA/REACTIVE AIRWAY DISEASE] for the first time during this period?

    1. MM/DD/YYYY or

    2. Month of pregnancy (B1, P1, P2, P3)

    3. DK

    4. RF

  6. When did you stop using [MEDICATION] for the last time during this time period?

    1. MM/DD/YYYY or

    2. Month of pregnancy (B1, P1, P2, P3) If valid response to Questions 13 and 14, skip Question 15

    3. DK

    4. RF

  7. How long did you take it?

    1. AMOUNT:__________

      1. Days

      2. Weeks

      3. Months

    2. DK

    3. RF

  8. How often did you use [MEDICINE] during the month before your pregnancy through the end of your third month of pregnancy? You can say the number of times per day, per week, per month, or during the entire 4 month period.

    1. AMOUNT: __________

      1. Per day

      2. Per week

      3. Per month

      4. Per period

    2. DK

    3. RF

  9. Did you take the same amount of medicine each time you took it throughout [START DATE OF B1] to [END DATE OF P3]? That is, for example, the same number of milligrams of medicine in each dose.

    1. YES Continue to Question 18

    2. NO Skip to Question 19

    3. DK Continue to Question 18

    4. RF Continue to Question 18

  10. What amount of [MEDICINE] did you take each time you took it?

    1. AMOUNT:__________ Skip to Question 22

      1. UNITS:__________

    2. DK Skip to Question 22

    3. RF Skip to Question 22

  11. What amount of [MEDICINE] did you take 1st/2nd/3rd/etc…?

    1. AMOUNT:__________

      1. UNITS:__________

    2. DK

    3. RF

  12. When did you begin taking that dose?

    1. MM/DD/YYYY or

    2. Month of pregnancy (B1, P1, P2, P3)

    3. DK

    4. RF

  13. When did you stop taking that dose?

    1. MM/DD/YYYY or

    2. Month of pregnancy (B1, P1, P2, P3)

    3. DK

    4. RF

  14. Did you take any fast-acting, or “rescue” medications or remedies for treatment of an asthma attack during the month before your pregnancy through the third month of pregnancy?

    1. YES Continue to Question 23

    2. NO Skip to next section

    3. DK Skip to next section

    4. RF Skip to next section

  15. What did you take? / Did you take anything else? IF CAN’T RECALL, READ FROM DRUG LIST:

    1. Albuterol (G) Skip to Question 25

    2. ProAir HFA Skip to Question 25

    3. Ventolin HFA Skip to Question 25

    4. Levalbuterol (G) Skip to Question 25

    5. Xopenex HFA Skip to Question 25

    6. Pirbuterol (G) Skip to Question 25

    7. Maxair Skip to Question 25

    8. Ipratropium (G) Skip to Question 25

    9. Atrovent Skip to Question 25

    10. Asthmanefrin Skip to Question 25

    11. Bronkaid Skip to Question 25

    12. Other steroids, such as prednisone or methylprednisone (G) Continue to Question 24

    13. Other (specify):__________ Skip to Question 25

    14. DK Skip to Question 25

    15. RF Skip to Question 25

  16. Did you get this medication from a pill that you swallowed or from a shot?

    1. Pill

    2. Shot (injection)

    3. DK

    4. RF

  17. How often did you use [MEDICINE] during the month before your pregnancy through the third month of your pregnancy? You can say the number of times per day, per week, per month, or during the entire 4 month period.

    1. AMOUNT: __________

      1. Per day

      2. Per week

      3. Per month

      4. Per period

    2. DK

    3. RF

  18. Did you use [MEDICATION] [FREQUENCY VALUE] per [FREQUENCY UNITS] throughout the entire time from a month before your pregnancy through the third month of your pregnancy?

    1. YES Skip to next section

    2. NO Continue to Question 27

    3. DK Continue to Question 27

    4. RF Continue to Question 27

  19. How often did you use [MEDICATION]…

    1. During the month before your pregnancy, which was [START DATE OF B1] to [END DATE OF B1]

      1. AMOUNT: __________

        1. Per day

        2. Per week

        3. Per month

      2. Didn’t take medication during this time

      3. DK

      4. RF

    2. During the first month of your pregnancy, which was [START DATE OF P1] to [END DATE OF P1]

      1. AMOUNT: __________

        1. Per day

        2. Per week

        3. Per month

      2. Didn’t take medication during this time

      3. DK

      4. RF

    3. During the second month of your pregnancy, which was [START DATE OF P2] to [END DATE OF P2]

      1. AMOUNT: __________

        1. Per day

        2. Per week

        3. Per month

      2. Didn’t take medication during this time

      3. DK

      4. RF

    4. During the third month of your pregnancy, which was [START DATE OF P3] to [END DATE OF P3]

      1. AMOUNT: __________

        1. Per day

        2. Per week

        3. Per month

      2. Didn’t take medication during this time

      3. DK

      4. RF





Section K: EPILEPSY

  1. Were you ever told by a doctor that you had epilepsy?

    1. YES Continue to Question 2

    2. NO Skip to next section

    3. DK Skip to next section

    4. RF Skip to next section

  2. What type of epilepsy do you have? IF CAN’T RECALL, READ FROM LIST:

    1. Temporal Lobe Epilepsy

    2. Frontal Lobe Epilepsy

    3. Reflex Epilepsy

    4. Childhood Absence Epilepsy

    5. Juvenile Absence Epilepsy

    6. (Additional conditions listed in QxQ; see below)

    7. DK

    8. RF

  3. When were you first diagnosed with epilepsy? [READ LIST]

    1. More than 2 years before [TAB: your pregnancy with [NOIB]; the pregnancy that ended on [DOPT]]

    2. In the 2 years before [TAB: your pregnancy with [NOIB]; the affected pregnancy]

    3. During the first trimester of [TAB: your pregnancy with [NOIB]; the affected pregnancy]

    4. After the first trimester but still during pregnancy

    5. After [TAB: your pregnancy with [NOIB]; the affected pregnancy] ended

    6. RF

    7. DK



IF Question 3=c, d, e, f, g THEN SKIP TO Question 7 (only ask Question 4 if Question 3=a, b)

  1. Either before or during your pregnancy, did you speak with a healthcare provider about your treatment options during pregnancy?

    1. YES Go to Question 5

    2. NO Skip to Question 7

    3. DK Skip to Question 7

    4. RF Skip to Question 7

  2. Did you discuss these options before your pregnancy began?

    1. YES Skip to Question 7

    2. NO Go to Question 6

    3. DK Skip to Question 7

    4. RF Skip to Question 7

  3. How far along were you in your pregnancy when you discussed treatment options with your provider?

    1. AMOUNT:__________

    2. UNITS:

      1. Days

      2. Weeks

      3. Months

      4. Trimester

    3. DK

    4. RF

  4. Did you take any medications or remedies for epilepsy during the month before your pregnancy through the third month of pregnancy?

    1. YES Continue to Question 8

    2. NO Skip to Question 19

    3. DK skip to Question 19

    4. RF skip to Question 19

  5. What did you take? / Did you take anything else? IF CAN’T RECALL, READ FROM DRUG LIST:

    1. Depakene, Depakote, valproic acid

    2. Dilantin, phenytoin

    3. Felbatol

    4. Klonopin, clonazepam

    5. Lamictal

    6. Phenobarbital

    7. Tegretol, Carbatrol

    8. Keppra

    9. Trileptal

    10. Topamax (topiramate)

    11. Other (SPECIFY)

    12. DK

    13. RF

  6. Did you use [MEDICATION] continuously throughout the month before your pregnancy through your third month of pregnancy, that is from [START DATE OF B1] to [END DATE OF P3]?

    1. YES Skip to Question 13

    2. NO Continue to Question 10

    3. DK Continue to Question 10

    4. RF Continue to Question 10

  7. When did you start using [MEDICINE] for epilepsy for the first time during this period?

    1. MM/DD/YYYY or

    2. Month of pregnancy (B1, P1, P2, P3)

    3. DK

    4. RF

  8. When did you stop using [MEDICINE] for the last time during this time period?

    1. MM/DD/YYYY or

    2. Month of pregnancy (B1, P1, P2, P3) If valid response to Question 10 and 11, skip Question 12

    3. DK

    4. RF

  9. How long did you take it?

    1. AMOUNT:________________

      1. Days

      2. Weeks

      3. Months

    2. DK

    3. RF

  10. How often did you use [MEDICINE] during the month before your pregnancy through the end of your third month of pregnancy? You can say the number of times per day, per week, per month, or during the entire 4 month period.

    1. AMOUNT:___________________________

      1. Per day

      2. Per week

      3. Per month

      4. Per period

    1. DK

    2. RF

  1. Did you take the same amount of medicine each time you took it throughout [START DATE OF B1] to [END DATE OF P3]? That is, for example, the same number of milligrams of medicine in each dose.

    1. YES Continue to Question 15

    2. NO Skip to Question 16

    3. DK Continue to Question 15

    4. RF Continue to Question 15

  2. What amount of [MEDICINE] did you take each time you took it?

    1. AMOUNT:__________ Skip to Question 19

      1. UNITS:____________

    1. DK Skip to Question 19

    2. RF Skip to Question 19

  1. What amount of [MEDICINE] did you take 1st/2nd/3rd/etc…?

    1. AMOUNT:__________

      1. UNITS:__________

    1. DK

    2. RF

  1. When did you begin taking that dose?

    1. MM/DD/YYYY or

    2. Month of pregnancy (B1, P1, P2, P3)

    3. DK

    4. RF

  2. When did you stop taking that dose?

    1. MM/DD/YYYY or

    2. Month of pregnancy (B1, P1, P2, P3)

    3. DK

    4. RF

  3. Did you have any seizures in the month before your pregnancy through the third month of pregnancy?

    1. YES Continue to Question 20

    2. NO Skip to next section

    3. DK Skip to next section

    4. RF Skip to next section

  4. How many seizures did you have altogether during that time?

    1. AMOUNT:__________

    2. DK

    3. RF





Section L: MIGRAINE

  1. Have you ever had a migraine headache, also sometimes called a sick headache?

    1. YES Continue to Question 2

    2. NO Skip to next section

    3. DK Skip to next section

    4. RF Skip to next section

  1. How old were you when you had the first migraine headache?

    1. AGE:___________

    2. DK

    3. RF

  2. Did you have any migraine headaches in the month before your pregnancy through the third month of pregnancy, that is from [START DATE OF B1] to [END DATA OF P3]?

    1. YES Continue to Question 4

    2. NO Skip to Question 5

    3. DK Skip to Question 5

    4. RF Skip to Question 5

  3. How many migraines did you have altogether during that time?

    1. Total number:__________ OR

    2. Frequency – AMOUNT:__________

      • Per day

      • Per week

      • Per month

    3. DK

    4. RF

Now I am going to ask about maintenance medications and remedies you may use to prevent migraines and then medications you use treat migraine symptoms when they occur.

  1. Did you take any medications or remedies to prevent migraines during the month before your pregnancy through the third month of pregnancy? [In QxQ make sure to distinguish from medications used to treat migraines themselves, which will be queried later.]

    1. YES Continue to Question 6

    2. NO Skip to Question 17

    3. DK Skip to Question 17

    4. RF Skip to Question 17

  2. What did you take? / Did you take anything else? IF CAN’T RECALL, READ FROM DRUG LIST:

    1. Beta-blockers (NOS)

    2. Propranolol (G)

    3. Inderal

    4. Innopran

    5. Atenolol

    6. Timolol

    7. Calcium channel blockers (NOS)

    8. Verapamil (G)

    9. Calan

    10. Verelan

    11. ACE inhibitors (NOS)

    12. Lisinopril (G)

    13. Zestril

    14. [Tricyclic antidepressants – don’t read; category heading only]

    15. Amitriptyline (G)

    16. Nortriptyline (G)

    17. Pamelor

    18. Protriptyline (G)

    19. Vivactil

    20. Doxepin

    21. [SNRIs – don’t read; category heading only]

    22. Venlafaxine (G)

    23. Effexor

    24. [Anti-seizure drugs – don’t read; category heading only]

    25. Valproate (G)

    26. Depakote

    27. Valproic acid (G)

    28. Divalproex

    29. Topiramate (G)

    30. Topamax

    31. Gabapentin (G)

    32. Neurontin

    33. Lamotrigine (G)

    34. Lamictal

    35. [NSAIDS – don’t read; category heading only]

    36. Motrin

    37. Ibuprofen (G)

    38. Advil

    39. Motrin

    40. Naproxen

    41. Aspirin

    42. Excedrin

    43. Aleve

    44. [Other drugs – don’t read; category heading only]

    45. Cyproheptadine

    46. Botox

    47. Other (specify):__________

    48. DK

    49. RF

  3. Did you use [MEDICATION] continuously throughout the month before your pregnancy through your third month of pregnancy?

    1. YES Skip to Question 11

    2. NO Continue to Question 8

    3. DK Continue to Question 8

    4. RF Continue to Question 8

  4. When did you start using [MEDICATION] to prevent migraines for the first time during this period?

    1. MM/DD/YYYY or

    2. Month of pregnancy (B1, P1, P2, P3)

    3. DK

    4. RF

  5. When did you stop using [MEDICATION] for the last time during this time period?

    1. MM/DD/YYYY or

    2. Month of pregnancy (B1, P1, P2, P3) If valid response to Question 8 and 9, skip Question 10

    3. DK

    4. RF

  6. How long did you take it?

    1. AMOUNT:__________

      1. Days

      2. Weeks

      3. Months

  7. How often did you use [MEDICINE] during the month before your pregnancy through the end of your third month of pregnancy? You can say the number of times per day, per week, per month, or during the entire 4 month period.

    1. AMOUNT:_____________

      1. Per day

      2. Per week

      3. Per month

      4. Per period

    1. DK

    2. RF

  1. Did you take the same amount of medicine each time you took it throughout [START DATE OF B1] to [END DATE OF P3]? That is, for example, the same number of milligrams of medicine in each dose.

    1. YES Continue to Question 13

    2. NO Skip to Question 14

    3. DK Continue to Question 13

    4. RF Continue to Question 13

  2. What amount of [MEDICINE] did you take each time you took it?

    1. AMOUNT:__________ Skip to Question 17

      1. UNITS:__________

    2. DK Skip to Question 17

    3. RF Skip to Question 17

  3. What amount of [MEDICINE] did you take 1st/2nd/3rd/etc…?

    1. AMOUNT:__________

      1. UNITS:__________

    2. DK

    3. RF

  4. When did you begin taking that dose?

    1. MM/DD/YYYY or

    2. Month of pregnancy (B1, P1, P2, P3)

    3. DK

    4. RF

  5. When did you stop taking that dose?

    1. MM/DD/YYYY or

    2. Month of pregnancy (B1, P1, P2, P3)

    3. DK

    4. RF

  6. Did you take any over-the-counter medications or remedies for pain relief from migraine headaches in the month before your pregnancy through the third month of pregnancy? These types of medications do not require a prescription from a healthcare provider.

    1. YES Continue to Question 18

    2. NO Skip to Question 22

    3. DK Skip to Question 22

    4. RF Skip to Question 22

  7. What did you take? / Did you take anything else? IF CAN’T RECALL, READ FROM DRUG LIST:

    1. Ibuprofen

    2. Advil

    3. Motrin

    4. Aleve

    5. Naproxen

    6. Acetaminophen

    7. Tylenol

    8. Aspirin

    9. Excedrin Migraine

    10. Other (Specify):__________

    11. DK

    12. RF

  8. How often did you use [MEDICINE] in the month before your pregnancy through the third month of your pregnancy? You can say the number of times per day, per week, per month, or during the entire 4 month period.

    1. AMOUNT:__________

      1. Per day

      2. Per week

      3. Per month

      4. Per period

    1. DK

    2. RF

  1. Did you use [MEDICATION] [FREQUENCY VALUE] per [FREQUENCY UNITS] throughout the entire time from the month before your pregnancy through the third month of your pregnancy?

    1. YES Skip to Question 22

    2. NO Continue to Question 21

    3. DK Continue to Question 21

    4. RF Continue to Question 21

  2. How often did you use [MEDICATION]…

    1. During the month before your pregnancy, which was [START DATE OF B1] to [END DATE OF B1]

      1. AMOUNT:__________

        1. Per day

        2. Per week

        3. Per month

        4. Per year

      1. Didn’t take medication during this time

      2. DK

      3. RF

    1. During the first month of your pregnancy, which was [START DATE OF P1] to [END DATE OF P1]

      1. AMOUNT: __________

        1. Per day

        2. Per week

        3. Per month

        4. Per year

      2. Didn’t take medication during this time

      3. DK

      4. RF

    2. During the second month of your pregnancy, which was [START DATE OF P2] to [END DATE OF P2]

      1. AMOUNT: __________

        1. Per day

        2. Per week

        3. Per month

        4. Per year

      2. Didn’t take medication during this time

      3. DK

      4. RF

    3. During the third month of your pregnancy, which was [START DATE OF P3] to [END DATE OF P3]

      1. AMOUNT: __________

        1. Per day

        2. Per week

        3. Per month

        4. Per year

      2. Didn’t take medication during this time

      3. DK

      4. RF

  1. Did you take any prescription medications or remedies for pain relief from migraine headaches in the month before your pregnancy through the third month of pregnancy? These types of medications require a prescription from a healthcare provider.

    1. YES Continue to Question 23

    2. NO Skip to next section

    3. DK Skip to next section

    4. RF Skip to next section

  2. What did you take? / Did you take anything else? IF CAN’T RECALL, READ FROM DRUG LIST:

    1. Indomethacin [prescription pain reliever]

    2. Fioricet (with or without codeine)

    3. Codeine or other narcotic (with or without acetaminophen)

    4. Treximet (sumatriptan plus naproxen)

    5. Imitrex (sumatriptan)

    6. Maxalt (rizatriptan)

    7. Axert (almotriptan)

    8. Amerge (naratriptan)

    9. Zomig (zolimitriptan)

    10. Frova (frovatriptan)

    11. Relpax (eletriptan)

    12. Ergotamine or dihydroergotamine (e.g., Cafergot, Migergot, Migranal)

    13. Other (Specify):__________

    14. DK

    15. RF

  3. How often did you use [MEDICINE] in the month before your pregnancy through the third month of your pregnancy? You can say the number of times per day, per week, per month, or during the entire 4 month period.

    1. AMOUNT:__________

      1. Per day

      2. Per week

      3. Per month

      4. Per period

  1. DK

  1. RF

  1. Did you use [MEDICATION] [FREQUENCY VALUE] per [FREQUENCY UNITS] throughout the entire time from the month before your pregnancy through the third month of your pregnancy?

    1. YES Skip to Question 27

    2. NO Continue to Question 26

    3. DK Continue to Question 26

    4. RF Continue to Question 26

  2. How often did you use [MEDICATION]…

    1. During the month before your pregnancy, which was [START DATE OF B1] to [END DATE OF B1]

      1. AMOUNT:__________

        1. Per day

        2. Per week

        3. Per month

        4. Per year

      1. Didn’t take medication during this time

      2. DK

      3. RF

    1. During the first month of your pregnancy, which was [START DATE OF P1] to [END DATE OF P1]

      1. AMOUNT: __________

        1. Per day

        2. Per week

        3. Per month

        4. Per year

      1. Didn’t take medication during this time

      2. DK

      3. RF

    1. During the second month of your pregnancy, which was [START DATE OF P2] to [END DATE OF P2]

      1. AMOUNT: __________

        1. Per day

        2. Per week

        3. Per month

        4. Per year

      1. Didn’t take medication during this time

      2. DK

      3. RF

    1. During the third month of your pregnancy, which was [START DATE OF P3] to [END DATE OF P3]

      1. AMOUNT: __________

        1. Per day

        2. Per week

        3. Per month

        4. Per year

      1. Didn’t take medication during this time

      2. DK

      3. RF

  1. When you used [MEDICINE] to treat your migraine pain, did you take the same amount each time you took it throughout [START DATE of B1] to [END DATE OF P3]?

    1. YES Continue to Question 28

    2. NO Skip to Question 29

    3. DK Continue to Question 28

    4. RF Continue to Question 28

  2. What amount of [MEDICINE] did you take each time you took it?

    1. AMOUNT:__________ Skip to next section

      1. UNITS:__________

    2. DK Skip to next section

    3. RF Skip to next section

  3. What amount of [MEDICINE] did you take 1st/2nd/3rd/etc…?

    1. AMOUNT:__________

      1. UNITS:__________

    2. DK

    3. RF

  4. When did you begin taking that dose?

    1. MM/DD/YYYY or

    2. Month of pregnancy (B1, P1, P2, P3)

    3. DK

    4. RF

  5. When did you stop taking that dose?

    1. MM/DD/YYYY or

    2. Month of pregnancy (B1, P1, P2, P3)

    3. DK

    4. RF





Section M: AUTOIMMUNE DISEASE

  1. Have you ever been diagnosed with any of the following [ASK EACH AND INDICATE ALL THAT APPLY]?

    1. Lupus

      1. YES

      2. NO

      3. DK

      4. RF

    2. Rheumatoid arthritis

      1. YES

      2. NO

      3. DK

      4. RF

    3. Multiple sclerosis

      1. YES

      2. NO

      3. DK

      4. RF

    4. Celiac disease

      1. YES

      2. NO

      3. DK

      4. RF

    5. Crohn’s disease

      1. YES

      2. NO

      3. DK

      4. RF

    6. Ulcerative colitis; please note that we are not asking about general colitis here

      1. YES

      2. NO

      3. DK

      4. RF

    7. Psoriasis

      1. YES

      2. NO

      3. DK

      4. RF

    8. Other autoimmune disease (not including diabetes or thyroid disorders, which we have already discussed) IF CAN’T RECALL, READ FROM LIST

      1. Immune/idiopathic thrombocytopenic purpura

      2. Interstitial cystitis

      3. Antiphospholipid antibody syndrome/lupus anticoagulant syndrome/APLS

      4. Addison’s disease

      5. Pernicious anemia

      6. Myasthenia gravis

      7. Autoimmune hemolytic anemia

      8. Berger’s disease/IgA nephropathy

      9. Alopecia, universalis or areata

      10. Vitiligo

      11. Juvenile arthritis

      12. Guillain Barre syndrome

      13. Scleroderma, morphea

      14. Sjögren's syndrome/Sicca syndrome

      15. Ankylosing spondylitis

      16. Rheumatic fever

      17. Other (specify):__________

      18. None

      19. DK

      20. RF



If YES to any, continue to Question 2

If NO/DK/RF to all, skip to next section



  1. When were you first diagnosed with [CONDITION]? READ OPTIONS (ask following questions for each condition if more than one condition reported) [READ LIST]

    1. More than 2 years before [TAB: your pregnancy with [NOIB]; the pregnancy that ended on [DOPT]]

    2. In the 2 years before [TAB: your pregnancy with [NOIB]; the affected pregnancy]

    3. During the first trimester of [TAB: your pregnancy with [NOIB]; the affected pregnancy]

    4. After the first trimester but still during pregnancy

    5. After [TAB: pregnancy with [NOIB]; the affected pregnancy] ended

    6. RF

    7. DK

IF Question 2=c, d, e, f, g THEN SKIP TO Question 6 (only ask Question 3 if Question 2=a or b)

  1. Either before or during your pregnancy, did you speak with a healthcare provider about your treatment options during pregnancy?

    1. YES Go to Question 4

    2. NO Skip to Question 6

    3. DK Skip to Question 6

    4. RF Skip to Question 6

  2. Did you discuss these options before your pregnancy began?

    1. YES Skip to Question 6

    2. NO Go to Question 5

    3. DK Skip to Question 6

    4. RF Skip to Question 6

  3. How far along were you in your pregnancy when you discussed treatment options with your provider?

    1. AMOUNT:__________

    2. UNITS:

      1. Days

      2. Weeks

      3. Months

      4. Trimester

    3. DK

    4. RF

  4. Did you take any medications or remedies for [CONDITION] in the month before your pregnancy through the third month of pregnancy, that is from [START DATE OF B1] TO [END DATE OF P3]?

    1. YES Continue to Question 7

    2. NO Skip to next section

    3. DK Skip to next section

    4. RF Skip to next section

  5. What did you take? / Did you take anything else? IF CAN’T RECALL, READ FROM DRUG LIST

    1. Lupus

      1. NSAIDs (Aleve, Advil, Motrin)

      2. Antimalarial drugs (Plaquenil, hydroxychloroquine)

      3. Corticosteroids (prednisone)

      4. Immune suppressants: Cytoxan (cyclophosphamide);Imuran, Azasan (azathioprine); Cellcept (mycophenolate); Arava (leflunomide); Trexall (methotrexate); Benlysta (belimumab)

    2. Rheumatoid arthritis

      1. NSAIDs (ibuprofen, Advil, Motrin, naproxen, Aleve)

      2. Steroids (prednisone)

      3. Disease-modifying antirheumatic drugs: Trexall (methotrexate); Arava (leflunomide); Plaquenil (hydroxychloroquine); Azulfidine (sulfasalazine);Dynacin, Minocin (minocycline)

      4. Immune suppressants: Imuran, Azasan (azathioprine); Neoral, Sandimmune, Gengraf (cyclosporine); Cytoxan (cyclophosphamide)

      5. TNF-alpha inhibitors: Enbrel (etanercept); Remicade (infliximab); Humira (adalimumab); Simponi (golimumab); Cimzia (certolizumab)

      6. Kineret (anakinra)

      7. Orencia (abatacept)

      8. Rituxan (rituximab)

      9. Actermra (tocilizumab)

    3. Multiple sclerosis

      1. Corticosteroids: Prednisone (oral); Solu-Medrol (IV; methylprednisone)

      2. Beta interferons (Avonex, Betaseron, Extavia, Rebif)

      3. Copaxone (Clatiramer acetate)

      4. Gilenya (fingolimod)

      5. Tysabri (natalizumab)

      6. Mitoxantrone

      7. Aubagio (teriflunomide)

      8. Ampyra (dalfampridine)

      9. Muscle relaxants: Lioresal (baclofen); Zanaflex (tizanidine), flexeril (cyclobenzaprine)

      10. Amantadine

    4. Crohn’s disease and ulcerative colitis

      1. Anti-inflammatory drugs: sulfasalazine (Azulfidine); mesalamine (Apriso, Asacol, Lialda); balsalazide (Colazal); olsalazine (Dipentum); corticosteroids

      2. Immune system suppressors: asathioprine (Azasan, Imuran); mercaptopurine (Purinethol); cyclosporine (Gengraf, Neoral, Sandimmune); inflizimab (Remicade); adalimumab (Humira); certolizumab pegol; Cimzia; methotrexate (Rhuematrex); natalizumab (Tysabril)

      3. Antibiotics: metronidazole (Flagyl); Ciprofloxacin (Cipro)

    5. Psoriasis (all topicals)

      1. Topical corticosteroids

      2. Dovonex (Vitamin D analogue)

      3. Anthralin

      4. Retina-A, Tretinoin (topical retinoids)

      5. Protopic, Elidel (Calcinerurin inhibitors)

      6. Salicylic acid

      7. Coal tar

    6. Other (specify):__________

    7. DK

    8. RF

  6. Did you use [MEDICATION] continuously throughout the month before your pregnancy through the third month of pregnancy?

    1. YES Skip to Question 12

    2. NO Continue to Question 9

    3. DK Continue to Question 9

    4. RF Continue to Question 9

  7. When did you start using [MEDICINE] for [CONDITION] for the first time during this period?

    1. MM/DD/YYYY or

    2. Month of pregnancy (B1, P1, P2, P3)

    3. DK

    4. RF

  8. When did you stop using [MEDICINE] for the last time during this time period?

    1. MM/DD/YYYY or

    2. Month of pregnancy (B1, P1, P2, P3) If valid start and stop date, skip Question 11

    3. DK

    4. RF

  9. How long did you take it?

    1. AMOUNT:__________

      1. Days

      2. Weeks

      3. Months

    2. DK

    3. RF

  10. How often did you use (MEDICINE) during the month before your pregnancy through the end of your third month of pregnancy? You can say the number of times per day, per week, per month, or during the entire 4 month period.

    1. AMOUNT:__________

      1. Per day

      2. Per week

      3. Per month

      4. Per period

    2. DK

    3. RF

  11. Did you take the same amount of medicine each time you took it throughout [START DATE OF B1] to [END DATE OF P3]? That is, for example, the same number of milligrams of medicine in each dose.

    1. YES Continue to Question 14

    2. NO Skip to Question 15

    3. DK Continue to Question 14

    4. RF Skip to Question 15

  12. What dose of [MEDICINE] did you take each time you took it?

    1. AMOUNT:__________ Skip to next section

      1. UNITS:__________

    2. DK Skip to next section

    3. RF Skip to next section

  13. What amount of [MEDICINE] did you take 1st/2nd/3rd/etc…?

    1. AMOUNT:__________

      1. UNITS:__________

    2. DK

    3. RF

  14. When did you begin taking that dose?

    1. MM/DD/YYYY or

    2. Month of pregnancy (B1, P1, P2, P3)

    3. DK

    4. RF

  15. When did you stop taking that dose?

    1. MM/DD/YYYY or

    2. Month of pregnancy (B1, P1, P2, P3)

    3. DK

    4. RF





Section N: TRANSPLANT RECEIPT

  1. Have you ever received an organ or tissue transplant?

    1. YES Continue to Question 2

    2. NO Skip to next section

    3. DK Skip to next section

    4. RF Skip to next section

  2. What organ or tissue was transplanted?

    1. RESPONSE:_________________________

    2. DK

    3. RF

  3. What was the date of the transplant?

    1. MM/DD/YYYY

    2. DK

    3. RF

  4. Did you take any medications related to your transplant during the month before your pregnancy through your third month of pregnancy, that is from [START DATE OF B1] to [END DATE OF P3]?

    1. YES Continue to Question 5

    2. NO Skip to next section

    3. DK Skip to next section

    4. RF Skip to next section

  5. What did you take? / Did you take anything else? IF CAN’T RECALL, READ FROM DRUG LIST

    1. Cyclosporine

    2. Prednisone

    3. Azathioprine

    4. Prograf / Tacrolimus / FK506

    5. Cellcept / Myfortic / Mycophenolate mofetil

    6. Sirolimus

    7. OKT3

    8. ATGAM

    9. Thymoglobulin

    10. Other (specify):__________

    11. DK

    12. RF

  6. Did you use [MEDICATION] continuously throughout the month before your pregnancy through your third month of pregnancy?

    1. YES Skip to Question 10

    2. NO Continue to Question 7

    3. DK Continue to Question 7

    4. RF Continue to Question 7

  7. When did you start using [MEDICINE] for your transplant for the first time during this period?

    1. MM/DD/YYYY or

    2. Month of pregnancy (B1, P1, P2, P3)

    3. DK

    4. RF

  8. When did you stop using [MEDICINE] for the last time during this time period?

    1. MM/DD/YYYY or

    2. Month of pregnancy (B1, P1, P2, P3) If valid start and stop date, skip Question 9

    3. DK

    4. RF

  9. How long did you take it?

    1. AMOUNT:__________

      1. Days

      2. Weeks

      3. Months

    2. DK

    3. RF

  10. How often did you use [MEDICINE] during the month before your pregnancy through the end of your third month of pregnancy? You can say the number of times per day, per week, per month, or during the entire 4 month period.

    1. AMOUNT:___________

      1. Per day

      2. Per week

      3. Per month

      4. Per period

    2. DK

    3. RF

  11. Did you take the same amount of medicine each time you took it throughout [START DATE OF B1] to [END DATE OF P3]? That is, for example, the same number of milligrams of medicine in each dose.

    1. YES Continue to Question 12

    2. NO Skip to Question 13

    3. DK Continue to Question 12

    4. RF Continue to Question 12

  12. What dose of [MEDICINE] did you take each time you took it?

    1. AMOUNT:__________ Skip to next section

      1. UNITS:__________

    2. DK Skip to next section

    3. RF Skip to next section

  13. What amount of [MEDICINE] did you take 1st/2nd/3rd/etc…?

    1. AMOUNT:__________

      1. UNITS:__________

    2. DK

    3. RF

  14. When did you begin taking that dose?

    1. MM/DD/YYYY or

    2. Month of pregnancy (B1, P1, P2, P3)

    3. DK

    4. RF

  15. When did you stop taking that dose?

    1. MM/DD/YYYY or

    2. Month of pregnancy (B1, P1, P2, P3)

    3. DK

    4. RF





Section O: DEPRESSION / ANXIETY

        1. Has a doctor or other healthcare provider EVER told you that you had an anxiety disorder, including acute stress disorder, anxiety, generalized anxiety disorder, obsessive-compulsive disorder, panic disorder, phobia, posttraumatic stress disorder, or social anxiety disorder?

          1. YES Continue to Question 2

          2. NO Skip to Question 4

          3. DK Skip to Question 4

          4. RF Skip to Question 4

        2. What condition were you told you had / Anything else?

          1. Specify:___________

          2. DK

          3. RF

        3. When were you first diagnosed? [READ LIST]

          1. More than 2 years before [TAB: your pregnancy with [NOIB]; the pregnancy that ended on [DOPT]]

          2. In the 2 years before [TAB: your pregnancy with [NOIB]; the affected pregnancy]

          3. During the first trimester of [TAB: your pregnancy with [NOIB]; the affected pregnancy]

          4. After the first trimester but still during pregnancy

          5. After [TAB: your pregnancy with [NOIB]; the affected pregnancy] ended

          6. RF

          7. DK

        4. Has a doctor or other healthcare provider EVER told you that you had depression?

          1. YES Continue to Question 5

          2. If NO/DK/RF, and YES to Question 1 Continue to Question 6

          3. If NO/DK/RF, and NO/DK/RF to Question 1 Skip to next section

        5. When were you first diagnosed with depression? [READ LIST]

          1. More than 2 years before [TAB: your pregnancy with [NOIB]; the pregnancy that ended on [DOPT]]

          2. In the 2 years before [TAB: your pregnancy with [NOIB]; the affected pregnancy]

          3. During the first trimester of [TAB: your pregnancy with [NOIB]; the affected pregnancy]

          4. After the first trimester but still during pregnancy

          5. After [TAB: pregnancy with [NOIB]; the affected pregnancy] ended

          6. RF

          7. DK

        6. Did you experience symptoms of [CONDITION(S)] in the month before your pregnancy through the end of the third month of pregnancy, that is from [START DATE OF B1] to [END DATE OF P3]?

          1. YES Continue to Question 7

          2. NO Skip to instructions before Question 8

          3. DK Skip to instructions before Question 8

          4. RF Skip to instructions before Question 8

        7. What were the symptoms you experienced?

          1. SPECIFY:__________

          2. DK

          3. RF

IF Question 1=a AND Question 4=a AND Question 3=c, d, e, f, g AND Question 5=c, d, e, f, g THEN SKIP TO Question 11 (reported anxiety and depression, but both were diagnosed during or after pregnancy)

IF Question 1=b, c, d AND Question 4=a AND Question 5=c, d, e, f, g THEN SKIP TO Question 11 (reported only depression diagnosed during or after pregnancy)

IF Question 4=b AND Question 3= c, d, e, f, g THEN SKIP TO Question 11 (reported only anxiety diagnosed during or after pregnancy)

        1. Either before or during your pregnancy, did you speak with a healthcare provider about your treatment options during pregnancy?

          1. YES Go to Question 9

          2. NO Skip to Question 11

          3. DK Skip to Question 11

          4. RF Skip to Question 11

        2. Did you discuss these options before your pregnancy began?

          1. YES Skip to Question 11

          2. NO Go to Question 10

          3. DK Skip to Question 11

          4. RF Skip to Question 11

        3. How far along were you in your pregnancy when you discussed treatment options with your provider?

          1. AMOUNT:__________

          2. UNITS:

            1. Days

            2. Weeks

            3. Months

            4. Trimester

          3. DK

          4. RF

        4. How did you treat [CONDITION(S)] in the month before your pregnancy through the end of the third month of pregnancy? (READ CHOICES; INDICATE ALL THAT APPLY)

          1. Under care of therapist/psychologist

          2. With medication

          3. You didn’t receive any treatment

          4. Or something else? (specify):__________

          5. DK

          6. RF

        5. Did you use medication to treat the [condition(s)] in the [month] before your pregnancy through the [third month of] pregnancy?

          1. YES Continue to Question 13

          2. NO Skip to next section

          3. DK Skip to next section

          4. RF Skip to next section

        6. What did you take? / Did you take anything else? IF CAN’T RECALL, READ FROM DRUG LIST

          1. Prozac (fluoxetine)

          2. Wellbutrin (bupropion)

          3. Paxil (paroxetine)

          4. Zoloft (sertraline)

          5. Effexor (venlafaxine)

          6. Celexa (citalopram)

          7. Lexapro (escitalopram)

          8. Cymbalta (duloxetine)

          9. Tofranil (imipramine)

          10. Clomipramine (anafranil)

          11. Klonopin (clonazepam)

          12. Valium (diazepam)

          13. Ativan (lorazepam)

          14. Xanax (alprazolam)

          15. Buspar (buspirone)

          16. Inderal (propranolol)

          17. Abilify (aripiprazole)

          18. St. John’s wort

          19. Other (specify):__________

          20. DK

          21. RF

        7. Did you use [MEDICATION] continuously throughout the month before your pregnancy through your third month of pregnancy?

          1. YES Skip to Question 18

          2. NO Continue to Question 15

          3. DK Continue to Question 15

          4. RF Continue to Question 15

        8. When did you start using [MEDICINE] for [CONDITION(S)] for the first time during this period?

          1. MM/DD/YYYY or

          2. Month of pregnancy (B1, P1, P2, P3)

          3. DK

          4. RF

        9. When did you stop using [MEDICINE] for the last time during this time period?

          1. MM/DD/YYYY or

          2. Month of pregnancy (B1, P1, P2, P3) If valid start and stop date, skip Question 17

          3. DK

          4. RF

        10. How long did you take it?

          1. AMOUNT:__________

            1. Days

            2. Weeks

            3. Months

          2. DK

          3. RF

        11. How often did you use [MEDICINE] during the month before your pregnancy through the end of your third month of pregnancy? You can say the number of times per day, per week, per month, or during the entire 4 month period.

          1. AMOUNT:__________

            1. Per day

            2. Per week

            3. Per month

            4. Per period

          2. DK

          3. RF

        12. Did you take the same amount of medicine each time you took it throughout [START DATE OF B1] to [END DATE OF P3]? That is, for example, the same number of milligrams of medicine in each dose.

          1. YES Continue to Question 20

          2. NO Skip to Question 21

          3. DK Continue to Question 20

          4. RF Continue to Question 20

        13. What amount of [MEDICINE] did you take each time you took it?

          1. AMOUNT:__________ Skip to next section

            1. UNITS:__________

          2. DK Skip to next section

          3. RF Skip to next section

        14. What amount of [MEDICINE] did you take 1st/2nd/3rd/etc…?

          1. AMOUNT:__________

            1. UNITS:__________

          2. DK

          3. RF

        15. When did you begin taking that dose?

          1. MM/DD/YYYY or

          2. Month of pregnancy (B1, P1, P2, P3)

          3. DK

          4. RF

        16. When did you stop taking that dose?

          1. MM/DD/YYYY or

          2. Month of pregnancy (B1, P1, P2, P3)

          3. DK

          4. RF





Section P: ATTENTION DEFICIT HYPERACTIVITY DISORDER (ADHD)

  1. Have you EVER been told by a doctor or other health professional that you had Attention-Deficit/Hyperactivity Disorder (ADHD) or Attention-Deficit Disorder (ADD)?

    1. YES Continue to Question 2

    2. NO Skip to next section

    3. DK Skip to next section

    4. RF Skip to next section

  2. With which condition were you diagnosed?

    1. Attention Deficit Hyperactivity Disorder

    2. Attention Deficit Disorder

    3. Other (specify):__________

    4. DK

    5. RF

  3. When were you diagnosed with [ADHD / ADD]? [READ LIST]

          1. More than 2 years before [TAB: your pregnancy with [NOIB]; the pregnancy that ended on [DOPT]]

          2. In the 2 years before [TAB: your pregnancy with [NOIB]; the affected pregnancy]

          3. During the first trimester of [TAB: your pregnancy with [NOIB]; the affected pregnancy]

          4. After the first trimester but still during pregnancy

          5. After [TAB: your pregnancy with [NOIB]; the affected pregnancy] ended

          6. RF

          7. DK

IF Question 3=c, d, e, f, g THEN SKIP TO Question 7 (only ask Question 4 if Question 3=a, b)

  1. Either before or during your pregnancy, did you speak with a healthcare provider about your treatment options during pregnancy?

    1. YES Go to Question 5

    2. NO Skip to Question 7

    3. DK Skip to Question 7

    4. RF Skip to Question 7

  2. Did you discuss these options before your pregnancy began?

    1. YES Skip to Question 7

    2. NO Go to Question 6

    3. DK Skip to Question 7

    4. RF Skip to Question 7

  3. How far along were you in your pregnancy when you discussed treatment options with your provider?

    1. AMOUNT:__________

    2. UNITS:

      1. Days

      2. Weeks

      3. Months

      4. Trimester

    3. DK

    4. RF

  4. Did you take any medications to treat your [ADHD / ADD] during the month before your pregnancy through the third month of pregnancy, that is from [START DATE OF B1] to [END DATE OF P3]?

    1. YES Continue to Question 8

    2. NO Skip to next section

    3. DK Skip to next section

    4. RF Skip to next section

  5. What did you take? / Did you take anything else? IF CAN’T RECALL, READ FROM DRUG LIST

    1. ADDERALL, ADDERALL XR, AMPHETAMINE

    2. CELEXA, CITALOPRAM

    3. CONCERTA

    4. DAYTRANA PATCH

    5. DEXEDRINE, DEXEDRINE SPANSULE, DEXTROSTAT, DEXTRO-AMPHETAMINE

    6. DEXMETHYLPHENIDATE

    7. FOCALIN, FOCALIN XR

    8. METADATE, METADATE CD

    9. METHYLIN

    10. METHYLPHENIDATE

    11. PROZAC

    12. RITALIN, RITALIN LA, RITALIN SR

    13. SERTRALINE

    14. STRATTERA, ATOMOXETINE

    15. VYVANSE, LISDEXAMFETAMINE

    16. ZOLOFT

    17. Intuniv (guanfacine)

    18. Kapvay (clonidine hydrochloride)

    19. Other (specify):__________

    20. DK

    21. RF

  6. Did you use [MEDICATION] continuously throughout the month before your pregnancy through your third month of pregnancy?

    1. YES Skip to Question 13

    2. NO Continue to Question 10

    3. DK Continue to Question 10

    4. RF Continue to Question 10

  7. When did you start using [MEDICINE] for [ILLNESS] for the first time during this period?

    1. MM/DD/YYYY or

    2. Month of pregnancy (B1, P1, P2, P3)

    3. DK

    4. RF

  8. When did you stop using [MEDICINE] for the last time during this time period?

    1. MM/DD/YYYY or

    2. Month of pregnancy (B1, P1, P2, P3) If valid start and stop date, skip Question 12

    3. DK

    4. RF

  9. How long did you take it?

    1. AMOUNT:__________

      1. Days

      2. Weeks

      3. Months

    2. DK

    3. RF

  10. How often did you use [MEDICINE] during the month before your pregnancy through the end of your third month of pregnancy? You can say the number of times per day, per week, per month, or during the entire 4 month period.

    1. AMOUNT:__________

      1. Per day

      2. Per week

      3. Per month

      4. Per period

    2. DK

    3. RF

  11. Did you take the same amount of medicine each time you took it throughout [START DATE OF B1] to [END DATE OF P3]? That is, for example, the same number of milligrams of medicine in each dose.

    1. YES Continue to Question 15

    2. NO Skip to Question 16

    3. DK Continue to Question 15

    4. RF Continue to Question 15

  12. What amount of [MEDICINE] did you take each time you took it?

    1. AMOUNT:__________ Skip to next section

      1. UNITS:__________

    2. DK Skip to next section

    3. RF Skip to next section

  13. What amount of [MEDICINE] did you take 1st/2nd/3rd/etc…?

    1. AMOUNT:__________

      1. UNITS:__________

    2. DK

    3. RF

  14. When did you begin taking that dose?

    1. MM/DD/YYYY or

    2. Month of pregnancy (B1, P1, P2, P3)

    3. DK

    4. RF

  15. When did you stop taking that dose?

    1. MM/DD/YYYY or

    2. Month of pregnancy (B1, P1, P2, P3)

    3. DK

    4. RF





Section Q: CHRONIC DISEASE CATCH-ALL QUESTION

  1. Have you ever been diagnosed with any other chronic diseases or long-term illnesses that we haven’t talked about such as fibromyalgia, hepatitis, blood clotting disorders, irritable bowel syndrome, sleep apnea or other sleep disorders, bipolar disorder, schizophrenia or other mental health conditions? PROMPT: This does not include short-term illnesses such as colds.

    1. YES Continue to Question 2

    2. NO Skip to next section

    3. DK Skip to next section

    4. RF Skip to next section

  2. What did you have? / Did you have anything else? LIST ALL. FOR EACH ILLNESS ASK ALL ADDITIONAL QUESTIONS THAT APPLY.

    1. Specify:__________________ Continue to Question 3

    2. DK Continue to Question 3

    3. RF Skip to next section

  3. How old were you when the disease was diagnosed?

    1. AGE:_____________________

      1. Years

      2. Months

    2. DK

    3. RF

  4. Did you take any medications or remedies for [ILLNESS] during the month before your pregnancy through the third month of pregnancy, that is from [START DATE OF B1] to [END DATE OF P3]?

    1. YES Continue to Question 5

    2. NO Skip to next section

    3. DK Skip to next section

    4. RF Skip to next section

  5. What did you take? / Did you take anything else?

    1. Specify:____________________________

    2. DK

    3. RF

  6. Did you use [MEDICATION] continuously throughout the month before your pregnancy through your third month of pregnancy?

    1. YES Skip to Question 10

    2. NO Continue to Question 7

    3. DK Continue to Question 7

    4. RF Continue to Question 7

  7. When did you start using [MEDICINE] for [ILLNESS] for the first time during this period?

    1. MM/DD/YYYY or

    2. Month of pregnancy (B1, P1, P2, P3)

    3. DK

    4. RF

  8. When did you stop using [MEDICINE] for the last time during this time period?

    1. MM/DD/YYYY or

    2. Month of pregnancy (B1, P1, P2, P3) If valid response to Questions 7 and 8, skip Question 9

    3. DK

    4. RF

  9. How long did you take it?

    1. AMOUNT:__________

      1. Days

      2. Weeks

      3. Months

    2. DK

    3. RF

  10. How often did you use [MEDICINE] during the month before your pregnancy through the end of your third month of pregnancy? You can say the number of times per day, per week, per month, or during the entire 4 month period.

    1. AMOUNT:__________

      1. Per day

      2. Per week

      3. Per month

      4. Per period

    2. DK

    3. RF

  11. Did you take the same amount of medicine each time you took it throughout [START DATE OF B1] to [END DATE OF P3]? That is, for example, the same number of milligrams of medicine in each dose.

    1. YES Continue to Question 12

    2. NO Skip to Question 13

    3. DK Continue to Question 12

    4. RF Continue to Question 12

  12. What amount of [MEDICINE] did you take each time you took it?

    1. AMOUNT:__________ Skip to next section

      1. UNITS:__________

    2. DK Skip to next section

    3. RF Skip to next section

  13. What amount of [MEDICINE] did you take 1st/2nd/3rd/etc…?

    1. AMOUNT:__________

      1. UNITS:__________

    2. DK

    3. RF

  14. When did you begin taking that dose?

    1. MM/DD/YYYY or

    2. Month of pregnancy (B1, P1, P2, P3)

    3. DK

    4. RF

  15. When did you stop taking that dose?

    1. MM/DD/YYYY

    2. Month of pregnancy (B1, P1, P2, P3)

    3. DK

    4. RF





Section R: GENITOURINARY INFECTIONS

  1. From the month before you became pregnant to the end of the third month of pregnancy, that is from [START DATE OF B1] to [END DATE OF P3], did you have any of the following illnesses…?

    1. a kidney, bladder, or urinary tract infection?

      1. YES

      2. NO

      3. DK

      4. RF

    2. pelvic inflammatory disease or PID?

      1. YES

      2. NO

      3. DK

      4. RF

    3. a sexually transmitted disease, such as chlamydia, HPV, herpes, syphilis, genital warts, or gonorrhea?

      1. YES

        1. Please specify:___________________________________

        2. DK

        3. RF

      2. NO

      3. DK

      4. RF

    4. a yeast infection

      1. YES

      2. NO

      3. DK

      4. RF

If YES to any, continue to Question 2

If NO/DK/RF to all, skip to next section

  1. Was the [INFECTION] diagnosed by a doctor? ask for each infection reported

    1. YES

    2. NO

    3. DK

    4. RF



  1. Did you take any medications or remedies for your [INFECTION]?

    1. YES Continue to Question 4

    2. NO Skip to next section

    3. DK Skip to next section

    4. RF Skip to next section

  2. IF ASKING FOR YEAST INFECTION: Did you take a medicine that a doctor prescribed for you or did you buy it “over-the-counter”, without a prescription?

    1. Prescription

    2. Over-the-counter

    3. DK

    4. RF

  3. IF ASKING FOR A YEAST INFECTION: Did you use a cream that you inserted or applied on the outside or a pill that you swallowed?

    1. External or internal cream Skip to next section

    2. Pill Skip to next section

    3. Other (specify):__________ Skip to next section

    4. DK Skip to next section

    5. RF Skip to next section

  4. IF ASKING FOR INFECTION OTHER THAN A YEAST INFECTION: What did you take? / Did you take anything else? (B60) IF CAN’T RECALL, READ FROM DRUG LIST

    1. If reporting medication use for a bacterial infection [kidney, bladder, urinary tract infection; PID; chlamydia; syphilis]

      1. Bactrim, Septra (sulfamethoxazole-thrimethoprim)

      2. Furadantin, Macrodantin (nitrofurantoin)

      3. Amoxicillin, Amoxil, Trimox

      4. Augmentin

      5. Biaxin

      6. Cipro

      7. Doxycycline, Vibramycin

      8. Erythromycin, Erythrocin, EES

      9. Levaquin

      10. Rebetol, Virazole

      11. Rebetron

      12. Zithromax

      13. Penicillin

      14. Cephtriaxone

      15. Azithromycin

      16. Antibiotic NOS

      17. Other (specify):__________

    2. If reporting medication use for herpes

      1. Acyclovir (G)

      2. Zovirax

      3. Famciclovir (G)

      4. Famvir

      5. Valacyclovir (G)

      6. Valtrex

    3. If reporting medication use for genital warts (HPV)

      1. Imiquimod (G)

      2. Aldara

      3. Zyclara

      4. Podophyllin / podofilox

      5. Condylox

      6. Trichloroacetic acid (TCA)

    4. DK

    5. RF

  5. Did you use [MEDICATION] continuously throughout the month before your pregnancy through your third month of pregnancy?

    1. YES Skip to Question 11

    2. NO Continue to Question 8

    3. DK Continue to Question 8

    4. RF Continue to Question 8

  6. When did you start using [MEDICINE] for [INFECTION] for the first time during this period?

    1. MM/DD/YYYY or

    2. Month of pregnancy (B1, P1, P2, P3)

    3. DK

    4. RF

  7. When did you stop using [MEDICINE] for the last time during this time period?

    1. MM/DD/YYYY or

    2. Month of pregnancy (B1, P1, P2, P3) If valid start and stop date, skip Question 10

    3. DK

    4. RF

  8. How long did you take it?

    1. AMOUNT:__________

      1. Days

      2. Weeks

      3. Months

    2. DK

    3. RF

  9. How often did you use [MEDICINE] during the month before your pregnancy through the end of your third month of pregnancy? You can say the number of times per day, per week, per month, or during the entire 4 month period.

    1. AMOUNT:__________

      1. Per day

      2. Per week

      3. Per month

      4. Per period

    2. DK

    3. RF

  10. Did you take the same amount of medicine each time you took it throughout [START DATE OF B1] to [END DATE OF P3]? That is, for example, the same number of milligrams of medicine in each dose.

    1. YES Continue to Question 13

    2. NO Skip to Question 14

    3. DK Continue to Question 13

    4. RF Continue to Question 13

  11. What amount of [MEDICINE] did you take each time you took it?

    1. AMOUNT:__________ Skip to next section

      1. UNITS:__________

    2. DK Skip to next section

    3. RF Skip to next section

  12. What amount of [MEDICINE] did you take 1st/2nd/3rd/etc…?

    1. AMOUNT:__________

      1. UNITS:__________

    2. DK

    3. RF

  13. When did you begin taking that dose?

    1. MM/DD/YYYY or

    2. Month of pregnancy (B1, P1, P2, P3)

    3. DK

    4. RF

  14. When did you stop taking that dose?

    1. MM/DD/YYYY or

    2. Month of pregnancy (B1, P1, P2, P3)

    3. DK

    4. RF





Section S: FEVERS

  1. From one month before you became pregnant to the end of the third month of your pregnancy, that is from [START DATE OF B1] to [END DATE OF P3], did you have any fevers, including those due to respiratory illness, bronchitis, pneumonia, a kidney, bladder, or urinary tract infection, pelvic inflammatory disease, or other infections or illness?

    1. YES Continue to Question 2

    2. NO Skip to next section

    3. DK Skip to next section

    4. RF Skip to next section

  2. How many fevers did you have?

    1. NUMBER:__________

    2. DK

    3. RF

  3. What was the cause of the (1st/2nd/3rd) fever?

    1. CAUSE:__________

    2. DK

    3. RF

  4. When you had [CAUSE OF FEVER], during which of those months did you have a fever?

    1. B1

    2. P1

    3. P2

    4. P3

    5. DK

    6. RF

  5. What was the highest temperature recorded during your fever?

    1. VALUE:__________

      1. UNITS: F or C

    2. DK

    3. RF

  6. Did you take any medications or remedies for the fever?

    1. YES Continue to Question 7

    2. NO Skip to next section

    3. DK Skip to next section

    4. RF Skip to next section

  7. What did you take? Did you take anything else? CODE ALL THAT APPLY. IF CAN’T RECALL, READ FROM DRUG LIST: Did you take…?

    1. Acetaminophen

    2. Advil

    3. Aleve

    4. Ibuprofen

    5. Motrin

    6. Naproxen sodium

    7. Nuprin

    8. Tylenol

    9. Other (specify):__________

    10. DK

    11. RF

  8. When did you start using (MEDICINE) for this [CAUSE OF FEVER] for the first time during this period?

    1. MM/DD/YYYY or

    2. Month of pregnancy (B1, P1, P2, P3)

    3. DK

    4. RF

  9. When did you stop using (MEDICINE) for the last time during this time period?

    1. MM/DD/YYYY or

    2. Month of pregnancy (B1, P1, P2, P3) If valid response to Questions 8 and 9, skip Question 10

    3. DK

    4. RF

  10. How long did you take it?

    1. AMOUNT:__________

      1. Days

      2. Weeks

      3. Months

    2. DK

    3. RF

  11. How often did you use [MEDICINE] during the month before your pregnancy through the end of your third month of pregnancy? You can say the number of times per day, per week, per month, or during the entire 4 month period.

    1. AMOUNT:__________

      1. Per day

      2. Per week

      3. Per month

      4. Per period



Section T: MEDICATIONS / HERBALS / VITAMINS

We are interested in medicines that you may have taken from 1 month before you became pregnant, which would be [START DATE OF B1], to the end of the third month of pregnancy, which would be [END DATE OF P3]. These would include prescription and nonprescription medicines. Please include medicines prescribed to you by a healthcare provider and medicines you used that may have been prescribed to someone else. Some of these medicines we may have already discussed, but please report on them again in response to these questions. Sometimes the same medication can be used for different reasons, which is why some questions may seem repetitive. To begin, I’m going to ask you about whether you have used certain types of medicines, and then I’ll ask about your use of specific medicines. If you filled out the medication worksheet we included in your introductory packet, it will be helpful for you to have it in front of you for these questions.



Medication Categories

  1. During [START DATE OF B1] to [END DATE OF P3] did you take any: [ASK EACH MEDICATION CATEGORY]

    1. Birth control pills

      1. YES Skip to Question 2

      2. NO Continue to Question 1b

      3. DK Continue to Question 1b

      4. RF Continue to Question 1b

    2. Antibiotics

      1. YES Skip to Question 2

      2. NO Continue to Question 1c

      3. DK Continue to Question 1c

      4. RF Continue to Question 1c

    3. Over-the-counter pain relievers

      1. YES Skip to Question 2

      2. NO Continue Question to 1d

      3. DK Continue Question to 1d

      4. RF Continue Question to 1d

    4. Prescription pain relievers

      1. YES Skip to Question 2

      2. NO Continue to Question 1e

      3. DK Continue to Question 1e

      4. RF Continue to Question 1e

    5. Medicines to help lower your cholesterol (“statins”)

      1. YES Skip to Question 2

      2. NO Continue to Question 1f

      3. DK Continue to Question 1f

      4. RF Continue to Question 1f

    6. Medicines to help you quit smoking

      1. YES Skip to Question 2

      2. NO Continue to Question 1g

      3. DK Continue to Question 1g

      4. RF Continue to Question 1g

    7. Medicines to help with allergies or cold symptoms (e.g. runny nose, cough)

      1. YES Skip to Question 2

      2. NO Continue to Question 1h

      3. DK Continue to Question 1h

      4. RF Continue to Question 1h

    8. Medicine to treat an infection with a virus, like the flu (“antiviral”)

      1. YES Skip to Question 2

      2. NO Continue to Question 1i

      3. DK Continue to Question 1i

      4. RF Continue to Question 1i

    9. Medicine to help you sleep (“sleep aid”)

      1. YES Skip to Question 2

      2. NO Continue to Question 1j

      3. DK Continue to Question 1j

      4. RF Continue to Question 1j

    10. Vaccines

      1. YES Skip to Question 2

      2. NO Continue to Question 1k

      3. DK Continue to Question 1k

      4. RF Continue to Question 1k

    11. Medicines to treat nausea or vomiting

      1. YES Continue to Question 2

      2. NO Skip to Specific Medications intro

      3. DK Skip to Specific Medications intro

      4. RF Skip to Specific Medications intro

  2. Do you remember the name of the medication or would you like us to go through a list?

    1. If she remembers the name continue to Question 3

    2. If she needs a list read the prompt list prepared for that Medication Category in the QxQ

  3. What was the name of the medication? / Did you take any other medicine in this category?

    1. NAME:__________

  4. Did you already tell me about taking this medication earlier in the interview?

    1. YES Continue to Question 5

    2. NO Continue to Question 7 or Question 8

    3. DK Continue to Question 7 or Question 8

    4. RF Continue to Question 7 or Question 8

  5. Which part of the interview did you tell me about it?

    1. Section:____________________________

    2. DK

    3. RF

  6. Did you take this medication for any other reasons that we have not already talked about?

    1. YES Continue to Question 7 or skip to Question 8

    2. NO Skip to Specific Medications intro

    3. DK Skip to Specific Medications intro

    4. RF Skip to Specific Medications intro

For all Medication Categories, except birth control pills, antihypertensives, statins, smoking cessation medications, sleep aids, and vaccines ask Question 7; for the aforementioned categories, skip to Question 8.

  1. Why did you take [MEDICINE]?

    1. REASON:__________

    2. DK

    3. RF

  2. Did you use [MEDICINE] continuously throughout the month before your pregnancy through your third month of pregnancy?

    1. YES Skip to Question 12

    2. NO Continue to Question 9

    3. DK Continue to Question 9

    4. RF Continue to Question 9



  1. When did you start using [MEDICINE] during the month before your pregnancy through the third month of pregnancy?

    1. MM/DD/YYYY or

    2. Month of pregnancy (B1, P1, P2, P3)

    3. DK

    4. RF

  2. When did you stop using [MEDICINE] for the last time during this time period?

    1. MM/DD/YYYY or

    2. Month of pregnancy (B1, P1, P2, P3) If valid stop and start date, skip Question 11

    3. DK

    4. RF

  3. How long did you take [MEDICINE]?

    1. AMOUNT:__________

      1. Days

      2. Weeks

      3. Months

    2. DK

    3. RF

  4. How often did you use [MEDICINE] during the month before your pregnancy through the end of your third month of pregnancy? You can say the number of times per day, per week, per month, or during the entire 4 month period.

    1. AMOUNT:__________

      1. Per day

      2. Per week

      3. Per month

      4. Per period

    2. DK

    3. RF

  5. Did you take the same amount of medicine, each time that you took it, for the whole time that you took it during the month before your pregnancy through the end of your third month of pregnancy? That is, for example, the same number of milligrams of medicine in each dose.

    1. YES Continue to Question 14

    2. NO Skip to Question 15

    3. DK Continue to Question 14

    4. RF Continue to Question 14

  6. What amount of [MEDICINE] did you take each time you took it?

    1. AMOUNT:__________ Skip to Question 18

      1. UNITS:__________

    2. DK Skip to Question 18

    3. RF Skip to Question 18

  7. What amount of [MEDICINE] did you take 1st/2nd/3rd/etc…?

    1. AMOUNT:__________

      1. UNITS:__________

    2. DK

    3. RF

  8. When did you begin taking that dose?

    1. MM/DD/YYYY or

    2. Month of pregnancy (B1, P1, P2, P3)

    3. DK

    4. RF

  9. When did you stop taking that dose?

    1. MM/DD/YYYY or

    2. Month of pregnancy (B1, P1, P2, P3)

    3. DK

    4. RF

Cycle back up to next medication category on the list and continue with questions until you have asked about each medication category through those for nausea and vomiting.



Specific Medications

Now I’m going to ask you about your use of specific medications. As I read the list, please tell me Yes or No for each medicine. We may have already discussed some of these medicines, but please report on them again in response to these questions.

  1. During [START DATE OF B1] to [END DATE OF P3] did you take:

    1. Prozac

      1. YES Skip to Question 19

      2. NO Continue to Question 18b

      3. DK Continue to Question 18b

      4. RF Continue to Question 18b

    2. Wellbutrin

      1. YES Skip to Question 19

      2. NO Continue to Question 18c

      3. DK Continue to Question 18c

      4. RF Continue to Question 18c

    3. Paxil

      1. YES Skip to Question 19

      2. NO Continue to Question 18d

      3. DK Continue to Question 18d

      4. RF Continue to Question 18d

    4. Zoloft

      1. YES Skip to Question 19

      2. NO Continue to Question 18e

      3. DK Continue to Question 18e

      4. RF Continue to Question 18e

    5. Effexor

      1. YES Skip to Question 19

      2. NO Continue to Question 18f

      3. DK Continue to Question 18f

      4. RF Continue to Question 18f

    6. Celexa

      1. YES Skip to Question 19

      2. NO Continue to Question 18g

      3. DK Continue to Question 18g

      4. RF Continue to Question 18g

    7. Lexapro

      1. YES Skip to Question 19

      2. NO Continue to Question 18h

      3. DK Continue to Question 18h

      4. RF Continue to Question 18h

    8. Cymbalta

      1. YES Skip to Question 19

      2. NO Continue to Question 18i

      3. DK Continue to Question 18i

      4. RF Continue to Question 18i

    9. Abilify

      1. YES Skip to Question 19

      2. NO Continue to Question 18j

      3. DK Continue to Question 18j

      4. RF Continue to Question 18j

    10. Seroquel

      1. YES Skip to Question 19

      2. NO Continue to Question 18k

      3. DK Continue to Question 18k

      4. RF Continue to Question 18k

    11. Zyprexa

      1. YES Skip to Question 19

      2. NO Continue to Question 18l

      3. DK Continue to Question 18l

      4. RF Continue to Question 18l

    12. Depakene, Depakote, or valproic acid

      1. YES Skip to Question 19

      2. NO Continue to Question 18m

      3. DK Continue to Question 18m

      4. RF Continue to Question 18m

    13. Dilantin or phenytoin

      1. YES Skip to Question 19

      2. NO Continue to Question 18n

      3. DK Continue to Question 18n

      4. RF Continue to Question 18n

    14. Felbatol

      1. YES Skip to Question 19

      2. NO Continue to Question 18o

      3. DK Continue to Question 18o

      4. RF Continue to Question 18o

    15. Klonopin or clonazepam

      1. YES Skip to Question 19

      2. NO Continue to Question 18p

      3. DK Continue to Question 18p

      4. RF Continue to Question 18p

    16. Lamictal

      1. YES Skip to Question 19

      2. NO Continue to Question 18q

      3. DK Continue to Question 18q

      4. RF Continue to Question 18q

    17. Phenobarbital

      1. YES Skip to Question 19

      2. NO Continue to Question 18r

      3. DK Continue to Question 18r

      4. RF Continue to Question 18r

    18. Topiramate or Topamax

      1. YES Skip to Question 19

      2. NO Continue to Question 18s

      3. DK Continue to Question 18s

      4. RF Continue to Question 18s

    19. Furadantin

      1. YES Skip to Question 19

      2. NO Continue to Question 18t

      3. DK Continue to Question 18t

      4. RF Continue to Question 18t

    20. Macrodantin

      1. YES Skip to Question 19

      2. NO Continue to Question 18u

      3. DK Continue to Question 18u

      4. RF Continue to Question 18u

    21. Qsymia

      1. YES Skip to Question 19

      2. NO Continue to Question 18v

      3. DK Continue to Question 18v

      4. RF Continue to Question 18v

    22. Thalidomide

      1. YES Skip to Question 19

      2. NO Continue to Question 18w

      3. DK Continue to Question 18w

      4. RF Continue to Question 18w

    23. Accutane/isotretinoin

      1. YES Skip to Question 19

      2. NO Continue to Question 18x

      3. DK Continue to Question 18x

      4. RF Continue to Question 18x

    24. CellCept

      1. YES Skip to Question 19

      2. NO Continue to Question 18y

      3. DK Continue to Question 18y

      4. RF Continue to Question 18y

    25. Myfortic

      1. YES Skip to Question 19

      2. NO Continue to Question 18z

      3. DK Continue to Question 18z

      4. RF Continue to Question 18z

    26. Cytotec

      1. YES Skip to Question 19

      2. NO Continue to Question 18aa

      3. DK Continue to Question 18aa

      4. RF Continue to Question 18aa

    27. Misoprostol

      1. YES Skip to Question 19

      2. NO Continue to Question 18bb

      3. DK Continue to Question 18bb

      4. RF Continue to Question 18bb

    28. Methotrexate

      1. YES Continue to Question 19

      2. NO Skip to Question 33

      3. DK Skip to Question 33

      4. RF Skip to Question 33

  2. Did you already tell me about taking this medication earlier in the interview?

    1. YES Continue to Question 20

    2. NO Continue to Question 22

    3. DK Continue to Question 22

    4. RF Continue to Question 22

  3. Which part of the interview did you tell me about it?

    1. Section:____________________________

    2. DK

    3. RF

  4. Did you take this medication for any other reasons that we have not already talked about?

    1. YES Continue to Question 22

    2. NO Skip to Question 33

    3. DK Skip to Question 33

    4. RF Skip to Question 33

  5. Why did you take [MEDICINE]?

    1. REASON:__________

    2. DK

    3. RF



  1. Did you use [MEDICINE] continuously throughout the month before your pregnancy through your third month of pregnancy?

    1. YES Skip to Question 27

    2. NO Continue to Question 24

    3. DK Continue to Question 24

    4. RF Continue to Question 24



  1. When did you start using [MEDICINE] during the month before your pregnancy through the third month of pregnancy?

    1. MM/DD/YYYY or

    2. Month of pregnancy (B1, P1, P2, P3)

    3. DK

    4. RF

  2. When did you stop using [MEDICINE] for the last time during this time period?

    1. MM/DD/YYYY or

    2. Month of pregnancy (B1, P1, P2, P3) If valid stop and start date, skip Question 26

    3. DK

    4. RF

  3. How long did you take [MEDICINE]?

    1. AMOUNT:__________

      1. Days

      2. Weeks

      3. Months

    2. DK

    3. RF

  4. How often did you use [MEDICINE] during the month before your pregnancy through the end of your third month of pregnancy? You can say the number of times per day, per week, per month, or during the entire 4 month period.

    1. AMOUNT:__________

      1. Per day

      2. Per week

      3. Per month

      4. Per period

    2. DK

    3. RF

  5. Did you take the same amount of medicine, each time you took it, for the whole time that you took it during the month before your pregnancy through the end of your third month of pregnancy? That is, for example, the same number of milligrams of medicine in each dose.

    1. YES Continue to Question 29

    2. NO Skip to Question 30

    3. DK Continue to Question 29

    4. RF Continue to Question 29

  6. What amount of [MEDICINE] did you take each time you took it?

    1. AMOUNT:__________ Skip to Question 33

      1. UNITS:__________

    2. DK Skip to Question 33

    3. RF Skip to Question 33

  7. What amount of [MEDICINE] did you take 1st/2nd/3rd/etc…?

    1. AMOUNT:__________

      1. UNITS:__________

    2. DK

    3. RF

  8. When did you begin taking that dose?

    1. MM/DD/YYYY or

    2. Month of pregnancy (B1, P1, P2, P3)

    3. DK

    4. RF

  9. When did you stop taking that dose?

    1. MM/DD/YYYY or

    2. Month of pregnancy (B1, P1, P2, P3)

    3. DK

    4. RF



Cycle back up to next specific medication on the list and continue with questions until you have asked about each specific medication through methotrexate.



Herbals

  1. From the month before you became pregnant to the end of your third month of pregnancy, did you use any herbs or folk medicines to treat any medical conditions, to keep you healthy, or to lose weight? Please do not include herbal teas.

    1. YES Continue to Question 34

    2. NO Skip to Question 40

    3. DK Skip to Question 40

    4. RF Skip to Question 40

  2. Between [START DATE OF B1] to [END DATE OF P3] what herbs or folk medicines did you take? / Anything else?

    1. SPECIFY:__________

    2. DK

    3. RF

  3. Did you use [HERBAL] continuously throughout the month before your pregnancy through your third month of pregnancy?

    1. YES Skip to Question 39

    2. NO Continue to Question 36

    3. DK Continue to Question 36

    4. RF Continue to Question 36

  4. When did you start using [HERBAL] for the first time during this period?

    1. MM/DD/YYYY or

    2. Month of pregnancy (B1, P1, P2, P3)

    3. DK

    4. RF

  5. When did you stop using [HERBAL] for the last time during this time period?

    1. MM/DD/YYYY or

    2. Month of pregnancy (B1, P1, P2, P3) If valid response to Questions 36 and 37, skip Question 38

    3. DK

    4. RF

  6. How long did you take it?

    1. AMOUNT:__________

      1. Days

      2. Weeks

      3. Months

    2. DK

    3. RF

  7. How often did you use [HERBAL] during the month before your pregnancy through the end of your third month of pregnancy? You can say the number of times per day, per week, per month, or during the entire 4 month period.

    1. AMOUNT:__________

      1. Per day

      2. Per week

      3. Per month

      4. Per period

    2. DK

    3. RF



Vitamins

Now I’m going to ask you about your vitamin use before and during your pregnancy.

  1. From the month before you became pregnant to the end of your pregnancy, which would be [START DATE OF B1] to [END DATE OF P3], did you take any multivitamins, prenatal vitamins, or folic acid supplements?

    1. YES Continue to Question 41

    2. NO Skip to Question 45

    3. DK Skip to Question 45

    4. RF Skip to Question 45

  2. Did you begin using it before your pregnancy began?

    1. YES Continue to Question 42

    2. NO Skip to Question 43

    3. DK Skip to Question 43

    4. RF Skip to Question 43

  3. Did you continue to use it after your pregnancy began?

    1. YES Skip to Question 45

    2. NO Skip to Question 45

    3. DK Skip to Question 45

    4. RF Skip to Question 45

  4. Did you begin using it in the first month of pregnancy?

    1. YES Skip to Question 45

    2. NO Continue to Question 44

    3. DK Continue to Question 44

    4. RF Continue to Question 38

  5. Did you begin using it after the first month of pregnancy?

    1. YES

    2. NO

    3. DK

    4. RF



Catch-All Medication Question

  1. During this time period, did you take any medications, remedies, or treatments that we haven’t already talked about? /Any others?

    1. YES Continue to Question 46

    2. NO Skip to next section

    3. DK Skip to next section

    4. RF Skip to next section

  2. What medicine did you take?

    1. SPECIFY:__________

    2. DK

    3. RF

  3. Why did you take [MEDICINE]?

    1. SPECIFY:__________

    2. DK

    3. RF

  4. Did you use [MEDICINE] continuously throughout the month before your pregnancy through your third month of pregnancy?

    1. YES Skip to Question 52

    2. NO Continue to Question 49

    3. DK Continue to Question 49

    4. RF Continue to Question 49

  5. When did you start using [MEDICINE] for the first time during this period?

    1. MM/DD/YYYY or

    2. Month of pregnancy (B1, P1, P2, P3)

    3. DK

    4. RF

  6. When did you stop using [MEDICINE] for the last time during this time period?

    1. MM/DD/YYYY or

    2. Month of pregnancy (B1, P1, P2, P3) If valid stop and start date, skip Question 51

    3. DK

    4. RF

  7. How long did you take [MEDICINE]?

    1. AMOUNT:__________

      1. Days

      2. Weeks

      3. Months

    2. DK

    3. RF

  8. How often did you use [MEDICINE] during the month before your pregnancy through the end of your third month of pregnancy? You can say the number of times per day, per week, per month, or during the entire 4 month period.

    1. AMOUNT:__________

      1. Per day

      2. Per week

      3. Per month

      4. Per period

    2. DK

    3. RF

  9. Did you take the same amount of [MEDICINE] each time you took it throughout [START DATE OF B1] to [END DATE OF P3]?

    1. YES Continue to Question 54

    2. NO Skip to Question 55

    3. DK Continue to Question 54

    4. RF Continue to Question 54

  10. What amount of [MEDICINE] did you take each time you took it?

    1. AMOUNT:__________ Skip to next section

      1. UNITS:__________

    2. DK Skip to next section

    3. RF Skip to next question

  11. What amount of [MEDICINE] did you take 1st/2nd/3rd/etc…?

    1. AMOUNT:__________

      1. UNITS:__________

    2. DK

    3. RF

  12. When did you begin taking that dose?

    1. MM/DD/YYYY or

    2. Month of pregnancy (B1, P1, P2, P3)

    3. DK

    4. RF

  13. When did you stop taking that dose?

    1. MM/DD/YYYY or

    2. Month of pregnancy (B1, P1, P2, P3)

    3. DK

    4. RF







Section U: STRESS

The next series of questions will be about events that may have occurred in your life from the 3 months before you became pregnant through your 3rd month of pregnancy, which would be [START DATE OF B3] through [END DATE OF P3]. These questions will be a little bit different from some of the other questions we have asked because we are asking now about the three months before you became pregnant, as well as the first three months of your pregnancy. Most people experience periods of stress in their lives, caused by major events and daily life. We will be asking whether or not an event happened during that time period, but we will not be asking for further details.

  1. From 3 months before you became pregnant through your 3rd month of pregnancy, did you experience any serious relationship difficulties with your husband or partner or become separated or divorced?

    1. YES

    2. NO

    3. DK

    4. RF

  2. During this same time period, did you or your husband or partner have any serious legal or financial problems?

    1. YES

    2. NO

    3. DK

    4. RF

  3. During this same time period, were you or someone close to you a victim of abuse, violence, or crime? Remember you just have to indicate yes or no. [MOTHER MUST USE HER OWN JUDGEMENT ON WHAT SHE THINKS IS MEANT BY “SOMEONE CLOSE TO YOU”.]

    1. YES

    2. NO

    3. DK

    4. RF

  4. During this same time period, did you or someone close to you have a serious illness or injury? [MOTHER MUST USE HER OWN JUDGEMENT ON WHAT SHE THINKS IS MEANT BY “SOMEONE CLOSE TO YOU”.]

    1. YES

    2. NO

    3. DK

    4. RF

  5. During this same time period, did someone close to you die? [MOTHER MUST USE HER OWN JUDGEMENT ON WHAT SHE THINKS IS MEANT BY “SOMEONE CLOSE TO YOU”.]

    1. YES

    2. NO

    3. DK

    4. RF

  6. During this same time period, could you count on anyone to provide you with emotional support such as talking over a problem or helping with a difficult decision, if you had needed it?

    1. YES

    2. NO

    3. DK

    4. RF

  7. During this same time period, could you count on anyone to provide you with help financially such as paying bills or providing food or clothes, if you had needed it?

    1. YES

    2. NO

    3. DK

    4. RF

  8. During this same time period, could you count on anyone to provide you with help with daily tasks such as grocery shopping, child care, or cooking, if you had needed it?

    1. YES

    2. NO

    3. DK

    4. RF

  9. During this same time period, how often did you feel nervous and stressed? Would you say…READ CHOICES

    1. Never

    2. Almost never

    3. Sometimes

    4. Somewhat often

    5. Very often

    6. DK

    7. RF





Section V: PHYSICAL ACTIVITY

I am going to ask you about the time you spent being physically active in the three months before you became pregnant. Please answer each question even if you do not consider yourself to be an active person. Think about the activities you do at work, as part of your house and yard work, to get from place to place, and in your spare time for recreation, exercise, or sport.



Now think about all the vigorous activities which take hard physical effort that you did in the three months before you became pregnant. Vigorous activities make you breathe much harder than normal and may include heavy lifting, digging, aerobics, running, or fast bicycling. Think only about those physical activities you did for at least 10 minutes at a time.

  1. During the three months before you became pregnant, in a typical week on how many days did you do vigorous physical activities? PROBE: Think only about those physical activities that you did for at least 10 minutes at a time. (P1)

    1. Days per week: ______

      1. If 0 Skip to introduction to Question 3

      2. If 1 – 7 Continue to Question 2

    2. DK Skip to introduction to Question 3

    3. RF Skip to introduction to Question 3

  2. How much time did you usually spend doing vigorous physical activities on one of those days? PROBE: Think only about those physical activities that you do for at least 10 minutes at a time. (P2)

    1. Hours per day:__________

    2. Minutes per day:__________ [FLAG: If they report 0-9 minutes, remind them that we only want them to report on activities they did for AT LEAST 10 minutes.]

    3. OR In the three months before you became pregnant, how much time in total would you spend in a typical week doing vigorous physical activities?

      1. Hours per week:__________

      2. Minutes per week:__________ [FLAG: If they report 0-9 minutes, remind them that we only want them to report on activities they did for AT LEAST 10 minutes.]

    4. DK

    5. RF

Now think about activities which take moderate physical effort that you did in the three months before you became pregnant. Moderate physical activities make you breathe somewhat harder than normal and may include child care while standing, carrying light loads at home or work, scrubbing or mopping floors, or bicycling at a regular pace. Do not include walking. Again, think only about those physical activities that you did for at least 10 minutes at a time.

  1. During the three months before you became pregnant, in a typical week on how many days did you do moderate physical activities? PROBE: Think only about those physical activities that you do for at least 10 minutes at a time. PROBE: Child care includes dressing, bathing, grooming, feeding, or occasional lifting. (P3)

    1. Days per week:__________

      1. If 0 Skip to introduction to Question 5

      2. If 1 – 7 Continue to Question 4

    2. DK Skip to introduction to Question 5

    3. RF Skip to introduction to Question 5

  2. How much time did you usually spend doing moderate physical activities on one of those days? PROBE: Think only about those physical activities that you do for at least 10 minutes at a time. (P4)

    1. Hours per day:__________

    2. Minutes per day:__________ [FLAG: If they report 0-9 minutes, remind them that we only want them to report on activities they did for AT LEAST 10 minutes.]

    3. OR In the three months before you became pregnant, what is the total amount of time you spent in a typical week doing moderate physical activities?

      1. Hours per week:__________

      2. Minutes per week:__________ [FLAG: If they report 0-9 minutes, remind them that we only want them to report on activities they did for AT LEAST 10 minutes.]

    4. DK

    5. RF

Now think about the time you spent walking in the three months before you became pregnant. This includes at work and at home, walking to travel from place to place, and any other walking that you might do solely for recreation, sport, exercise, or leisure.

  1. During the three months before you became pregnant, in a typical week on how many days did you walk for at least 10 minutes at a time? PROBE: Think only about the walking that you do for at least 10 minutes at a time. (P5)

    1. Days per week:____________

      1. If 0 Skip to introduction to Question 7

      2. If 1 – 7 Continue to Question 6

    2. DK Skip to introduction to Question 7

    3. RF Skip to introduction to Question 7

  2. How much time did you usually spend walking on one of those days? (P6)

    1. Hours per day:__________

    2. Minutes per day:__________ [FLAG: If they report 0-9 minutes, remind them that we only want them to report on activities they did for AT LEAST 10 minutes.]

    3. OR In the three months before you became pregnant, what is the total amount of time you spent walking in a typical week?

      1. Hours per week:__________

      2. Minutes per week:__________ [FLAG: If they report 0-9 minutes, remind them that we only want them to report on activities they did for AT LEAST 10 minutes.]

    4. DK

    5. RF

Now think about the time you spent sitting on week days in the three months before you became pregnant. Include time spent at work, at home, while doing course work, and during leisure time. This may include time sitting at a desk, visiting friends, reading or sitting or lying down to watch television.

  1. In the three months before you became pregnant, in a typical week, how much time did you usually spend sitting on a week day? PROBE: Include time spent lying down (awake) as well as sitting. (P7)

    1. Hours per day:__________

    2. Minutes per day:__________

    3. OR What is the total amount of time you spent sitting on a typical Wednesday?

      1. Hours on Wednesday:__________

      2. Minutes on Wednesday:__________

    4. DK

    5. RF

Section W: OBESITY

Now I have some questions about weight changes before [TAB: your pregnancy with [NOIB]; your pregnancy).

  1. What is your height without shoes?

    1. Feet:__________

      1. Inches:__________

    2. Centimeters:__________

    3. DK

    4. RF

  2. How much did you weigh before [TAB: your pregnancy with [NOIB]; your pregnancy)?

    1. WEIGHT:__________

      1. Units: Pounds

      2. Units: Kilograms

    2. DK

    3. RF

  3. Not including pregnancy, when you gain weight, where on your body do you mostly add the weight? READ OPTIONS A-D

    1. Waist and/or upper body?

    2. Hips, bottom and/or upper thighs?

    3. Evenly over your body?

    4. Don’t gain weight?

    5. DK

    6. RF

  4. Which describes the underlying shape of your body, regardless of weight gain or loss? READ OPTIONS A-C

    1. You carry most of your weight around your waist and/or upper body (apple shaped)?

    2. You carry most of your weight around your hips, bottom, or upper thighs (pear shaped)?

    3. You carry most of your weight evenly over your body?

    4. DK

    5. RF

  5. What is the most you have ever weighed outside of pregnancy?

    1. WEIGHT:__________

      1. Units: Pounds

      2. Units: Kilograms

    2. DK

    3. RF

  6. What was your age when you were that weight?

    1. AGE:__________

    2. DK

    3. RF

  7. What is the least you have weighed outside of pregnancy in the last 5 years?

    1. WEIGHT:__________

      1. Units: Pounds

      2. Units: Kilograms

    2. DK

    3. RF

  8. What was your age when you were that weight?

    1. AGE:__________

    2. DK

    3. RF

  9. In the year before [TAB: your pregnancy with [NOIB]; your pregnancy], did your weight change by more than 20 pounds/9 kilograms?

    1. YES Continue to Question 10

    2. NO Skip to Question 12

    3. DK Skip to Question 12

    4. RF Skip to Question 12

  10. How much did your weight change? NOTE: REFERENCE WEIGHT = THEIR WEIGHT AT THE START OF THEIR PREGNANCY

    1. AMOUNT:__________

      1. Units: Pounds

      2. Units: Kilograms

    2. DK

    3. RF

  11. Was this change related to a pregnancy?

    1. YES

    2. NO

    3. DK

    4. RF

  12. Have you ever had surgery to help you lose weight? This does not include cosmetic procedures such as liposuction.

    1. YES Continue to Question 13

    2. NO Skip to Question 14

    3. DK Skip to Question 14

    4. RF Skip to Question 14

  13. What procedure did you have?

    1. Gastric bypass

    2. Belly band / lap band / gastric banding

    3. Gastric sleeve / sleeve gastrectomy

    4. DK

    5. RF

  14. In the month before your pregnancy through the end of your third month of pregnancy, that is [START DATE OF B1] to [END DATE OF P3], did you follow any of the following types of diet? [INDICATE ALL THAT APPLY]

    1. Vegetarian

      1. YES

      2. NO

      3. DK

      4. RF

    2. Vegan

      1. YES

      2. NO

      3. DK

      4. RF

    3. Low carbohydrate / low “carb”

      1. YES

      2. NO

      3. DK

      4. RF

    4. Low fat

      1. YES

      2. NO

      3. DK

      4. RF

    5. Gluten free

      1. YES

      2. NO

      3. DK

      4. RF

    6. Dairy free

      1. YES

      2. NO

      3. DK

      4. RF

    7. Other (specify):__________

    8. None

    9. DK

    10. RF





Section X: DENTAL PROCEDURES

The next set of questions is about dental visits you may have had right before and early in your pregnancy.

  1. During the month before your pregnancy through the third month of your pregnancy, that is from [START DATE OF B1] to [END DATE OF P3] did you go to the dentist or other dental specialist, such as a periodontist or oral surgeon?

    1. YES Continue to Question 2

    2. NO Skip to next section

    3. DK Skip to next section

    4. RF Skip to next section

  2. How many times did you go to the dentist during that time period?

    1. NUMBER:__________

    2. DK

    3. RF

  3. What dental procedures did you receive at that visit/those visits? IF DON’T KNOW GIVE OPTIONS. CAN REPORT MULTIPLE PROCEDURES.

    1. Teeth cleaning and/or routine checkup

    2. Cavity filled or dental filling placed Continue with Questions 4 – 19, but skip Question 20 and go to Question 21

    3. Root canal

    4. Teeth whitening

    5. Teeth removal (e.g. wisdom teeth)

    6. Place dental crown

    7. Dental bridge

    8. Oral surgery

    9. Other (specify):__________

    10. DK

    11. RF

  4. Did you have any x-rays taken during the visit/visits?

    1. YES Continue to Question 5

    2. NO Skip to Question 6

    3. DK Skip to Question 6

    4. RF Skip to Question 6

  5. Did they provide a protective cover for your body during the x-rays?

    1. YES for all X-rays

    2. YES for some, but not all X-rays

    3. NO for all X-rays

    4. DK

    5. RF

  6. Did you receive a shot to numb your mouth during the visit/at least one of the visits (an injectable anesthetic)? ?

    1. YES

    2. NO

    3. DK

    4. RF

  7. Did you receive “laughing gas”, also called nitrous oxide, during the visit/ at least one of the visits? ? [Can report more than one response if multiple visits]

    1. YES

    2. NO

    3. DK

    4. RF

  8. Were you prescribed any medications for your dental visit/visits or at the visit/visits?

    1. YES Continue to Question 9

    2. NO Skip to Question 14

    3. DK Skip to Question 14

    4. RF Skip to Question 14

  9. What medicine were you prescribed / Anything else? IF CAN’T RECALL, READ FROM LIST. MULTIPLE MEDICATIONS CAN BE REPORTED; ASK FOLLOW-UP QUESTIONS FOR EACH.

    1. Pain medication

      1. Codeine

      2. Hydrocodone

      3. Vicodin

      4. Vicoprofen

      5. Tylenol #3

    2. Antibiotics

      1. Penicillin

      2. Amoxicillin

      3. Amoxil

      4. Erythromycin

      5. Benzamycin

    3. Anti-inflammatory pastes

      1. Kenalog

      2. Orabase

      3. Oracort

      4. Oralone

    4. Mouth rinse

      1. Chlorhexidine

      2. “Magic mouthwash”

        1. Probe for name:

    5. Prescription-strength fluoride

    6. Anxiety medications

      1. Diazepam

      2. Valium

    7. Other (specify):__________

    8. DK

    9. RF

  10. When did you start taking [MEDICINE]?

    1. MM/DD/YYYY or

    2. Month of pregnancy (B1, P1, P2, P3)

    3. Didn’t take it (only received prescription; didn’t fill it)

    4. DK

    5. RF

  11. When did you stop using [MEDICINE] for the last time during this time period?

    1. MM/DD/YYYY or

    2. Month of pregnancy (B1, P1, P2, P3) If valid response to Questions 9 and 10, skip Question 11

    3. DK

    4. RF

  12. How long did you take it?

    1. AMOUNT:__________

      1. Days

      2. Weeks

      3. Months

      4. DK

      5. RF

  13. How often did you use [MEDICATION] during the month before your pregnancy through the end of your third month of pregnancy? You can say the number of times per day, per week, per month, or during the entire 4 month period.

    1. AMOUNT:__________

      1. Per day

      2. Per week

      3. Per month

      4. Per period

    2. DK

    3. RF

  14. Did you take any over-the-counter medicines just before your dental visit/visits or just after your visit/visits?

    1. YES Continue to Question 15

    2. NO Skip to Question 20

    3. DK Skip to Question 20

    4. RF Skip to Question 20

  15. What did you take? / Anything else? IF CAN’T RECALL, READ FROM LIST. MULTIPLE MEDICATIONS CAN BE REPORTED; ASK FOLLOW-UP QUESTIONS FOR EACH

    1. Anbesol

    2. Chloraseptic

    3. Orajel

    4. Xylocaine

    5. Ibuprofen (Advil, Nuprin, Motrin)

    6. Acetaminophen (Tylenol)

    7. Aspirin (Bayer)

    8. Other (specify):__________

    9. DK

    10. RF

  16. When did you start taking [MEDICINE] for your dental visit?

    1. MM/DD/YYYY or

    2. Month of pregnancy (B1, P1, P2, P3)

    3. DK

    4. RF

  17. When did you stop using [MEDICINE] for the last time during this time period?

    1. MM/DD/YYYY or

    2. Month of pregnancy (B1, P1, P2, P3) If valid response to Questions 16 and 17, skip Question 18

    3. DK

    4. RF

  18. How long did you take it?

    1. AMOUNT:__________

      1. Days

      2. Weeks

      3. Months

      4. DK

      5. RF

  19. How often did you use [MEDICATION] during the month before your pregnancy through the end of your third month of pregnancy? You can say the number of times per day, per week, per month, or during the entire 4 month period.

    1. AMOUNT:__________

      1. Per day

      2. Per week

      3. Per month

      4. Per period

    2. DK

    3. RF

  20. Did you have any cavities filled or dental fillings placed during the visit/visits? [Ask only if they did not report having a cavity filled in Question 3; if they reported having a cavity filled in Question 3 skip this question and continue to Question 21]

    1. YES Continue to Question 21

    2. NO Skip to next section

    3. DK Skip to next section

    4. RF Skip to next section

  21. How many dental fillings were placed during your visits? IF THEY REPORT MULTIPLE VISITS CONFIRM THAT THEY HAVE SUMMED ACROSS VISITS

    1. NUMBER:__________

    2. DK

    3. RF

  22. What was/were the date(s) of the visit(s) when the filling(s) was/were placed? ASK FOR EACH VISIT IF MULTIPLE VISITS

    1. MM/DD/YYYY or

    2. Month of pregnancy (B1, P1, P2, P3)

    3. DK

    4. RF

  23. Was the filling/Were the fillings silver in color, also called an amalgam filling, or tooth-colored, also called a composite resin filling? ASK FOR EACH DATE REPORTED. ALLOW MULTIPLE RESPONSES IF MORE THAN ONE FILLING WAS PLACED DURING A SINGLE VISIT.

    1. Amalgam / silver-colored

    2. Composite resin / tooth-colored

    3. DK

    4. RF



Section Y: SMOKING

The next questions are about tobacco use.

  1. At any time from 1 month before you became pregnant to the end of your third month of pregnancy, that is from [START DATE OF B1] to [END DATE OF P3] did you smoke cigarettes? PROMPT: Even if you did not smoke the whole time, we are interested in whether you smoked any cigarettes at all during this time period.

    1. YES Continue to Question 2

    2. NO Skip to next section

    3. DK Skip to next section

    4. RF Skip to next section

  2. During which months did you smoke? INDICATE ALL THAT APPLY

    1. B1

    2. P1

    3. P2

    4. P3

    5. DK

    6. RF





Section Z: ALCOHOL

Now I’m going to ask you some questions about drinking alcoholic beverages.

  1. From one month before you became pregnant to the end of your third month of pregnancy, did you drink any wine, beer, mixed drinks or shots of liquor?

    1. YES Continue to Question 2

    2. NO Skip to next section

    3. DK Skip to next section

    4. RF Skip to next section

  2. During which months did you drink any alcoholic beverages?

    1. B1

    2. P1

    3. P2

    4. P3

    5. DK

    6. RF

  3. What was the greatest number of drinks you had on one occasion in [P1/P2/P3]? We define one drink as one beer, one glass of wine, one mixed drink, or one shot of liquor. ASK FOR EACH MONTH THAT ALCOHOL CONSUMPTION IS REPORTED.

    1. NUMBER:__________

    2. DK

    3. RF





Section AA: RESIDENCE HISTORY

We would like to know the address at which you lived when [TAB: you became pregnant with [NOIB]; the affected pregnancy began) so that we can study possible environmental exposures.

  1. Do you currently live at the same address that you did at the time [TAB: you became pregnant with ([NOIB]/the pregnancy began]?

    1. YES Continue to Question 2

    2. NO Skip to Question 4

    3. DK Skip to Question 4

    4. RF Skip to Question 4

  2. Is your current address [populated with current address on file]?

    1. YES Skip to next section

    2. NO Continue to Question 3

    3. DK Skip to Question 4

    4. RF Skip to Question 4

  3. What is your current address?

    1. ADDRESS:__________ Skip to next section

    2. DK Continue to Question 4

    3. RF Continue to Question 4

  4. What was your address at the time [TAB: your pregnancy with [NOIB]; the affected pregnancy] began? This would be on or around [START DATE OF P1].

    1. ADDRESS:__________

    2. DK

    3. RF





Section BB: MATERNAL OCCUPATION

The next set of questions asks about your work experiences – paid, volunteer, or military service. This includes part-time and full-time jobs that lasted one month or more, including jobs you worked at home, jobs on a farm, or jobs outside your home.

  1. From 1 month before you became pregnant to the end of your third month of pregnancy, that is from [START DATE OF B1] to [END DATE OF P3] did you have a job?

    1. YES Skip to Question 4

    2. NO Continue to Question 2

    3. DK Continue to Question 2

    4. RF Continue to Question 2

  2. Were you [READ CHOICES] or did you do something else?

    1. A homemaker/parent Skip to next section

    2. A student Go to Question 3

    3. Disabled Skip to next section

    4. Unemployed / in between jobs Skip to next section

    5. OTHER (SPECIFY):__________ Skip to next section

    6. DK Skip to next section

    7. RF Skip to next section

  3. IF STUDENT: From 1 month before you became pregnant to the end of your third month of pregnancy, that is from [START DATE OF B1] to [END DATE OF P3] did you also have a paid or volunteer job while in school, including on-the-job training, such as an apprenticeship, internship, practicum or clinical experience?

    1. YES Continue to Question 4

    2. NO Skip to next section

    3. DK Skip to next section

    4. RF Skip to next section

  4. What kind of a company did you work for? Please be as specific as possible. (What did your company make or do?) LIST ALL EMPLOYERS, INCLUDING “SELF EMPLOYED”

    1. RESPONSE:__________________________________

    2. DK

    3. RF

  5. What was your job title there? [ASK FOR EACH EMPLOYER]

    1. RESPONSE:__________________________________

    2. DK

    3. RF

  6. Describe what you did and how you did it. What were your main activities or duties? Anything else? [ASK FOR EACH EMPLOYER]

    1. RESPONSE:___________________________________

    2. DK

    3. RF

  7. Did you hold a job during that time:

    1. In the healthcare field?

      1. YES Queue request at end of interview for on-line follow-up questions

      2. NO

      3. DK

      4. RF

    2. On a farm, ranch, orchard, or in a greenhouse?

      1. YES Queue request at end of interview for on-line follow-up questions

      2. NO

      3. DK

      4. RF

    3. As a janitor, housekeeper, maid, or other cleaning staff?

      1. YES Queue request at end of interview for on-line follow-up questions

      2. NO

      3. DK

      4. RF

    4. As a hairdresser, cosmetologist, or nail technician?

      1. YES Queue request at end of interview for on-line follow-up questions

      2. NO

      3. DK

      4. RF

    5. As a teacher or teaching assistant?

      1. YES Queue request at end of interview for on-line follow-up questions

      2. NO

      3. DK

      4. RF

    6. In a restaurant, café, or coffee shop?

      1. YES Queue request at end of interview for on-line follow-up questions

      2. NO

      3. DK

      4. RF

    7. In an office building, performing primarily office, administrative, or computer work

      1. YES Queue request at end of interview for on-line follow-up questions

      2. NO

      3. DK

      4. RF

    8. As a scientist?

      1. YES Queue request at end of interview for on-line follow-up questions

      2. NO

      3. DK

      4. RF

    9. As an electronic equipment operator?

      1. YES Queue request at end of interview for on-line follow-up questions

      2. NO

      3. DK

      4. RF





Section CC: RACE / ACCULTURATION / EDUCATION

Now I will be asking about your ethnic background.

  1. Were you born in the U.S.?

    1. YES Skip to Question 4

    2. NO Continue to Question 2

    3. DK Skip to Question 4

    4. RF Skip to Question 4

  2. Where were you born?

    1. SPECIFY:__________

    2. DK

    3. RF

  3. How many years have you lived in the US?

    1. YEARS:__________

    2. DK

    3. RF

  4. What language do you usually speak at home?

    1. SPECIFY:__________

  5. Are you Hispanic or Latino?

    1. (  ) Yes Ask Question 9

    2. (  )  No

  6. How would you describe your race? I’m going to read you a list and then please tell me all categories that apply to you. You can select more than one category.

    1. American Indian or Alaskan Native Ask Question 8

    2. Asian Ask Question 7

    3. Black or African American Skip to Question 10, unless (5a), (6a), (6b), or (6d) also selected

    4. Native Hawaiian or Other Pacific Islander Ask Question 7

    5. White Skip to Question 10, unless (5a), (6a), (6b), or (6d) also selected

    6. DK Skip to Question 10, unless (5a), (6a), (6b), or (6d) also selected

    7. RF Skip to Question 10, unless (5a), (6a), (6b), or (6d) also selected

  7. What country? PROMPT: Referring to Asian, Native Hawaiian or other Pacific Island countries

    1. COUNTRY:__________

    2. DK

    3. RF

  8. What tribe do you consider yourself a member of?

    1. TRIBE:__________

    2. DK

    3. RF

  9. Which Hispanic or Spanish group do you consider yourself a member of? PROMPT: Mexican, Puerto Rican, Salvadoran, Honduran, Colombian, Peruvian, Guatemalan, Spanish, Central American, South American, etc?

    1. SPECIFY:__________

    2. DK

    3. RF

  10. What was the highest grade or year of school or college that you had competed [TAB: at the time [NOIB] was born; by [DOPT]]? IF RESPONDENT HESITATES, BEGIN READING CATEGORIES.

    1. RESPONSE:__________ OR options below

    2. No formal schooling

    3. 1-6 years

    4. 7-8 years

    5. 9-11 years

    6. 12 years, completed high school or equivalent

    7. 1-3 years college

    8. Completed technical college

    9. 4 years college or Bachelor’s degree

    10. Master’s degree

    11. Advanced degree (MD, PhD, JD)

    12. DK

    13. RF

IF THE FATHER IS UNKNOWN, SKIP TO THE NEXT SECTION

The next few questions are about [TAB: [NOIB]’s; the] biological or natural father.

  1. Was he born in the U.S.?

    1. YES Skip to Question 14

    2. NO Continue to Question 12

    3. DK Skip to Question 14

    4. RF Skip to Question 14

  2. Where was he born?

    1. SPECIFY:__________

    2. DK

    3. RF

  3. How many years has he lived in the U.S.?

    1. YEARS:__________

    2. DK

    3. RF

  4. Is the father Hispanic or Latino?

    1. (  ) Yes Ask Question 18

    2. (  )  No

  5. How would you describe his race? I’m going to read you a list and then please tell me all categories that apply to you. You can select more than one category.

    1. American Indian or Alaskan Native Ask Question 17

    2. Asian Ask Question 16

    3. Black or African American Skip to Question 19, unless (14a), (15a), (15b), or (15d) also selected

    4. Native Hawaiian or Other Pacific Islander Ask Question 16

    5. White Skip to Question 19, unless (14a), (15a), (15b), or (15d) also selected

    6. DK Skip to Question 19, unless (14a), (15a), (15b), or (15d) also selected

    7. RF Skip to Question 19, unless (14a), (15a), (15b), or (15d) also selected

  6. What country? PROMPT: Referring to Asian, Native Hawaiian or other Pacific Island countries.

    1. COUNTRY:__________

    2. DK

    3. RF

  7. What tribe does he consider himself a member of?

    1. TRIBE:__________

    2. DK

    3. RF

  8. Which Hispanic or Spanish group does he consider himself a member of? PROMPT: Mexican, Puerto Rican, Salvadoran, Honduran, Colombian, Peruvian, Guatemalan, Spanish, Central American, South American, etc?

    1. SPECIFY:__________

    2. DK

    3. RF

  9. What was the highest grade or year of school or college that he had completed [TAB: at the time [NOIB] was born; by [DOPT]]? IF RESPONDENT HESITATES, BEGIN READING CATEGORIES.

    1. RESPONSE:__________ OR options below

    2. No formal schooling

    3. 1-6 years

    4. 7-8 years

    5. 9-11 years

    6. 12 years, completed high school or equivalent

    7. 1-3 years college

    8. Completed technical college

    9. 4 years college or Bachelor’s degree

    10. Master’s degree

    11. Advanced degree (MD, PhD, JD)

    12. DK

    13. RF





Section DD: INSURANCE STATUS

The next questions are about health insurance. Include health insurance obtained through your job or that you bought directly, as well as government programs like Medicare and Medicaid that provide medical care or help pay medical bills. Please do not include private plans that only provide extra cash while hospitalized (e.g. Aflack).

  1. In the month before your pregnancy began, were you covered by health insurance or some other kind of health care plan?

    1. YES Continue to Question 2

    2. NO Skip to Question 3

    3. DK Skip to Question 3

    4. RF Skip to Question 3

  2. What was the name of your insurance? / Any other insurance? PROVIDE EXAMPLE IF NEEDED: Blue Cross/Blue Shield, Wellpoint, UnitedHealth, Wellmark, Medicaid, Medicare, Tricare

    1. NAME:__________

    2. DK

    3. RF

  3. During your pregnancy, were you covered by health insurance or some other kind of health care plan?

    1. YES, for the entire pregnancy Continue to Question 4

    2. YES, for part of the pregnancy Continue to Question 4

    3. NO Skip to next section

    4. DK Skip to next section

    5. RF Skip to next section

  4. What was the name of your insurance? / Any other insurance? PROVIDE EXAMPLES IF NEEDED: Blue Cross/Blue Shield, Wellpoint, UnitedHealth, Wellmark, Medicaid, Medicare, Tricare

    1. NAME:__________

    2. DK

    3. RF





Section EE: CLOSING

  1. IF THE MOTHER REPORTED ONE OF THE OCCUPATIONAL CATEGORIES OF INTEREST: In the interview, you told me that you worked in the [OCCUPATION] field at some point during the month before your pregnancy through your third month of pregnancy. We would like to get some additional information about your activities at that job. Would you be willing to let us send you an email with a link to an on-line survey with these additional questions once they become available?

    1. YES Continue to Question 2

    2. NO Skip to Question 3

    3. DK Skip to Question 3

  2. What is your email address, so that we can send you a link to the questionnaire?

    1. EMAIL ADDRESS:______________________________

    2. DK

  3. We may have other on-line surveys in the future on other topics. Would you be willing to let us send you an email telling you about them to see if you are interested in participating?

    1. YES

    2. NO

    3. DK



  1. IF MOTHER WAS NOT ASKED ABOUT EMAIL ADDRESS IN QUESTIONS 1-3: We may have on-line surveys in the future to get additional information on certain topics. Would you be willing to let us send you an email telling you about them to see if you are interested in participating?

    1. YES Continue to Question 5

    2. NO Skip to Question 6

    3. DK Skip to Question 6

  2. What is your email address?

    1. EMAIL ADDRESS:_____________________________

    2. DK



  1. In case we need to get in touch with you in the future, would you be willing to give us the name and address of someone who would always know where you are? This information will be kept separate from your questionnaire. It will be locked except when needed by the research team, and will be destroyed when the study is finished.

    1. YES Continue to Question 7

    2. NO Skip to Question 8

    3. DK Skip to Question 8

  2. Contact information

    1. FIRST NAME:_______________________

    2. LAST NAME:_______________________

    3. STREET/APARTMENT:_________________________

      1. DK

      2. RF

    4. CITY/STATE/ZIP:______________________________

      1. DK

      2. RF

    5. HOME PHONE:_______________________________

      1. DK

      2. RF

    6. WORK PHONE:___________________________________

      1. DK

      2. RF

    7. RELATIONSHIP:_________________________

      1. DK

      2. RF



  1. That completes the interview, but as you read in the advance letter, there are two parts to the study. You just completed the first part, the interview, which will help us understand the environmental causes of birth defects. The second part of the study will help us understand the role genetic factors have in causing birth defects. [IF BEFORE SALIVA KITS HAVE STARTED BEING SENT OUT: Within the next few months] We will mail a kit to you to collect saliva (spit) samples from you, [NOIB – skip if deceased], and [NOIB’s] father [skip if father unknown]. We will enclose a $20 gift card per family in the kit to compensate you for your time. You can decide whether to take part in the second part of the study after you receive the kit.

IF ADDRESS PROVIDED IN RESIDENCE HISTORY QUESTION 3: To confirm, I have your address as (ADDRESS)? Is that the address where you receive mail?

    1. YES Skip to Question 10

    2. NO Continue to Question 9

    3. DK Continue to Question 9

    4. RF Skip to question 10



  1. ASK ONLY IF ADDRESS NOT PROVIDED IN RESIDENCE HISTORY QUESTION 3 OR ADDRESS ON FILE IS INCORRECT: What is your current mailing address?

    1. STREET/APT:_________________________

    2. CITY:___________________________

    3. STATE:______________

    4. ZIP:____________________________

    5. RF



  1. In the introductory letter we sent you, there was a $20 gift card to Wal-Mart included as a token of appreciation for your interest. As I just mentioned, you will be sent an additional $20 gift card with the kit to collect saliva samples, and you will have the opportunity to be sent a 3rd $20 gift card. We also have gift cards to Amazon and Target available. In the future, would you like to receive gift cards from Amazon, Target or Wal-Mart?

    1. Amazon

    2. Target

    3. Wal-Mart

  2. We publish an electronic newsletter yearly to update participants on the progress of the study. You can access this newsletter at www.BDSTEPS.org. We can print the most recent one for you. Would you like us to send you a printed copy of the newsletter?

    1. Yes

    2. No

FINAL REMARK

In closing, we would like to sincerely thank you for your time and efforts. Your contribution to this important study will help us greatly in our efforts to better understand the causes of birth defects. Thank you.





Section FF: INTERVIEWER REMARKS

        1. The overall quality of this interview was:

          1. High quality

          2. Generally reliable

          3. Questionable

          4. Unsatisfactory

        2. Did the father [NOIB’S] contribute to the mother’s answers?

          1. YES

          2. NO

          3. DK

        3. Did some other person contribute to the mother’s answers?

          1. YES Continue to Question 4

          2. NO Skip to Question 5

          3. DK Skip to Question 5

        4. Who was it?

          1. Specify:__________

          2. DK

        5. IF QUESTION 1 = C OR D: The main reason for questionable or unsatisfactory quality of information was because the respondent: INDICATE ALL THAT APPLY

          1. Did not know enough information regarding the topic

          2. Did not want to be more specific

          3. Sounded bored or uninterested

          4. Sounded upset, depressed, or angry

          5. Had poor hearing or speech

          6. Sounded confused or distracted by frequent interruptions

          7. Sounded inhibited by others around her

          8. Sounded embarrassed by the subject matter

          9. Sounded emotionally unstable

          10. Sounded physically ill

          11. Not comfortable with language of the questionnaire

          12. Doesn’t have the time

          13. Felt interview too long

          14. Other (specify):__________

        6. Was the majority of the interview done in English or Spanish?

          1. English

          2. Spanish

          3. Both equally



Public reporting burden of this collection of information is estimated to average 45 minutes, including the time for reviewing instructions, searching existing data sources, gathering and maintaining the data needed, and completing and reviewing the collection of information. An agency may not conduct or sponsor, and a person is not required to respond to a collection of information unless it displays a currently valid OMB control number.  Send comments regarding this burden estimate or any other aspect of this collection of information, including suggestions for reducing this burden to CDC/ATSDR Reports Clearance Officer; 1600 Clifton Road NE, MS D-74,  Atlanta, Georgia 30333; ATTN:  PRA (0920-0010).


File Typeapplication/vnd.openxmlformats-officedocument.wordprocessingml.document
AuthorSarah C Tinker
File Modified0000-00-00
File Created2021-01-28
© 2025 OMB.report | Privacy Policy