Form Approved
OMB No. 0920-0010
Exp. Date: 04/30/2026
Centers for Birth Defects Research and Prevention
Birth Defects Study To Evaluate Pregnancy exposureS (BD-STEPS)
Computer-Assisted Telephone Interview
Questionnaire Version 11.0.0
For CATI version 8.1.X
English Version
April 3, 2024
Section A: ESTABLISHING DATES 1
Section B: MULTIPLE GESTATION 2
Section C: PREGNANCY HISTORY 3
Maternal Health Introduction 12
Section M: AUTOIMMUNE DISEASE 54
Section N: TRANSPLANT RECEIPT 62
Section O: DEPRESSION / ANXIETY 65
Section P: ATTENTION DEFICIT HYPERACTIVITY DISORDER (ADHD) 70
Section Q: CHRONIC DISEASE CATCH-ALL QUESTION 74
Section S: GENITOURINARY INFECTIONS 79
Section V: MEDICATIONS/HERBALS/VITAMINS 93
Section X: PHYSICAL ACTIVITY 116
Section Z: DENTAL PROCEDURES 122
Section DD: RESIDENCE HISTORY 130
Section EE: MATERNAL OCCUPATION 131
Section FF: RACE / ACCULTURATION / EDUCATION 132
Section GG: INSURANCE STATUS 136
Section II: INTERVIEWER REMARKS 140
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.
ENTER DATE OF CONSENT: MM/DD/YYYY (TODAY’S DATE IF UNKNOWN)
NOTE: THE WORDING FOR TABS AND STILLBIRTHS ARE THE SAME.
I’m going to ask many questions about the time before and during [your pregnancy with NOIB]; TAB/STILLBIRTH: the affected pregnancy]. In order to do this, I need to start by asking you some dates.
A1. What was [NOIB/the baby]’s date of birth? / If [TAB]: On what date did the affected pregnancy end?
MM/DD/YYYY CAN USE DK OR RF FOR MM OR DD OR YY
A2. What date did the doctor or other health care provider give you as a due date for [NOIB]’s birth; TAB: the affected pregnancy]? That is, when was [[NOIB]; TAB: the baby] expected to be born? [Note: IF MOM KNOWS DUE DATE, CATI WILL CALCULATE WHICH PREGNANCY MONTHS CORRESPOND WITH CALENDAR DATES. IF MOM DOES NOT KNOW DUE DATE, USE THE EDD RECORDED IN THE TRACKING DATABASE TO CALCULATE DATES.]
MM/DD/YYYY CAN USE DK OR RF FOR MM OR DD OR YY
IF NOIB IS TAB OR STILLBIRTH, SKIP TO A6
A3. Is [NOIB] still living?
YES SKIP TO A6
NO CONTINUE TO A4
DK SKIP TO A6
RF SKIP TO A6
A4. What did s/he die of? IF NEEDED, ASK THE MOTHER TO BE AS SPECIFIC AS POSSIBLE
SPECIFY:__________ DK RF
A5. How old was s/he when s/he died? NOTE: IF THE BABY LIVED LESS THAN 24 HOURS, THE RESPONSE LESS THAN 1 DAY CAN BE RECORDED AS 1 DAY.
AGE:__________ DK RF
UNITS:__________ (Days, Weeks, Months, Years)
A6. What is your date of birth? MOTHER’S
MM/DD/YYYY CAN USE DK OR RF FOR MM OR DD OR YYYY
A7. I would like to ask about [[NOIB]’s; TAB: the baby’s] biologic or natural father. What is his date of birth? [PROBE: IF DK: You don’t know the date of birth or you don’t know the biologic father?]
MM/DD/YYYY CAN USE DK OR RF FOR MM OR DD OR YYYY
DK WHO FATHER IS
B1. In [your pregnancy with [NOIB]; TAB: the affected pregnancy], how many babies were you carrying? PROBE: Were you carrying a single baby, twins, or more babies?
Number of babies:__________
IF 1 (SINGLE BABY) SKIP TO NEXT SECTION
IF ≥2 (TWINS OR HIGHER ORDER MULTIPLE) CONTINUE TO B2; IF TAB: SKIP TO NEXT SECTION
DK SKIP TO NEXT SECTION
RF SKIP TO NEXT SECTION
B2. [Is the other baby/are the other babies] still living?
Yes, all other babies still living
Some babies still living, others are not
No, no other babies still living
DK
RF
B3. In addition to the baby we have already discussed, what was the sex of the [B1=2: other; B1 >2: [1st, 2nd, etc.] additional] baby? [RECORD FOR EACH ADDITIONAL BABY]
Girl
Boy
Indeterminate
DK
RF
B4. Was this baby affected by a birth defect? [RECORD FOR EACH ADDITIONAL BABY]
YES CONTINUE TO B5
NO SKIP TO B6/NEXT SECTION
DK SKIP TO B6/NEXT SECTION
RF SKIP TO B6/NEXT SECTION
B5. What was the birth defect? / Anything else? [RECORD FOR EACH ADDITIONAL BABY] [PROBE: IF CAN’T RECALL, READ FROM PROMPTS PROVIDED IN QxQ]
B6. 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]
Look/ed virtually the same, as physically alike as “two peas in a pod”; or
As similar as typical brothers or sisters at the same age; or
Do not look very much alike at all?
DK
Now I’m going to ask you about your previous pregnancy experiences.
C1. Before [[NOIB]; TAB: the pregnancy that ended on [DOIB/DOPT]], how many times were you pregnant, including pregnancies that may have ended in miscarriages, stillbirths, induced abortions, or other outcomes?
NUMBER:__________
IF 0 SKIP TO NEXT SECTION
IF >0 CONTINUE TO C2
DK SKIP TO NEXT SECTION
RF SKIP TO NEXT SECTION
C2. When did the last pregnancy before [[NOIB]; TAB: the pregnancy that ended on [DOIB/DOPT]] end?
MM/DD/YYYY CAN USE DK OR RF FOR MM OR DD OR YYYY OR
TIME PERIOD AGO:__________
YEARS
MONTHS
WEEKS
C3a. Did that pregnancy end with a live birth? [IF A MULTIPLE PREGNANCY HAD AT LEAST ONE FETUS BORN LIVE, SELECT YES]
YES SKIP TO NEXT SECTION IF C1a = 1/SKIP TO C5b if C1a=2/ SKIP TO C5a IF C1a > 2
NO CONTINUE TO C3b
DK SKIP TO NEXT SECTION IF C1a = 1/ SKIP TO C5b if C1a=2/ SKIP TO C5a IF C1a > 2
RF SKIP TO NEXT SECTION IF C1a = 1/ SKIP TO C5b if C1a=2/ SKIP TO C5a IF C1a > 2
C3b. Did that pregnancy end with (a/an) (READ CATEGORIES: stillbirth, induced abortion, miscarriage, or some other outcome)? IF 2 OR MORE OUTCOMES IN 1 PREGNANCY SELECT OTHER
Stillbirth CONTINUE TO C4
Induced abortion CONTINUE TO C4
Miscarriage CONTINUE TO C4
Some other outcome (SPECIFY) CONTINUE TO C4
DK CONTINUE TO C4
RF CONTINUE TO C4
C4. IF REPORTING ANY OUTCOME BESIDES LIVE BIRTH: How far along were you in your pregnancy when the pregnancy ended? For example, what week or month? [IF MORE THAN 1 OUTCOME AND OUTCOMES ENDED ON DIFFERENT DATES, RECORD THE LATEST DATE]
AMOUNT:______________ SKIP TO NEXT SECTION IF C1a=1/ SKIP TO C5b if C1a=2/ CONTINUE TO C5a IF C1a>2
i. UNITS:___________(Days, Weeks, Months, Trimesters)
DK SKIP TO NEXT SECTION IF C1a=1/ SKIP TO C5b if C1a=2/ CONTINUE TO C5a IF C1a>2
RF SKIP TO NEXT SECTION IF C1a=1/ SKIP TO C5b if C1a=2/ CONTINUE TO C5a IF C1a>2
C5a. IF MORE THAN 1 PREVIOUS PREGNANCY: Now, I would like to get some information about your other pregnancies, starting with the first one.
C5b. INTERVIEWER, PLEASE ENTER IN (C1# - 1) BELOW
C5c. Did your [1st, etc ] pregnancy end in a live birth?
YES SKIP TO NEXT SECTION/ASK ABOUT NEXT PREGNANCY
NO CONTINUE TO C6
DK SKIP TO NEXT SECTION/ASK ABOUT NEXT PREGNANCY
RF SKIP TO NEXT SECTION/ASK ABOUT NEXT PREGNANCY
C6. Did that pregnancy end with (a/an) (READ CATEGORIES): stillbirth, induced abortion, miscarriage, or some other outcome? [IF 2 OR MORE OUTCOMES IN 1 PREGNANCY ENTER IN OTHER]
a. Stillbirth CONTINUE TO C7
b. Induced abortion CONTINUE TO C7
c. Miscarriage CONTINUE TO C7
d. Other (SPECIFY) CONTINUE TO C7
e. DK CONTINUE TO C7
f. RF CONTINUE TO C7
C7. IF REPORTING ANY OUTCOME BESIDES LIVE BIRTH: How far along were you in your pregnancy when the pregnancy ended? For example, the week or month? [IF MORE THAN 1 OUTCOME AND OUTCOMES ENDED ON DIFFERENT DATES, RECORD THE LATEST DATE]
AMOUNT:______________ SKIP TO NEXT SECTION/ASK ABOUT NEXT PREGNANCY
i. UNITS:___________(Days, Weeks, Months, Trimesters)
b. DK SKIP TO NEXT SECTION/ASK ABOUT NEXT PREGNANCY
c. RF SKIP TO NEXT SECTION/ASK ABOUT NEXT PREGNANCY
D1. Did you have a health problem at birth or a birth defect that was diagnosed in childhood?
YES CONTINUE TO D2
NO SKIP TO D3
DK SKIP TO D3
RF SKIP TO D3
D2. What was the health problem or birth defect? / Anything else? [PROBE: IF CAN’T RECALL, READ FROM PROMPTS PROVIDED IN QxQ]
Specify:___________________________
DK
RF
D3. IF FATHER UNKNOWN, SKIP TO D5: Did [[NOIB]’s; TAB: the] biological or natural father have a health problem at birth or a birth defect that was diagnosed in childhood?
YES CONTINUE TO D4
NO SKIP TO D5/NEXT SECTION
DK SKIP TO D5/NEXT SECTION
RF SKIP TO D5/NEXT SECTION
D4. What was the problem at birth or birth defect? / Anything else? [PROBE: IF CAN’T RECALL, READ FROM PROMPTS PROVIDED IN QxQ]
SPECIFY:___________________________
DK
RF
D5. IF PREVIOUS PREGNANCIES REPORTED: Did any of [[NOIB]’s; TAB: 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.
YES CONTINUE TO D6
NO SKIP TO NEXT SECTION
DK SKIP TO NEXT SECTION
RF SKIP TO NEXT SECTION
D6. What was the health problem or birth defect? / Anything else? [PROBE: IF CAN’T RECALL, READ FROM PROMPTS PROVIDED IN QxQ]
SPECIFY:___________________________
DK
RF
Now I have some questions specific to your pregnancy [with [NOIB]; TAB: that ended on [DOIB/DOPT]].
E1. How long were you trying to get pregnant with [[NOIB]; TAB: the pregnancy that ended on [DOIB/DOPT]], before you became pregnant? [READ OPTIONS]
We were not trying SKIP TO E14b IF PREVIOUS PREGNANCIES; SKIP TO E15 IF NO PREVIOUS PREGNANCIES
Less than 6 months
6 months or more, but less than a year
A year or more, but less than 3 years
3 years or more, but less than 5 years
5 years or more, but less than 7 years
7 years or more
DK
RF
E2a. In the two months before you became pregnant with [[NOIB]; TAB: the pregnancy that ended on [DOIB/DOPT]] did you use In-vitro fertilization, also known as IVF, Intracytoplasmic sperm injection, also known as ICSI, or Artificial insemination to help you become pregnant?
YES CONTINUE TO E2b
NO SKIP TO E9
DK SKIP TO E9
RF SKIP TO E9
E2b. Which procedure or procedures did you use? READ LIST (INDICATE ALL THAT APPLY):
In-vitro fertilization, or IVF
Intracytoplasmic sperm injection, or ICSI
Artificial insemination
DK SKIP TO E9
RF SKIP TO E9
IF YES TO ONLY ONE PROCEDURE SKIP TO E4
IF YES TO MORE THAN ONE PROCEDURE CONTINUE TO E3
E3. Which was the last procedure you used before getting pregnant with [[NOIB]; TAB: the affected pregnancy]?
IN-VITRO FERTILIZATION, OR IVF
INTRACYTOPLASMIC SPERM INJECTION, OR ICSI
ARTIFICIAL INSEMINATION
DK
RF
E4. What was the date of that procedure?
MM/DD/YYYY CAN USE DK OR RF FOR MM OR DD OR YYYY
E5. Were donor egg(s), donor sperm, or donor embryo(s) used on [DATE]/ [(IF UNSPECIFIED DATE) during this last procedure]?
YES CONTINUE TO E6
NO SKIP TO E7
DK SKIP TO E7
RF SKIP TO E7
E6. Which of these were used? [SELECT ALL THAT APPLY]
Donor eggs
Donor sperm
Donor embryos
DK
RF
E7. Were frozen egg(s), frozen sperm, or frozen embryo(s) used on [DATE OF PROCEDURE, ANSWER E4]?
YES CONTINUE TO E8
NO SKIP TO E9
DK SKIP TO E9
RF SKIP TO E9
E8. Which of these were used? [SELECT ALL THAT APPLY]
Frozen eggs
Frozen sperm
Frozen embryos
DK
RF
E9. In the two months before you became pregnant with [[NOIB]; TAB: the pregnancy that ended on [DOIB/DOPT]] did you take any medications to help you become pregnant?
YES ASK E9a
NO IF E2a = YES SKIP TO E11. IF E2a = NO/DK/RF AND IF C1 = 0 SKIP TO E15. IF E2a = NO/DK/RF AND IF C1 = >0 SKIP TO E14b.
DK IF E2a = YES SKIP TO E11. IF E2a = NO/DK/RF AND IF C1 = 0 SKIP TO E15. IF E2a = NO/DK/RF AND IF C1 = >0 SKIP TO E14b.
RF IF E2a = YES SKIP TO E11. IF E2a = NO/DK/RF AND IF C1 = 0 SKIP TO E15. IF E2a = NO/DK/RF AND IF C1 = >0 SKIP TO E14b.
E9a. Did you take Clomid or clomiphene citrate?
YES ASK E10a
NO ASK E9b
DK ASK E9b
RF ASK E9b
E9b. Did you take Letrozole/Femara?
YES ASK E10b
NO ASK E9c
DK ASK E9c
RF ASK E9c
E9c. Did you take anything else?
YES ASK E9d
NO IF E2a = YES SKIP TO E11. IF E2a = NO/DK/RF AND IF C1 = 0 SKIP TO E15. IF E2a = NO/DK/RF AND IF C1 = >0 SKIP TO E14b
DK IF E2a= YES SKIP TO E11. IF E2a = NO/DK/RF AND IF C1 = 0 SKIP TO E15. IF E2a = NO/DK/RF AND IF C1 = >0 SKIP TO E14b
RF IF E2a = YES SKIP TO E11. IF E2a = NO/DK/RF AND IF C1 = 0 SKIP TO E15. IF E2a = NO/DK/RF AND IF C1 = >0 SKIP TO E14b
E9d. What did you take? IF CAN’T RECALL, READ LIST:
Bromocriptine
Danazol
Danocrine
Depo-Provera
Factrel
Lupron
Lutrepulse
Metrodin
Parlodel
Pergonal
Pregnyl
Profasi HP
Provera
Serophene
Synarel
OTHER, SPECIFY:_____________
DK
RF
E10a. IF E9a=YES: How many Clomid or clomiphene citrate pills per day did you take at your last cycle before getting pregnant?
NUMBER:__________
DK
RF
GO
BACK TO E9b
E10b. IF E9b=YES: How many Letrozole/Femara pills per day did you take at your last cycle before getting pregnant?
NUMBER:__________
DK
RF
GO BACK TO E9c
E11. IF REPORT ANY FERTILITY PROCEDURES OR MEDICATIONS: How many menstrual cycles with fertility treatments (complete or incomplete) did you have before [you got pregnant with [NOIB]; TAB: the pregnancy that ended on [DOIB/DOPT]]?
1 cycle
2-3 cycles
4-6 cycles
more than 6 cycles
DK
RF
E12. INDICATE ALL THAT APPLY IF REPORT ANY FERTILITY PROCEDURES OR MEDICATIONS: What was the reason(s) for fertility treatments? Was it… [READ OPTIONS]
A female issue, such as blocked fallopian tubes or Polycystic Ovary Syndrome CONTINUE TO E13
A male issue, such as low sperm count or low motility SKIP TO E14b IF PREVIOUS PREGNANCY REPORTED/E15 IF ONLY ONE PREGNANCY REPORTED
No male partner SKIP TO E14b/E15
Unexplained SKIP TO E14b/E15
DK SKIP TO E14b/E15
RF SKIP TO E14b/E15
E13. IF REPORT FEMALE FACTOR: What was the female issue? Was it… [READ OPTIONS; INDICATE ALL THAT APPLY]
Blocked fallopian tubes
Polycystic Ovary Syndrome (PCOS)
Endometriosis
Ovulation problems (irregular periods)
OTHER (SPECIFY):_______________
DK
RF
E14. IF PREVIOUS PREGNANCY REPORTED: Have you ever conceived a previous pregnancy using… [READ ALL, INDICATE ALL THAT APPLY]:
E14b. |
Ovulation stimulation pills, such as Clomid or Femara |
YES |
NO |
DK |
RF |
E14c. |
Artificial insemination |
YES |
NO |
DK |
RF |
E14d. |
In-vitro fertilization, or IVF |
YES |
NO |
DK |
RF |
E14e. |
Intracytoplasmic sperm injection, or ICSI |
YES |
NO |
DK |
RF |
E15. During the first trimester of your pregnancy with [[NOIB]; TAB: the pregnancy that ended on [DOIB/DOPT]], did you take any medications to prevent pregnancy complications or pregnancy loss, such as hormones, steroids, or injections?
YES CONTINUE TO E16
NO SKIP TO NEXT SECTION
DK SKIP TO NEXT SECTION
RF SKIP TO NEXT SECTION
E16. What did you take? / Did you take anything else? [LIST ALL. IF CAN’T RECALL, READ LIST: Was it…?]
Depo-Provera
Magnesium Sulfate
Progesterone
Rho(D) immune globulin
Rhogam
Calcium Channel Blockers
Steroid
OTHER, SPECIFY:________
DK SKIP TO NEXT SECTION
RF SKIP TO NEXT SECTION
E17. When in the first trimester did you start using [MEDICINE, ANSWER E16] to prevent complications or pregnancy loss? FOR DAY CAN INDICATE BEGINNING, MIDDLE, OR END OF MONTH.CAN USE DK OR RF FOR MM OR DD OR YY
MM/DD/YYYY OR
MONTH OF PREGNANCY (P1, P2, P3, T1)
DK
RF
E18. When did you use [MEDICINE, ANSWER E16] for the last time during this time period? [CAN USE DK OR RF FOR MM OR DD OR YY]
MM/DD/YYYY OR
MONTH OF PREGNANCY(P1, P2, P3, T1) IF VALID START AND STOP DATE, SKIP TO E20
DK
RF
OR
E19. How long did you take it? You can say the length of time in days, weeks or months.
AMOUNT:__________
Days
Weeks
Months
DK
RF
E20. How often did you use [MEDICINE, ANSWER E16] 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.
AMOUNT:__________ Per Day/Per Week/Per Month/Per Time Period/DK/RF
(THE FOLLOWING SPECIAL CODES ARE ALSO INCLUDED IN ALL THE RESPONSE OPTIONS FOR ALL MEDICATION FREQUENCY QUESTIONS:
IV (Any) (includes IV Continuous and IV pump)
Patch (worn continuously)
Schedule varied/only as needed (NOTE: Only use this code as a last resort, and always document what Subject said in a Comment.)
Tapering frequency (document what Subject said in a Comment)
Per time period (Refers to the number of times Subject took a drug between the dates she reported.)
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. Many of these questions will refer to the 4 month period from the month before your pregnancy began through the end of your third month of pregnancy. 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.
F1. Were you ever told by a doctor or other health care provider that you had diabetes (including gestational diabetes), sometimes called sugar diabetes or diabetes mellitus?
YES CONTINUE TO F2
NO SKIP TO NEXT SECTION
DK SKIP TO NEXT SECTION
RF SKIP TO NEXT SECTION
F2. What type of diabetes did you or do you currently have? Was it [READ LIST]?
Gestational, that is, during pregnancy only
Type 1, also called insulin-dependent diabetes, or Juvenile
Type II, also called non-insulin-dependent diabetes, , or adult onset
DK
RF
F3. When were you first diagnosed with diabetes in relation to your pregnancy with [[NOIB]; TAB: the affected pregnancy]? [READ LIST]
Before this pregnancy and not during any other pregnancy?
During a previous pregnancy?
During this pregnancy?
DK
RF
IF F2=a, d, or e OR F3=b, c, d, e THEN SKIP TO F7 [ONLY ASK F4 if F2 = b or c AND F3=a]
F4. Either before or during [[your pregnancy with NOIB]: TAB/STILLBIRTH: the affected pregnancy]], did you speak with a healthcare provider about your treatment options during pregnancy?
YES GO TO F5
NO SKIP TO F7
DK SKIP TO F7
RF SKIP TO F7
F5. Did you discuss these options before your pregnancy began?
YES SKIP TO F7
NO GO TO F6
DK SKIP TO F7
RF SKIP TO F7
F6. How far along were you in your pregnancy when you discussed treatment options with your provider?
AMOUNT:__________
UNITS:
Days
Weeks
Months
Trimesters
DK
RF
F7. 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.
Take medications or other remedies IF YES, CONTINUE TO F8 AFTER QUERYING F7b-F7d
Modify your eating habits IF YES, ASK F19
Control your weight or weight gain IF YES, ASK F19
Do anything else IF YES, ASK F20
NONE OF THE ABOVE SKIP TO F22
DK SKIP TO F22
RF SKIP TO F22
F8. IF F7=a: What medications did you take? / Did you take anything else? LIST ALL. [IF CAN’T RECALL, READ FROM DRUG LIST. Did you take…?]
Actos
Amaryl
Byetta
Diabeta
Diabinese
Glucophage
Glucotrol
Glucotrol XL
Glumetza
Glyburide
Glynase PresTab
Humalog
Humulin N
Humulin R
Januvia
Lantus
Levemir
Metformin HCL
Micronase
Novolin N
Novolin-R
Novolog
Onglyza
Prandin
Precose
Starlix
Victoza
OTHER (SPECIFY): _______
DK SKIP TO F19/F20 OR F21
RF SKIP TO F19/F20 OR F21
ANSWER F9-F18 FOR ALL DRUGS SELECTED IN F8.
F9. Did you use [DRUG, ANSWER F8] for the entire time from the month before your pregnancy through your third month of pregnancy, that is from [B1] to [P4(-1)]?
YES SKIP TO F13
NO CONTINUE TO F10
DK CONTINUE TO F10
RF CONTINUE TO F10
F10. When did you start using [DRUG, ANSWER F8] for diabetes for the first time during this period? (For day can indicate beginning, middle, or end of month) [CAN USE DK OR RF FOR MM OR DD OR YY]
MM/DD/YYYY or
MONTH OF PREGNANCY (B1, P1, P2, P3)
DK
RF
F11. When did you use [DRUG, ANSWER F8] for the last time during this time period? [CAN USE DK OR RF FOR MM OR DD OR YY]
MM/DD/YYYY or
MONTH OF PREGNANCY (B1, P1, P2, P3) IF VALID RESPONSE TO F10 AND F11, SKIP F12
DK
RF
OR
F12. How long did you take it?
AMOUNT:__________
Days
Weeks
Months
DK
RF
F13. How often did you use [DRUG, ANSWER F8] 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.
AMOUNT:__________ Per Day/Per Week/Per Month/Per Time Period/DK/RF
F14. Did you take the same dose of [DRUG, ANSWER F8] each time you took it throughout [B1] TO [P4(-1)]? That is, for example, the same number of milligrams of medicine in each dose.
YES CONTINUE TO F15
NO SKIP TO F16a
DK CONTINUE TO F15
RF CONTINUE TO F15
F15. What dose of [DRUG, ANSWER F8] did you take each time you took it?
AMOUNT:_______________ SKIP TO F19 (IF F7b OR F7c also =YES), OR
SKIP TO F20 (IF F7b AND F7c=NO AND F7d=YES)
SKIP TO F21a (IF F7b, F7c, AND F7d=NO)
UNITS:__________
DK or RF SKIP TO F19 (IF F7b OR F7c=YES) OR F20 (IF F7b AND F7c=NO AND F7d=YES) OR F21a (IF F7b, F7c, AND F7d=NO)
FOR EACH DRUG UNIT RESPONSE IN SECTION F THROUGH X, THESE ARE THE OPTIONS:
MICROGRAMS
MILLIGRAM(S)
MILLILITER(S)
TEASPOON(S)
TABLESPOON(S)
INTERNATIONAL UNITS
PILL/CAPSULE/CAPLET(S)
PUFF(S)
DROP(S)
OTHER, SPECIFY
DK, RF
F16a. How many different dosage amounts do you remember taking? [If mom knows she took more than one dosage, but can't remember how many, select 1 for the number of dosages and report the dosage info she does remember. You may put additional details in a comment field.]
AMOUNT:__________ RF
F16b. What dose of [DRUG, ANSWER F8] did you take the [1st, 2nd, etc.] time?
AMOUNT:__________
DK SKIP TO F17
RF SKIP TO F17
UNITS:__________ DK RF
F17. When did you begin taking that dose? [CAN USE DK OR RF FOR MM OR DD OR YY]
MM/DD/YYYY or
MONTH OF PREGNANCY(B1, P1, P2, P3)
DK
RF
F18. When did you stop taking that dose?
MM/DD/YYYY OR CONTINUE TO F19 (IF F7b OR F7c=YES) OR F20 (IF F7b AND F7c=NO AND F7d=YES) OR F21 (IF F7b, F7c, AND F7d=NO)
MONTH OF PREGNANCY (B1, P1, P2, P3) IF VALID RESPONSE TO F17 AND F18, SKIP F18a. CONTINUE TO F19 (IF F7b OR F7c=YES) OR F20 (IF F7b AND F7c=NO AND F7d=YES) OR F21 (IF F7b, F7c, AND F7d=NO)
DK CONTINUE TO F19 (IF F7b OR F7c=YES) OR F20 (IF F7b AND F7c=NO AND F7d=YES) OR F21 (IF F7b, F7c, AND F7d=NO)
RF CONTINUE TO F19 (IF F7b OR F7c=YES) OR F20 (IF F7b AND F7c=NO AND F7d=YES) OR F21 (IF F7b, F7c, AND F7d=NO)
OR
F18a. How long did you take it?
AMOUNT:__________ DK RF
Days
Weeks
Months
(ANSWER F16b – F18a FOR ALL DOSES REPORTED IN F16a)
F19. ASK IF F7b OR F7c=YES: In order to modify your eating habits or control your weight during the month before your pregnancy through the end of your third month of pregnancy, did you…? [READ OPTIONS AND ASK: “Did you do anything else?”]
Follow a diet specifically for diabetes
Eat healthier but no specific diabetes diet
Do physical exercise
OTHER, SPECIFY____________________________
DK
RF
F20. IF F7d=YES: What else did you do to manage your diabetes and its complications during the month before your pregnancy through the end of your third month of pregnancy? / Anything else?
SPECIFY:_____________________________
DK
RF
F21a. IF F7a = YES: How often did taking medications or other remedies work in controlling your diabetes during the month before your pregnancy through the end of your third month of pregnancy? [READ OPTIONS.]
Always
Most of the time
Part of the time
Never or rarely
DK
RF
F21b. IF F7b = YES: How often did modifying your eating habits work in controlling your diabetes during the month before your pregnancy through the end of your third month of pregnancy? [READ OPTIONS.]
Always
Most of the time
Part of the time
Never or rarely
DK
RF
F21c. IF F7c = YES: How often did controlling your weight gain work in controlling your diabetes during the month before your pregnancy through the end of your third month of pregnancy? [READ OPTIONS.]
Always
Most of the time
Part of the time
Never or rarely
DK
RF
F21d. IF F7d = YES: How often did ([ACTIVITY TO MANAGE DIABETES, ANSWER F20]) work in controlling your diabetes during the month before your pregnancy through the end of your third month of pregnancy? [RE-WORD APPROPRIATELY IF F20 =DO NOT KNOW. READ OPTIONS.]
Always
Most of the time
Part of the time
Never or rarely
DK
RF
F22. 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 [NOIB]; TAB: the pregnancy that ended on [DOIB/DOPT]], had a doctor or other health care provider ever checked your glycosylated hemoglobin or “A one C”?
YES CONTINUE TO F23
NO SKIP TO NEXT SECTION
DK SKIP TO NEXT SECTION
RF SKIP TO NEXT SECTION
F23. What was your “A one C” level at the time it was tested closest to when you became pregnant with [NOIB]; TAB: the pregnancy that ended on [DOIB/DOPT]]? PROBE: If you can't remember the actual number, do you know if it was normal or high?
AMOUNT:__________/High/Normal/DK/RF
F24. When was the “A one C” test conducted?
MM/DD/YYYY OR
RELATIVE TO PREGNANCY:
1 month to 3 months before pregnancy
4 months to 6 months before pregnancy
6 months to 1 year before pregnancy
Greater than 1 year before pregnancy
DK
RF
G1. Have you ever been told by a doctor or other health care provider that you had cancer or a malignancy of any kind?
YES CONTINUE TO G2
NO SKIP TO NEXT SECTION
DK SKIP TO NEXT SECTION
RF SKIP TO NEXT SECTION
G2. What kind of cancer was it? CAN ENTER MULTIPLE SITES IF APPLICABLE.
SPECIFY:__________
DK
RF
G3. How old were you when you were diagnosed with cancer for the first time?
AGE:_______________________
DK
RF
G4. What is the current status of your cancer? (READ OPTIONS) IF MOTHER SAYS “IN PARTIAL REMISSION”, RECORD AS ‘ACTIVE”.
Active SKIP TO NEXT SECTION
In remission CONTINUE TO G5
DK SKIP TO NEXT SECTION
RF SKIP TO NEXT SECTION
G5. How long has it been in remission?
TIME:__________
Years
Months
Weeks
Days
H1. Do you have a heart problem that has been present since birth? Please do not include problems that went away on their own. PROBE: Please do not include arrhythmia, as we will be discussing this later.
YES CONTINUE TO H2
NO SKIP TO H15
DK SKIP TO H15
RF SKIP TO H15
H2. What is it?
SPECIFY:__________
DK
RF
H3. Did you take any medications or remedies for [HEART PROBLEM, ANSWER H2] during the month before your pregnancy through the third month of your (pregnancy with [[NOIB]; TAB: the pregnancy that ended on [DOIB/DOPT]]?
YES CONTINUE TO H4
NO SKIP TO H15
DK SKIP TO H15
RF SKIP TO H15
H4. What did you take? / Did you take anything else?
SPECIFY:__________
DK SKIP TO H15
RF SKIP TO H15
H5. Did you use [MEDICINE, ANSWER H4] for the entire time from the month before your pregnancy through your third month of pregnancy, that is from [B1] through [P4 (-1)]?
YES SKIP TO H9
NO CONTINUE TO H6
DK CONTINUE TO H6
RF CONTINUE TO H6
H6. When did you start using [MEDICINE, ANSWER H4] for the first time during this period? (For day can indicate beginning, middle, or end of month) [CAN USE DK OR RF FOR MM OR DD OR YY]
MM/DD/YYYY or
MONTH OF PREGNANCY (B1, P1, P2, P3)
DK
RF
H7. When did you use [MEDICINE, ANSWER H4] for the last time during this time period? [CAN USE DK OR RF FOR MM OR DD OR YY]
MM/DD/YYYY or
MONTH OF PREGNANCY (B1, P1, P2, P3) IF VALID RESPONSE TO H6 AND H7, SKIP H8
DK
RF
OR
H8. How long did you take it?
AMOUNT:__________
Days
Weeks
Months
DK
RF
H9. How often did you use [MEDICINE, ANSWER H4] 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.
AMOUNT:__________ Per Day/Per Week/Per Month/Per Time Period/DK/RF
H10. Did you take the same dose of medicine each time you took it throughout [B1] to [P4 (-1)]? That is, for example, the same number of milligrams of medicine in each dose.
YES CONTINUE TO H11
NO SKIP TO H12a
DK CONTINUE TO H11
RF CONTINUE TO H11
H11. What dose of [MEDICINE, ANSWER H4] did you take each time you took it?
AMOUNT:__________ SKIP TO H15
DK SKIP TO H15
RF SKIP TO H15
UNITS:__________ SKIP TO H15
DK SKIP TO H15
RF SKIP TO H15
H12a. How many different dosage amounts do you remember taking? [If mom knows she took more than one dosage, but can't remember how many, select 1 for the number of dosages and report the dosage info she does remember. You may put additional details in a comment field.]
AMOUNT:__________ RF
H12b. What dose of [MEDICINE, ANSWER H4] did you take the [1st, 2nd, etc.] time?
AMOUNT:__________
DK SKIP TO H13
RF SKIP TO H13
UNITS:__________ DK RF
H13. When did you begin taking that dose?
MM/DD/YYYY or
MONTH OF PREGNANCY(B1, P1, P2, P3)
DK
RF
H14. When did you stop taking that dose?
MM/DD/YYYY or
MONTH OF PREGNANCY(B1, P1, P2, P3) IF VALID RESPONSE TO H13 AND H14, SKIP H14a
DK
RF
OR
H14a. How long did you take it?
AMOUNT:__________
Days
Weeks
Months
DK
RF
(ANSWER H12b-H14a FOR ALL DOSES REPORTED IN H12a.)
H15. Have you ever been diagnosed with cardiac arrhythmias?
YES CONTINUE TO H16
NO SKIP TO H28
DK SKIP TO H28
RF SKIP TO H28
H16. Did you take any medication for arrhythmias during the month before your pregnancy through the third month of pregnancy?
YES CONTINUE TO H17
NO SKIP TO H28
DK SKIP TO H28
RF SKIP TO H28
H17. What did you take? / Did you take anything else? [IF CAN’T RECALL, READ FROM DRUG LIST]:
Amiodarone
Atenolol
Betapace
Cardizem
Cartia XT
Carvedilol
Cordarone
Diltiazem HCL
Labetolol
Lopressor
Metoprolol
Pacerone
Propafenone HCL
Propranolol
Rythmol
Sotalol
Toprol XL
Verapamil
OTHER (SPECIFY)
DK SKIP TO H28
RF SKIP TO H28
H18. Did you use [DRUG, ANSWER H17] for the entire time from the month before your pregnancy through the third month of pregnancy, that is from [B1] to [P4 (-1)]?
YES SKIP TO H22
NO CONTINUE TO H19
DK CONTINUE TO H19
RF CONTINUE TO H19
H19. When did you start using [DRUG, ANSWER H17] for arrhythmias for the first time during this period? [CAN USE DK OR RF FOR MM OR DD OR YY]
MM/DD/YYYY or
MONTH OF PREGNANCY(B1, P1, P2, P3)
DK
RF
H20. When did you use [DRUG, ANSWER H17] for arrhythmias for the last time during this time period? [CAN USE DK OR RF FOR MM OR DD OR YY]
MM/DD/YYYY or
MONTH OF PREGNANCY(B1, P1, P2, P3) IF VALID RESPONSE TO H19 AND H20, SKIP H21
DK
RF
OR
H21. How long did you take it?
AMOUNT:__________
Days
Weeks
Months
DK
RF
H22. How often did you use [DRUG, ANSWER H17] 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.
AMOUNT:__________ Per Day/Per Week/Per Month/Per Time Period/DK/RF
H23. Did you take the same dose of medicine each time you took it throughout [B1] to [P4(-1)]? That is, for example, the same number of milligrams of medicine in each dose.
YES CONTINUE TO H24
NO SKIP TO H25a
DK CONTINUE TO H24
RF CONTINUE TO H24
H24. What dose of [DRUG, ANSWER H17] did you take each time you took it?
AMOUNT:__________ SKIP TO H28
UNITS:__________
DK SKIP TO H28
RF SKIP TO H28
H25a. How many different dosage amounts do you remember taking? [If mom knows she took more than one dosage, but can't remember how many, select 1 for the number of dosages and report the dosage info she does remember. You may put additional details in a comment field.]
AMOUNT:__________ RF
H25b. What dose of [DRUG, ANSWER H17] did you take the [1st, 2nd, etc.] time?
AMOUNT:__________
DK SKIP TO H26
RF SKIP TO H26
UNITS:__________ DK RF
H26. When did you begin taking that dose?
MM/DD/YYYY or
MONTH OF PREGNANCY(B1, P1, P2, P3)
DK
RF
H27. When did you stop taking that dose?
MM/DD/YYYY or
MONTH OF PREGNANCY(B1, P1, P2, P3) IF VALID RESPONSE TO H26 and H27, SKIP H27a
DK
RF
OR
H27a. How long did you take it?
AMOUNT:__________ DK RF
Days
Weeks
Months
ANSWER H25b-H27a FOR ALL DOSES REPORTED IN H25a.
H28. Were you ever in your life told by a doctor or other health care provider that you had high blood pressure?
YES CONTINUE TO H29
NO SKIP TO NEXT SECTION
DK SKIP TO NEXT SECTION
RF SKIP TO NEXT SECTION
H29. Did you have high blood pressure [when you were pregnant with [NOIB]; TAB: this pregnancy]?
a. YES
b. NO
c. DK
d. RF
H30. 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.
Pregnancy related
Chronic hypertension
Both
DK
RF
IF H30=a, d, or e THEN SKIP TO H34 (ONLY ASK H31 if H30=b, c)
H31. Either before or during your pregnancy, did you speak with a healthcare provider about your treatment options during pregnancy?
YES GO TO H32
NO SKIP TO H34
DK SKIP TO H34
RF SKIP TO H34
H32. Did you discuss these options before your pregnancy began?
YES SKIP TO H34
NO GO TO H33
DK SKIP TO H34
RF SKIP TO H34
H33. How far along were you in your pregnancy when you discussed treatment options with your provider?
AMOUNT:__________ Days/Weeks/Months/Trimesters/DK/RF
H34. Did you take any medications or remedies for high blood pressure during the month before your pregnancy through the third month of pregnancy?
YES CONTINUE TO H35
NO SKIP TO NEXT SECTION
DK SKIP TO NEXT SECTION
RF SKIP TO NEXT SECTION
H35. What did you take? / Did you take anything else? IF CAN’T RECALL, READ FROM DRUG LIST:
Accupril
Adalat
Altace
Amlodipine
Atenolol
Avapro
Benazepril HCL
Benicar
Calan
Capoten
Cardizem
Covera -HS
Cozaar
Diltiazem HCL
Diovan
Enalapril Maleate
Hydralazine
Hydrochlorothiazide
Inderal
Irbesartan
Labetalol
Lisinopril
Losartan Potassium
Lotensin
Methyldopa
Metoprolol
Microzide
Nifedipine
Normodyne
Norvasc
Olmesartan Medoxomil
Prinivil
Procardia
Propranolol
Quinapril HCL
Ramipril
Tenormin
Tiazac
Trandate
Valsartan
Vasotec
Verapamil
Verelan
Zestril
OTHER (SPECIFY):__________
DK SKIP TO NEXT SECTION
RF SKIP TO NEXT SECTION
H36. Did you use [DRUG, ANSWER H35] for the entire time from the month before your pregnancy through your third month of pregnancy, that is from [B1] to [P4 (-1)]?
YES SKIP TO H39
NO CONTINUE TO H36
DK CONTINUE TO H36
RF CONTINUE TO H36
H37. When did you start using [DRUG, ANSWER H35] for high blood pressure for the first time during this period? [CAN USE DK OR RF FOR MM OR DD OR YY]
MM/DD/YYYY or
MONTH OF PREGNANCY(B1, P1, P2, P3)
DK
RF
H38. When did you us [DRUG, ANSWER H34] for the last time during this time period? [CAN USE DK OR RF FOR MM OR DD OR YY]
MM/DD/YYYY or
MONTH OF PREGNANCY(B1, P1, P2, P3) IF VALID RESPONSE TO H37 and H38, SKIP H39
DK
RF
OR
H39. How long did you take it?
AMOUNT:__________ DK RF
Days
Weeks
Months
H40. How often did you use [DRUG, ANSWER H35] 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.
AMOUNT:__________ Per Day/Per Week/Per Month/Per Time Period/DK/RF
H41. Did you take the same dose of medicine each time you took it throughout [B1] to [P4 (-1)]? That is, for example, the same number of milligrams of medicine in each dose.
YES CONTINUE TO H42
NO SKIP TO H43a
DK CONTINUE TO H42
RF CONTINUE TO H42
H42. What dose of [DRUG, ANSWER H34] did you take each time you took it?
AMOUNT:__________
DK SKIP TO NEXT SECTION
RF SKIP TO NEXT SECTION
UNITS:__________ DK RF
H43a. How many different dosage amounts do you remember taking? [If mom knows she took more than one dosage, but can't remember how many, select 1 for the number of dosages and report the dosage info she does remember. You may put additional details in a comment field.]
AMOUNT:__________ RF
H43b. What dose of [DRUG, ANSWER H34] did you take the [1st, 2nd, etc.] time?
AMOUNT:__________
DK SKIP TO H44
RF SKIP TO H44
UNITS:__________ DK RF
H44. When did you begin taking that dose?
MM/DD/YYYY or
MONTH OF PREGNANCY(B1, P1, P2, P3)
DK
RF
H45. When did you stop taking that dose?
MM/DD/YYYY or
MONTH OF PREGNANCY(B1, P1, P2, P3) IF VALID RESPONSE TO H43 and H44, SKIP H44a
DK
RF
OR
H45a. How long did you take it?
AMOUNT:__________ DK RF
Days
Weeks
Months
I1. Have you ever been diagnosed with thyroid disease, not including thyroid cancer, which we have already talked about?
YES CONTINUE TO I2
NO SKIP TO NEXT SECTION
DK SKIP TO NEXT SECTION
RF SKIP TO NEXT SECTION
I2. What type of thyroid disease were you diagnosed with originally? Was it… [READ ALL; ASK ALL OPTIONS AND ALLOW MULTIPLE TYPES]
Hypothyroidism, also called having an “underactive” thyroid
Hashimoto’s Disease or autoimmune thyroiditis
Hyperthyroidism, also called having an “overactive” thyroid
Graves’ Disease
OTHER, SPECIFY:_______________________________________
NOTE: THYROID CANCER COVERED EARLIER
DK SKIP TO NEXT SECTION
RF SKIP TO NEXT SECTION
I3. When was [THYROID DISEASE, ANSWER I2] first diagnosed relative to [your pregnancy with [NOIB]; TAB: the pregnancy that ended on [DOIB/DOPT]]? [READ LIST]
More than 2 years before
In the 2 years before
During the first trimester
After the first trimester but still during pregnancy
After the pregnancy
DK
RF
I4. [IF REPORTING HYPERTHYROIDISM/OVERACTIVE THYROID/GRAVES’ DISEASE CONTINUE, OTHERWISE, SKIP TO I9]: Have you had surgery to remove all or part of your thyroid gland?
YES CONTINUE TO I5
NO SKIP TO I7
DK SKIP TO I7
RF SKIP TO I7
I5. Did you have all or part of your thyroid gland removed?
All
Part
DK
RF
I6. When did you have this surgery?
MM/DD/YYYY OR
AGE:__________ or
Time period ago:__________
Years
Months
Weeks
Days
DK
RF
I7. Did you have treatment with radioactive iodine?
YES CONTINUE TO I8
NO, DK, RF SKIPSKIP TO I9
I8. When did you have this procedure?
MM/DD/YYYY or
AGE:__________ or
Time period ago:__________ DK RF
Years
Months
Weeks
Days
IF I3=c, d, e, f, OR g THEN SKIP TO I12 (ONLY ASK I9 IF I3=a or b)
I9. Either before or during your pregnancy, did you speak with a healthcare provider about your treatment options during pregnancy?
YES GO TO I10
NO SKIP TO I12
DK SKIP TO I12
RF SKIP TO I12
I10. Did you discuss these options before your pregnancy began?
YES SKIP TO I12
NO GO TO I11
DK SKIP TO I12
RF SKIP TO I12
I11. How far along were you in your pregnancy when you discussed treatment options with your provider?
AMOUNT:__________ DK RF
UNITS:
Days
Weeks
Months
Trimesters
I12. Did you take any medications or remedies for [THYROID DISEASE, ANSWER I2] during the month before your pregnancy through the third month of pregnancy, that is from [B1] to [P4(-1)]?
YES CONTINUE TO I13
NO SKIP TO NEXT SECTION
DK SKIP TO NEXT SECTION
RF SKIP TO NEXT SECTION
I13. What did you take? / Did you take anything else?
IF CAN’T RECALL, READ FROM LIST:
Armour Thyroid
Carbimazole
Cytomel
Levothroid
Levothyroxine Sodium
Levoxyl
Liothyronine
Liotrix
Methimazole
Nature-throid
Propylthiouracil (PTU)
Synthroid
Thiamazole
Thyrolar
Tirosint
Unithroid
Westhroid
OTHER (SPECIFY):__________
DK SKIP TO NEXT SECTION
RF SKIP TO NEXT SECTION
I14. Did you use [MEDICINE, ANSWER I13] for the entire time from the month before your pregnancy through the third month of your pregnancy?
YES SKIP TO I18
NO CONTINUE TO I15
DK CONTINUE TO I15
RF CONTINUE TO I15
I15. When did you start using [MEDICINE, ANSWER I13] for [THYROID DISEASE, ANSWER I2] for the first time during this period? [CAN USE DK OR RF FOR MM OR DD OR YY]
MM/DD/YYYY or
MONTH OF PREGNANCY(B1, P1, P2, P3)
DK
RF
I16. When did you use [MEDICINE, ANSWER I13] for [THYROID DISEASE, ANSWER I2] for the last time during this time period? [CAN USE DK OR RF FOR MM OR DD OR YY]
MM/DD/YYYY OR
MONTH OF PREGNANCY(B1, P1, P2, P3) IF VALID RESPONSE TO I15 AND I16, SKIP I17
DK
RF
OR
I17. How long did you take it?
AMOUNT:__________
Days
Weeks
Months
DK
RF
I18. How often did you use [MEDICINE, ANSWER I13] 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.
AMOUNT:__________ Per Day/Per Week/Per Month/Per Time Period/DK/RF
I19. Did you take the same dose of medicine each time you took it throughout [B1] to [P4 (-1)]? That is, for example, the same number of milligrams of medicine in each dose.
YES CONTINUE TO I20
NO SKIP TO I21a
DK CONTINUE TO I20
RF CONTINUE TO I20
I20. What dose of [MEDICINE, ANSWER I13] did you take each time you took it?
AMOUNT:__________ DK or RF SKIP TO NEXT SECTION
UNITS:__________
I21a. How many different dosage amounts do you remember taking? [If mom knows she took more than one dosage, but can't remember how many, select 1 for the number of dosages and report the dosage info she does remember. You may put additional details in a comment field]
AMOUNT:__________ RF
I21b. What dose of [MEDICINE, ANSWER I13] did you take the [1st, 2nd, etc.] time?
AMOUNT:__________
DK SKIP TO I22
RF SKIP TO I22
UNITS:__________ DK RF
I22. When did you begin taking that dose?
MM/DD/YYYY OR
MONTH OF PREGNANCY(B1, P1, P2, P3)
DK
RF
I23. When did you stop taking that dose?
MM/DD/YYYY or
MONTH OF PREGNANCY(B1, P1, P2, P3) IF VALID RESPONSE TO I22 and I23, SKIP I23a
DK
RF
OR
I23a. How long did you take it?
AMOUNT:__________ DK RF
Days
Weeks
Months
J1. Have you ever been diagnosed with asthma or reactive airway disease?
YES CONTINUE TO J2
NO SKIP TO NEXT SECTION
DK SKIP TO NEXT SECTION
RF SKIP TO NEXT SECTION
J2. When was your asthma or reactive airway disease first diagnosed, relative to [your pregnancy with [NOIB]; TAB: the pregnancy that ended on [DOIB/DOPT]]? [READ LIST]
More than 2 years before
In the 2 years before
During the first trimester
After the first trimester but still during pregnancy
After the pregnancy
RF
DK
J3. Did you have any asthma symptoms in the month before your pregnancy through your third month of pregnancy, that is from [B1] to [P4 (-1)]? These symptoms include shortness of breath, chest tightness or pain, coughing or wheezing, or low peak expiratory flow (PEF) readings.
YES CONTINUE TO J4
NO SKIP TO J6
DK SKIP TO J6
RF SKIP TO J6
J4. During that 4 month period did you miss any work, school, or normal daily activities because of your asthma?
YES
NO
DK
RF
J5. During that 4 month period how often did you wake up at night because of your asthma? [READ OPTIONS]
Not at all
Less than once per month
Once or twice per month
More than twice per month
DK
RF
IF J2=c, d, e, f, g THEN SKIP TO J9 (ONLY ASK J6 IF J2=a, b).
J6. Either before or during your pregnancy, did you speak with a healthcare provider about your treatment options during pregnancy?
YES GO TO J7
NO SKIP TO J9
DK SKIP TO J9
RF SKIP TO J9
J7. Did you discuss these options before your pregnancy began?
YES SKIP TO J9
NO GO TO J8
DK SKIP TO J9
RF SKIP TO J9
J8. How far along were you in your pregnancy when you discussed treatment options with your provider?
AMOUNT:__________ DK RF
UNITS:
Days
Weeks
Months
Trimesters
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…
J9. 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?
YES CONTINUE TO J10a
NO SKIP TO J45
DK SKIP TO J45
RF SKIP TO J45
J10a. First, I will ask about use of nasal sprays, then inhalers, and then pills used to control your asthma. Did you use any nasal sprays?
YES CONTINUE TO J10b
NO SKIP TO J22a
DK SKIP TO J22a
RF SKIP TO J22a
J10b. What did you take? / Did you take anything else? [IF CAN’T RECALL, READ FROM DRUG LIST]
NASAL SPRAYS
Flonase
Flunisolide
Fluticasone Nasal Spray
Nasonex Nasal Spray
Omnaris Nasal Spray
Qnasl Nasal Aerosol
Rhinocort
OTHER (SPECIFY):__________
DK SKIP TO J22a
RF SKIP TO J22a
ASK J12-J21, AS APPROPRIATE FOR EACH DRUG USED IN J10b: [Note: Question J11 Removed]
J12. Did you use [NASAL SPRAY, ANSWER J10b] for the entire time from the month before your pregnancy through your third month of pregnancy?
YES SKIP TO J16
NO CONTINUE TO J13
DK CONTINUE TO J13
RF CONTINUE TO J13
J13. When did you start using [NASAL SPRAY, ANSWER J10b] for asthma or reactive airway disease for the first time during this period? [CAN USE DK OR RF FOR MM OR DD OR YY]
MM/DD/YYYY OR
MONTH OF PREGNANCY(B1, P1, P2, P3)
DK
RF
J14. When did you use [NASAL SPRAY, ANSWER J10b] for the last time during this time period? [CAN USE DK OR RF FOR MM OR DD OR YY]
MM/DD/YYYY or
MONTH OF PREGNANCY(B1, P1, P2, P3) IF VALID RESPONSE TO J13 AND J14, SKIP J15
DK
RF
OR
J15. How long did you take it?
AMOUNT:__________ DK RF
Days
Weeks
Months
J16. How often did you use [NASAL SPRAY, ANSWER J10b] 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.
AMOUNT:__________ Per Day/Per Week/Per Month/Per Time Period/DK/RF
J17 Did you take the same dose of medicine each time you took it throughout [B1] to [P4(-1)]? That is, for example, the same number of milligrams of medicine in each dose.
YES J18
NO SKIP TO J19a
DK CONTINUE TO J18
RF CONTINUE TO J18
J18. What dose of [NASAL SPRAY, ANSWER J10b] did you take each time you took it?
AMOUNT:__________ SKIP TO J22a
UNITS:__________
DK SKIP TO J22a
RF SKIP TO J22a
J19a. How many different dosage amounts do you remember taking? [If mom knows she took more than one dosage, but can't remember how many, select 1 for the number of dosages and report the dosage info she does remember. You may put additional details in a comment field.]
AMOUNT:__________ RF
J19b. What dose of [NASAL SPRAY, ANSWER J10b did you take the [1st, 2nd, etc.] time?
AMOUNT:__________
DK SKIP TO J20
RF SKIP TO J20
UNITS:__________ DK RF
J20. When did you begin taking that dose?
MM/DD/YYYY or
MONTH OF PREGNANCY(B1, P1, P2, P3)
DK
RF
J21. When did you stop taking that dose?
MM/DD/YYYY or
MONTH OF PREGNANCY(B1, P1, P2, P3) IF VALID RESPONSE TO J20 and J21, SKIP J21a
DK
RF
OR
J21a. How long did you take it?
AMOUNT:__________ DK RF
Days
Weeks
Months
J22a. Did you use any oral inhalants, that is medicine you sprayed in your mouth? As a reminder, here I’m asking about long-term medications to control your asthma; I will ask about use of rescue inhalers later.
YES CONTINUE TO J22b
NO SKIP TO J34a
DK SKIP TO J34a
RF SKIP TO J34a
J22b. What did you take? / Did you take anything else? IF CAN’T RECALL, READ FROM DRUG LIST:
ORAL INHALANTS
Advair
Aerobid
Aerospan Hfa
Alvesco Inhaler
Asmanex Twisthaler
Budesonide Inhalation Suspension
Dulera
Flovent
Foradil
Formoterol Fumarate
Perforomist
Pulmicort
Qvar HFA Inhaler
Salmeterol Xinafoate
Serevent
Symbicort
OTHER (SPECIFY):__________
DK SKIP TO J34a
RF SKIP TO J34a
ASK J23-J32, AS APPROPRIATE FOR EACH DRUG USED IN J22b:
J23. Did you use [ORAL INHALANT, ANSWER J22b] for the entire time from the month before your pregnancy through your third month of pregnancy?
YES SKIP TO J27
NO CONTINUE TO J24
DK CONTINUE TO J24
RF CONTINUE TO J24
J24. When did you start using [ORAL INHALANT, ANSWER J22b] for asthma or reactive airway disease for the first time during this period? [CAN USE DK OR RF FOR MM OR DD OR YY]
MM/DD/YYYY OR
MONTH OF PREGNANCY(B1, P1, P2, P3)
DK
RF
J25. When did you use [ORAL INHALANT, ANSWER J22b] for the last time during this time period? [CAN USE DK OR RF FOR MM OR DD OR YY]
MM/DD/YYYY OR
MONTH OF PREGNANCY(B1, P1, P2, P3) IF VALID RESPONSE TO J24 and J25, SKIP J26
DK
RF
OR
J26. How long did you take it?
AMOUNT:__________ DK RF
Days
Weeks
Months
J27. How often did you use [ORAL INHALANT, ANSWER J22b] 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.
AMOUNT:__________ Per Day/Per Week/Per Month/Per Time Period/DK/RF
J28 Did you take the same dose of medicine each time you took it throughout [B1] to [P4(-1)]? That is, for example, the same number of milligrams of medicine in each dose.
YES J29
NO SKIP TO J30a
DK CONTINUE TO J29
RF CONTINUE TO J29
J29. What dose of [ORAL INHALANT, ANSWER J22b] did you take each time you took it?
AMOUNT:___________ SKIP TO J34a
UNITS:__________
DK SKIP TO J34a
RF SKIP TO J34a
J30a. How many different dosage amounts do you remember taking?
AMOUNT:__________ RF
J30b. What dose of [ORAL INHALANT, ANSWER J22b] did you take the [1st, 2nd, etc.] time?
AMOUNT:__________
DK SKIP TO J31
RF SKIP TO J31
UNITS:__________ DK RF
J31. When did you begin taking that dose?
MM/DD/YYYY or
MONTH OF PREGNANCY(B1, P1, P2, P3)
DK
RF
J32. When did you stop taking that dose?
MM/DD/YYYY or
MONTH OF PREGNANCY(B1, P1, P2, P3) IF VALID RESPONSE TO J31 and J32, SKIP J32a
DK
RF
OR
J32a. How long did you take it?
AMOUNT:__________ DK RF
Days
Weeks
Months
J33 [QUESTION NUMBER NOT USED]
J34a. Did you use any pills you took by mouth?
YES CONTINUE TO J34b
NO SKIP TO J45
DK SKIP TO J45
RF SKIP TO J45
J34b. What did you take? / Did you take anything else? IF CAN’T RECALL, READ FROM DRUG LIST:
ORAL TABLETS/CAPS
Accolate
Montelukast Sodium
Singulair
Zafirlukast
Zileuton
Zyflo
OTHER (SPECIFY):__________
DK SKIP TO J45
RF SKIP TO J45
ASK J35-J44, AS APPROPRIATE FOR EACH DRUG USED IN J34b:
J35. Did you use [ORAL TABLET/CAP, ANSWER J34b] for the entire time from the month before your pregnancy through your third month of pregnancy?
YES SKIP TO J39
NO CONTINUE TO J36
DK CONTINUE TO J36
RF CONTINUE TO J36
J36. When did you start using [ORAL TABLET/CAP, ANSWER J34b] for asthma or reactive airway disease for the first time during this period? [CAN USE DK OR RF FOR MM OR DD OR YY]
MM/DD/YYYY OR
MONTH OF PREGNANCY(B1, P1, P2, P3)
DK
RF
J37. When did you use [ORAL TABLET/CAP, ANSWER J34b] for the last time during this time period? [CAN USE DK OR RF FOR MM OR DD OR YY]
MM/DD/YYYY OR
MONTH OF PREGNANCY(B1, P1, P2, P3) IF VALID RESPONSE TO J36 and J37, SKIP J38
DK
RF
OR
J38. How long did you take it?
AMOUNT:__________ DK RF
Days/Weeks/Months
J39. How often did you use [ORAL TABLET/CAP, ANSWER J34b] 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.
AMOUNT:__________ Per Day/Per Week/Per Month/Per Time Period/DK/RF
J40. Did you take the same dose of medicine each time you took it throughout [B1] to [P4 (-1)]? That is, for example, the same number of milligrams of medicine in each dose.
YES J41
NO SKIP TO J42a
DK CONTINUE TO J41
RF CONTINUE TO J41
J41. What dose of [ORAL TABLET/CAP, ANSWER J34b] did you take each time you took it?
AMOUNT:_____ SKIP TO J45
UNITS:__________
DK SKIP TO J45
RF SKIP TO J45
J42a. How many different dosage amounts do you remember taking? [If mom knows she took more than one dosage, but can't remember how many, select 1 for the number of dosages and report the dosage info she does remember. You may put additional details in a comment field.]
AMOUNT:__________ RF
J42b. What dose of [ORAL TABLET/CAP, ANSWER J34b] did you take the [1st, 2nd, etc.] time?
AMOUNT:__________
DK SKIP TO J43
RF SKIP TO J43
UNITS:__________ DK RF
J43. When did you begin taking that dose?
MM/DD/YYYY OR
MONTH OF PREGNANCY(B1, P1, P2, P3)
DK
RF
J44. When did you stop taking that dose?
MM/DD/YYYY OR
MONTH OF PREGNANCY(B1, P1, P2, P3) IF VALID RESPONSE TO J43 and J44, SKIP J44a
DK
RF
OR
J44a. How long did you take it?
AMOUNT:__________ DK RF
Days
Weeks
Months
J45. 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?
YES CONTINUE TO J46
NO SKIP TO NEXT SECTION
DK SKIP TO NEXT SECTION
RF SKIP TO NEXT SECTION
J46. What did you take? / Did you take anything else? [IF CAN’T RECALL, READ FROM DRUG LIST: AFTER READING LIST, ASK "Other steroids, such as prednisone or methylprednisone ". RECORD RESPONSE IN "OTHER" BOX.]
Albuterol SKIP TO J48
Asthmanefrin SKIP TO J48
Atrovent HFA SKIP TO J48
Ipratropium Bromide SKIP TO J48
Levalbuterol Tartrate SKIP TO J48
Maxair SKIP TO J48
Pirbuterol Acetate SKIP TO J48
ProAir HFA Inhaler SKIP TO J48
Ventolin HFA SKIP TO J48
Xopenex HFA SKIP TO J48
OTHER (SPECIFY):__________ CONTINUE TO J47
DK SKIP TO K1
RF SKIP TO K1
J47. Did you get [MEDICINE, J46 OTHER SPECIFIED] from a pill that you swallowed or from a shot?
Pill
Shot (injection)
Inhaler
DK
RF
ASK J48-J50, AS APPROPRIATE FOR EACH DRUG USED IN J46:
J48. How often did you use [MEDICINE, ANSWER J46] 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.
AMOUNT:__________ Per Day/Per Week/Per Month/Per Time Period/DK/RF
J49. Did you use [MEDICINE, ANSWER J46] for the entire time from a month before your pregnancy through the third month of your pregnancy? [IF TIME PERIOD IS "PER PERIOD", DO NOT READ THIS QUESTIONS AND CHOOSE "NA"]
YES SKIP TO NEXT SECTION
NO CONTINUE TO J50a
DK CONTINUE TO J50a
RF CONTINUE TO J50a
NA SKIP TO NEXT SECTION WITHOUT READING THIS QUESTION
J50a. How often did you use [MEDICINE, ANSWER J46] during the month before your pregnancy, which was [B1] to [P1 (-1)]?
AMOUNT:__________ Per Day/Per Week/Per Month/Per Time Period/Per Year/DK/RF
DID NOT TAKE
J50b. How often did you use [MEDICINE, ANSWER J46] during the first month of your pregnancy, which was [P1] to [P2 (-1)]?
AMOUNT:__________ Per Day/Per Week/Per Month/ Per Time Period/Per Year/DK/RF
DID NOT TAKE
J50c. How often did you use [MEDICINE, ANSWER J46] during the second month of your pregnancy, which was [P2] to [P3 (-1)]?
AMOUNT:__________ Per Day/Per Week/Per Month/ Per Time Period/Per Year/DK/RF
DID NOT TAKE
J50d. How often did you use [MEDICINE, ANSWER J46] during the third month of your pregnancy, which was [P3] to [P4 (-1)]?
K1. Were you ever told by a doctor or other health care provider that you had epilepsy? IF MOM REPORTS SHE HAD A SEIZURE ONCE, REPEAT THE QUESTION, EMPHASIZING, "…ever told by a doctor or health care provider that you had epilepsy"
YES CONTINUE TO K2
NO SKIP TO NEXT SECTION
DK SKIP TO NEXT SECTION
RF SKIP TO NEXT SECTION
K2. What type of epilepsy do you have? IF CAN’T RECALL, READ FROM LIST:
Temporal Lobe Epilepsy
Frontal Lobe Epilepsy
Reflex Epilepsy
Childhood Absence Epilepsy
Juvenile Absence Epilepsy
Generalized epilepsy
Focal epilepsy
Generalized and focal epilepsy
OTHER, SPECIFY:____________
DK
RF
K3. When were you first diagnosed with epilepsy in relation to [your pregnancy with [[NOIB]; TAB: the pregnancy that ended on [DOIB/DOPT]]? [READ LIST]
More than 2 years before
In the 2 years before
During the first trimester
After the first trimester but still during pregnancy
After the pregnancy
RF
DK
IF K3=c, d, e, f, g THEN SKIP TO K7 (ONLY ASK K4 if K3=a, b)
K4. Either before or during your pregnancy, did you speak with a healthcare provider about your treatment options during pregnancy?
YES GO TO K5
NO SKIP TO K7
DK SKIP TO K7
RF SKIP TO K7
K5. Did you discuss these options before your pregnancy began?
YES SKIP TO K7
NO GO TO K6
DK SKIP TO K7
RF SKIP TO K7
K6. How far along were you in your pregnancy when you discussed treatment options with your provider?
AMOUNT:__________ DK RF
Days
Weeks
Months
Trimesters
K7. Did you take any medications or remedies for epilepsy during the month before your pregnancy through the third month of pregnancy?
YES CONTINUE TO K8
NO SKIP TO K19
DK SKIP TO K19
RF SKIP TO K19
K8. What did you take? / Did you take anything else? [IF CAN’T RECALL, READ FROM DRUG LIST]:
Carbamazepine
Carbatrol
Clonazepam
Depacon
Depakene Capsules
Depakote
Dilantin
Epitol
Equetro
Felbatol
Phenobarbital
Keppra
Klonopin
Phenytoin
Lamictal
Stavzor
Tegretol
Lamotrigine
Topamax
Topiramate
Trileptal
Valproic Acid
OTHER (SPECIFY)
DK or RF SKIP TO K19
K9. Did you use [MEDICINE, ANSWER K8] for the entire time from the month before your pregnancy through your third month of pregnancy, that is from [B1] to [P4 (-1)]?
YES SKIP TO K13
NO CONTINUE TO K10
DK CONTINUE TO K10
RF CONTINUE TO K10
K10. When did you start using [MEDICINE, ANSWER K8] for epilepsy for the first time during this period? [CAN USE DK OR RF FOR MM OR DD OR YY]
MM/DD/YYYY OR
MONTH OF PREGNANCY(B1, P1, P2, P3)
DK
RF
K11. When did you use [MEDICINE, ANSWER K8] for the last time during this time period? [CAN USE DK OR RF FOR MM OR DD OR YY]
MM/DD/YYYY OR
MONTH OF PREGNANCY(B1, P1, P2, P3) IF VALID RESPONSE TO K10 and K11, SKIP K12
DK
RF
OR
K12. How long did you take it?
AMOUNT:________________ DK RF
Days
Weeks
Months
K13. How often did you use [MEDICINE, ANSWER K8] 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.
AMOUNT:__________ Per Day/Per Week/Per Month/Per Time Period/DK/RF
K14. Did you take the same dose of medicine each time you took it throughout [B1] to [P4 1)]? That is, for example, the same number of milligrams of medicine in each dose.
YES CONTINUE TO K15
NO SKIP TO K16a
DK CONTINUE TO K15
RF CONTINUE TO K15
K15. What dose of [MEDICINE, ANSWER K8] did you take each time you took it?
AMOUNT:__________ SKIP TO K19
UNITS:____________
DK SKIP TO K19
RF SKIP TO K19
K16a. How many different dosage amounts do you remember taking? [If mom knows she took more than one dosage, but can't remember how many, select 1 for the number of dosages and report the dosage info she does remember. You may put additional details in a comment field.]
AMOUNT:__________ RF
K16b. What dose of [MEDICINE, ANSWER K8] did you take the [1st, 2nd, etc.] time?
AMOUNT:__________
DK SKIP TO K17
RF SKIP TO K17
UNITS:__________ DK RF
K17. When did you begin taking that dose?
MM/DD/YYYY or
MONTH OF PREGNANCY(B1, P1, P2, P3)
DK
RF
K18. When did you stop taking that dose?
MM/DD/YYYY or
MONTH OF PREGNANCY(B1, P1, P2, P3) IF VALID RESPONSE TO K17 and K18, SKIP K18a
DK
RF
OR
K18a. How long did you take it?
AMOUNT:________________ DK RF
Days
Weeks
Months
K19. Did you have any seizures in the month before your pregnancy through the third month of pregnancy?
YES CONTINUE TO K20
NO SKIP TO NEXT SECTION
DK SKIP TO NEXT SECTION
RF SKIP TO NEXT SECTION
K20. How many seizures did you have altogether during that time?
AMOUNT:__________ DK RF
L1. Have you ever had a migraine headache, also sometimes called a sick headache?
YES CONTINUE TO L2
NO SKIP TO NEXT SECTION
DK SKIP TO NEXT SECTION
RF SKIP TO NEXT SECTION
L2. How old were you when you had the first migraine headache?
AGE:___________ DK RF
L3. Did you have any migraine headaches in the month before your pregnancy through the third month of pregnancy, that is from [B1] to [P4 (-1)]?
YES CONTINUE TO L4
NO SKIP TO L5
DK SKIP TO L5
RF SKIP TO L5
L4. How many migraines did you have altogether during that time?
How many?:__________ DK RF
Frequency – UNIT:__________
Total 4 month period
Per day
Per week
Per month
DK
RF
Other, Specify:________
Now I am going to ask about maintenance medications and remedies you may use for your migraines. Please include medications that you may use to keep from having or to prevent migraines and medications that you may use to treat migraine pain when it happens. Please include over-the-counter medications and prescription medications.
L5. Did you take any medications or remedies for migraines during the month before your pregnancy through the third month of pregnancy?
YES CONTINUE TO L6
NO SKIP TO NEXT SECTION
DK SKIP TO NEXT SECTION
RF SKIP TO NEXT SECTION
L6. What did you take? / Did you take anything else? [IF CAN’T RECALL: Was this a medication you used to prevent a migraine from starting or to treat pain from a migraine that already started? IF IT WAS PAIN MEDICATION: Was this over-the-counter or prescription? THEN READ FROM THE APPROPRIATE DRUG LIST:]
PREVENTION MEDICATIONS:
Advil
Aleve
Amitriptyline
Aspirin
Atenolol
Botox
Calan
Carbamazepine
Carbatrol
Cyproheptadine HCL
Depacon
Depakene
Depakote
Diltiazem
Divalproex Sodium
Doxepin
Effexor
Epitol
Equetro
Excedrin Extra Strength Caplets/Tablets/Geltabs
Gabapentin
Ibuprofen
Inderal
Innopran XL
Lamictal
Lamotrigine
Lisinopril
Metoprolol
Motrin
Motrin IB
Nadolol
Naproxen Sodium
Neurontin
Nifedipine
Nimodipine
Nortriptyline
Pamelor
Propranolol
Protriptyline HCL
Tegretol
Timolol
Topamax
Topiramate
Valproate Sodium
Valproic Acid
Venlafaxine
Verapamil
Verelan
Vivactil
Zestril
OVER-THE-COUNTER PAIN MEDICATIONS:
Acetaminophen
Advil
Aleve
Aspirin
Excedrin Migraine
Ibuprofen
Motrin
Naproxen Sodium
Tylenol
PRESCRIPTION PAIN MEDICATIONS:
aaa. Acetaminophen with Codeine
bbb. Almotriptan Maleate
ccc. Amerge
ddd. Axert
eee. Cafergot
fff. Dihydroergotamine
ggg. Eletriptan Hydrobromide
hhh. Ergotamine
iii. Fioricet
jjj. Frova
kkk. Frovatriptan Succinate
lll. Imitrex
mmm. Indomethacin
nnn. Maxalt
ooo. Migergot Suppositories
ppp. Migranal
qqq. Naproxen Sodium / Sumatriptan Succinate
rrr. Naratriptan
sss. Relpax
ttt. Rizatriptan
uuu. Sumatriptan Succinate
vvv. Treximet
www. Tylenol with Codeine
xxx. Zolmitriptan
yyy. Zomig
zzz. OTHER (SPECIFY):__________
aaaa. DK SKIP TO NEXT SECTION
bbbb. RF SKIP TO NEXT SECTION
ASK L7-L16, AS APPROPRIATE FOR EACH DRUG USED IN L6:
L7. Did you use [MEDICINE, ANSWER L6] for the entire time from the month before your pregnancy through your third month of pregnancy?
YES SKIP TO L11
NO CONTINUE TO L8
DK CONTINUE TO L8
RF CONTINUE TO L8
L8. When did you start using [MEDICINE, ANSWER L6] for migraines for the first time during this period? [CAN USE DK OR RF FOR MM OR DD OR YY]
MM/DD/YYYY or
MONTH OF PREGNANCY (B1, P1, P2, P3)
DK
RF
L9. When did you use [MEDICINE, ANSWER L6] for the last time during this time period? [CAN USE DK OR RF FOR MM OR DD OR YY]
MM/DD/YYYY or
MONTH OF PREGNANCY (B1, P1, P2, P3) IF VALID RESPONSE TO L8 and L9, SKIP L10
DK
RF
OR
L10. How long did you take it?
AMOUNT:________________ DK RF
Days
Weeks
Months
L11. How often did you use [MEDICINE, ANSWER L6] 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.
AMOUNT:__________ Per Day/Per Week/Per Month/Per Time Period/DK/RF
L12. Did you take the same dose of medicine each time you took it throughout [B1] to [P4 (-1)]? That is, for example, the same number of milligrams of medicine in each dose.
YES CONTINUE TO L13
NO SKIP TO L14a
DK CONTINUE TO L13
RF CONTINUE TO L13
L13. What dose of [MEDICINE, ANSWER L6] did you take each time you took it?
AMOUNT:__________ SKIP TO NEXT SECTION
UNITS:__________
DK SKIP TO NEXT SECTION
RF SKIP TO NEXT SECTION
L14a. How many different dosage amounts do you remember taking? [If mom knows she took more than one dosage, but can't remember how many, select 1 for the number of dosages and report the dosage info she does remember. You may put additional details in a comment field.]
AMOUNT:__________ RF
L14b. What dose of [MEDICINE, ANSWER L6] did you take the [1st, 2nd, etc.] time?
AMOUNT:__________
DK SKIP TO L15
RF SKIP TO L15
UNITS:__________ DK RF
L15. When did you begin taking that dose?
MM/DD/YYYY or
MONTH OF PREGNANCY(B1, P1, P2, P3)
DK
RF
L16. When did you stop taking that dose?
MM/DD/YYYY or
MONTH OF PREGNANCY(B1, P1, P2, P3) IF VALID RESPONSE TO L15 and L16, SKIP L16a
DK
RF
OR
L16a. How long did you take it?
AMOUNT:__________ DK RF
Days
Weeks
Months
M1. Have you ever been diagnosed with any of the following? INDICATE ALL THAT APPLY. [READ EACH UP TO RESPONSES PRECEEDED BY "OTHER" THEN ASK: "Other autoimmune disease (not including diabetes or thyroid disorders, which we have already discussed)" THEN, IF CAN'T RECALL, READ RESPONSES PRECEEDED BY "OTHER"] [IF REPORTS OSTEOARTHRITIS, DO NOT RECORD ANSWER, BUT SAY: I’ll ask about osteoarthritis later. Have you ever been diagnosed with any (other) autoimmune disease?]
Lupus
Rheumatoid arthritis
Multiple sclerosis
Celiac disease
Crohn’s disease
Ulcerative colitis; (PleasePlease note that we are not asking about general colitis here)
Psoriasis
Other autoimmune disease (not including diabetes or thyroid disorders, which we have already discussed) IF CAN’T RECALL, READ FROM LIST:
Immune/idiopathic thrombocytopenic purpura
Interstitial cystitis
Antiphospholipid antibody syndrome/lupus anticoagulant syndrome/APLS
Addison’s disease
Pernicious anemia
Myasthenia gravis
Autoimmune hemolytic anemia
Berger’s disease/IgA nephropathy
Alopecia, universalis or areata
Vitiligo
Juvenile arthritis
Guillain Barre syndrome
Scleroderma, morphea
Sjögren's syndrome/Sicca syndrome
Ankylosing spondylitis
Rheumatic fever
OTHER (SPECIFY):__________
NONE OF THE ABOVE SKIP TO NEXT SECTION
DK SKIP TO NEXT SECTION
RF SKIP TO NEXT SECTION
IF YES TO ANY, CONTINUE TO M2
ASK FOLLOWING QUESTIONS FOR EACH CONDITION IF MORE THAN ONE CONDITION REPORTED:
M2. When were you first diagnosed with [AUTOIMMUNE DISEASE, ANSWER M1] relative to [your pregnancy with [NOIB]; TAB: the pregnancy that ended on [DOIB/DOPT]]? [READ OPTIONS.]
More than 2 years before
In the 2 years before
During the first trimester
After the first trimester but still during pregnancy
After the pregnancy
DK
RF
IF M2=c, d, e, f, g THEN SKIP TO M6 (ONLY ASK M3 IF M2=a or b)
M3. Either before or during your pregnancy, did you speak with a healthcare provider about your treatment options during pregnancy?
YES GO TO M4
NO SKIP TO M6
DK SKIP TO M6
RF SKIP TO M6
M4. Did you discuss these options before your pregnancy began?
YES SKIP TO M6
NO GO TO M5
DK SKIP TO M6
RF SKIP TO M6
M5. How far along were you in your pregnancy when you discussed treatment options with your provider?
AMOUNT:__________ DK RF
UNITS:
Days
Weeks
Months
Trimesters
M6. Did you take any medications or remedies for [AUTOIMMUNE DISEASE, ANSWER M1] in the month before your pregnancy through the third month of pregnancy, that is from [B1] TO [P4 (-1)]?
YES CONTINUE TO M7
NO SKIP TO NEXT SECTION OR M2 IF > 1 CONDITION IN M1
DK SKIP TO NEXT SECTION OR M2 IF > 1 CONDITION IN M1
RF SKIP TO NEXT SECTION OR M2 IF > 1 CONDITION IN M1
M7. What did you take? / Did you take anything else? [IF CAN’T RECALL, READ FROM DRUG LIST FOR DISEASE REPORTED IN SQUARE BRACKETS].
[LUPUS]:
Advil
Aleve
Arava
Azasan
Azathioprine
Belimumab
Benlysta
Cellcept
Cyclophosphamide
Cytoxan
Hydroxychloroquine Sulfate
Leflunomide
Methotrexate
Motrin
Mycophenolate Mofetil
Plaquenil
Prednisone
Trexall
OTHER, SPECIFY:______________
DK SKIP TO NEXT CONDITION/NEXT SECTION
RF SKIP TO NEXT CONDITION/NEXT SECTION
[Rheumatoid arthritis]:
Abatacept
Actemra
Adalimumab
Advil
Aleve
Anakinra
Arava
Azasan
Azathioprine
Azulfidine
Certolizumab Pegol
Cimzia
Cyclophosphamide
Cyclosporine
Cytoxan
Dynacin
Enbrel
Etanercept
Gengraf
Golimumab
Humira
Hydroxychloroquine Sulfate
Ibuprofen
Imuran
Infliximab
Kineret
Leflunomide
Methotrexate
Minocin
Minocycline
Motrin
Naproxen Sodium
Neoral
Orencia
Plaquenil
Prednisone
Remicade
Rituxan
Rituximab
Sandimmune
Simponi
Sulfasalazine
Tocilizumab
Trexall
OTHER, SPECIFY:______________
DK SKIP TO NEXT CONDITION/NEXT SECTION
RF SKIP TO NEXT CONDITION/NEXT SECTION
Multiple sclerosis [MS]:
Amantadine
Ampyra
Amrix
Aubagio
Avonex
Baclofen
Betaseron
Copaxone
Cyclobenzaprine
Dalfampridine
Extavia
Fingolimod
Flexeril
Gilenya
Glatiramer Acetate
Lioresal
Methylprednisolone
Mitoxantrone HCL
Natalizumab
Prednisone
Rebif
Solu-Medrol
Tecfidera
Teriflunomide
Tizanidine HCL
Tysabri
Zanaflex
OTHER, SPECIFY:______________
DK SKIP TO NEXT CONDITION/NEXT SECTION
RF SKIP TO NEXT CONDITION/NEXT SECTION
Crohn’s disease and ulcerative colitis [CROHNS]:
Adalimumab
Apriso
Asacol
Azasan
Azathioprine
Azulfidine
Balsalazide Disodium
Certolizumab Pegol
Cimzia
Cipro
Ciprofloxacin HCL
Colazal
Cyclosporine
Dipentum
Flagyl
Gengraf
Humira
Imuran
Infliximab
Lialda
Mercaptopurine
Mesalamine
Methotrexate
Metronidazole
Natalizumab
Neoral
Olsalazine Sodium
Purinethol
Remicade
Rheumatrex
Sandimmune
Sulfasalazine
Tysabri
OTHER (SPECIFY):__________
DK SKIP TO NEXT CONDITION/NEXT SECTION
RF SKIP TO NEXT CONDITION/NEXT SECTION
[Psoriasis]:
Anthralin
Calcipotriene
Coal Tar
Dovonex
Elidel
Protopic Ointment
Retin-A
Salicylic Acid
Tazorac
Tazarotene
Tretinoin
OTHER (SPECIFY):__________
DK SKIP TO NEXT CONDITION/NEXT SECTION
RF SKIP TO NEXT CONDITION/NEXT SECTION
M8. Did you use [MEDICINE, ANSWER M7] for the entire time from the month before your pregnancy through the third month of pregnancy?
YES SKIP TO M12
NO CONTINUE TO M9
DK CONTINUE TO M9
RF CONTINUE TO M9
M9. When did you start using [MEDICINE, ANSWER M7] for [CONDITION, ANSWER M1] for the first time during this period? [CAN USE DK OR RF FOR MM OR DD OR YY]
MM/DD/YYYY or
MONTH OF PREGNANCY(B1, P1, P2, P3)
DK
RF
M10. When did you use [MEDICINE, ANSWER M7] for the last time during this time period? [CAN USE DK OR RF FOR MM OR DD OR YY]
MM/DD/YYYY or
MONTH OF PREGNANCY(B1, P1, P2, P3) IF VALID START AND STOP DATE, SKIP M11
DK
RF
OR
M11. How long did you take it?
AMOUNT:__________ DK RF
Days
Weeks
Months
M12. How often did you use [MEDICINE, ANSWER M7] 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.
AMOUNT:__________ Per Day/Per Week/Per Month/Per Time Period/DK/RF
M13. Did you take the same dose of medicine each time you took it throughout [B1] to [P4 (-1)]? That is, for example, the same number of milligrams of medicine in each dose.
YES CONTINUE TO M14
NO SKIP TO M15a
DK CONTINUE TO M14
RF SKIP TO M14
M14. What dose of [MEDICINE, ANSWER M7] did you take each time you took it?
AMOUNT:__________ SKIP TO NEXT SECTION
UNITS:__________
DK SKIP TO NEXT SECTION
RF SKIP TO NEXT SECTION
M15a. How many different dosage amounts do you remember taking? [If mom knows she took more than one dosage, but can't remember how many, select 1 for the number of dosages and report the dosage info she does remember. You may put additional details in a comment field.]
AMOUNT:__________ RF
M15b. What dose of [MEDICINE, ANSWER M7] did you take the [1st, 2nd, etc.] time?
AMOUNT:__________
DK SKIP TO M16
RF SKIP TO M16
UNITS:__________ DK RF
M16. When did you begin taking that dose?
MM/DD/YYYY or
MONTH OF PREGNANCY(B1, P1, P2, P3)
DK
RF
M17. When did you stop taking that dose?
MM/DD/YYYY or
MONTH OF PREGNANCY(B1, P1, P2, P3) IF VALID START AND STOP DATE, SKIP M17a
DK
RF
OR
M17a. How long did you take it?
AMOUNT:__________ DK RF
Days
Weeks
Months
N1. Have you ever received an organ or tissue transplant? DOES NOT INCLUDE BLOOD TRANSFUSIONS OR TISSUE TRANSFERS
YES CONTINUE TO N2
NO SKIP TO NEXT SECTION
DK SKIP TO NEXT SECTION
RF SKIP TO NEXT SECTION
N2. What organ or tissue was transplanted?
SPECIFY:_________________________ DK RF
N3. What was the date of the transplant?
MM/DD/YYYY
DK
RF
N4. Did you take any medications related to your transplant during the month before your pregnancy through your third month of pregnancy, that is from [B1] to [P4 (-1)]?
YES CONTINUE TO N5
NO SKIP TO NEXT SECTION
DK SKIP TO NEXT SECTION
RF SKIP TO NEXT SECTION
N5. What did you take? / Did you take anything else? [IF CAN’T RECALL, READ FROM DRUG LIST]
ATGAM
Azathioprine
Cellcept
Cyclosporine
Mycophenolate Mofetil
Myfortic
Orthoclone OKT3
Prednisone
Prograf
Sirolimus
Tacrolimus
Thymoglobulin
OTHER (SPECIFY):__________
DK SKIP TO NEXT CONDITION/NEXT SECTION
RF SKIP TO NEXT CONDITION/NEXT SECTION
N6. Did you use [MEDICINE, ANSWER N5] for the entire time from the month before your pregnancy through your third month of pregnancy?
YES SKIP TO N10
NO CONTINUE TO N7
DK CONTINUE TO N7
RF CONTINUE TO N7
N7. When did you start using [MEDICINE, ANSWER N5] for your transplant for the first time during this period? [CAN USE DK OR RF FOR MM OR DD OR YY]
MM/DD/YYYY or
MONTH OF PREGNANCY(B1, P1, P2, P3)
DK
RF
N8. When did you use [MEDICINE, ANSWER N5] for the last time during this time period? [CAN USE DK OR RF FOR MM OR DD OR YY]
MM/DD/YYYY or
MONTH OF PREGNANCY(B1, P1, P2, P3) IF VALID START AND STOP DATE, SKIP N9
DK
RF
OR
N9. How long did you take it?
AMOUNT:__________ DK RF
Days
Weeks
Months
N10. How often did you use [MEDICINE, ANSWER N5] 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.
AMOUNT:__________ Per Day/Per Week/Per Month/Per Time Period/DK/RF
N11. Did you take the same dose of medicine each time you took it throughout [B1] to [P4(-1)]? That is, for example, the same number of milligrams of medicine in each dose.
YES CONTINUE TO N12
NO SKIP TO N13a
DK CONTINUE TO N12
RF CONTINUE TO N12
N12. What dose of [MEDICINE, ANSWER N5] did you take each time you took it?
AMOUNT:__________ SKIP TO NEXT SECTION
UNITS:__________
DK SKIP TO NEXT SECTION
RF SKIP TO NEXT SECTION
N13a. How many different dosage amounts do you remember taking? [If mom knows she took more than one dosage, but can't remember how many, select 1 for the number of dosages and report the dosage info she does remember. You may put additional details in a comment field.]
AMOUNT:__________ RF
N13b. What dose of [MEDICINE, ANSWER N5] did you take the [1st, 2nd, etc.] time?
AMOUNT:__________
DK SKIP TO N14
RF SKIP TO N14
UNITS:__________ DK RF
N14. When did you begin taking that dose?
MM/DD/YYYY or
MONTH OF PREGNANCY(B1, P1, P2, P3)
DK
RF
N15. When did you stop taking that dose?
MM/DD/YYYY or
MONTH OF PREGNANCY(B1, P1, P2, P3) IF VALID START AND STOP DATE, SKIP N15a
DK
RF
OR
N15a. How long did you take it?
AMOUNT:__________ DK RF
Days
Weeks
Months
O1. Has a doctor or other health care 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?
YES CONTINUE TO O2
NO SKIP TO O4
DK SKIP TO O4
RF SKIP TO O4
O2. What condition were you told you had / Anything else?
SPECIFY:___________ DK RF
O3. When were you first diagnosed relative to [your pregnancy with [NOIB]; TAB: the pregnancy that ended on [DOIB/DOPT]]? [READ LIST]
More than 2 years before
In the 2 years before
During the first trimester
After the first trimester but still during pregnancy
After the pregnancy
DK
RF
O4. Has a doctor or other healthcare provider EVER told you that you had depression?
YES CONTINUE TO O5
If NO/DK/RF, and YES to O1 CONTINUE TO O6
If NO/DK/RF, and NO/DK/RF to O1 SKIP TO NEXT SECTION
O5. When were you first diagnosed with depression relative to [your pregnancy with [NOIB]; TAB: the pregnancy that ended on [DOIB/DOPT]]? [READ LIST]
More than 2 years before
In the 2 years before
During the first trimester
After the first trimester but still during pregnancy
After the pregnancy
DK
RF
O6. Did you experience any symptoms in the month before your pregnancy through the end of the third month of pregnancy, that is from [B1] to [P4 (-1)]?
YES CONTINUE TO O7
NO SKIP TO INSTRUCTIONS BEFORE O8
DK SKIP TO INSTRUCTIONS BEFORE O8
RF SKIP TO INSTRUCTIONS BEFORE O8
O7. What were the symptoms you experienced?
SPECIFY:__________ DK RF
IF O1=a AND O4=a AND O3=c, d, e, f, g AND O5=c, d, e, f, g THEN SKIP TO O11 (REPORTED ANXIETY AND DEPRESSION, BUT BOTH WERE DIAGNOSED DURING OR AFTER PREGNANCY)
IF O1=b, c, d AND O4=a AND O5=c, d, e, f, g THEN SKIP TO O11 (REPORTED ONLY DEPRESSION DIAGNOSED DURING OR AFTER PREGNANCY)
IF O1 = a AND O4=b AND O3= c, d, e, f, g THEN SKIP TO O11 (REPORTED ONLY ANXIETY DIAGNOSED DURING OR AFTER PREGNANCY)
O8. IF O3 OR O5 = a or b, ASK O8 THROUGH REST OF SECTION JUST ONCE: Either before or during your pregnancy, did you speak with a healthcare provider about your treatment options during pregnancy?
YES GO TO O9
NO SKIP TO O11
DK SKIP TO O11
RF SKIP TO O11
O9. Did you discuss these options before your pregnancy began?
YES SKIP TO O11
NO GO TO O10
DK SKIP TO O11
RF SKIP TO O11
O10. How far along were you in your pregnancy when you discussed treatment options with your provider?
AMOUNT:__________ DK RF
UNITS:
Days
Weeks
Months
Trimesters
O11. How did you treat your condition(s) in the month before your pregnancy through the end of the third month of pregnancy? [INDICATE ALL THAT APPLY. READ CHOICES. AFTER READING CHOICES, ASK: "Or something else?"]
Under care of therapist/psychologist IF THIS ONLY SKIP TO NEXT SECTION
With medication IF YES, CONTINUE WITH O12
You didn’t receive any treatment IF THIS ONLY SKIP TO NEXT SECTION
Or something else? (SPECIFY):__________IF THIS ONLY SKIP TO NEXT SECTION
DK CONTINUE WITH O12
RF IF THIS ONLY SKIP TO NEXT SECTION
O12. Did you use medication to treat your condition(s) in the month before your pregnancy through the third month of pregnancy?
YES CONTINUE TO O13
NO SKIP TO NEXT SECTION
DK SKIP TO NEXT SECTION
RF SKIP TO NEXT SECTION
O13. What did you take? / Did you take anything else? IF CAN’T RECALL, READ FROM DRUG LIST
Abilify
Alprazolam
Anafranil
Aripiprazole
Ativan
Bupropion
Buspar
Buspirone
Carbatrol
Celexa
Citalopram
Clomipramine
Clonazepam
Cymbalta
Depacon
Depakene
Depakote
Diazepam
Duloxetine
Effexor
Epitol
Equetro
Escitalopram
Fluoxetine
Imipramine
Inderal
Klonopin
Lamictal
Lamotrigine
Lexapro
Lorazepam
Paroxetine
Paxil
Propranolol
Prozac
Sertraline
St. John’s Wort
Tegretol
Tofranil
Valium
Valproic Acid
Venlafaxine
Wellbutrin
Xanax
Zoloft
Carbamazepine
OTHER (SPECIFY):__________
DK SKIP TO NEXT SECTION
RF SKIP TO NEXT SECTION
O14. Did you use [MEDICINE, ANSWER O13] for the entire time from the month before your pregnancy through your third month of pregnancy?
YES SKIP TO O18
NO CONTINUE TO O15
DK CONTINUE TO O15
RF CONTINUE TO O15
O15. When did you start using [MEDICINE, ANSWER O13] for your condition(s) for the first time during this period? [CAN USE DK OR RF FOR MM OR DD OR YY]
MM/DD/YYYY or
MONTH OF PREGNANCY(B1, P1, P2, P3)
DK
RF
O16. When did you use [MEDICINE, ANSWER O13] for the last time during this time period? [CAN USE DK OR RF FOR MM OR DD OR YY]
MM/DD/YYYY or
MONTH OF PREGNANCY(B1, P1, P2, P3) IF VALID START AND STOP DATE, SKIP O17
DK
RF
OR
O17. How long did you take it?
AMOUNT:__________ DK RF
Days
Weeks
Months
O18. How often did you use [MEDICINE, ANSWER O13] 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.
AMOUNT:__________ Per Day/Per Week/Per Month/Per Time Period/DK/RF
O19. Did you take the same dose of medicine each time you took it throughout [B1] to [P4 (-1)]? That is, for example, the same number of milligrams of medicine in each dose.
YES CONTINUE TO O20
NO SKIP TO O21a
DK CONTINUE TO O20
RF CONTINUE TO O20
O20. What dose of [MEDICINE, ANSWER O13] did you take each time you took it?
AMOUNT:__________ SKIP TO NEXT SECTION
UNITS:__________
DK SKIP TO NEXT SECTION
RF SKIP TO NEXT SECTION
O21a. How many different dosage amounts do you remember taking? [If mom knows she took more than one dosage, but can't remember how many, select 1 for the number of dosages and report the dosage info she does remember. You may put additional details in a comment field.]
AMOUNT:__________ RF
O21b. What dose of [MEDICINE, ANSWER O13] did you take the [1st, 2nd, etc.] time?
AMOUNT:__________
DK SKIP TO O22
RF SKIP TO O22
UNITS:__________ DK RF
O22. When did you begin taking that dose?
MM/DD/YYYY or
MONTH OF PREGNANCY(B1, P1, P2, P3)
DK
RF
O23. When did you stop taking that dose?
MM/DD/YYYY or
MONTH OF PREGNANCY(B1, P1, P2, P3) IF VALID START AND STOP DATE in O22 and O23, SKIP O23a
DK
RF
OR
O23a. How long did you take it?
AMOUNT:__________ DK RF
Days
Weeks
Months
P1. Have you EVER been told by a doctor or other health care provider that you had Attention-Deficit/Hyperactivity Disorder (ADHD) or Attention-Deficit Disorder (ADD)?
YES CONTINUE TO P2
NO SKIP TO NEXT SECTION
DK SKIP TO NEXT SECTION
RF SKIP TO NEXT SECTION
P2. With which condition were you diagnosed? IF MOM SAYS SHE USED TO HAVE ONE KIND BUT NOW THEY SAY IT'S A DIFFERENT KIND, USE "Other, specify" AND ENTER BOTH TYPES
Attention Deficit Hyperactivity Disorder
Attention Deficit Disorder
OTHER (SPECIFY):__________
DK
RF
P3. When were you diagnosed with [DIAGNOSED CONDITION, ANSWER P2] relative to [your pregnancy with [NOIB]; TAB: the pregnancy that ended on [DOIB/DOPT]]? [READ LIST]
More than 2 years before
In the 2 years before
During the first trimester
After the first trimester but still during pregnancy
After the pregnancy
DK
RF
IF P3=c, d, e, f, g THEN SKIP TO P7 (ONLY ASK P4 if P3=a, b)
P4. Either before or during your pregnancy, did you speak with a healthcare provider about your treatment options during pregnancy?
YES GO TO P5
NO SKIP TO P7
DK SKIP TO P7
RF SKIP TO P7
P5. Did you discuss these options before your pregnancy began?
YES SKIP TO P7
NO GO TO P6
DK SKIP TO P7
RF SKIP TO P7
P6. How far along were you in your pregnancy when you discussed treatment options with your provider?
AMOUNT:__________ DK RF
UNITS:
Days
Weeks
Months
Trimesters
P7. Did you take any medications to treat your [DIAGNOSED CONDITION, ANSWER P2] during the month before your pregnancy through the third month of pregnancy, that is from [B1] to [P4(-1)]?
YES CONTINUE TO P8
NO SKIP TO NEXT SECTION
DK SKIP TO NEXT SECTION
RF SKIP TO NEXT SECTION
P8. What did you take? / Did you take anything else? IF CAN’T RECALL, READ FROM DRUG LIST
Adderall
Adderall XR
Amphetamine
Atomoxetine
Celexa
Citalopram
Clonidine Hydrochloride
Concerta
Daytrana Patch
Dexedrine
Dexmethylphenidate
Dextroamphetamine
Dextrostat
Focalin
Focalin XR
Guanfacine
Intuniv
Kapvay
Lisdexamfetamine
Metadate CD
Methylin
Methylphenidate
Prozac
Ritalin
Ritalin LA
Ritalin SR
Sertraline
Strattera
Vyvanse
Zoloft
OTHER, SPECIFY: ____________
DK SKIP TO NEXT SECTION
RF SKIP TO NEXT SECTION
P9. Did you use [MEDICINE, ANSWER P8] for the entire time from the month before your pregnancy through your third month of pregnancy?
YES SKIP TO P13
NO CONTINUE TO P10
DK CONTINUE TO P10
RF CONTINUE TO P10
P10. When did you start using [MEDICINE, ANSWER P8] for [DIAGNOSED CONDITION, ANSWER P2] for the first time during this period? [CAN USE DK OR RF FOR MM OR DD OR YY]
MM/DD/YYYY or
MONTH OF PREGNANCY(B1, P1, P2, P3)
DK
RF
P11. When did you use [MEDICINE, ANSWER P8] for the last time during this time period? [CAN USE DK OR RF FOR MM OR DD OR YY]
MM/DD/YYYY or
MONTH OF PREGNANCY(B1, P1, P2, P3) IF VALID START AND STOP DATE, SKIP P12
DK
RF
OR
P12. How long did you take it?
AMOUNT:__________ DK RF
Days
Weeks
Months
P13. How often did you use [MEDICINE, ANSWER P8] 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.
AMOUNT:__________ Per Day/Per Week/Per Month/Per Time Period/DK/RF
P14. Did you take the same dose of medicine each time you took it throughout [B1] to [P4(-1)]? That is, for example, the same number of milligrams of medicine in each dose.
YES CONTINUE TO P15
NO SKIP TO P16a
DK CONTINUE TO P15
RF CONTINUE TO P15
P15. What dose of [MEDICINE, ANSWER P8] did you take each time you took it?
AMOUNT:__________ SKIP TO NEXT SECTION
UNITS:__________
DK SKIP TO NEXT SECTION
RF SKIP TO NEXT SECTION
P16a. How many different dosage amounts do you remember taking? [If mom knows she took more than one dosage, but can't remember how many, select 1 for the number of dosages and report the dosage info she does remember. You may put additional details in a comment field]
AMOUNT:__________ RF
P16b. What dose of [MEDICINE, ANSWER P8] did you take the [1st, 2nd, etc.] time?
AMOUNT:__________
DK SKIP TO P17
RF SKIP TO P17
UNITS:__________ DK RF
P17. When did you begin taking that dose?
MM/DD/YYYY or
MONTH OF PREGNANCY(B1, P1, P2, P3)
DK
RF
P18. When did you stop taking that dose?
MM/DD/YYYY or
MONTH OF PREGNANCY(B1, P1, P2, P3) IF VALID START AND STOP DATE, SKIP P18a
DK
RF
OR
P18a. How long did you take it?
AMOUNT:__________ DK RF
Days
Weeks
Months
Q1. 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? [PROBE: This does not include short-term illnesses such as colds.]
YES CONTINUE TO Q2
NO SKIP TO NEXT SECTION
DK SKIP TO NEXT SECTION
RF SKIP TO NEXT SECTION
Q2. What did you have? / Did you have anything else? [READ LIST IF NECESSARY] DO NOT INCLUDE ALLERGIES
Fibromyalgia
Hepatitis
Blood clotting disorders
Irritable bowel syndrome
Sleep apnea or other sleep disorders
Bipolar disorder
Schizophrenia
Other mental health conditions
UNSPECIFIED CHRONIC DISEASE OR LONG-TERM ILLNESS
SPECIFY:__________________ CONTINUE TO Q3
RF SKIP TO NEXT SECTION
Q3. How old were you when the [CHRONIC DISEASE, ANSWER Q2] was diagnosed?
AGE:_____________________ DK RF
Years
Months
Q4. Did you take any medications or remedies for [CHRONIC DISEASE, ANSWER Q2] during the month before your pregnancy through the third month of pregnancy, that is from [B1] to [P4 (-1)]? [DO NOT RECORD CPAP HERE]
YES CONTINUE TO Q5
NO SKIP TO NEXT SECTION
DK SKIP TO NEXT SECTION
RF SKIP TO NEXT SECTION
Q5. What did you take? / Did you take anything else?
SPECIFY:____________________________
DK SKIP TO NEXT SECTION
RF SKIP TO NEXT SECTION
Q6. Did you use [MEDICINE, ANSWER Q5] for the entire time from the month before your pregnancy through your third month of pregnancy?
YES SKIP TO Q10
NO CONTINUE TO Q7
DK CONTINUE TO Q7
RF CONTINUE TO Q7
Q7. When did you start using [MEDICINE, ANSWER Q5] for [CHRONIC DISEASE, ANSWER Q2] for the first time during this period? [CAN USE DK OR RF FOR MM OR DD OR YY]
MM/DD/YYYY or
MONTH OF PREGNANCY(B1, P1, P2, P3)
DK
RF
Q8. When did you use [MEDICINE, ANSWER Q5] for the last time during this time period? [CAN USE DK OR RF FOR MM OR DD OR YY]
MM/DD/YYYY or
MONTH OF PREGNANCY(B1, P1, P2, P3) IF VALID RESPONSE TO Q7 and Q8, SKIP Q9
DK
RF
OR
Q9. How long did you take it?
AMOUNT:__________ DK RF
Days
Weeks
Months
Q10. How often did you use [MEDICINE, ANSWER Q5] 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.
AMOUNT:__________ Per Day/Per Week/Per Month/Per Time Period/DK/RF
Q11. Did you take the same dose of medicine each time you took it throughout [B1] to [P4(-1)]? That is, for example, the same number of milligrams of medicine in each dose.
YES CONTINUE TO Q12
NO SKIP TO Q13a
DK CONTINUE TO Q12
RF CONTINUE TO Q12
Q12. What dose of [MEDICINE, ANSWER Q5] did you take each time you took it?
AMOUNT:__________ SKIP TO NEXT SECTION
UNITS:__________
DK SKIP TO NEXT SECTION
RF SKIP TO NEXT SECTION
Q13a. How many different dosage amounts do you remember taking? [If mom knows she took more than one dosage, but can't remember how many, select 1 for the number of dosages and report the dosage info she does remember. You may put additional details in a comment field.]
AMOUNT:__________ RF
Q13b. What dose of [MEDICINE, ANSWER Q5] did you take the [1st, 2nd, etc.] time?
AMOUNT:__________ DK or RF SKIP TO Q14
UNITS:__________ DK RF
Q14. When did you begin taking that dose?
MM/DD/YYYY or
MONTH OF PREGNANCY(B1, P1, P2, P3)
DK
RF
Q15. When did you stop taking that dose?
MM/DD/YYYY
MONTH OF PREGNANCY(B1, P1, P2, P3) IF VALID RESPONSE TO Q14 and Q15, SKIP Q15a
DK
RF
OR
Q15a. How long did you take it?
AMOUNT:__________ DK RF
Days
Weeks
Months
R1. From one month before you became pregnant to the end of the third month of your pregnancy, that is from [B1] to [P4(-1)], did you have any fevers? [PROBE: The fever could have been due to respiratory illness, bronchitis, pneumonia, a kidney, bladder, or urinary tract infection, pelvic inflammatory disease, or other infections or illness.]
YES CONTINUE TO S2
NO SKIP TO NEXT SECTION
DK SKIP TO NEXT SECTION
RF SKIP TO NEXT SECTION
R2. How many fevers do you remember having? [IF DK NUMBER, SELECT 1 AND ASK MOM FOR DETAILS ABOUT 1 FEVER SHE REMEMBERS.] [ASK S3-S11 FOR EACH FEVER LISTED.]
a. NUMBER:
R3. What was the cause of the [1st, 2nd, etc.] fever?
CAUSE:
DK
RF
R4. When you had [CAUSE OF FEVER, ANSWER R3], during which of these months did you have a fever?
B1
P1
P2
P3
DK
RF
R5. What was the highest temperature recorded during your fever?
VALUE: DK RF NOT RECORDED SKIP UNITS
UNITS: F or C
R6. Did you take any medications or remedies for the fever?
YES CONTINUE TO R7
NO SKIP TO NEXT SECTION
DK SKIP TO NEXT SECTION
RF SKIP TO NEXT SECTION
R7. What did you take? Did you take anything else? [CODE ALL THAT APPLY. IF CAN’T RECALL, READ FROM DRUG LIST: Did you take…?]
Acetaminophen
Advil
Aleve
Ibuprofen
Motrin
Naproxen sodium
Nuprin
Tylenol
OTHER (SPECIFY):
DK SKIP TO NEXT SECTION
RF SKIP TO NEXT SECTION
R8. When did you start using [DRUG, ANSWER R7] for this [CAUSE OF FEVER, ANSWER R3] for the first time during this period? [CAN USE DK OR RF FOR MM OR DD OR YY]
MM/DD/YYYY or
MONTH OF PREGNANCY(B1, P1, P2, P3)
DK
RF
R9. When did you use [DRUG, ANSWER R7] for the last time during this time period? [CAN USE DK OR RF FOR MM OR DD OR YY]
MM/DD/YYYY or DK or RF or
MONTH OF PREGNANCY(B1, P1, P2, P3) IF VALID RESPONSE TO R8 and R9, SKIP R10
OR
R10. How long did you take it?
AMOUNT: DK RF
Days
Weeks
Months
R11. How often did you use [DRUG, ANSWER R7] 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.
a. AMOUNT: Per Day/Per Week/Per Month/Per Time Period/DK/RF
S1. From the month before you became pregnant to the end of the third month of pregnancy, that is from [B1] to [P4 (-1)], did you have a kidney, bladder, or urinary tract infection? DO NOT INCLUDE KIDNEY STONES
YES CONTINUE TO S2
NO SKIP TO S15
DK SKIP TO S15
RF SKIP TO S15
ASK THE FOLLOWING QUESTIONS FOR EACH INFECTION REPORTED:
S2. Was the infection diagnosed by a doctor or other health care provider? IF ONLY DIAGNOSED WITH KIT TEST RESULT, ENTER "No".
YES
NO
DK
RF
S3. From the month before you became pregnant to the end of the third month of pregnancy, that is from [B1] to [P4 (-1)], did you take any medications or remedies for your infection?
YES CONTINUE TO S4
NO SKIP TO S15
DK SKIP TO S15
RF SKIP TO S15
|
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|
ASK THIS SERIES FOR EACH MEDICINE USED: |
|
ROW # |
|
QUESTION |
RESPONSE |
1 |
S4. S18. S32. |
What did you take? / Did you take anything else? |
MEDICATION:______________________
DK RF |
|
|
S4, S18 (UTI OR PID MEDS): PROBE: IF CAN’T RECALL, READ FROM DRUG LIST:
Amoxicillin Amoxil Augmentin Azithromycin Bactrim Biaxin Ceftriaxone sodium Cipro Doxycycline EES Erythrocin Erythromycin Furadantin Levaquin Macrobid Macrodantin Nitrofurantoin Nitrofurantoin Macrocrystals Penicillin Rebetol Rebetron Septra Sulfamethoxazole/trimethoprim Trimox Vibramycin Virazole Zithromax Antibiotic |
S4: IF NO/DK/RF SKIP TO S15
S18: IF NO/DK/RF SKIP TO S29
S32: IF NO/DK/RF SKIP TO S43 |
|
|
S32 (STD MEDS): [PROBE: IF CAN’T RECALL, READ FROM DRUG LIST]
Acyclovir Aldara Condylox Famciclovir Famvir Imiquimod Podofilox Podophyllin Trichloroacetic acid (TCA) Valacyclovir Valtrex Zovirax Zyclara |
|
2 |
S5. S19. S33. |
Did you use [MEDICINE, ANSWER S4, S18, S32] for the entire time from the month before your pregnancy through your third month of pregnancy? |
YES SKIP TO ROW 6
NO DK RF CONTINUE TO ROW 3 |
3 |
S6. S20. S34. |
When did you start using [MEDICINE, ANSWER S4, S18, S32] for [the infection/CONDITION] for the first time during this period? |
MM/DD/YYYY __ /__ /____ or MONTH OF PREGNANCY(B1, P1, P2, P3)
DK RF |
4 |
S7. S21. S35. |
When did you use [MEDICINE, ANSWER S4, S18, S32] for the last time during this time period? |
MM/DD/YYYY __ /__ /____ or MONTH OF PREGNANCY(B1, P1, P2, P3) IF VALID START AND STOP DATE, SKIP ROW 5
DK RF
|
5 |
S8. S22. S36. |
How long did you take it? |
AMOUNT:__________ Days Weeks Months
DK RF
|
6 |
S9. S23. S37. |
How often did you use [MEDICINE, ANSWER S4, S18, S32] 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. |
AMOUNT:__________ Per day/Per week/Per month/Per time period
DK RF |
7 |
S10. S24. S38. |
Did you take the same dose of medicine each time you took it throughout [B1] to [P4(-1)]? That is, for example, the same number of milligrams of medicine in each dose. |
YES, DK, RF CONTINUE TO ROW 8
NO SKIP TO ROW 9
|
8 |
S11. S25. S39. |
What dose of [MEDICINE, ANSWER S4, S18, S32] did you take each time you took it? |
AMOUNT:______ DK, RF SKIP UNITS UNITS:_________ DK S11 SKIP TO S15 S25 SKIP TO S29 S39 SKIP TO S43 |
9 |
S12a. S26a. S40a. |
How many different dosage amounts do you remember taking? |
AMOUNT:__________ RF |
10 |
S12b. S26b. S40b. |
What dose of [MEDICINE, ANSWER S4, S18, S32] did you take the [1st, 2nd, etc.] time? |
AMOUNT:______ DK, RF SKIP UNITS UNITS:_________ DK RF |
11 |
S13. S27. S41a. |
When did you begin taking that dose? |
MM/DD/YYYY __ /__ /____ or MONTH OF PREGNANCY(B1, P1, P2, P3) DK RF
|
12 |
S14. S28. S41b. |
When did you stop taking that dose? |
MM/DD/YYYY __ /__ /____ or MONTH OF PREGNANCY(B1, P1, P2, P3) IF VALID START AND STOP DATE, SKIP ROW 13 DK RF |
13 |
S14a S28a S42. |
Or How long did you take it? |
AMOUNT:__________ Days Weeks Months DK RF |
AFTER S14, CONTINUE WITH S15 BELOW. AFTER S28a, CONTINUE WITH S29 BELOW.
FOR S15-S28, FOR S29 –SXX, USE SAME RESPONSES AND SKIP PATTERNS AS FOR SIMILAR QUESTIONS IN S1-S14 ABOVE.
S15. From the month before you became pregnant to the end of the third month of pregnancy, that is from [B1] to [P4 (-1)], did you have pelvic inflammatory disease or PID?
YES CONTINUE TO S16
NO SKIP TO S29
DK SKIP TO S29
RF SKIP TO S29
S16. Was the pelvic inflammatory disease or PID diagnosed by a doctor or other health care provider?
YES
NO
DK
RF
S17. From the month before you became pregnant to the end of the third month of pregnancy, that is from [B1] to [P4 (-1)], did you take any medications or remedies for your pelvic inflammatory disease or PID?
YES CONTINUE TO S18 IN TABLE ABOVE
NO SKIP TO S29
DK SKIP TO S29
RF SKIP TO S29
AFTER S18 – S28 IN TABLE ABOVE, CONTINUE:
Questions S29-S42 were removed.
S43. From the month before you became pregnant to the end of the third month of pregnancy, that is from [B1] to [P4 (-1)], did you have a yeast infection?
YES CONTINUE TO S29A
NO SKIP TO NEXT SECTION
DK or RF SKIP TO NEXT SECTION
S44. Was the yeast infection diagnosed by a doctor or other health care provider?
YES
NO
DK
RF
S45. From the month before you became pregnant to the end of the third month of pregnancy, that is from [B1] to [P4 (-1)], did you take any medications or remedies for your yeast infection?
YES CONTINUE TO S46
NO SKIP TO NEXT SECTION
DK SKIP TO NEXT SECTION
RF SKIP TO NEXT SECTION
S46. Did you take a medicine that a doctor prescribed for you or did you buy it “over-the-counter”, without a prescription? SELECT ALL THAT APPLY
Prescription
Over-the-counter
DK
RF
S47. Did you use a medicine that you inserted or applied on the outside or a pill that you swallowed? SELECT ALL THAT APPLY
External or inserted product SKIP TO NEXT SECTION
Pill SKIP TO NEXT SECTION
OTHER (SPECIFY):__________ SKIP TO NEXT SECTION
DK SKIP TO NEXT SECTION
RF SKIP TO NEXT SECTION
INFECTIONS – Gateway Table
(FOLLOW-UP QUESTIONS FOR EVERY “YES” RESPONSE BEGIN IN NEXT TABLE |
|||||
Has a doctor or other health care provider ever told you that you had any of the following infections? |
IF YES, ASK FOLLOW-UP QUESTIONS |
IF NO, ASK NEXT CATEGORY |
IF DK, ASK NEXT CATEGORY |
IF RF, ASK NEXT CATEGORY |
|
|
|
YES |
NO |
DK |
RF |
T1. |
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Zika virus |
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Chikungunya |
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Dengue |
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Lyme disease |
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Malaria |
|
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West Nile |
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Hepatitis A |
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Hepatitis B |
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Hepatitis C |
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HIV |
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Syphilis |
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Chlamydia |
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Gonorrhea |
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Human papillomavirus (HPV) |
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|
Any other sexually transmitted disease, such as herpes or trichomoniasis? |
What was it? |
|
|
|
For each infection that the mother reported, ask the following questions: |
||
T2. |
When was your infection first diagnosed? |
a. MM/DD/YYYY OR b. Age in years OR c. Time period ago d. DK e. RF |
T3. |
Did you have any symptoms during the 3 months before your pregnancy through the end of your [pregnancy with [NOIB]; TAB: the pregnancy that ended on [DOIB/DOPT]], that is from [B3] to the end of your pregnancy? Please note that this is a longer time period than most of my other questions. |
a. YES CONTINUE TO T4 b. NO SKIP TO T5 c. DK SKIP TO T5 d. RF SKIP TO T5 |
T4. |
During which months did you have symptoms? |
a. B3 b. B2 c. B1 d. P1 e. P2 f. P3 g. T2 h. T3 i. DK j. RF |
T5. |
Did you take any medications or remedies for [INFECTION] during the 3 months before your pregnancy through the end of your [pregnancy with [NOIB]; TAB: the pregnancy that ended on [DOIB/DOPT]]? |
a. YES CONTINUE TO T6 b. NO SKIP TO NEXT INFECTION/SECTION c. DK SKIP TO NEXT INFECTION/SECTION d. RF SKIP TO NEXT INFECTION/SECTION |
T6. |
What did you take? Did you take anything else? [LIST ALL] |
a. Medication:_______________ b. DK c. RF |
T7. |
Did you use [MEDICINE] for the entire time from 3 months before your pregnancy through the end of your [pregnancy with [NOIB]; TAB: the pregnancy that ended on [DOIB/DOPT]]? |
a. YES SKIP TO T11 b. NO CONTINUE TO T8 c. DK CONTINUE TO T8 d. RF CONTINUE TO T8 |
T8. |
When did you start using [MEDICINE] for the first time during this period? [CAN USE DK OR RF FOR MM OR DD OR YY] |
a. MM/DD/YYYY or b. MONTH OF PREGNANCY (B3, B2, B1, P1, P2, P3, T2, T3) c. DK d. RF |
T9. |
When did you use [MEDICINE] for the last time during this period? [CAN USE DK OR RF FOR MM OR DD OR YY]
|
a. MM/DD/YYYY or b. MONTH OF PREGNANCY (B3, B2, B1, P1, P2, P3, T2, T3) c. DK d. RF |
T10. |
OR
How long did you take it? |
a. AMOUNT:__________ i. Days ii. Weeks iii. Months b. DK c. RF |
T11. |
How often did you use [MEDICINE] during the 3 months before your pregnancy through the end of your [pregnancy with [NOIB]; TAB: the pregnancy that ended on [DOIB/DOPT]]? You can say the number of times per day, per week, per month, or during the entire period. |
a. AMOUNT:_____________ i. Per Day ii. Per Week iii. Per Month vi. Per Time Period [Note to interviewers that this refers to B3-end of pregnancy; e.g., if the mother only took the medication once during that entire time period they would put AMOUNT=1 per time period] b. DK c. RF |
T12. |
Did you take the same dose of medicine each time you took it throughout [B3] to [DOIB/DOPT]? That is, for example, the same number of milligrams of medicine in each dose? |
a. YES CONTINUE TO T13 b. NO SKIP TO T14 c. DK CONTINUE TO T13 d. RF CONTINUE TO T13 |
T13. |
What dose of [MEDICINE] did you take each time you took it? |
a. AMOUNT:____________ SKIP TO NEXT MEDICINE/INFECTION/SECTION i. UNITS:_____________ b. DK SKIP TO NEXT MEDICINE/INFECTION/SECTION c. RF SKIP TO NEXT MEDICINE/INFECTION/SECTION |
T14. |
How many different dosage amounts do you remember taking? [If mom knows she took more than one dosage, but can’t remember how many, select 1 for the number of dosages and report the dosage information she does remember. You may put additional details in a comment field.] |
a. AMOUNT:____________ b. RF |
T15. |
What dose of [MEDICINE] did you take the [1st, 2nd, etc.] time? |
a. AMOUNT:_____________ i. UNITS:______________ b. DK c. RF |
T16. |
When did you begin taking that dose? |
a. MM/DD/YYYY or b. MONTH OF PREGNANCY (B3, B2, B1, P1, P2, P3, T2, T3) c. DK d. RF |
T17. |
When did you stop taking that dose? |
a. MM/DD/YYYY or b. MONTH OF PREGNANCY (B3, B2, B1, P1, P2, P3, T2, T3) c. DK d. RF |
T18. |
OR
How long did you take it? |
a. AMOUNT:__________ i. Days ii. Weeks iii. Months b. DK c. RF |
T19. Have you ever had a coronavirus/COVID-19 infection or tested positive for COVD-19?
a. YES CONTINUE TO T20
b. NO SKIP TO NEXT SECTION
c. DK SKIP TO NEXT SECTION
d. RF SKIP TO NEXT SECTION
T20. How many coronavirus/COVID-19 infections have you had? You may have received more than one positive test for one infection. If you recovered from COVID-19 and then were infected with COVID-19 again that would count as a separate infection. [IF DK NUMBER, SELECT 1 AND ASK MOM FOR DETAILS ABOUT 1 INFECTION SHE REMEMBERS.] [ASK T21-T40 FOR EACH INFECTION LISTED.]
a. NUMBER:
For each COVID infection that the mother reported, ask the following questions: |
||
T21. |
I’m going to ask you a set of questions about your [1st/2nd/3rd/etc.] COVID infection. When was your infection first diagnosed? |
a. MM/DD/YYYY OR b. Age in years OR c. Time period ago d. DK e. RF |
T22. |
Did a doctor or other healthcare provider tell you that you had COVID?
[If diagnosed by a drive-through testing site or pharmacy technician select “Yes”] |
a. Yes b. No e. DK f. RF
|
T23. |
Did you test positive on a home test? |
a. Yes b. No e. DK f. RF |
T24. |
Did you have any symptoms during the 3 months before your pregnancy through the end of your [pregnancy with [NOIB]; TAB: the pregnancy that ended on [DOIB/DOPT]], that is from [B3] to the end of your pregnancy? Please note that this is a longer time period than most of my other questions. |
a. YES CONTINUE TO T25 b. NO SKIP TO T26 c. DK SKIP TO T26 d. RF SKIP TO T26 |
T25. |
During which months did you have symptoms? |
a. B3 b. B2 c. B1 d. P1 e. P2 f. P3 g. T2 h. T3 i. DK j. RF |
T26. |
How would you describe the level of care you received? If you contacted a healthcare provider through email or phone or telemedicine select that you received medical care. [READ OPTIONS A-C]: |
a. Did not seek medical care b. Received medical care but was not hospitalized c. Was hospitalized and not admitted to ICU d. Was hospitalized and admitted to ICU i. DK j. RF |
T27. |
Did you take any medications or remedies for [INFECTION] during the 3 months before your pregnancy through the end of your [pregnancy with [NOIB]; TAB: the pregnancy that ended on [DOIB/DOPT]]? |
a. YES CONTINUE TO T28 b. NO SKIP TO NEXT INFECTION/SECTION c. DK SKIP TO NEXT INFECTION/SECTION d. RF SKIP TO NEXT INFECTION/SECTION |
T28. |
What did you take? / Did you take anything else (such as monoclonal antibodies, steroids, antibiotics, ivermectin, or hydroxychloroquine)? PROBE: READ LIST IF NECESSARY |
NAME:_____________________ DK à SKIP TO NEXT SECTION RF à SKIP TO NEXT SECTION |
|
COVID MEDICATION PROMPTS: |
SELECT EACH YES: |
|
Acetaminophen |
Y |
|
Advil |
Y |
|
Ibuprofen |
Y |
|
Motrin |
Y |
|
Tylenol |
Y |
|
Remdesivir |
Y |
|
Paxlovid |
Y |
|
OTHER, SPECIFY: |
Y |
T29. |
Did you use [MEDICINE] for the entire time from 3 months before your pregnancy through the end of your [pregnancy with [NOIB]; TAB: the pregnancy that ended on [DOIB/DOPT]]? |
a. YES SKIP TO T32 b. NO CONTINUE TO T29 c. DK CONTINUE TO T29 d. RF CONTINUE TO T29 |
T30. |
When did you start using [MEDICINE] for the first time during this period? [CAN USE DK OR RF FOR MM OR DD OR YY] |
a. MM/DD/YYYY or b. MONTH OF PREGNANCY (B3, B2, B1, P1, P2, P3, T2, T3) c. DK d. RF |
T31. |
When did you use [MEDICINE] for the last time during this period? [CAN USE DK OR RF FOR MM OR DD OR YY]
|
a. MM/DD/YYYY or b. MONTH OF PREGNANCY (B3, B2, B1, P1, P2, P3, T2, T3) c. DK d. RF |
T32. |
OR
How long did you take it? |
a. AMOUNT:__________ i. Days ii. Weeks iii. Months b. DK c. RF |
T33. |
How often did you use [MEDICINE] during the 3 months before your pregnancy through the end of your [pregnancy with [NOIB]; TAB: the pregnancy that ended on [DOIB/DOPT]]? You can say the number of times per day, per week, per month, or during the entire period. |
a. AMOUNT:_____________ i. Per Day ii. Per Week iii. Per Month vi. Per Time Period [Note to interviewers that this refers to B3-end of pregnancy; e.g., if the mother only took the medication once during that entire time period they would put AMOUNT=1 per time period] b. DK c. RF |
T34. |
Did you take the same dose of medicine each time you took it throughout [B3] to [DOIB/DOPT]? That is, for example, the same number of milligrams of medicine in each dose? |
a. YES CONTINUE TO T35 b. NO SKIP TO T36 c. DK CONTINUE TO T35 d. RF CONTINUE TO T35 |
T35. |
What dose of [MEDICINE] did you take each time you took it? |
a. AMOUNT:____________ SKIP TO NEXT MEDICINE/INFECTION/SECTION i. UNITS:_____________ b. DK SKIP TO NEXT MEDICINE/INFECTION/SECTION c. RF SKIP TO NEXT MEDICINE/INFECTION/SECTION |
T36. |
How many different dosage amounts do you remember taking? [If mom knows she took more than one dosage, but can’t remember how many, select 1 for the number of dosages and report the dosage information she does remember. You may put additional details in a comment field.] |
a. AMOUNT:____________ b. RF |
T37. |
What dose of [MEDICINE] did you take the [1st, 2nd, etc.] time? |
a. AMOUNT:_____________ i. UNITS:______________ b. DK c. RF |
T38. |
When did you begin taking that dose? |
a. MM/DD/YYYY or b. MONTH OF PREGNANCY (B3, B2, B1, P1, P2, P3, T2, T3) c. DK d. RF |
T39. |
When did you stop taking that dose? |
a. MM/DD/YYYY or b. MONTH OF PREGNANCY (B3, B2, B1, P1, P2, P3, T2, T3) c. DK d. RF |
T40. |
OR
How long did you take it? |
a. AMOUNT:__________ i. Days ii. Weeks iii. Months b. DK c. RF |
The next questions are about places you may have traveled before and during your pregnancy.
U1. Did you spend any time outside the continental United States during the time period from 3 months before pregnancy through the end of pregnancy, that is from [B3] TO [DOIB/DOPT]? We are interested in travel you took to other countries, to Hawaii, or to U.S. territories such as Puerto Rico or the U.S. Virgin Islands. [Note to interviewers: We are not interested in travel to Alaska in this question, even though it can be considered outside of the continental Unites States.]
a. YES CONTINUE TO U2
b. NO SKIP TO NEXT SECTION
c. DK SKIP TO NEXT SECTION
d. RF SKIP TO NEXT SECTION
U2. Where did you travel to? Anywhere else?
[Interviewer guidance will be provided that multiple locations (e.g. different cities) within a trip to a country/U.S. territory would only be recorded as a single location here.]
Location [1]:
Location [2]:
Location [3]:
Etc…
ASK QUESTIONS U3 – U11 FOR EACH LOCATION, IF MULTIPLE TRIPS TO THE SAME LOCATION, RECORD EACH TRIP SEPARATELY
U3. What date did your trip to [Location[N]] start?
a. MM/DD/YYYY or MM/YYYY
b. MONTH OF PREGNANCY (B3, B2, B1, P1, P2, P3, T2, T3)
c. DK
d. RF
U4. When did your trip to [Location[N]] end?
a. MM/DD/YYYY
b. MONTH OF PREGNANCY (B3, B2, B1, P1, P2, P3, T2, T3)
c. DK
d. RF
OR
U4a. How long was your trip?
a. AMOUNT:_________________ DK RF
i. Days
ii. Weeks
iii. Months
U5. Did you get sick during your trip to [Location[N]] or within 2 weeks of your return to the U.S.?
a. YES CONTINUE TO U6
b. NO SKIP TO NEXT SECTION
c. DK SKIP TO NEXT SECTION
d. RF SKIP TO NEXT SECTION
U6. Did you have any of the following symptoms with this illness:
a. Rash: YES / NO / DK / RF
b. Conjunctivitis or “pink eye”: YES / NO / DK / RF
c. Pain behind eyes: YES / NO / DK / RF
d. Joint pain: YES / NO / DK / RF
e. Body pain in your muscles or bones: YES / NO / DK / RF
f. Chills: YES / NO / DK / RF
g. Headache: YES / NO / DK / RF
h. Persistent vomiting: YES / NO / DK / RF
i. Diarrhea: YES / NO / DK / RF
j. Nasal congestion: YES / NO / DK / RF
k. Cough: YES / NO / DK / RF
l. Sore throat: YES / NO / DK / RF
m. Difficulty breathing: YES / NO / DK / RF
n. Fever: YES / NO / DK / RF
o. None of the above
U7. Did you have any other symptoms with this illness?
a. YES CONTINUE TO U7a
b. NO SKIP TO U8
c. DK SKIP TO U8
d. RF SKIP TO U8
U7a. What other symptoms did you have?
Symptom 1:_____________________________
Symptom 2:_____________________________
[allow them to report as many additional symptoms as they had]
DK
RF
U8. Did you receive a diagnosis from a doctor or other healthcare provider?
a. YES CONTINUE TO U9
b. NO SKIP TO U10
c. DK SKIP TO U10
d. RF SKIP TO U10
U9. What diagnosis did they give you?
Diagnosis:____________________________
DK
RF
U10. |
Did you take any medications or remedies for this illness in the 3 months before pregnancy through the end of pregnancy? |
a. YES CONTINUE TO U10a b. NO SKIP TO NEXT SECTION c. DK SKIP TO NEXT SECTION d. RF SKIP TO NEXT SECTION |
U10a. |
Did you already tell me about the medications you took for this illness? |
a. YES SKIP TO NEXT SECTION b. NO CONTINUE TO U11 c. DK CONTINUE TO U11 d. RF CONTINUE TO U11 |
U11. |
What did you take? Did you take anything else? [LIST ALL] |
a. Medication:_______________ b. DK c. RF |
U12. |
Did you use [MEDICINE] for the entire time from the 3 months before pregnancy through the end of pregnancy? |
a. YES SKIP TO U16 b. NO CONTINUE TO U13 c. DK CONTINUE TO U13 d. RF CONTINUE TO U13 |
U13 . |
When did you start using [MEDICINE] for the first time during this period? [CAN USE DK OR RF FOR MM OR DD OR YY] |
a. MM/DD/YYYY or b. MONTH OF PREGNANCY (B1, P1, P2, P3) c. DK d. RF |
U14. |
When did you use [MEDICINE] for the last time during this period? [CAN USE DK OR RF FOR MM OR DD OR YY]
|
a. MM/DD/YYYY or b. MONTH OF PREGNANCY (B1, P1, P2, P3) c. DK d. RF |
U15. |
OR
How long did you take it? |
a. AMOUNT:__________ i. Days ii. Weeks iii. Months b. DK c. RF |
U16. |
How often did you use [MEDICINE] during the 3 months before pregnancy through the end of pregnancy? You can say the number of times per day, per week, per month, or during the entire 4 month period. |
a. AMOUNT:_____________ i. Per Day ii. Per Week iii. Per Month vi. Per Time Period [Note to interviewers that this refers to B3-end of pregnancy; e.g., if the mother only took the medication once during that entire time period they would put AMOUNT=1 per time period] b. DK c. RF |
U17. |
Did you take the same dose of medicine each time you took it throughout [B3] to [DOIB/DOPT]? That is, for example, the same number of milligrams of medicine in each dose? |
a. YES CONTINUE TO U18 b. NO SKIP TO U19 c. DK CONTINUE TO U18 d. RF CONTINUE TO U18 |
U18. |
What dose of [MEDICINE] did you take each time you took it? |
a. AMOUNT:____________ i. UNITS:_____________ b. DK c. RF |
U19. |
How many different dosage amounts do you remember taking? [If mom knows she took more than one dosage, but can’t remember how many, select 1 for the number of dosages and report the dosage information she does remember. You may put additional details in a comment field.] |
a. AMOUNT:____________ b. RF |
U20. |
What dose of [MEDICINE] did you take the [1st, 2nd, etc.] time? |
a. AMOUNT:_____________ i. UNITS:______________ b. DK c. RF |
U21. |
When did you begin taking that dose? |
a. MM/DD/YYYY or b. MONTH OF PREGNANCY (B3, B2, B1, P1, P2, P3, T2, T3) c. DK d. RF |
U22. |
When did you stop taking that dose? |
a. MM/DD/YYYY or b. MONTH OF PREGNANCY (B3, B2, B1, P1, P2, P3, T2, T3) c. DK d. RF |
U23. |
OR
How long did you take it? |
a. AMOUNT:__________ i. Days ii. Weeks iii. Months b. DK c. RF |
We are interested in medicines that you may have taken from 1 month before you became pregnant, which would be [B1], to the end of the third month of pregnancy, which would be [P4 (-1)]. 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. To keep you from having to repeat information we’ve already discussed, I may ask you for your help in remembering whether you’ve reported using a medication to me already and for what medical condition you reported taking it for. Unfortunately we are not able to see your responses from earlier in the interview. |
||||||
Medication Categories (FOLLOW-UPS BEGIN WITH V3 on page 97) |
||||||
|
|
QUESTION |
RESPONSES |
|||
|
|
During [B1] to [P4(-1)] did you take…./did you get any vaccines (V154)? |
IF YES, ASK FOLLOW-UP QUESTIONS |
IF NO, ASK NEXT CATEGORY |
IF DK, ASK NEXT CATEGORY |
IF RF, ASK NEXT CATEGORY |
|
V1. |
Birth control pills (V3) |
Y |
N |
DK |
RF |
|
V18. |
Antibiotics (V20) |
Y |
N |
DK |
RF |
|
V35. |
Over-the-counter pain relievers (T37) |
Y |
N |
DK |
RF |
|
V52. |
Prescription pain relievers (V54) |
Y |
N |
DK |
RF |
|
V69. |
Medicines to help you lower your cholesterol (“statins”) (V71) |
Y |
N |
DK |
RF |
|
V86. |
Medicines to help you quit smoking (V88) |
Y |
N |
DK |
RF |
|
V103. |
Medicines to help with allergies or cold symptoms (e.g. runny nose, cough) (V105) |
Y |
N |
DK |
RF |
|
V120. |
Medicine to treat an infection with a virus, like the flu (“antiviral”) (V122) |
Y |
N |
DK |
RF |
|
V137. |
Medicine to help you sleep (“sleep aid”) (V139) |
Y |
N |
DK |
RF |
|
V154. |
Vaccines (WILL ONLY CAPTURE NAME & DATE OF VACCINES) (V156) |
Y |
N |
DK |
RF |
|
V171. |
Medicines to treat nausea or vomiting (V173) |
Y |
N |
DK |
RF
|
|
V3. |
What was the name of the medication? / Did you take any other medicine in this category? PROBE: READ LIST IF NECESSARY |
NAME:_____________________ DK SKIP TO NEXT CATEGORY RF SKIP TO NEXT CATEGORY |
|
|
BIRTH CONTROL PILLS PROMPTS: |
SELECT EACH YES: |
|
|
Apri |
Y |
|
|
Aviane (21, 28) |
Y |
|
|
Beyaz |
Y |
|
|
Brevicon (21,28) |
Y |
|
|
Camila |
Y |
|
|
Cryselle 28 |
Y |
|
|
Cyclessa |
Y |
|
|
Desogen |
Y |
|
|
Jolivette |
Y |
|
|
Kariva |
Y |
|
|
Levora |
Y |
|
|
Lo Loestrin Fe |
Y |
|
|
Lo Ovral 21 |
Y |
|
|
LoSeasonique |
Y |
|
|
Low-Ogestrel (21,28) |
Y |
|
|
Micronor |
Y |
|
|
Mircette |
Y |
|
|
Nor-QD |
Y |
|
|
Nora-BE |
Y |
|
|
Nordette (21,28) |
Y |
|
|
Ogestrel 0.5/50 |
Y |
|
|
Ortho-Cept |
Y |
|
|
Ortho-Cyclen |
Y |
|
|
Ortho-Novum 1/35 (21, 28) |
Y |
|
|
Ortho-Novum 7/7/7 (21, 28) |
Y |
|
|
Ortho Tri-Cyclen |
Y |
|
|
Ortho Tri-Cyclen Lo |
Y |
|
|
Ovcon 35 (21, 28) |
Y |
|
|
Ovcon 50 (21, 28) |
Y |
|
|
Portia 28 |
Y |
|
|
Seasonale |
Y |
|
|
Seasonique |
Y |
|
|
Sprintec |
Y |
|
|
TriNessa |
Y |
|
|
Tri-Norinyl (21, 28) |
Y |
|
|
Tri-Sprintec 28 |
Y |
|
|
Trivora |
Y |
|
|
Yasmin |
Y |
|
|
Yaz |
Y |
|
|
OTHER, SPECIFY: |
Y |
FOR EACH REPORTED DRUG ABOVE, CONTINUE WITH V4/ROW 1 THROUGH V6/ROW 3 AND SKIP TO V8/ROW 5. |
|
V20. |
What was the name of the medication? / Did you take any other medicine in this category? PROBE: READ LIST IF NECESSARY
|
NAME:_____________________ DK SKIP TO NEXT CATEGORY RF SKIP TO NEXT CATEGORY
|
|
|
ANTIBIOTICS PROMPTS: |
SELECT EACH YES: |
|
|
Amoxicillin |
Y |
|
|
Amoxil |
Y |
|
|
Augmentin |
Y |
|
|
Biaxin |
Y |
|
|
Cipro |
Y |
|
|
Ciprofloxacin |
Y |
|
|
Cleocin |
Y |
|
|
Doxycycline |
Y |
|
|
Erythromycin |
Y |
|
|
Flagyl |
Y |
|
|
Macrodantin |
Y |
|
|
Nitrofurantoin |
Y |
|
|
Penicillin |
Y |
|
|
Sulfamethoxazole/Trimethoprim |
Y |
|
|
Vancocin |
Y |
|
|
Vibramycin |
Y |
|
|
Zithromax |
Y |
|
|
Z-Pak |
Y |
|
|
OTHER, SPECIFY: |
Y |
FOR EACH REPORTED DRUG ABOVE, CONTINUE WITH V4/ROW 1-V24/ROW 4. |
|
V37. |
What was the name of the medication? / Did you take any other medicine in this category? PROBE: READ LIST IF NECESSARY |
NAME:_____________________ DK SKIP TO NEXT CATEGORY RF SKIP TO NEXT CATEGORY
|
|
|
OVER-THE-COUNTER PAIN RELIEVERS PROMPTS: |
SELECT EACH YES: |
|
|
Acetaminophen |
Y |
|
|
Advil |
Y |
|
|
Aleve |
Y |
|
|
Aspirin |
Y |
|
|
Excedrin Extra Strength Caplets/Tablets/Geltabs |
Y |
|
|
Ibuprofen |
Y |
|
|
Motrin |
Y |
|
|
Naproxen Sodium |
Y |
|
|
Tylenol |
Y |
|
|
OTHER, SPECIFY: |
Y |
FOR EACH REPORTED DRUG ABOVE, CONTINUE WITH V4/ROW 1-V24/ROW 4. |
|
V54. |
What was the name of the medication? / Did you take any other medicine in this category? PROBE: READ LIST IF NECESSARY
|
NAME:_____________________ DK SKIP TO NEXT CATEGORY RF SKIP TO NEXT CATEGORY |
|
|
PRESCRIPTION PAIN RELIEVERS |
SELECT EACH YES: |
|
|
Celebrex |
Y |
|
|
Hydrocodone Bitartrate/ APAP |
Y |
|
|
Lorcet |
Y |
|
|
Lortab |
Y |
|
|
Neurontin |
Y |
|
|
Oxycodone/Acetaminophen |
Y |
|
|
Oxycontin |
Y |
|
|
Percocet |
Y |
|
|
Roxicet |
Y |
|
|
Tramadol |
Y |
|
|
Tramadol HCL/ Acetaminophen |
Y |
|
|
Tylenol #1,#2,#3,#4 |
Y |
|
|
Ultram |
Y |
|
|
Vicodin |
Y |
|
|
OTHER, SPECIFY: |
Y |
FOR EACH REPORTED DRUG ABOVE, CONTINUE WITH V4/ROW 1-V24/ROW 4. |
|
V71. |
What was the name of the medication? / Did you take any other medicine in this category? PROBE: READ LIST IF NECESSARY |
NAME:_____________________ DK SKIP TO NEXT CATEGORY RF SKIP TO NEXT CATEGORY
|
|
|
MEDICINES TO HELP LOWER YOUR CHOLESTEROL (“STATINS”) |
SELECT EACH YES: |
|
|
Altoprev |
Y |
|
|
Atorvastatin |
Y |
|
|
Crestor |
Y |
|
|
Fluvastatin |
Y |
|
|
Lescol |
Y |
|
|
Lipitor |
Y |
|
|
Livalo |
Y |
|
|
Lovastatin |
Y |
|
|
Mevacor |
Y |
|
|
Pitavastatin |
Y |
|
|
Pravachol |
Y |
|
|
Pravastatin Sodium |
Y |
|
|
Rosuvastatin Calcium |
Y |
|
|
Simvastatin |
Y |
|
|
Zocor |
Y |
|
|
OTHER, SPECIFY: |
Y |
FOR EACH REPORTED DRUG ABOVE, CONTINUE WITH V4/ROW 1 THROUGH V6/ROW 3 AND SKIP TO V8/ROW 5.
|
|
V88. |
What was the name of the medication? / Did you take any other medicine in this category? PROBE: READ LIST IF NECESSARY
|
NAME:_____________________ DK SKIP TO NEXT CATEGORY RF SKIP TO NEXT CATEGORY
|
|
|
MEDICINES TO HELP YOU QUIT SMOKING |
SELECT EACH YES: |
|
|
Budeprion SR |
Y |
|
|
Bupropion HCL |
Y |
|
|
Chantix |
Y |
|
|
Clonidine |
Y |
|
|
Nicoderm CQ |
Y |
|
|
Nicorette Gum |
Y |
|
|
Nicotine Gum |
Y |
|
|
Nicotine Inhaler |
Y |
|
|
Nicotrol Inhaler |
Y |
|
|
Nortriptyline |
Y |
|
|
Pamelor |
Y |
|
|
Varenicline Tartrate |
Y |
|
|
Wellbutrin |
Y |
|
|
Wellbutrin XL |
Y |
|
|
Zyban |
Y |
|
|
OTHER, SPECIFY: |
Y |
FOR EACH REPORTED DRUG ABOVE, CONTINUE WITH V4/ROW 1 THROUGH V6/ROW 3 AND SKIP TO V8/ROW 5.
|
|
V105. |
What was the name of the medication? / Did you take any other medicine in this category? PROBE: READ LIST IF NECESSARY
|
NAME:_____________________ DK SKIP TO NEXT CATEGORY RF SKIP TO NEXT CATEGORY |
|
|
MEDICINES TO HELP WITH ALLERGIES OR COLD SYMPTOMS (E.G. RUNNY NOSE, COUGH) |
SELECT EACH YES: |
|
|
Afrin 12 Hour Nasal Spray |
Y |
|
|
Allegra |
Y |
|
|
Allegra D |
Y |
|
|
Benadryl |
Y |
|
|
Clarinex |
Y |
|
|
Clarinex D |
Y |
|
|
Claritin |
Y |
|
|
Claritin D |
Y |
|
|
Delsym 12 Hour Cough Relief |
Y |
|
|
Mucinex |
Y |
|
|
Mucinex Dm |
Y |
|
|
Phenylephrine |
Y |
|
|
Pseudoephedrine |
Y |
|
|
Sudafed PE Nasal Decongestant |
Y |
|
|
Sudafed Nasal Decongestant |
Y |
|
|
Zyrtec |
Y |
|
|
Zyrtec D |
Y |
|
|
OTHER, SPECIFY: |
Y |
FOR EACH REPORTED DRUG ABOVE, CONTINUE WITH V4/ROW 1-V24/ROW 4.
|
|
V122. |
What was the name of the medication? / Did you take any other medicine in this category?
|
NAME:_____________________ DK SKIP TO NEXT CATEGORY RF SKIP TO NEXT CATEGORY
|
|
|
MEDICINE TO TREAT AN INFECTION WITH A VIRUS, LIKE THE FLU (“ANTIVIRAL”) |
SELECT EACH YES: |
|
|
Acyclovir |
Y |
|
|
Amantadine |
Y |
|
|
Combivir |
Y |
|
|
Oseltamivir Phosphate |
Y |
|
|
Relenza |
Y |
|
|
Tamiflu |
Y |
|
|
Zanamivir |
Y |
|
|
OTHER, SPECIFY: |
Y |
FOR EACH REPORTED DRUG ABOVE, CONTINUE WITH V4/ROW 1-V24/ROW 4.
|
|||
|
V139. |
What was the name of the medication? / Did you take any other medicine in this category? PROBE: READ LIST IF NECESSARY |
NAME:_____________________ DK SKIP TO NEXT CATEGORY RF SKIP TO NEXT CATEGORY
|
|
|
MEDICINE TO HELP YOU SLEEP (“SLEEP AID”) |
SELECT EACH YES: |
|
|
Ambien |
Y |
|
|
Benadryl |
Y |
|
|
Compoz |
Y |
|
|
Diphenhydramine |
Y |
|
|
Doxylamine |
Y |
|
|
Eszopiclone |
Y |
|
|
Kava-Kava, Herb |
Y |
|
|
L-Tryptophan |
Y |
|
|
Lunesta |
Y |
|
|
Melatonin |
Y |
|
|
Nytol |
Y |
|
|
Prosom |
Y |
|
|
Ramelteon |
Y |
|
|
Restoril |
Y |
|
|
Rozerem |
Y |
|
|
Sleepinal |
Y |
|
|
Sominex |
Y |
|
|
Sonata |
Y |
|
|
Tryptophan |
Y |
|
|
Valerian Extract |
Y |
|
|
Zaleplon |
Y |
|
|
Zolpidem Tartrate |
Y |
|
|
Zzzquil Liquicaps Sleep-Aid |
Y |
|
|
Zzzquil Liquid Sleep-Aid |
Y |
|
|
OTHER, SPECIFY: |
Y |
FOR EACH REPORTED DRUG ABOVE, CONTINUE WITH V4/ROW 1 THROUGH V6/ROW 3 AND SKIP TO V8/ROW 5. |
|
V156. |
Which vaccines did you get? We will ask you about any COVID vaccines later. PROBE: READ LIST IF NECESSARY |
NAME:_____________________ DK SKIP TO NEXT CATEGORY RF SKIP TO NEXT CATEGORY |
|
|
VACCINES |
SELECT EACH YES: |
|
|
|
|
|
|
Chickenpox Vaccine- |
Y |
|
|
Flu Vaccine |
Y |
|
|
Hepatitis A Vaccine |
Y |
|
|
Hepatitis B Vaccine |
Y |
|
|
HPV Vaccine (Human Papillomavirus) |
Y |
|
|
Measles, Mumps, Rubella Vaccine |
Y |
|
|
Meningococcal Vaccine |
Y |
|
|
Pneumococcal Vaccine, Polyvalent |
Y |
|
|
Shingles Vaccine- |
Y |
|
|
OTHER, SPECIFY_______________________
|
Y |
|
|
|
|
|
V157. |
When did you get the [NAME OF VACCINE]?
|
a. MM/DD/YYYY or b. MONTH OF PREGNANCY(B1, P1, P2, P3) or c. HOW LONG AGO (with units for days, weeks, months, years) d. DK e. RF |
|
|
|
|
SKIP TO CONTINUE TO V171, NEXT CATEGORY. |
|
V173. |
What was the name of the medication? / Did you take any other medicine in this category? PROBE: READ LIST IF NECESSARY
|
NAME:_____________________ DK SKIP TO SPECIFIC MEDICINES RF SKIP TO SPECIFIC MEDICINES
|
|
|
MEDICINES TO TREAT NAUSEA OR VOMITING |
SELECT EACH YES: |
|
|
Benadryl |
Y |
|
|
Bonine |
Y |
|
|
Diphenhydramine |
Y |
|
|
Doxylamine |
Y |
|
|
Ginger |
Y |
|
|
Metoclopramide |
Y |
|
|
Ondansetron |
Y |
|
|
Phenergan |
Y |
|
|
Preggie Pops (Various Flavors) |
Y |
|
|
Promethazine |
Y |
|
|
Reglan |
Y |
|
|
Tigan |
Y |
|
|
Unisom Tablets |
Y |
|
|
Vitamin B6 |
Y |
|
|
Zofran |
Y |
|
|
OTHER, SPECIFY
|
Y |
FOR EACH REPORTED DRUG ABOVE, CONTINUE WITH V4/ROW 1-V24/ROW 4. |
ASK THIS SERIES FOR EACH MEDICINE USED IN V1 THROUGH V137 AND V171. NOT ASKED OF VACCINES. |
||||||||||||||
Row |
Quex # |
Question Text |
Responses |
|||||||||||
1 |
V4 V21 V38 V55 V72 V89 V106 V123 V140 V174
|
Did you already tell me about taking [MEDICATION] earlier in the interview? |
a. YES CONTINUE TO V5/ROW2 b. NO CONTINUE TO V24/ROW 4 or SKIP TO V8/ROW 5 c. DK CONTINUE TO V24/ROW 4 or SKIP TO V8/ROW 5 d. RF CONTINUE TO V24/ROW 4 or SKIP TO V8/ROW 5
|
|||||||||||
2 |
V5 V22 V39 V56 V73 V90 V107 V124 V141 V175
|
Could you please remind me of the medical condition you took this for?
|
|
|
||||||||||
3 |
V6 V23 V40 V57 V74 V91 V108 V125 V176 |
Did you take this medication for any other reasons that we have not already talked about? |
a.. YES CONTINUE TO V24/ROW 4 OR SKIP TO V8/ROW 5 b.. NO/DK/RF CONTINUE TO NEXT MEDICATION CATEGORY OR SKIP TO SPECIFIC MEDICATIONS INTRO
|
|
||||||||||
FOR ALL MEDICATION CATEGORIES, EXCEPT BIRTH CONTROL PILLS, STATINS, SMOKING CESSATION MEDICATIONS, SLEEP AIDS, AND VACCINES ASK V24/ROW 4; FOR THE AFOREMENTIONED CATEGORIES, SKIP TO V8/ROW 5. |
|
|||||||||||||
4 |
V24 V41 V58 V109 V126 V177
|
Why did you take [this medication]?
|
a. REASON:__________ b. DK c. RF |
|
||||||||||
5 |
V8 V25 V42 V59 V76 V93 V110 V127 V144 V178
|
Did you use [this medication] for the entire time from the month before your pregnancy through your third month of pregnancy?
|
a. YES SKIP TO V12/ROW 9 b. NO CONTINUE TO V9/ROW 6 c. DK CONTINUE TO V9/ROW 6 d. RF CONTINUE TO V9/ROW 6 |
|
||||||||||
6 |
V9 V26 V43 V60 V77 V94 V111 V128 V145 V179
|
When did you start using [this medication] during the month before your pregnancy through the third month of pregnancy? |
a. MM/DD/YYYY or b. MONTH OF PREGNANCY(B1, P1, P2, P3) c. DK d. RF
|
|
||||||||||
7 |
V10 V27 V44 V61 V78 V95 V112 V129 V146 V180
|
When did you use [this medication] for the last time during this time period?
|
a. MM/DD/YYYY or b. MONTH OF PREGNANCY(B1, P1, P2, P3) IF VALID STOP AND START DATE, SKIP V11/ROW 8 c. DK d. RF
|
|||||||||||
8 |
V11 V28 V45 V62 V79 V96 V113 V130 V147 V181
|
Or how long did you take [this medication]?
|
AMOUNT_______ Days Weeks Months DK RF
|
|||||||||||
9 |
V12 V29 V46 V63 V80 V97 V114 V131 V148 V182
|
How often did you use [this 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.
|
AMOUNT:__________ Per day/Per week/Per month/Per time period DK RF |
|||||||||||
10 |
V13 V30 V47 V64 V81 V98 V115 V132 V149 V183
|
Did you take the same dose 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.
|
a. YES CONTINUE TO V14/ROW 11 b. NO SKIP TO T15a/ROW 12 c. DK CONTINUE TO T14/ROW 11 d. RF CONTINUE TO T14/ROW 11 |
|||||||||||
11 |
V14 V31 V48 V65 V82 V99 V116 V133 V150 V184
|
What dose of [this medication] did you take each time you took it?
|
AMOUNT:______ DK, RF SKIP UNITS UNITS:_________ DK
SKIP TO V18/NEXT CATEGORY
|
|||||||||||
12 |
V15a V32a V49a V66a V83a V100a V117a V134a V151a V185a
|
How many different dosage amounts do you remember taking? [IF MOM KNOWS SHE TOOK MORE THAN ONE DOSAGE, BUT CAN'T REMEMBER HOW MANY, SELECT 1 FOR THE NUMBER OF DOSAGES AND REPORT THE DOSAGE INFO SHE DOES REMEMBER. YOU MAY PUT ADDITIONAL DETAILS IN A COMMENT FIELD.]
|
AMOUNT_______ RF
|
|||||||||||
13 |
V15b V32b V49b V66b V83b V100b V117b V134b V151b V185b
|
What dose of [this medication] did you take the [1st, 2nd, etc.] time?
|
AMOUNT:______ DK, RF SKIP UNITS UNITS:_________ DK
|
|||||||||||
14 |
V16 V33 V50 V67 V84 V101 V118 V135 V152 V186
|
When did you begin taking that dose?
|
a. MM/DD/YYYY or b. MONTH OF PREGNANCY(B1, P1, P2, P3) c. DK d. RF |
|||||||||||
15 |
V17 V34 V51 V68 V85 V102 V119 V136 V153 V187
|
When did you stop taking that dose?
|
a. MM/DD/YYYY or b. MONTH OF PREGNANCY(B1, P1, P2, P3) IF VALID STOP AND START DATE, SKIP V17a/ROW 16 c. DK d. RF
|
|||||||||||
16 |
V17a V34a V51a V68a V85a V102a V119a V136a V153a V187a |
Or how long did you take it?
|
AMOUNT_______ Days Weeks Months DK RF |
|||||||||||
AFTER V17, CONTINUE TO V18 AT BEGINNING OF TABLE, OR NEXT CATEGORY. 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. |
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SPECIFIC MEDICATIONS:
|
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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.
|
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|
|
During [B1] to [P4(-1)] did you take:
|
IF YES, ASK NEXT QUESTION IN ROW 17 |
IF NO, ASK NEXT DRUG |
IF DK, ASK NEXT DRUG |
IF RF, ASK NEXT DRUG |
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|
V188. |
Prozac |
Y |
N |
DK |
RF |
||||||||
|
V203. |
Wellbutrin |
Y |
N |
DK |
RF |
||||||||
|
V218. |
Paxil |
Y |
N |
DK |
RF |
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|
V233. |
Zoloft |
Y |
N |
DK |
RF |
||||||||
|
V248. |
Effexor |
Y |
N |
DK |
RF |
||||||||
|
V263. |
Celexa |
Y |
N |
DK |
RF |
||||||||
|
V278. |
Lexapro |
Y |
N |
DK |
RF |
||||||||
|
V293. |
Cymbalta |
Y |
N |
DK |
RF |
||||||||
|
V308. |
Abilify |
Y |
N |
DK |
RF |
||||||||
|
V323. |
Seroquel |
Y |
N |
DK |
RF |
||||||||
|
V338. |
Zyprexa |
Y |
N |
DK |
RF |
||||||||
|
V353. |
Depakene, Depakote, or Valproic acid |
Y |
N |
DK |
RF |
||||||||
|
V368. |
Dilantin or Phenytoin |
Y |
N |
DK |
RF |
||||||||
|
V383. |
Felbatol |
Y |
N |
DK |
RF |
||||||||
|
V398. |
Klonopin or Clonazepam |
Y |
N |
DK |
RF |
||||||||
|
V413. |
Lamictal |
Y |
N |
DK |
RF |
||||||||
|
V428. |
Phenobarbital |
Y |
N |
DK |
RF |
||||||||
|
V443. |
Topiramate or Topamax |
Y |
N |
DK |
RF |
||||||||
|
V458. |
Furadantin |
Y |
N |
DK |
RF |
||||||||
|
V473. |
Macrodantin |
Y |
N |
DK |
RF |
||||||||
|
V488. |
Qsymia |
Y |
N |
DK |
RF |
||||||||
|
V503. |
Thalidomide |
Y |
N |
DK |
RF |
||||||||
|
V518. |
Accutane/isotretinoin |
Y |
N |
DK |
RF |
||||||||
|
V533. |
CellCept |
Y |
N |
DK |
RF |
||||||||
|
V548. |
Myfortic |
Y |
N |
DK |
RF |
||||||||
|
V563. |
Cytotec |
Y |
N |
DK |
RF |
||||||||
|
V578. |
Misoprostol |
Y |
N |
DK |
RF |
||||||||
|
V593. |
Methotrexate |
Y |
N
SKIP TO V608 |
DK
SKIP TO V608 |
RF
SKIP TO V608
|
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|
|
|
|
|
|
|
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|
|
|
|
|
|
|
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ASK THIS SERIES FOR EACH MEDICATION TAKEN IN V188-V593: |
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ROW |
Quex # |
Question Text |
Responses |
|||||||||||
17 |
V189 V204 V219 V234 V249 V264 V279 V309 V324 V339 V354 V369 V384 V399 V414 V429 V444 V459 V474 V489 V504 V519 V534 V549 V564 V579 V594 |
Did you already tell me about taking [MEDICATION] earlier in the interview? |
a. YES CONTINUE TO V190/ROW 18 b. NO SKIP TO V192/ROW 20 c. DK SKIP TO V192/ROW 20 d. RF SKIP TO V192/ROW 20
|
|||||||||||
18 |
V190 V205 V220 V235 V250 V265 V280 V295 V310 V325 V340 V355 V370 V385 V400 V415 V430 V445 V460 V475 V490 V505 V520 V535 V550 V565 V580 V595 |
Could you please remind me of the medical condition you took this for?
|
|
|||||||||||
19 |
V191 V206 V221 V236 V251 V266 V281 V296 V311 V326 V341 V356 V371 V386 V401 V416 V431 V446 V461 V476 V491 V506 V521 V536 V551 V566 V581 V596 |
Did you take this medication for any other reasons that we have not already talked about? |
a. YES CONTINUE TO V192/ROW 20 b. NO SKIP TO V203/NEXT MEDICINE c. DK SKIP TO V203/NEXT MEDICINE d. RF SKIP TO V203/NEXT MEDICINE
|
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20 |
V192 V207 V222 V237 V252 V267 V282 V297 V312 V327 V342 V357 V372 V387 V402 V417 V432 V447 V462 V477 V492 V507 V522 V537 V552 V567 V582 V597 |
Why did you take [MEDICINE]? |
a. REASON:__________ b. DK c. RF
|
|||||||||||
21 |
V193 V208 V223 V238 V253 V268 V283 V298 V313 V328 V343 V358 V373 V388 V403 V418 V433 V448 V463 V478 V493 V508 V523 V538 V553 V568 V583 V598 |
Did you use [MEDICINE] for the entire time from the month before your pregnancy through your third month of pregnancy? |
a. YES SKIP TO V197/ROW 25 b. NO CONTINUE TO V194/ROW 22 c. DK CONTINUE TO V194/ROW 22 d. RF CONTINUE TO V194/ROW 22
|
|||||||||||
22 |
V194 V209 V224 V239 V254 V269 V284 V299 V314 V329 V344 V359 V374 V389 V404 V419 V434 V449 V464 V479 V494 V509 V524 V539 V554 V569 V584 V599 |
When did you start using [MEDICINE] during the month before your pregnancy through the third month of pregnancy? |
a. MM/DD/YYYY or b. MONTH OF PREGNANCY(B1, P1, P2, P3) c. DK d. RF
|
|||||||||||
23 |
V195 V210 V225 V240 V255 V270 V285 V300 V315 V330 V345 V360 V375 V390 V405 V420 V435 V450 V465 V480 V495 V510 V525 V540 V555 V570 V585 V600 |
When did you use [MEDICINE] for the last time during this time period?
|
a. MM/DD/YYYY or b. MONTH OF PREGNANCY(B1, P1, P2, P3) IF VALID STOP AND START DATE, SKIP V196/ROW 24 c. DK d. RF
|
|||||||||||
24 |
V196 V211 V226 V241 V256 V271 V286 V301 V316 V331 V346 V361 V376 V391 V406 V421 V436 V451 V466 V481 V496 V511 V526 V541 V556 V571 V586 V601 |
Or how long did you take [MEDICINE]?
|
AMOUNT_______ Days Weeks Months DK RF
|
|||||||||||
25 |
V197 V212 V227 V242 V257 V272 V287 V302 V317 V332 V347 V362 V377 V392 V407 V422 V437 V452 V467 V482 V497 V512 V527 V542 V557 V572 V587 V602 |
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.
|
AMOUNT:__________ Per day/Per week/Per month/Per time period DK RF |
|||||||||||
26 |
V198 V213 V228 V243 V258 V273 V288 V303 V318 V333 V348 V363 V378 V393 V408 V423 V438 V453 V468 V483 V498 V513 V528 V543 V558 V573 V588 V603 |
Did you take the same dose 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.
|
a. YES CONTINUE TO V199/ROW 27 b. NO SKIP TO V200a/ROW 28 c. DK CONTINUE TO V199/ROW 27 d. RF CONTINUE TO V199/ROW 27
|
|||||||||||
27 |
V199 V214 V229 V244 V259 V274 V289 V304 V319 V334 V349 V364 V379 V394 V409 V424 V439 V454 V469 V484 V499 V514 V529 V544 T559 V574 V589 V604. |
What dose of [MEDICINE] did you take each time you took it?
|
AMOUNT:______ DK, RF UNITS:_________ DK RF SKIP TO T203
|
|||||||||||
28 |
V200a V215a V230a V245a V260a V275a V290a V305a V320a V335a V350a V365a V380a V395a V410a V425a V440a V455a V470a V485a V500a V515a V530a V545a V560a V575a V590a V605a |
How many different dosage amounts do you remember taking? [If mom knows she took more than one dosage, but can't remember how many, select 1 for the number of dosages and report the dosage info she does remember. You may put additional details in a comment field.]
|
AMOUNT_______ RF
|
|||||||||||
29 |
V200b V215b V230b V245b V260b V275b V290b V305b V320b V335b V350b V365b V380b V395b V410b V425b V440b V455b V470b V485b V500b V515b V530b V545b V560b V575b V590b V605b |
What dose of [MEDICINE] did you take the [1st, 2nd, etc.] time? |
AMOUNT:______ DK, RF SKIP UNITS UNITS:_________ DK
|
|||||||||||
30 |
V201 V216 V231 V246 V261 V276 V291 V306 V321 V336 V351 V366 V381 V396 V411 V426 V441 V456 V471 V486 V501 V516 V531 V546 V561 V576 V591 V606 |
When did you begin taking that dose?
|
a. MM/DD/YYYY or b. MONTH OF PREGNANCY(B1, P1, P2, P3) c. DK d. RF
|
|||||||||||
31 |
V202 V217 V232 V247 V262 V277 V292 V307 V322 V337 V352 V367 V382 V397 V412 V427 V442 V457 V472 V487 V502 V517 V532 V547 V562 V577 V592 V607 |
When did you stop taking that dose? |
a. MM/DD/YYYY or b. MONTH OF PREGNANCY(B1, P1, P2, P3) IF VALID STOP AND START DATE, SKIP V202a/ROW 32 c. DK d. RF
|
|||||||||||
32 |
V202a V217a V232a V247a V262a V277a V292a V307a V322a V337a V352a V367a V382a V397a V412a V427a V442a V457a V472a V487a V502a V517a V532a V547a V562a V577a V592a V607a |
Or how long did you take it?
|
AMOUNT_______ Days Weeks Months DK RF
|
HERBALS: |
||||
|
V608. |
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.
|
a. YES CONTINUE TO V609 b. NO SKIP TO V615 c. DK SKIP TO V615 d. RF SKIP TO V615
|
|
|
V609. |
Between [START DATE OF B1] to [P4(-1)END DATE OF P3] what herbs or folk medicines did you take? / Anything else?
|
HERBALS_____________ DK SKIP TO V615 RF SKIP TO V615 |
|
ASK THIS SERIES FOR EACH HERBAL PRODUCT USED: |
||||
|
V610. |
Did you use [Name of herb/medicine] for the entire time from the month before your pregnancy through your third month of pregnancy? |
|
|
|
V611. |
When did you start using [Name of herb/medicine] during the month before your pregnancy through the third month of pregnancy? |
a. MM/DD/YYYY or b. MONTH OF PREGNANCY(B1, P1, P2, P3) c. DK d. RF
|
|
|
V612. |
When did you use [Name of herb/medicine] for the last time during this time period? |
a. MM/DD/YYYY or b. MONTH OF PREGNANCY(B1, P1, P2, P3) IF VALID STOP AND START DATE, SKIP V613 c. DK d. RF
|
|
|
V613. |
Or how long did you take [Name of herb/medicine]? |
AMOUNT_______ Days Weeks Months DK RF
|
|
|
V614. |
How often did you use [Name of herb/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. |
AMOUNT:__________ Per day/Per week/Per month/Per time period DK RF |
VITAMINS:
|
|||
Now I’m going to ask you about your vitamin use before and during your pregnancy.
|
|||
|
V615. |
From the month before you became pregnant to the end of the third month of pregnancy, which would be [B1] to [P4(-1)], did you take any multivitamins, prenatal vitamins, or folic acid supplements?
|
|
|
V616. |
Did you begin using it before your pregnancy began? |
|
|
V617. |
Did you continue to use it after your pregnancy began? |
|
|
V618. |
Did you begin using it in the first month of pregnancy? |
|
|
V619. |
Did you begin using it after the first month of pregnancy? |
|
Catch-All Medication Question
|
|||
|
V620. |
During this time period, did you take any medications, remedies, or treatments that we haven’t already talked about? For example, Ozempic or Wegovy, or over the counter or prescription medications for constipation (such as prucalopride)? We will ask you about any COVID vaccines later./Any others? |
|
|
V621. |
What medicine did you take?
|
SPECIFY______________ DK SKIP TO NEXT SECTION RF SKIP TO NEXT SECTION
|
|
V622. |
Why did you take [ANSWER T621]? |
a. REASON:__________ b. DK c. RF
|
|
V623. |
Did you use [MEDICINE, ANSWER 621] for the entire time from the month before your pregnancy through your third month of pregnancy?
|
|
|
V624. |
When did you start using [MEDICINE, ANSWER 621] during the month before your pregnancy through the third month of pregnancy? |
a. MM/DD/YYYY or b. MONTH OF PREGNANCY(B1, P1, P2, P3) c. DK d. RF
|
|
V625. |
When did you use [MEDICINE, ANSWER 621] for the last time during this time period? |
a. MM/DD/YYYY or b. MONTH OF PREGNANCY(B1, P1, P2, P3) IF VALID STOP AND START DATE, SKIP V626 c. DK d. RF |
|
V626. |
Or how long did you take [MEDICINE, ANSWER T621]? |
AMOUNT_______ Days Weeks Months DK RF |
|
V627. |
How often did you use [MEDICINE, ANSWER T621during 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.
|
AMOUNT:__________ Per day/Per week/Per month/Per time period DK RF |
|
V628. |
Did you take the same dose of [MEDICINE, ANSWER T621] each time you took it throughout [B1] to [P4(-1)]? |
|
|
V629. |
What dose of [MEDICINE, ANSWER T621] did you take each time you took it? |
AMOUNT:______ DK, RF SKIP UNITS UNITS:_________ DK RF
SKIP TO NEXT SECTION
|
|
V630a. |
How many different dosage amounts do you remember taking?
|
AMOUNT_______ RF
|
|
V630b. |
What dose of [MEDICINE, ANSWER T621] did you take the [1st, 2nd, etc.] time? |
AMOUNT:______ DK, RF SKIP UNITS UNITS:_________ DK RF
|
|
V631. |
When did you begin taking that dose? |
a. MM/DD/YYYY or b. MONTH OF PREGNANCY(B1, P1, P2, P3) c. DK d. RF
|
|
V632. |
When did you stop taking that dose? |
a. MM/DD/YYYY or b. MONTH OF PREGNANCY(B1, P1, P2, P3) IF VALID STOP AND START DATE, SKIP V632b c. DK d. RF
|
|
V632b. |
OR how long did you take it? |
AMOUNT_______ Days Weeks Months DK RF
|
COVID-19 VACCINE |
|||
|
V639 |
Have you ever received a COVID vaccine? |
a. YES CONTINUE TO V640 b. NO SKIP TO NEXT SECTION c. DK SKIP TO NEXT SECTION
d. RF SKIP TO NEXT SECTION |
|
V640 |
How many COVID-19 vaccine doses do you remember getting? This includes any boosters you may have received.
|
a. Number: ________________________ [IF DK NUMBER, SELECT 1 AND ASK MOM FOR DETAILS ABOUT 1 VACCINE SHE REMEMBERS.] [ASK V641-V642 FOR EACH VACCINE DOSE LISTED.] |
For each vaccine dose that the mother reported, ask the following questions: |
||
V641 |
When did you get the [1st/2nd/3rd/etc.] vaccine dose? |
a. MM/DD/YYY or b. Before B1 OR c. MONTH OF PREGNANCY (B1-P9) d. After P9 OR e. HOW LONG AGO (with units for days, weeks, months, years) f. Age in years OR g. DK h. RF |
V642 |
Do you know what type of COVID-19 vaccine you received? |
a. YES CONTINUE TO V642a. b. NO RECORD NEXT DOSE INFORMATION OR GO TO NEXT SECTION |
V642a. |
Which brand of COVID-19 vaccine did you receive? |
a. Pfizer-BioNTech b. Moderna c. Johnson and Johnson (Janssen) d. One of the brands that require two initial shots, but not sure which brand c. Other (SPECIFY): _______ d. DK f. RF |
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 [P4(-1)]. 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.
W1. 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?
YES
NO
DK
RF
W2. During this same time period, did you or your husband or partner have any serious legal or financial problems?
YES
NO
DK
RF
W3. 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”]
YES
NO
DK
RF
W4. 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”]
YES
NO
DK
RF
W5. 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”]
YES
NO
DK
RF
W6. 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?
YES
NO
DK
RF
W7. 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?
YES
NO
DK
RF
W8. 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?
YES
NO
DK
RF
W9. During this same time period, how often did you feel nervous and stressed? Would you say…[READ CHOICES]
Never
Almost never
Sometimes
Somewhat often
Very often
DK
RF
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.
X1. 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)
Days Per Week: ______
IF 0 SKIP TO INTRODUCTION TO X3
IF 1 – 7 CONTINUE TO X2
DK SKIP TO INTRODUCTION TO X3
RF SKIP TO INTRODUCTION TO X3
X2. 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)] [REMINDER: IF THEY ANSWER LESS THAN 10 MINUTES, REMIND THEM WE ARE ONLY INTERESTED IN ACTIVITIES DONE AT LEAST 10 MINUTES AT A TIME.]
Hours Per Day:__________ SKIP TO INTRODUCTION TO X3
Minutes Per Day:__________ SKIP TO INTRODUCTION TO X3 [REMINDER: IF THEY ANSWER LESS THAN 10 MINUTES, REMIND THEM THAT WE ARE ONLY INTERESTED IN ACTIVITIES DONE AT LEAST 10 MINUTES AT A TIME.]
DK CONTINUE TO X2b
RF CONTINUE TO X2b
X2b. In the three months before you became pregnant, how much time in total would you spend in a typical week doing vigorous physical activities? [PROBE: Think only about those physical activities that you do for at least 10 minutes at a time.]
Hours:__________
Minutes:_________
DK
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 do for at least 10 minutes at a time.
X3. 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 (P3). Child care includes dressing, bathing, grooming, feeding, or occasional lifting.]
Days Per Week:__________
IF 0 SKIP TO INTRODUCTION TO X5
IF 1 – 7 CONTINUE TO X4
DK SKIP TO INTRODUCTION TO X5
RF SKIP TO INTRODUCTION TO X5
X4. 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)] [REMINDER: IF THEY ANSWER LESS THAN 10 MINUTES, REMIND THEM WE ARE ONLY INTERESTED IN ACTIVITIES DONE AT LEAST 10 MINUTES AT A TIME.]
Hours Per Day:__________ SKIP TO INTRODUCTION TO X5
Minutes Per Day:__________ SKIP TO INTRODUCTION TO X5 [REMINDER: IF THEY ANSWER LESS THAN 10 MINUTES, REMIND THEM THAT WE ARE ONLY INTERESTED IN ACTIVITIES DONE AT LEAST 10 MINUTES AT A TIME.]
DK CONTINUE TO X4b
RF CONTINUE TO X4b
X4b. 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? PROBE: Think only about those physical activities that you do for at least 10 minutes at a time.
HOURS:__________
MINUTES:__________
DK
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.
X5. 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)]
Days Per Week:____________
IF 0 SKIP TO INTRODUCTION TO X7
IF 1 – 7 CONTINUE TO X6
DK or RF SKIP TO INTRODUCTION TO X7
X6. How much time did you usually spend walking on one of those days? (P6) [REMINDER: IF THEY ANSWER LESS THAN 10 MINUTES, REMIND THEM WE ARE ONLY INTERESTED IN ACTIVITIES DONE AT LEAST 10 MINUTES AT A TIME.]
Hours Per Day:__________ SKIP TO INTRODUCTION TO X7
Minutes Per Day:__________ SKIP TO INTRODUCTION TO X7 [REMINDER: IF THEY ANSWER LESS THAN 10 MINUTES, REMIND THEM WE ARE ONLY INTERESTED IN ACTIVITIES DONE AT LEAST 10 MINUTES AT A TIME.]
DK or RF CONTINUE TO X6b
X6b. In the three months before you became pregnant, what is the total amount of time you spent walking in a typical week?
Hours:__________
Minutes:__________
DK
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.
X7. 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)]
Hours Per Day:__________ SKIP TO NEXT SECTION
Minutes Per Day:__________ SKIP TO NEXT SECTION
DK RF CONTINUE TO X7b
X7b. What is the total amount of time you spent sitting on a typical Wednesday? PROBE: [Include time spent lying down (awake) as well as sitting.]
Hours:__________
Minutes:__________
DK
RF
Now I have some questions about weight changes before [your pregnancy with [NOIB]; TAB: your pregnancy that ended on [DOIB/DOPT]]. {IF MOM’S RESPONSE SEEMS ILLOGICAL, VERIFY HER RESPONSE.) (IF MOM DOESN'T KNOW HEIGHT: Sometimes your height is on your driver's license or your identification card. Do you need a moment to check one of these for your height?) (IF MORE COMFORTABLE WITH METRIC: Do you know your height in centimeters?)
Y1. What is your height without shoes?
Feet:__________
Inches:__________ OR
Centimeters:__________
DK
RF
Y2. How much did you weigh before [your pregnancy with [NOIB]; TAB: your pregnancy]?
WEIGHT:__________
Pounds
Kilograms
DK
RF
Y3. Not including pregnancy, when you gain weight, where on your body do you mostly add the weight? [READ OPTIONS A-D]:
Waist and/or upper body?
Hips, bottom and/or upper thighs?
Evenly over your body?
Don’t gain weight?
DK
RF
Y4. Which describes the underlying shape of your body, regardless of weight gain or loss?
[READ OPTIONS A-C]:
You carry most of your weight around your waist and/or upper body (apple shaped)?
You carry most of your weight around your hips, bottom, or upper thighs (pear shaped)?
You carry most of your weight evenly over your body?
DK
RF
Y5. What is the most you have ever weighed outside of pregnancy?
WEIGHT:__________
POUNDS
KILOGRAMS
DK
RF
Y6. What was your age when you were that weight?
AGE:__________
DK
RF
Y7. What is the least you have weighed outside of pregnancy in the last 5 years?
WEIGHT:__________
POUNDS
KILOGRAMS
DK
RF
Y8. What was your age when you were that weight?
AGE:__________
DK
RF
Y9. In the year before [your pregnancy with [NOIB]; TAB: your pregnancy], did your weight change by more than 20 pounds/9 kilograms?
YES CONTINUE TO Y10
NO SKIP TO Y12
DK SKIP TO Y12
RF SKIP TO Y12
Y10. How much did your weight change? [NOTE: REFERENCE WEIGHT = THEIR WEIGHT AT THE START OF THEIR PREGNANCY]
AMOUNT:__________ DK RF
POUNDS
KILOGRAM
Y11. Was this change related to a pregnancy?
YES
NO
DK
RF
Y12. Have you ever had surgery to help you lose weight? This does not include cosmetic procedures such as liposuction.
YES CONTINUE TO Y13
NO SKIP TO Y14
DK SKIP TO Y14
RF SKIP TO Y14
Y13. What procedure did you have? SELECT ALL THAT APPLY
Gastric bypass
Belly band / lap band / gastric banding
Gastric sleeve / sleeve gastrectomy
OTHER (SPECIFY): _______
DK
RF
Y14. In the month before your pregnancy through the end of your third month of pregnancy, that is [B1] to [P4 (-1)], did you follow any of the following types of diet? [READ LIST. INDICATE ALL THAT APPLY]
Vegetarian
Vegan
Low carbohydrate / low “carb”
Low fat
Gluten free
Dairy free
OTHER (SPECIFY):__________
NONE OF THE ABOVE
DK
RF
The next set of questions is about dental visits you may have had right before and early in your pregnancy.
During the month before your pregnancy through the third month of your pregnancy, that is from [B1] to [P4 (-1)] did you go to the dentist or other dental specialist, such as a periodontist or oral surgeon?
YES CONTINUE TO Z2
NO SKIP TO NEXT SECTION
DK SKIP TO NEXT SECTION
RF SKIP TO NEXT SECTION
How many times did you go to the dentist during that time period?
NUMBER:__________ DK RF
What dental procedures did you receive at that visit/those visits? IF DON’T KNOW GIVE OPTIONS. CAN REPORT MULTIPLE PROCEDURES. X-RAYS WILL BE REPORTED IN Z4. (NEXT QUESTION).
Teeth cleaning and/or routine checkup
Cavity filled or dental filling placed CONTINUE WITH Z4 – Z19, BUT SKIP Z20 AND GO TO Z21
Root canal
Teeth whitening
Teeth removal (e.g. wisdom teeth)
Place dental crown
Dental bridge
Oral surgery
OTHER (SPECIFY):__________
DK
RF
Did you have any x-rays taken during the visit/visits?
YES CONTINUE TO Z5
NO SKIP TO Z6
DK SKIP TO Z6
RF SKIP TO Z6
Did they provide a protective cover for your body during the x-rays?
Yes for all X-rays
Yes for some, but not all X-rays
No for all X-rays
DK
RF
Did you receive a shot to numb your mouth during the visit/at least one of the visits (an injectable anesthetic)?
YES
NO
DK
RF
Did you receive “laughing gas”, also called nitrous oxide, during the visit/ at least one of the visits?
YES
NO
DK
RF
Were you prescribed any medications for your dental visit/visits or at the visit/visits? (IF MOM PRESCRIBED DRUG BUT NEVER TOOK IT, SELECT "YES”.)
YES CONTINUE TO Z9
NO SKIP TO Z14
DK SKIP TO Z14
RF SKIP TO Z14
What medicine were you prescribed / Anything else? [PROBE: IF CAN’T RECALL, READ FROM LIST. MULTIPLE MEDICATIONS CAN BE REPORTED.]
Acetaminophen w/Codeine
Amoxicillin
Amoxil
Clindamycin
Chlorhexidine Gluconate
Diazepam
Doxycycline
Erythromycin
Fluoride Phosphate, Acidulated
Hydrocodone/Ibuprofen
Hydrocodone Bitartrate/ APAP
Hydrocodone , product unknown
Kenalog in Orabase
Magic mouthwash
Orabase
Orafate Paste
Oxycodone with Acetaminophen
Penicillin
Percocet
Periostat
Tylenol #1,#2,#3,#4
Valium
Vicodin
Vicoprofen
Pain Medication W/Codeine Unknown
OTHER (SPECIFY):__________
DK SKIP TO Z14
RF SKIP TO Z14
ASK SERIES FOR EACH DRUG in Z9:
Z10. When did you start taking [ANSWER X9]? [CAN USE DK OR RF FOR MM OR DD OR YY]
MM/DD/YYYY or
MONTH OF PREGNANCY(B1, P1, P2, P3)
DIDN’T TAKE IT (ONLY RECEIVED PRESCRIPTION; DIDN’T FILL IT)
DK
RF
When did you use [ANSWER Z9] for the last time during this time period? [CAN USE DK OR RF FOR MM OR DD OR YY]
MM/DD/YYYY or
MONTH OF PREGNANCY(B1, P1, P2, P3) IF VALID RESPONSE TO Z10 and Z11, SKIP Z12
DK
RF
OR
How long did you take it?
AMOUNT:__________ DK RF
Days
Weeks
Months
How often did you use [ANSWER] 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.
AMOUNT:__________ Per Day/Per Week/Per Month/Per Time Period/DK/RF
Did you take any over-the-counter medicines just before your dental visit/visits or just after your visit/visits?
YES CONTINUE TO Z15
NO SKIP TO X20 OR Z21A
DK SKIP TO X20 OR Z21A
RF SKIP TO X20 OR Z21A
What did you take? / Anything else? [IF CAN’T RECALL, READ FROM LIST. MULTIPLE MEDICATIONS CAN BE REPORTED.]
Acetaminophen
Advil
Anbesol Liquid /Gel
Aspirin
Bayer Aspirin
Chloraseptic Liquid/Spray
Ibuprofen
Motrin
Nuprin
Ora-jel
Tylenol
Xylocaine
OTHER (SPECIFY):__________
DK SKIP TO Z20/Z21a
RF SKIP TO Z20/Z21a
ASK SERIES BELOW FOR EACH DRUG:
When did you start taking [ANSWER X15] for your dental visit? [CAN USE DK OR RF FOR MM OR DD OR YY]
MM/DD/YYYY or
MONTH OF PREGNANCY(B1, P1, P2, P3)
DK
RF
When did you use [ANSWER Z15] for the last time during this time period? [CAN USE DK OR RF FOR MM OR DD OR YY]
MM/DD/YYYY or
MONTH OF PREGNANCY(B1, P1, P2, P3) IF VALID RESPONSE TO Z16 and Z17, SKIP Z18
DK
RF
OR
How long did you take it?
AMOUNT:__________ DK RF
Days
Weeks
Months
How often did you use [ANSWER X15] 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.
AMOUNT:__________ Per Day/Per Week/Per Month/Per Time Period/DK/RF
IF THEY REPORTED HAVING A CAVITY FILLED IN Z3 SKIP Z20 AND CONTINUE TO Z21a.
IF THEY DID NOT REPORT HAVING A CAVITY FILLED IN Z3: Did you have any cavities filled or dental fillings placed during the visit/visits?
YES CONTINUE TO Z21a
NO SKIP TO NEXT SECTION
DK SKIP TO NEXT SECTION
RF SKIP TO NEXT SECTION
Z21a. During how many of the visits did you have a dental filling placed?
NUMBER:__________ DK RF
Z21b. During the [1st, 2nd, etc.] visit in which you had a dental filling placed, how many dental fillings do you remember having placed? (IF MOM KNOWS SHE HAD AT LEAST ONE FILLING BUT DOESN'T KNOW HOW MANY, SELECT 1 AND DESCRIBE SITUATION IN COMMENTS)
NUMBER:__________ DK RF
Z22. What was the date of the [1st, 2nd, etc.] visit when the filling(s) was/were placed? [ASK FOR EACH VISIT IF MULTIPLE VISITS]
MM/DD/YYYY OR
MONTH OF PREGNANCY(B1, P1, P2, P3)
DK
RF
Z23. 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.]
Amalgam / silver-colored
Composite resin / tooth-colored
DK
RF
The next questions are about cigarette use.
At any time from 1 month before you became pregnant to the end of your third month of pregnancy, that is from [B1] to [P4 (-1)] did you smoke cigarettes? WE ARE ONLY INTERESTED IN TOBACCO CIGARETTES [PROBE: Even if you did not smoke the whole time, we are interested in whether you smoked any cigarettes at all during this time period.]
YES CONTINUE TO AA2
NO SKIP TO AA3
DK SKIP TO AA3
RF SKIP TO AA3
During which months did you smoke? INDICATE ALL THAT APPLY
B1
P1
P2
P3
DK
RF
AA3. At any time from 1 month before you became pregnant to the end of your third month of pregnancy did you use electronic cigarettes, or any other electronic nicotine vaping devices? [PROBE: Some examples of electronic vaping devices include vape pens, mods, tank systems, e-hookahs, e-cigars, e-pipes, and ENDS. Even if you did not smoke the whole time, we are interested in whether you smoked any e-cigarettes at all during this time period.]
YES CONTINUE TO AA4
NO SKIP TO NEXT SECTION
DK SKIP TO NEXT SECTION
RF SKIP TO NEXT SECTION
AA4. How often did you use electronic cigarettes during the month before through the third month of pregnancy?
Every Day
Some Days
Rarely
DK
RF
The next questions are about marijuana cannabis products, sometimes called pot, weed, hashish, or concentrates. Some of the ways these products can be used are smoking (such as in joints, pipes, bongs, blunts, or hookahs), vaping (using vape pens, dab pens, tabletop vaporizers, or portable vaporizers), dabbing, eating or drinking, or applying as a lotion.
BB1. At any time from 1 month before you became pregnant to the end of your third month of pregnancy, that is from [B1] to [P4(-1)] did you use any form of marijuana? [PROBE: Even if you did not use any of these products the whole time, we are interested in whether you used any of them at all during this time period.]
a. YES CONTINUE TO BB2
b. NO SKIP TO NEXT SECTION
c. DK SKIP TO NEXT SECTION
d. RF SKIP TO NEXT SECTION
BB2. During the month before through your third month of pregnancy, in which of the following ways did you use marijuana or any cannabis product? [SELECT ALL THAT APPLY]
a. Smoking IF YES, ASK BB3
b. Vaping IF YES, ASK BB6
c. Dabbing IF YES, ASK BB7
d. Eating IF YES, ASK BB4
e. Drinking IF YES, ASK BB5
f. Putting drops, strips, lozenges, or sprays in your mouth or under your tongue IF YES, ASK BB8
g. Applying lotion, cream, or patches to your skin IF YES, ASK BB8
h. Taking pills IF YES, ASK BB8
i. Some other way? CONTINUE TO BB2a.
BB2a. How did you use it? CONTINUE TO BB8
j. DK
BB3. On average, how often did you smoke marijuana during the month before through the third month of pregnancy? You can say the number of times per day, per week, per month, or during the entire 4 month period.
Enter frequency:
Select time period:
PER DAY
PER WEEK
PER MONTH
PER ENTIRE 4 MONTH PERIOD
BB4. On average, how often did you eat foods containing marijuana during the month before through the third month of pregnancy? You can say the number of times per day, per week, per month, or during the entire 4 month period.
Enter frequency:
Select time period:
PER DAY
PER WEEK
PER MONTH
PER ENTIRE 4 MONTH PERIOD
BB5. On average, how often did you drink something containing marijuana during the month before through the third month of pregnancy? You can say the number of times per day, per week, per month, or during the entire 4 month period.
Enter frequency:
Select time period:
PER DAY
PER WEEK
PER MONTH
PER ENTIRE 4 MONTH PERIOD
BB6. On average, how often did you vape marijuana during the month before through the third month of pregnancy? You can say the number of times per day, per week, per month, or during the entire 4 month period.
Enter frequency:
Select time period:
PER DAY
PER WEEK
PER MONTH
PER ENTIRE 4 MONTH PERIOD
BB7. On average, how often did you dab marijuana during the month before through the third month of pregnancy? You can say the number of times per day, per week, per month, or during the entire 4 month period.
Enter frequency:
Select time period:
PER DAY
PER WEEK
PER MONTH
PER ENTIRE 4 MONTH PERIOD
BB8. On average, how often did you use marijuana through [RESPONSE TO “OTHER”] during the month before through the third month of pregnancy? You can say the number of times per day, per week, per month, or during the entire 4 month period.
Enter frequency:
Select time period:
PER DAY
PER WEEK
PER MONTH
PER ENTIRE 4 MONTH PERIOD
BB9. Why did you use marijuana products during this 4 month time period? [READ ALL OPTIONS; SELECT ALL THAT APPLY]
a. To relieve nausea
b. To relieve vomiting
c. To relieve stress or anxiety
d. To relieve symptoms of a chronic condition
e. To relieve pain
f. For fun or to relax
g. Some other reason
i. SPECIFY:_________________________________________________
Now I’m going to ask you some questions about drinking alcoholic beverages.
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?
YES CONTINUE TO CC2
NO SKIP TO NEXT SECTION
DK SKIP TO NEXT SECTION
RF SKIP TO NEXT SECTION
During the month before [your pregnancy with [NOIB]; the affected pregnancy] through the third month of pregnancy, which months did you drink any alcoholic beverages? INDICATE ALL THAT APPLY
B1
P1
P2
P3
DK
RF
What was the greatest number of drinks you had on one occasion from the beginning of your pregnancy through the end of your third month of pregnancy? We define one drink as one beer, one glass of wine, one mixed drink, or one shot of liquor.
NUMBER:__________ DK RF
We would like to know the address at which you lived when [you became pregnant with [NOIB]; TAB: the affected pregnancy began] so that we can study possible environmental exposures.
What is your current address? [REMEMBER TO ASK ABOUT AN APARTMENT NUMBER IF NONE GIVEN]
ADDRESS:__________ DK RF
Do you currently live at the same address that you did at the time [you became pregnant with [NOIB]; TAB: the pregnancy began]?
YES SKIP TO NEXT SECTION
NO CONTINUE TO QUESTION DD3
DK SKIP TO NEXT SECTION
RF SKIP TO NEXT SECTION
DD3. What was your address at the time [your pregnancy with [NOIB]; TAB: the pregnancy] began? This would be on or around [START DATE OF P1]. [REMEMBER TO ASK ABOUT AN APARTMENT NUMBER IF NONE GIVEN]
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.
From 1 month before you became pregnant to the end of your third month of pregnancy, that is from [B1] to [P4 (-1)] did you have a job?
YES SKIP TO EE4
NO CONTINUE TO EE2
DK CONTINUE TO EE2
RF CONTINUE TO EE2
Were you [READ CHOICES] or did you do something else?
A homemaker/parent SKIP TO NEXT SECTION
A student GO TO EE3
Disabled SKIP TO NEXT SECTION
Unemployed / in between jobs SKIP TO NEXT SECTION
OTHER (SPECIFY):__________ SKIP TO NEXT SECTION
DK or RF SKIP TO NEXT SECTION
IF STUDENT: From 1 month before you became pregnant to the end of your third month of pregnancy, that is from [B1] to [P4(-1)] 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?
YES CONTINUE TO EE4
NO SKIP TO NEXT SECTION
DK SKIP TO NEXT SECTION
RF SKIP TO NEXT SECTION
Did you hold a job during that time in one of the following categories? If your job could fit into more than one category, please choose the ONE category that best describes how you spent most of your time at that job. If you had multiple jobs, please pick the best category for each job. [READ CHOICES. SELECT MULTIPLE IF MULTIPLE JOBS.]:
a. In the healthcare field, specifically as a healthcare professional providing direct patient care, or providing healthcare support such as diagnostic testing?
b. On a farm, ranch, orchard, or in a greenhouse?
c. As a janitor, housekeeper, maid, or other cleaning staff?
d. As a hairdresser, cosmetologist, or nail technician?
e. As a teacher or teaching assistant?
f. In a restaurant, café, or coffee shop?
g. In an office setting, performing primarily office, administrative, or computer work
h. As an electronic equipment operator in a call center, phone bank, or as a dispatcher?
i. NONE OF THE ABOVE
j. DK
k. RF
IF ANY YES, QUEUE REQUEST AT END OF INTERVIEW FOR ON-LINE FOLLOW-UP QUESTIONS
EE5. Now think about all the jobs, paid or volunteer, you held from [B1] to [P4 (-1)]. What kind of a company did you work for? Please be as specific as possible. (What did your company make or do?) [PROBE: LIST ALL EMPLOYERS, INCLUDING “SELF EMPLOYED”.]
SPECIFY:__________________________________
DK IF MOTHER RESPONDS DK, ENTER UNKNOWN IN RESPONSE BOX.
RF
EE6. At the company that did [BB5 RESPONSE], what was your job title there? [ASK FOR EACH EMPLOYER]
SPECIFY:__________________________________ DK RF
EE7. At the company that did [BB5 RESPONSE], describe what you did and how you did it. What were your main activities or duties? Anything else? [ASK FOR EACH EMPLOYER]
SPECIFY:___________________________________
DK
RF
Now I will be asking about your ethnic background.
Were you born in the U.S.?
YES SKIP TO FF4
NO CONTINUE TO FF2
DK SKIP TO FF4
RF SKIP TO FF4
Where were you born?
COUNTRY:__________DK RF
OTHER (SPECIFY):__________
How many years have you lived in the US?
YEARS:__________ DK RF
What language do you usually speak at home? [READ FROM LIST ONLY IF NECESSARY TO CLARIFY]
LANGUAGE:__________DK RF
OTHER (SPECIFY):________
Are you Hispanic or Latina?
YES CONTINUE TO FF6
NO SKIP TO FF7
DK SKIP TO FF7
RF SKIP TO FF7
Which Hispanic or Spanish group do you consider yourself a member of? [PROBE: Mexican, Puerto Rican, Salvadoran, Honduran, Colombian, Peruvian, Guatemalan, Spanish, Central American, South American, etc.?]
GROUP:__________ DK RF
OTHER
(SPECIFY):________
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.
American Indian or Alaska Native ASK FF9
Asian CONTINUE TO FF8
Black or African American SKIP TO FF10, unless (FF7a), (FF7b), or (FF7d) also selected
Native Hawaiian or Other Pacific Islander CONTINUE TO FF8
White SKIP TO FF10, unless (FF7a), (FF7b), or (FF7d) also selected
DK SKIP TO FF10
RF SKIP TO FF10
IF FF7 = b OR d: What country? PROBE: Referring to Asian, Native Hawaiian or other Pacific Island countries
COUNTRY:__________ DK RF
OTHER (SPECIFY):_________
IF FF7 = a: What tribe do you consider yourself a member of?
TRIBE:__________ DK RF
OTHER (SPECIFY):________
What was the highest grade or year of school or college that you had completed [at the time [NOIB] was born; TAB: by [DOIB/DOPT]]? [PROBE: IF RESPONDENT HESITATES, BEGIN READING CATEGORIES].
No formal schooling
1-6 years
7-8 years
9-11 years
12 years, completed high school or equivalent
1-3 years college
Completed technical college
4 years college or Bachelor’s degree
Master’s degree
Advanced degree (MD, PhD, JD)
DK
RF
IF THE FATHER IS UNKNOWN, SKIP TO NEXT SECTION
The next few questions are about [[NOIB]’s; TAB: the] biological or natural father.
Was he born in the U.S.?
YES SKIP TO FF14
NO CONTINUE TO FF12
DK SKIP TO FF14
RF SKIP TO FF14
Where was he born?
COUNTRY:__________ DK RF
OTHER (SPECIFY):_________
How many years has he lived in the U.S.?
YEARS:__________ DK RF
Is the father Hispanic or Latino?
Yes ASK FF15
NO SKIP TO FF16
DK SKIP TO FF16
RF SKIP TO FF16
Which Hispanic or Spanish group does he consider himself a member of? [PROBE: Mexican, Puerto Rican, Salvadoran, Honduran, Colombian, Peruvian, Guatemalan, Spanish, Central American, South American, etc.?]
GROUP:__________ DK RF
OTHER (SPECIFY):__________
How would you describe his race? I’m going to read you a list and then please tell me all categories that apply to him. You can select more than one category.
American Indian or Alaska Native ASK FF18
Asian ASK FF17
Black or African American SKIP TO FF19, UNLESS (FF16a), (FF16b), OR (FF16d) ALSO SELECTED
Native Hawaiian or Other Pacific Islander ASK FF17
White SKIP TO FF19, UNLESS (FF16a), (FF16b), OR (FF16d) ALSO SELECTED
DK SKIP TO FF 19
RF SKIP TO FF19
IF FF16 = b or d: What country? [PROBE: Referring to Asian, Native Hawaiian or other Pacific Island countries.]
COUNTRY:__________ DK RF
OTHER (SPECIFY):__________
IF FF16 = a: What tribe does he consider himself a member of?
TRIBE:__________ DK RF
OTHER (SPECIFY):__________
What was the highest grade or year of school or college that he had completed [at the time [NOIB] was born; TAB: by [DOIB/DOPT]]? [IF RESPONDENT HESITATES, BEGIN READING CATEGORIES.]
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).
In the month before your pregnancy began, were you covered by health insurance or some other kind of health care plan?
YES CONTINUE TO GG2
NO SKIP TO GG3
DK SKIP TO GG3
RF SKIP TO GG3
What was the name of your insurance? / Any other insurance? [PROBE: PROVIDE EXAMPLE IF NEEDED: Blue Cross/Blue Shield, Wellpoint, UnitedHealth, Wellmark, Medicaid, Medicare, Tricare]
NAME:__________ DK RF
During your pregnancy, were you covered by health insurance or some other kind of health care plan?
YES, for the entire pregnancy CONTINUE TO GG4
YES, for part of the pregnancy CONTINUE TO GG4
NO SKIP TO NEXT SECTION
DK SKIP TO NEXT SECTION
RF SKIP TO NEXT SECTION
What was the name of your insurance? / Any other insurance? [PROBE: PROVIDE EXAMPLES IF NEEDED: Blue Cross/Blue Shield, Wellpoint, UnitedHealth, Wellmark, Medicaid, Medicare, Tricare]
NAME:__________ DK RF
IF THE MOTHER REPORTED ONE OF THE OCCUPATIONAL CATEGORIES OF INTEREST, ASK HH1.
OTHERWISE, BEGIN WITH HH4.
We would like to get some additional information about your activities at the job you had during the month before your pregnancy through your third month of pregnancy. 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?
YES CONTINUE TO HH2
NO SKIP TO HH3b
DK SKIP TO HH3b
What is your email address, so that we can send you a link to the questionnaire?
REMINDER: READ BACK EMAIL ADDRESS
EMAIL ADDRESS 1:______________________________
EMAIL ADDRESS 2:______________________________
EMAIL ADDRESS 3:______________________________
DK
HH3a. 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?
YES SKIP TO HH6
NO SKIP TO HH6
DK SKIP TO HH6
HH3b. IF EE1 = NO OR DK: 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?
YES SKIP TO HH5
NO SKIP TO HH6
DK SKIP TO HH6
HH4. IF MOTHER WAS NOT ASKED ABOUT EMAIL ADDRESS IN EE1-EE3 (DID NOT SELECT AN OCCUPATION OF INTEREST): 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?
YES CONTINUE TO HH5
NO SKIP TO HH6
DK SKIP TO HH6
HH5. What is your email address?
REMINDER: READ BACK EMAIL ADDRESS
EMAIL ADDRESS 1:______________________________
EMAIL ADDRESS 2:______________________________
EMAIL ADDRESS 3:______________________________
DK
HH6. In case we need to get in touch with you in the future, would you be willing to give us the name, address and phone number 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.
YES CONTINUE TO HH7
NO SKIP TO HH8
DK SKIP TO HH8
HH7. Contact information
PREFIX: Ms, Mrs, Mr, Dr
FIRST NAME:_______________________
LAST NAME:________________________
RELATIONSHIP:______________________
HOME PHONE:______________________
WORK PHONE:______________________
STREET/APARTMENT:________________
CITY/STATE/ZIP:_____________________
COUNTRY:_______________
DK
RF
FOR HH8, INTERVIEWERS WILL NEED TO USE STATE AND INFANT STATUS TO DETERMINE WHICH SCRIPT TO USE:
HH8. FOR IA, NC, and TX CENTERS AND A LIVEBORN INFANT: That completes the interview, but as you read in the advance packet, you may be asked to participate in other parts of the study. To thank you for your time, we will send you a $30 gift card. Along with the gift card, we may mail you a consent form. This form asks for your permission to request leftover newborn bloodspots that were already collected shortly after your baby’s birth by your state’s newborn screening program. This part of the study will help us to understand the role genetic and other biologic factors have in causing birth defects. If you choose to return the consent form, we will send you a $10 gift card as a token of appreciation for your continued interest in our study.
AR,MA, or NY:
LIVE BIRTHS WITH BIRTH DEFECTS:
That completes the interview, but as you read in the advance packet, you may be asked to participate in other parts of the study. To thank you for your time, we will send you a $30 gift card. Along with the gift card, we may mail you a consent form. This form asks for your permission to request leftover newborn bloodspots that were already collected shortly after your baby’s birth by your state’s newborn screening program. This part of the study will help us to understand the role genetic and other biologic factors have in causing birth defects. If you choose to return the consent form, we will send you a $10 gift card as a token of appreciation for your continued interest in our study.
CONTROLS:
That completes the first part of the interview. To thank you for your time completing this part of the interview, we will send you a $30 gift card. Along with the gift card, we may mail you a consent form. This form asks for your permission to request leftover newborn bloodspots that were already collected shortly after your baby’s birth by your state’s newborn screening program. This part of the study will help us to understand the role genetic and other biologic factors have in causing birth defects. If you choose to return the consent form, we will send you a $10 gift card as a token of appreciation for your continued interest in our study.
STILLBIRTHS WITH OR WITHOUT A BIRTH DEFECT:
That completes the first part of the interview. To thank you for your time completing this part of the interview, we will send you a $30 gift card.
FOR CENTERS THAT ARE NOT COLLECTING BLOODSPOTS (STATE: CA, GA) OR FOR A NON-LIVEBORN INFANT EXCEPT AR, MA, AND NY STILLBIRTHS : That completes the interview, but as you read in the advance packet, you may be asked to participate in other parts of the study. So that we may contact you in the future we would like to confirm your address. To thank you for your time, we will send you a $30 gift card.
HH8b. IF ADDRESS PROVIDED IN RESIDENCE HISTORY DD3: To confirm, I have your address as [PULL STREET ADDRESS FROM DD3]. Is that the address where you receive mail?
HH9. ASK ONLY IF ADDRESS NOT PROVIDED IN RESIDENCE HISTORY DD3 OR ADDRESS ON FILE IS INCORRECT/DON’T KNOW: What is your current mailing address? REMEMBER TO ASK ABOUT APT NUMBER IF NONE IS GIVEN.
STREET/APT:_________________________ DK RF
CITY:___________________________
STATE:______________ ZIP:____________________________
HH11. We publish an electronic newsletter to update participants on the progress of the study. We post each new newsletter on the www.bdsteps.org website. Will you be able to access the newsletter on our website? IF ‘NO’, THEN ASK: We want to make sure families without access to the internet can also receive the newsletter. Would you like us to mail you a paper copy of the newsletter?
YES to internet
NO to internet; YES to newsletter
NO to internet; NO to newsletter
DK
RF
FINAL REMARK [ALL SUBJECTS EXCEPT AR, MA, and NY STILLBIRTHS WITH AND WITHOUT DEFECTS AND CONTROLS]
[AR, MA, AND NY STILLBIRTHS WITH AND WITHOUT DEFECTS AND CONTROLS: Open/Refer to BD-STEPS – Stillbirth Pilot Supplement, Introductory Telephone Script and Informed Consent (Att45)]
HH12. 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.
II1. The overall quality of this interview was:
HIGH QUALITY
GENERALLY RELIABLE
QUESTIONABLE
UNSATISFACTORY
II2. Did the father contribute to the mother’s answers? SKIP IF FATHER UNKNOWN
YES
NO
DK
II3. Did some other person contribute to the mother’s answers?
YES CONTINUE TO II4
NO SKIP TO II5
DK SKIP TO II5
II4. Who was it?
SPECIFY:__________ DK
II5. IF II1 = C OR D: The main reason for questionable or unsatisfactory quality of information was because the respondent: INDICATE ALL THAT APPLY
DID NOT KNOW ENOUGH INFORMATION REGARDING THE TOPIC
DID NOT WANT TO BE MORE SPECIFIC
SOUNDED BORED OR UNINTERESTED
SOUNDED UPSET, DEPRESSED, OR ANGRY
HAD POOR HEARING OR SPEECH
SOUNDED CONFUSED OR DISTRACTED BY FREQUENT INTERRUPTIONS
SOUNDED INHIBITED BY OTHERS AROUND HER
SOUNDED EMBARRASSED BY THE SUBJECT MATTER
SOUNDED EMOTIONALLY UNSTABLE
SOUNDED PHYSICALLY ILL
NOT COMFORTABLE WITH LANGUAGE OF THE QUESTIONNAIRE
DOESN’T HAVE THE TIME
FELT INTERVIEW TOO LONG
OTHER (SPECIFY):__________
II6. Was the majority of the interview done in English or Spanish?
ENGLISH
SPANISH
BOTH EQUALLY
II7. INTERVIEW IS COMPLETE. PLEASE CLICK THE FINISH BUTTON
Public reporting burden of this collection of information is estimated to average 55 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 Type | application/vnd.openxmlformats-officedocument.wordprocessingml.document |
Author | Sarah C Tinker |
File Modified | 0000-00-00 |
File Created | 2024-07-20 |