Appendix
A A.1.1.a–
Visit Type: Enumeration
Target: Adult Household Member
T 16/17 Week Phone Call
T 16/17 Week Phone Call
BOX FY00
CHECK ITEM:
|
FY001. I’m going to start by asking you about how your pregnancy is progressing. We have your due date recorded as {DUE DATE}. Is this still accurate?
YES 1 (BOX FY02)
NO, DATE IS DIFFERENT 2
NO, PREGNANCY LOST 3 (FY003)
REFUSED 9--97 (BOX FY02)
DON’T KNOW 9--98 (BOX FY02)
FY002. What is that due date?
|___|___| |___|___| |___|___|___|___|
MM DD YYYY
REFUSED 9--97 (BOX FY02)
DON’T KNOW 9--98 (BOX FY02)
FY003. I’m so sorry for your loss. I realize it may be difficult for you to talk about it, but it’s important for us to know when you lost your baby. Can you please tell me the date when it happened?
|___|___| |___|___| |___|___|___|___|
MM DD YYYY
REFUSED 9--97
DON’T KNOW 9--98
FY004. DID RESPONDENT REQUEST ADDITIONAL INFORMATION ON PREGNANCY LOSS?
YES 1 (FY047)
NO 2 (FY047)
FY005. QUESTION DELETED
FY006. QUESTION DELETED
FY007. QUESTION DELETED
BOX FY02
CHECK ITEM:
|
FY008. Are you using the Medical Care Log? This is the booklet that you or your doctor uses to record information about your doctor visits.
YES 1 (BOX FY03)
NO 2
REFUSED 9--97 (BOX FY03)
DON’T KNOW 9--98 (BOX FY03)
FY009. Is that because…
You haven’t had a medical visit since our last interview, 1
You’ve misplaced the log, or 2
You’ve forgotten to bring it to your medical visits? 3
OTHER (SPECIFY): 6
REFUSED 9--97
DON’T KNOW 9--98
BOX FY03
CHECK ITEM:
|
FY010. We’ll get another Medical Care Log in the mail to you today.
FY011. This information is very important to the study. Please keep the log in a safe place and bring the log with you to all of your medical visits.
FY012. I am now going to ask some questions about visits to a doctor or other health care provider. It would be helpful if you referred to the Medical Care Log that you received as part of this study or to any other personal record or calendar that you keep that would help you to remember the dates of these visits. {I’ll be asking you to put a check mark in the box next to each visit once you’ve finished telling me about it.} If you have this information available, please go and get it now.
FY013. Not including any overnight hospital stays, have you seen a doctor or other heath care provider since {MONTH}? Please include routine pregnancy checkups, sonograms or ultrasounds and other tests, as well as any other visits to a doctor or other health care provider because you were sick or injured, or for any other reason. (These would be the visits you noted in the yellow part of your Medical Care Log.)
YES 1
NO 2 (FY028)
REFUSED 9--97 (FY028)
DON’T KNOW 9--98 (FY028)
BEGIN LOOP FY01
LOOP:
|
FY014. What was the date of {your/the next} most recent visit or checkup?
INTERVIEWER INSTRUCTION:
ENTER A TWO DIGIT MONTH, TWO DIGIT DAY AND A FOUR DIGIT YEAR.
|___|___| |___|___| |___|___|___|___|
MM DD YYYY
REFUSED 9--97
DON’T KNOW 9--98
FY015. What kind of place did you go to? Was it a:
Doctor’s office, clinic, or health center 1
Hospital emergency room 2
Urgent care center, or 3
Some other place? (SPECIFY): 6
REFUSED 9--97
DON’T KNOW 9--98
FY016. What was the main reason for the visit? Was it for:
Routine pregnancy care, 1
Illness or injury, or 2 (FY023)
Some other reason? (SPECIFY): 6 (FY023)
REFUSED 9--97 (FY023)
DON’T KNOW 9--98 (FY023)
FY016a. What type of provider did you see? Was it an:
Obstetrician/Gynecologist, 1
Family physician, 2
Nurse/Midwife, or 3
Another type of provider? (SPECIFY): 6
REFUSED 9--97
DON’T KNOW 9--98
FY017. At this visit, was your weight measured?
YES 1
NO 2 (FY019)
REFUSED 9--97 (FY019)
DON’T KNOW 9--98 (FY019)
FY018. At this visit, what was your weight?
|___|___|___|.|___|
WEIGHT
POUNDS 1
KILOGRAMS 2
REFUSED 9--97
DON’T KNOW 9--98
FY019. At this visit, was your blood pressure measured?
YES 1
NO 2 (FY022)
REFUSED 9--97 (FY022)
DON’T KNOW 9--98 (FY022)
FY020. At this visit, what was your blood pressure?
|___|___|___|
SYSTOLIC BLOOD PRESSURE
|___|___|___|
DIASTOLIC BLOOD PRESSURE
REFUSED 9--97
DON’T KNOW 9--98
BOX FY05
CHECK ITEM:
|
FY021. Do you remember if it was:
Normal, 1
High, or 2
Low? 3
REFUSED 9--97
DON’T KNOW 9--98
FY022. At this visit, were any of the following procedures performed?
YES NO RF DK
a. Ultrasound or sonogram? 1 2 9--97 9--98
b. Amniocentesis? 1 2 9--97 9--98
c. Chorionic Villus Sampling or CVS? 1 2 9--97 9--98
d. Any other test or procedure? (SPECIFY): 1 2 9--97 9--98
BOX FY06
CHECK ITEM:
|
FY023. Did the doctor or other health care provider give you any diagnosis at this visit?
YES 1 (FY024a)
NO 2 (FY025)
REFUSED 9--97 (FY025)
DON’T KNOW 9--98 (FY025)
FY024. At this visit, did the doctor or other health care provider tell you that you have any of the following conditions?
YES NO RF DK
a. Diabetes? 1 2 9--97 9--98
b. High blood pressure? 1 2 9--97 9--98
c. Protein in your urine? 1 2 9--97 9--98
d. Preeclampsia or toxemia? 1 2 9--97 9--98
e. Early or premature labor? 1 2 9--97 9--98
f. Anemia? 1 2 9--97 9--98
g. Severe nausea or hyperemisis? 1 2 9--97 9--98
h. Bladder or kidney Infection 1 2 9--97 9--98
i. Rh disease or isoimmunization? 1 2 9--97 9--98
j. Group B strep? 1 2 9--97 9--98
k. Herpes? 1 2 9--97 9--98
l. Bacterial vaginosis? 1 2 9--97 9--98
m. Pelvic inflammatory disease (PID), or infection in your tubes? 1 2 9--97 9--98
n. Other sexually transmitted disease or infection, such as chlamydia,
syphilis, or gonorrhea? 1 2 9--97 9--98
o. Any other serious condition? (SPECIFY): 1 2 9--97 9--98
FY024a. What was the diagnosis?
SELECT ALL THAT APPLY.
COLD OR UPPER RESPIRATORY INFECTION 1
BLADDER OR KIDNEY INFECTION 2
FEVER 3
OTHER (SPECIFY): 6
REFUSED 9--97
DON’T KNOW 9--98
FY025. Were you given any vaccinations at this visit? Vaccinations are usually injections or shots that strengthen people’s immune systems so that their bodies can fight off serious infectious diseases. Do not include allergy shots or Rhogam injections.
YES 1
NO 2 (FY027)
REFUSED 9--97 (FY027)
DON’T KNOW 9--98 (FY027)
FY026. What type of vaccination did you receive?
SELECT ALL THAT APPLY.
INTERVIEWER INSTRUCTION:
IF THE RESPONDENT ANSWERS “TETANUS”, PROBE WHETHER SHE RECEIVED TETANUS/DIPHTHERIA (Td), or TETANUS, DIPHTHERIA AND PERTUSSIS (Tdap). IF SHE IS NOT SURE, SELECT “TETANUS/DIPHTHERIA (Td)”.
IF THE RESPONDENT ANSWERS “HEPATITIS”, PROBE TO FIND OUT WHETHER IT WAS FOR HEPATITIS A OR HEPATITIS B.
FLU/INFLUENZA 01
HEPATITIS B 02
HEPATITIS A 03
TETANUS/DIPHTHERIA (Td) 04
TETANUS, DIPHTHERIA AND PERTUSSIS (Tdap) 05
MENINGOCOCCAL 06
OTHER (SPECIFY): 96
REFUSED 9--97
DON’T KNOW 9--98
FY027. If you haven’t yet, please put a check mark in the box next to the visit you just told me about in your Medical Care Log. Have you had any other visits to a doctor or other health care provider since {MONTH}?
YES 1
NO 2
REFUSED 9--97
DON’T KNOW 9--98
END LOOP FY01
LOOP:
|
FY028. Since {MONTH} have you spent 1 or more nights in the hospital?
YES 1
NO 2 (FY036)
REFUSED 9--97 (FY036)
DON’T KNOW 9--98 (FY036)
BEGIN LOOP FY02
LOOP:
|
FY029. What was the admission date of your {next} most recent hospital stay?
INTERVIEWER INSTRUCTION:
ENTER A TWO DIGIT MONTH, TWO DIGIT DAY AND A FOUR DIGIT YEAR.
|___|___| |___|___| |___|___|___|___|
MM DD YYYY
REFUSED 9--97
DON’T KNOW 9--98
FY030. How many nights did you stay in the hospital during this hospital stay?
|___|___|___|
NUMBER OF NIGHTS
REFUSED 9--97
DON’T KNOW 9--98
FY031. Did a doctor or other health care provider give you a diagnosis during this hospital stay?
YES 1
NO 2 (FY033)
REFUSED 9--97 (FY033)
DON’T KNOW 9--98 (FY033)
FY032. What was the diagnosis?
SELECT ALL THAT APPLY.
DEHYDRATION 01
PRETERM LABOR 02
HYPEREMISIS 03
PREECLAMPISA 04
RUPTURE OF MEMBRANES 05
KIDNEY DISORDER 06
OTHER (SPECIFY): 96
REFUSED 9--97
DON’T KNOW 9--98
FY033. Did you receive any treatments during this hospital stay? Please include any vaccinations you may have received.
YES 1
NO 2 (FY035)
REFUSED 9--97 (FY035)
DON’T KNOW 9--98 (FY035)
FY034. What treatments did you receive?
_____________________________________________________
TREATMENTS
REFUSED 9--97
DON’T KNOW 9--98
FY035. If you haven’t yet, put a check mark in the box next to the visit that you just told me about in your Medical Care Log. Have you had any other hospital stays since {MONTH}?
YES 1
NO 2
REFUSED 9--97
DON’T KNOW 9--98
END LOOP FY02
LOOP:
|
FY036. Now I’m going to change the subject and ask you about your relationship with your spouse or partner.
Most people have disagreements in their relationships. Please tell me the approximate extent of agreement or disagreement between you and your spouse or partner for each item.
FY037. DOES RESPONDENT VOLUNTEER “I DON’T HAVE A SPOUSE / PARTNER”?
R DOES NOT SAY ANYTHING ABOUT HAVING A
SPOUSE/PARTNER 1
R VOLUNTERS SHE DOES NOT HAVE A SPOUSE/PARTNER 2 (FY046)
FY038. Philosophy of life. Do you and your spouse or partner:
Always agree, 1
Almost always agree, 2
Sometimes agree, 3
Hardly ever agree, 4
Never agree? 5
REFUSED 9--97
DON’T KNOW 9--98
FY039. Aims, goals and things believed important. Do you and your spouse or partner:
Always agree, 1
Almost always agree, 2
Sometimes agree, 3
Hardly ever agree, 4
Never agree? 5
REFUSED 9--97
DON’T KNOW 9--98
FY040. Amount of time spent together. Do you and your spouse or partner:
Always agree, 1
Almost always agree, 2
Sometimes agree, 3
Hardly ever agree, 4
Never agree? 5
REFUSED 9--97
DON’T KNOW 9--98
FY041. Please tell me how often you do the following with your spouse or partner.
FY042. How often do you have an interesting chat:
Never, 1
Less than once a month, 2
Once or twice a month, 3
Once or twice a week, 4
Once a day, 5
More often? 6
REFUSED 9--97
DON’T KNOW 9--98
FY043. How often do you calmly discuss something:
Never, 1
Less than once a month, 2
Once or twice a month, 3
Once or twice a week, 4
Once a day, 5
More often? 6
REFUSED 9--97
DON’T KNOW 9--98
FY044. How often do you work together on a project:
Never, 1
Less than once a month, 2
Once or twice a month, 3
Once or twice a week, 4
Once a day, 5
More often? 6
REFUSED 9--97
DON’T KNOW 9--98
FY045. Please indicate the degree of happiness in your relationship. Are you:
Very unhappy, 1
Somewhat unhappy, 2
Fairly happy, 3
Mostly happy, or 4
Very happy? 5
REFUSED 9--97
DON’T KNOW 9--98
FY046. These are all the questions I have at this time. {We’ll send another Medical Care Log in the mail right away.} {Please remember to bring the Medical Care Log with you to any doctor’s visits you may have.} Thank you for your time.
FY047. Again, I’d like to say how sorry I am for your loss. {We’ll send the information packet you requested as soon as possible.} Please accept our best wishes for a quick recovery. {We’ll call you again within a few months to see how you’re doing.} Thank you for your time.
Revised 7/2/08
| File Type | application/msword |
| File Title | Pregnancy Phone Follow-up – T 16-17 Weeks |
| File Modified | 2008-09-15 |
| File Created | 2008-09-15 |