SEED Blood Draw

S tudy to Explore Early Development

Interviewer_______________ Study ID#_____________

Date of Completion ___________

Time of Completion___________

Blood Draw Information Form

1. List all medications, vitamins, and supplements, both prescription and over the counter, <you> have taken in the last month. Check box for MOST RECENT time frame when medication was last taken:

If no medications, vitamins, or supplements given in last month, check here: ___

Name of medication, vitamin or supplement

Last 4 hours

Last 24 hours

Last 3 days

Last 7 days

Last month

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2. List any cold, flu or other illness you have had in the last 2 weeks. Check box for MOST RECENT time frame when illness occurred:

If no illness in last 2 weeks, check here: _______

Illness

Today

Last 2 days

Last 2 weeks

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3. Have <you> been exposed to tobacco smoke in the last 4 hours? __Yes __No

4a.What food or foods did <you> eat during their last meal or snack? List:

4b.What time was that food eaten? Time:

5. Has there been a significant event in <your> life during the past month? Examples of a significant event may include: illness or death in the family, divorce, moving or relocation, new school or day care, or other potentially stressful situation for <you>.

Describe:

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