1 Survey

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Overview

General Instructions
Pregnancy Diary

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Sheet 1: General Instructions

Pregnancy Diary

General Instructions

• The purpose of the Pregnancy Diary is to gather information about the types of things you may be exposed to in your pregnancy.
• This Diary contains a card for each week during your pregnancy.
• At the end of every week, please tear off the card and return it to your Study Center via mail. The postage for delivery of the card has already been taken care of.
• Please answer these questions at the same time each day so that we will have the most consistent information possible.
• When answering the questions, consider that each day ends at midnight.
• Please answer each question as best as you can.
• Use only a black ball-point pen to complete the Pregnancy Diary. Do not use a pencil or felt-tip pen.
• If you make any changes, cross out the incorrect answer, record a new answer and draw a circle around the new answer.

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Sheet 2: Pregnancy Diary

PREGNANCY DIARY

SPID # _________________________

Please answer the following questions as appropriate. Please do not leave any questions blank. At the end of the week, tear off the card and return it to your Study Center via mail.

Week beginning ____ ____ / ____ ____ / 20 ______

Sun

Mon

Tues

Weds

Thurs

Fri

Sat

Comments

How much vaginal spotting or bleeding did you have?

(0 = none; 1 = spotting; 2 = light; 3 = moderate; 4 = heavy)

Did you have any nausea?

(1 = yes; 2 = no)

Did you have any vomiting?

(1 = yes; 2 = no)

Did you take any multivitamins, including prenatal vitamins?

(1 = yes; 2 = no)

Did you take folic acid, not as part of a multivitamin?

(1 = yes; 2 = no)

Did you take calcium, not as part of a multivitamin?

(1 = yes; 2 = no)

Did you take aspirin?

(1 = yes; 2 = no)

Did you take ibuprofen (e.g., Advil or Motrin)?

(1 = yes; 2 = no)

How many drinks of beer, wine, or other alcohol did you have?

(A drink is 5 oz. of wine, 12 oz. of beer, or 1 1/2 oz. of liquor. Please fill in number; 0 = none)

How many cigarettes did you smoke?

(A pack of cigarettes contains 20 cigarettes. Please fill in the # of cigarettes smoked, not the # of packs smoked; 0 = none)

How many servings of fish or shellfish did you eat?

(A serving is a little larger than a deck of playing cards; Please fill in number; 0 = none)

How many servings of nuts, peanuts or peanut butter did you eat?

(A serving is about the size of the palm of your hand. Please include all nuts, peanuts, and peanut butter. Please fill in number, 0 = none)

How many cups of caffeinated beverages did you drink?

(Include all drinks that contain caffeine, such as energy drinks, soft drinks, coffee, and tea. Please fill in number, 0 = none)

Did you have a fever of 101° F (38.3° C) or higher?

(1 = yes; 2 = no; 3 = don't know))

Did you take a hot bath or sit in a hot tub?

(1 = yes; 2 = no)

Did you START taking any prescription medications?

(Please provide one answer for the entire week under the Sat (Saturday) column. 1 = yes; 2 = no)

(Fill in the names of the prescription medications you started taking in the space provided)

Did you STOP taking any prescription medications?

(Please provide one answer for the entire week under the Sat (Saturday) column. 1 = yes; 2 = no)

(Fill in the names of the prescription medications you stopped taking in the space provided)