1 Survey

Routine / Well Visits

Reported to study staff

Date of visit

Name of medical provider

Weight

Blood pressure

Protein in urine?

PROCEDURES

Ultrasound?

Amniocentesis?

Chorionic Villus Sampling (CVS)?

Vaccinations?

Any other treatments or procedures?

Sick Visits

Reported to study staff

Date of visit (include entire length of stay)

LOCATION OF SICK VISIT

Drs. office or clinic?

Emergency Room (outpatient)?

Hospital (inpatient)?

Diagnosis?

Treatments?

Appendix A A.2.1.e–5