1 Survey

	Medical Care Log

This Medical Care Log will help you keep track of all of your visits to doctors or other medical providers during your pregnancy. We will ask you about these visits during upcoming interviews. The log has two parts. The first part (in yellow) is for all visits to a doctor or other health care provider, or hospital emergency room except overnight hospital stays. The second part (in blue) is for hospital stays during which you spent one or more nights in the hospital. Please take this Medical Care Log with you to each of your medical visits. If you forget to bring it with you, please complete it as soon as possible afterwards.

Instructions for Completing Doctor Visits Log  Each time you go to the doctor or other health care provider, record information about the visit on a new line in the log.  Write in the date of the visit, the type of place you went (e.g., doctor’s office, ER, radiology clinic, urgent care center), the type of provider you saw (e.g., Ob/Gyn, family physician, nurse/midwife), and the reason for the visit (e.g., pregnancy checkup, illness, etc.) in columns 2 through 5.  If your weight and blood pressure were taken, write the numbers in the log in columns 6 and 7.  If you had a sonogram or ultrasound, an amniocentesis, or chorionic villus sampling (CVS), put a checkmark in the corresponding box in columns 8 through 10.  If you received any vaccinations (e.g., flu shot, tetanus/diphtheria), write in the name of the vaccinations in column 11.  If you received any other treatments or had any other procedures (e.g., triple screen test, Rhogam injection, allergy shot, glucose tolerance test), write them in column 12.  If you were told that you had a medical condition at this visit (e.g., high blood pressure, diabetes, infection, etc.), write the diagnosis in column 13.

DOCTOR VISITS

1

2

3

4

5

6

7

8

9

10

11

12

13

Reported to Study Staff

Date of Visit

Location

Provider type

Reason

Weight

Blood Pressure

Ultrasound

Amniocentesis

Chorionic Villus Sampling (CVS)

Vaccinations

Any Other Treatments/ Procedures

Diagnosis



Example3/18/08

Doctor’s office

OB/GYN

Pregnancy checkup

155

120/80



Triple screen test

Protein in urine



Example 4/12/08

pharmacy

nurse

got flu shot

Influenza

Example 4/18/08

Doctor’s office

Family physician

Felt sick

157

122/80

Sinus infection

Example 5/1/08

Doctor’s office

OB/GYN

Pregnancy checkup

158

122/80

Rhogam shot

DOCTOR VISITS
1	2	3	4	5	6	7	8	9	10	11	12	13
Reported to Study Staff	Date of Visit	Location	Provider type	Reason	Weight	Blood Pressure	Ultrasound	Amniocentesis	Chorionic Villus Sampling (CVS)	Vaccinations	Any Other Treatments/ Procedures	Diagnosis

Instructions for Completing Hospitalizations Log  Write in the admission date of your hospital stay (e.g., 3/12/08) in column 2.  Write in the total number of nights you stayed in the hospital in column 3.  If you were told that you had a medical condition during this hospital stay (e.g., high blood pressure, diabetes, infection, etc.), write the diagnosis in column 4.  If you received any treatments or any procedures were done, write what the treatments or procedures were in column 5.

HOSPITALIZATIONS
1	2	3	4	5
Reported to Study Staff	Admission Date	Total number of nights	Diagnosis	Treatments/Procedures
	Example 3/12/08	1	Severe nausea and dehydration	Received medication for nausea and IV fluids for dehydration

Appendix A A.2.1.e–15