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FORM: 02
VERSION: 5.1
FORM APPROVED: OMB # 0920-0010
OMB EXPIRATION DATE: 03/31/2012
National Birth Defects
Prevention Study
Mother Questionnaire
CATI Version 5.1
Centers for Disease Control and Prevention
U.S. Department of Health and Human Services
Public Health Service
April 6, 2010
Information contained on this form which could permit identification of any individual or
establishment has been collected with an assurance that it will be held in strict confidence
by the contractor and CDC, will be used only for purposes stated in this study, and will not
be disclosed or released to anyone other than authorized staff of CDC without the consent
of the participant in accordance with Section 301(d) of the Public Health Service Act (42
U.S.C. 241d).
Public reporting burden of this collection of information is estimated to average 64 minutes per response, including the
time for reviewing instructions, searching existing data sources, gathering and maintaining the data needed, and
completing and reviewing the collection of information. An agency may not conduct or sponsor, and a person is not
required to respond to a collection of information unless it displays a currently valid OMB control number. Send
comments regarding this burden estimate or any other aspect of this collection of information, including suggestions for
reducing this burden to CDC/ATSDR Reports Clearance Officer; 1600 Clifton Rd NE, MS D-74, Atlanta, GA 30333;
4/6/2010
ID #
NOIB STATUS:
Live Birth
Stillbirth
Deceased
Therapeutic Abortion
FATHER UNKNOWN
NOIB’S
FIRST NAME: ___________________________________
PREGNANCY CALENDAR
MONTH
MONTH BEGIN
MM
DD
YYYY
EDD:
MM
DD
YYYY
DOIB/DOPT:
MM
MONTH END
MM
DD
YYYY
DD
YYYY
CHECK DOIB
OR DOPT
MONTH
B3
B2
B1
P1
T1
T2
T3
DATE OF CONCEPTION
P2
P3
P4
P5
P6
P7
P8
P9
P10
CALENDAR GENERATED BY PROGRAM. REFER TO THESE TIME PERIODS DURING INTERVIEW.
4/6/2010
HARDCOPY INSTRUCTIONS:
On hardcopy, “don’t know” (DK) options or check boxes show at most fields but “refused” (RF)
options are not always shown. When subjects refuse, interviewers should write “RF” near
response fields on the hardcopy. Instructions for refusals should follow same instructions as for
don’t know.
INVESTIGATORS and ANALYSTS:
PLEASE NOTE: We have tried to make the codes in this document match the codes used in the
CATI and in the analytic database. Some codes are not included here, such as the 6-digit Slone
drug dictionary codes, and other open-ended text coding lists, as those coding lists are always
growing as new codes are needed. For the definite listing of all codes, investigators should refer
to NBDPS documentation and all coding lists on the study website. Please also read the
Appendix at the back of this document for details about response codes and conventions used in
CATI versus the hardcopy questionnaire.
THERAPEUTIC ABORTIONS:
To be sensitive to mothers who have had a therapeutic abortion (TAB), we are using alternate
wording in scripts that refer to the baby’s name or the baby’s father, or the baby’s date of birth.
The convention in the hard copy will be to have the different phrases in parentheses, separated
by a slash, such as (DOIB/DOPT) to signify date of infant’s birth versus date of pregnancy
termination, or (your pregnancy with [NOIB]/your pregnancy).
The first phrase in the parentheses will be the wording for live births and stillbirths, while the
second phrase will be the wording for TABs.
The CATI will be programmed to insert the correct phrase automatically based on information
obtained at each Center and linked to the CATI.
BABY’S NAME:
If the participant gives the interviewer her baby’s name, that name will be inserted in the CATI
every time NOIB shows in the hard copy. If she chooses not to give her baby’s name, the
interviewer types in “the baby” and that phrase is inserted wherever NOIB appears in the CATI.
OTHER CONVENTIONS USED:
Text in lower case is meant to be read aloud by the interviewer. Text in upper case is only meant
for interviewer instructions, or sometimes for programmer instruction. This is also true of
response options. Response options in lower case are the ones to be read to the participant.
Upper case responses are not read. Prompts and probes should be in lower case as they may
need to be read aloud, as needed.
SECTION P: In 2010, Section P was added to accommodate new questions about physical
activity. This new section was inserted between Section I and Section J, so it is not in
alphabetical order.
4/6/2010
TABLE OF CONTENTS
SECTION
Page
A. Establishing Dates and Pregnancy Details ............................................................................ 1
B. Maternal Health ................................................................................................................... 17
C. Medications and Herbal Remedies ...................................................................................... 44
D. Vitamins and Dietary Details ................................................................................................ 49
E. Stress .................................................................................................................................. 63
F. Tobacco, Alcohol and Substance Abuse ............................................................................. 64
G. Water Exposures ................................................................................................................. 72
H. Mother’s Occupation ............................................................................................................ 75
I.
Father’s Occupation............................................................................................................. 77
P. Physical Activity ................................................................................................................... 79
J. Family Demographics .......................................................................................................... 82
K. Closing................................................................................................................................. 86
Appendix.................................................................................................................................... 90
4/6/2010
National Birth Defects Prevention Study—Mother Questionnaire
Page 1
OPENING STATEMENT
In this interview we will be asking you questions about your family, health, lifestyle habits, and work history. The
questions cover many topics because we don't know what causes most birth defects. We will study the answers
from thousands of mothers hoping to learn something new about the causes of birth defects. Your individual
responses are being collected with an assurance of confidentiality.
SECTION A: ESTABLISHING DATES
I’m going to ask many questions about the year before ([NOIB]’s birth/you had a pregnancy affected by a birth
defect). In order to do this, I need to start by asking you some dates.
WORDING FOR LIVE BIRTHS AND TABS: DIFFERENT SCRIPTS FOR LIVE BIRTHS AND TABS WILL BE SEPARATED BY
A SLASH WITHIN PARENTHESES IN THE HARD COPY AND PROGRAMMED ACCORDINGLY IN CATI. WORDING FOR
LIVE BIRTHS WILL BE FIRST.
A1.
A2.
(What was [NOIB]’s date of birth/On what date
did the affected pregnancy end?)
What date did the doctor give you as a due
date for ([NOIB]’s birth/the affected pregnancy)?
That is, when was ([NOIB]/the baby) expected
to be born?
DOIB/DOPT ....................
MM
DD
YYYY
MM
DD
YYYY
DUE DATE .....................
CHECK IF DK ......................
MM
DD
YYYY
NOTE: IF MOM KNOWS DUE DATE, CATI WILL CALCULATE WHICH PREGNANCY MONTHS CORRESPOND WITH
CALENDAR DATES. IF MOM DOES NOT KNOW DUE DATE, USE THE EDD RECORDED IN THE TRACKING
DATABASE TO CALCULATE DATES.
A3.
In this pregnancy, how many babies were you
carrying? PROBE: Did you have a single baby,
twins, or more babies?
# BABIES ...................................................................
CHECK IF RF ..........
CHECK IF DK ..........
IF NOIB IS “TAB” OR “STILLBIRTH,”THEN SKIP TO A7.
A4.
Is (NOIB) still living?
A5.
What did s/he die of?
YES ............................... (SKIP TO A7) .......................... 1
NO .................................................................................. 2
DK ................................. (SKIP TO A7) ......................... -1
RF ................................. (SKIP TO A7) ......................... -2
SPECIFY: ____________________________________________________________________________
CHECK IF RF ..........
CHECK IF DK ..........
4/6/2010
National Birth Defects Prevention Study—Mother Questionnaire
A6.
How old was s/he when s/he died?
IF THE BABY LIVED LESS THAN 24 HOURS, THE
RESPONSE LESS THAN 1 DAY CAN BE
RECORDED AS 1 DAY.
A7.
What was your date of birth?
Page 2
AGE .........................................................................
CHECK IF DK ......
DAY(S) .............................................................................. 1
WEEK(S) ........................................................................... 2
MONTH(S)......................................................................... 3
YEAR(S) ............................................................................ 4
DK .................................................................................... -1
DOB..................................
CHECK IF DK ........................
MM
DD
DD
YYYY
DD
YYYY
MM
CHECK IF RF ........................
A8.
I would like to ask about ([NOIB]’s/the baby’s)
biologic or natural father.
What was his date of birth? IF DK, PROBE: You
don’t know the date of birth or you don’t know
the biologic father?
YYYY
DOB...................................
MM
CHECK IF DK DOB .................
MM
DD
YYYY
CHECK IF DK WHO FATHER IS .............................
PREGNANCY HISTORY
Now I’m going to ask about your pregnancy experiences.
A9.
How many times have you been pregnant
before ([NOIB]/the pregnancy that ended on
[DOPT]), including pregnancies that may have
ended in miscarriages, stillbirths, abortion, or a
tubal or molar pregnancy?
# TIMES PREGNANT ................................................
RF
DK
IF A9 = 0, SKIP TO INTRO SCRIPT
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National Birth Defects Prevention Study—Mother Questionnaire
Page 3
PREGNANCY OUTCOMES
A10.
st
In your (1 /
nd rd
2 /3 , etc.)
pregnancy,
how many
babies were
you carrying?
A11.
For the next question I need to read the list of
possible answers. Please answer the question
after I read the list of responses.
st
nd
rd
IF A10 = 1: Did your (1 /2 /3 , etc.)
pregnancy end with (a/an) (READ
CATEGORIES)?
st
nd
A12.
st
nd rd
In your (1 / 2 /3 ,
etc.) pregnancy, was
there a health problem
with the pregnancy or
was a birth defect
diagnosed at any
time?
A13.
IF YES:
What was it?
rd
IF A10 >1: For your (1 / 2 /3 , etc.)
pregnancy, what was the outcome for the
st
nd rd
(1 / 2 /3 , etc.) baby? READ CATEGORIES
AND RECORD OUTCOME FOR EACH BABY.
IF A10 = DK OR
RF, TREAT AS 1
BABY
PREG
1.
PREG
2.
PREG
3.
PREG
4.
PREG
5.
#
RF
DK
#
RF
DK
#
RF
DK
#
RF
DK
#
RF
DK
01 = Live birth
02 = Stillbirth
03 = Induced abortion
04 = Miscarriage
05 = Tubal pregnancy (SKIP TO NEXT PREG)
06 = Molar pregnancy (SKIP TO NEXT PREG)
BABY1 BABY2 BABY3 BABY4 BABY5
RF ..........
DK ..........
BABY1 BABY2 BABY3 BABY4 BABY5
RF ..........
DK ..........
BABY1 BABY2 BABY3 BABY4 BABY5
RF ..........
DK ..........
BABY1 BABY2 BABY3 BABY4 BABY5
RF ..........
DK ..........
BABY1 BABY2 BABY3 BABY4 BABY5
RF ..........
DK ..........
THIS APPLIES TO ANY
AND ALL FETUSES.
BIRTH DEFECTS DO NOT
GET LINKED TO
SPECIFIC FETUS IF
MULTIPLE FETUSES IN
PREGNANCY.
YES ................................. 1
NO ....... (SKIP TO A14) ... 2
DK ....... (SKIP TO A14) .. -1
RF ....... (SKIP TO A14) .. -2
___________________
___________________
BIRTH DEFECT
DK
YES ................................. 1
NO ....... (SKIP TO A14) ... 2
DK ....... (SKIP TO A14) .. -1
RF ....... (SKIP TO A14) .. -2
___________________
___________________
BIRTH DEFECT
DK
YES ................................. 1
NO ....... (SKIP TO A14) ... 2
DK ....... (SKIP TO A14) .. -1
RF ....... (SKIP TO A14) .. -2
___________________
BIRTH DEFECT
___________________
___________________
BIRTH DEFECT
DK
YES ................................. 1
NO ....... (SKIP TO A14) ... 2
DK ....... (SKIP TO A14) .. -1
RF ....... (SKIP TO A14) .. -2
___________________
DK
YES ................................. 1
NO ....... (SKIP TO A14) ... 2
DK ....... (SKIP TO A14) .. -1
RF ....... (SKIP TO A14) .. -2
___________________
___________________
BIRTH DEFECT
DK
FOR THE LAST PREGNANCY BEFORE NOIB, ASK:
A14.
When did the last pregnancy before (NOIB/the
affected pregnancy) end?
DATE .......................
MM
RF
DK
DD
YYYY
4/6/2010
National Birth Defects Prevention Study—Mother Questionnaire
Page 4
INTRO SCRIPT:
During this interview we will be asking many questions about different aspects of your life from (BEGINNING OF B3)
to (DATE OF BIRTH OR PREGNANCY TERMINATION). This time period includes your pregnancy and the 3 months
before you became pregnant. Depending on the question we may refer to different time periods.
RESIDENCE DURING PREGNANCY
We would like to know the addresses at which you lived from (B3) to ([DOIB][/DOPT]) to be able to study
possible environmental exposures.
A15.
From 3 months before you became pregnant to
the end of your pregnancy in how many places
did you live for more than one month?
# HOMES ...............................................................
DK
– SKIPS TO A19
RF
– SKIPS TO A19
RESIDENCE HISTORY
A16.
A17.
What was the street address of your
st nd rd
(1 /2 /3 ) residence? LIST ALL IN
CHART.
A.
STREET:
________________________
CITY:
________________________
STATE:
________________________
ZIP:
________________________
COUNTRY:
________________________
DK
B.
RF
________________________
CITY:
________________________
STATE:
________________________
ZIP:
________________________
COUNTRY:
________________________
RF
________________________
CITY:
________________________
STATE:
________________________
ZIP:
________________________
COUNTRY:
________________________
RF
MM
RF
DK
YYYY
What month and year did
you stop living there?
MM
RF
DK
YYYY
IF CURRENTLY LIVING THERE,
THEN USE TODAY’S DATE.
MM
RF
DK
YYYY
MM
RF
DK
YYYY
IF CURRENTLY LIVING THERE,
THEN USE TODAY’S DATE.
STREET:
DK
What month and year did you
start living there?
STREET:
DK
C.
A18.
MM
RF
DK
YYYY
MM
RF
DK
YYYY
IF CURRENTLY LIVING THERE,
THEN USE TODAY’S DATE.
4/6/2010
National Birth Defects Prevention Study—Mother Questionnaire
Page 5
PREGNANCY HISTORY FOR INDEX BABY
Now I have some questions specific to your pregnancy (with [NOIB]/affected by a birth defect).
A19.
From 3 months before you became pregnant to the
end of your pregnancy, did you use any method of
contraception or birth control?
YES ................................................................................ 1
NO .......................... (SKIP TO A27) ............................... 2
DK .......................... (SKIP TO A27) .............................. -1
A20.
For the same time period, did you use any birth
control pills or morning after pills?
YES ................................................................................ 1
NO .......................... (SKIP TO A24) ............................... 2
DK .......................... (SKIP TO A24) .............................. -1
A21.
What was the name of your pills?/Any others? IF MOM DOES NOT KNOW, READ
ENTIRE LIST. Was it (READ LIST)? LIST ALL BELOW .
Alesse
Demulen
Depo-provera
Desogen
Estrogen/Progesterone
Levlen
Lo/Ovral
Loestrin
Micronor
Minipill
Mircette
Morning after pill
Necon
Nordette
Norethin
Ortho-Cept
Ortho-Cyclen
Ortho-Novum
Ortho-Novum 777
OrthoTri-Cyclen
Ovcon
Tri-Levlen
Tri-Norinyl
Triphasil
Birth Control Pill (NOS)
Other (Specify Below)
A22.
Which months were you using
(CONTRACEPTIVE)?
MO
YES
NO
DK
B3
1
2
-1
B2
1
2
-1
_______________________________________________________
B1
1
2
-1
FIRST BIRTH CONTROL OR MORNING AFTER PILL
P1
1
2
-1
P2
1
2
-1
P3
1
2
-1
T2
1
2
-1
T3
1
2
-1
DK
ASK A22
RF
SKIP TO A23
B3
1
2
-1
_______________________________________________________
B2
1
2
-1
SECOND BIRTH CONTROL OR MORNING AFTER PILL
B1
1
2
-1
P1
1
2
-1
P2
1
2
-1
P3
1
2
-1
T2
1
2
-1
T3
1
2
-1
B3
1
2
-1
_______________________________________________________
B2
1
2
-1
THIRD BIRTH CONTROL OR MORNING AFTER PILL
B1
1
2
-1
P1
1
2
-1
P2
1
2
-1
P3
1
2
-1
T2
1
2
-1
T3
1
2
-1
DK
ASK A22
DK
ASK A22
RF
SKIP TO A23
RF
SKIP TO A23
4/6/2010
National Birth Defects Prevention Study—Mother Questionnaire
A23.
Did you use any other method of contraception
during this same time period?
A24.
Which methods of contraception did you use?/Any others?
Page 6
YES ................................................................................ 1
NO ......................... (SKIP TO A26) ................................ 2
DK ......................... (SKIP TO A26) ............................... -1
A25.
Which months were you using (METHOD)?
LIST ALL.
A.
DK
ASK A25
RF
SKIP TO A26
B.
BIRTH CONTROL PATCH (ORTHO EVRA) = 23
CERVICAL CAP = 01
CONDOMS (FEMALE) = 02
CONDOMS (MALE) = 20
CONTRACEPTIVE FILM/VCF = 24
DEPO PROVERA INJECTIONS = 03
DIAPHRAGM = 04
FOAM = 05
GEL = 06
INJECTIONS, NOS = 08
INJECTIONS FROM MEXICO = 09
IUD = 10
NATURAL FAMILY PLANNING/
BASAL TEMPERATURE/MUCUS METHOD = 11
NORPLANT = 12
NUVARING = 31
RHYTHM METHOD = 13
SPERMICIDE, NOS = 14
SPONGE/ VAGINAL SPONGE = 15
SUPPOSITORY OR INSERT = 16
TUBAL LIGATION = 17
VASECTOMY = 18
WITHDRAWAL = 19
OTHER, = -5
SPECIFY: _______________________________
DK
ASK A25
RF
SKIP TO A26
A26.
Did you (READ CHOICES)?
MO
YES
NO
DK
B3
1
2
-1
B2
1
2
-1
B1
1
2
-1
P1
1
2
-1
P2
1
2
-1
P3
1
2
-1
T2
1
2
-1
T3
1
2
-1
B3
1
2
-1
B2
1
2
-1
B1
1
2
-1
P1
1
2
-1
P2
1
2
-1
P3
1
2
-1
T2
1
2
-1
T3
1
2
-1
Stop using contraception to get
pregnant.................... (SKIP TO A28) ...................... 1
Get pregnant during an interruption in using
contraception, or ................................................... 2
Get pregnant while consistently using contraception
............................... (SKIP TO A28) ........................ 3
DK ................................................................................... -1
A27.
At the time that you became pregnant (with
[NOIB]/with this pregnancy), did you want to
become pregnant then, did you want to wait until
later, or did you not want to become pregnant at
all?
WANT TO BE PREGNANT THEN .................................... 1
WANT TO WAIT TILL LATER ........................................... 2
DIDN’T WANT TO BECOME PREGNANT
AT ALL............................................................................. 3
DIDN’T CARE ................................................................... 4
DK ........................................................................... -1
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National Birth Defects Prevention Study—Mother Questionnaire
Page 7
PRENATAL CARE
A28.
How far along were you when you found out
you were pregnant?
WEEKS ................................................................
OR
MONTHS ..............................................................
DK
A29.
Did you have prenatal care with ([NOIB]’s/this)
pregnancy?
A30.
When was your first prenatal visit? Do not
include the visit in which your pregnancy was
first confirmed.
IF SHE ONLY USED A HOME PREGNANCY TEST,
THEN WE’RE REFERRING TO THE FIRST VISIT
AFTER THE POSITIVE HOME TEST.
RF
YES .................................................................................1
NO ..........................(SKIP TO A31) .................................2
DK ..........................(SKIP TO A31) ............................... -1
DATE............................
MM
DD
YYYY
OR
WEEKS PREGNANT ...........................................
DK
RF
Now I’m going to ask about tests you may have had during (your pregnancy with [NOIB]/this pregnancy).
AMNIOCENTESIS
A31.
Did you have an Amniocentesis or amnio?
YES .................................................................................1
NO ..........................(SKIP TO A33) .................................2
DK ..........................(SKIP TO A33) ............................... -1
DEFINITION IF NEEDED: Amniocentesis is a procedure done during pregnancy to test for various birth defects.
A thin needle is inserted through the abdomen and into the uterus and a few teaspoons of amniotic fluid are
withdrawn. The fetal cells that float in the amniotic fluid are then studied in a lab.
A32.
What was the date or week of pregnancy when
the amniocentesis was done?
DATE:
MM
DD
YYYY
OR
WEEKS PREGNANT ..........................................
DK
RF
CVS
A33.
Did you have Chorionic Villus Sampling or
CVS?
YES ...................................................................................1
NO ................................... (SKIP TO A35) .........................2
DK ................................... (SKIP TO A35) ....................... -1
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National Birth Defects Prevention Study—Mother Questionnaire
Page 8
IF NEEDED: Chorionic villus sampling or CVS:
This is a genetic test performed by a physician specialist to determine if a baby has a chromosome problem such as Down
syndrome. It is usually performed between 10 and 13 weeks of pregnancy. To perform the test, a tiny piece of the placenta is
removed from the womb using either a needle through the mother's abdomen or a thin catheter (plastic flexible tube) through the
mother's vagina. The test is always performed using ultrasound to help guide the placement of the abdominal needle or vaginal
catheter.
Transvaginal ultrasound: This is a procedure in which an ultrasound transducer shaped like a wand is placed into the mother's
vagina in order to examine closely either the baby or the mother's cervix. This is used most often in the first half of the pregnancy
and is very good at determining whether the due date should be changed.
(NOTE: THIS TEST ALONG WITH AN ABDOMINAL ULTRASOUND MAY GIVE SOME INFORMATION ABOUT WHETHER THE FETUS IS AT
INCREASED RISK FOR DOWN SYNDROME WHEN BACK OF THE BABY'S NECK IS MEASURED BETWEEN 11 AND 13 WEEKS.
HOWEVER, THIS TYPE OF ULTRASOUND EXAMINATION IS USED ONLY TO ADJUST RISK, NOT TO MAKE A DIAGNOSIS. A MOTHER
WOULD HAVE TO UNDERGO EITHER A CVS OR AMNIOCENTESIS TO BE CERTAIN ABOUT THE BABY'S CHROMOSOMES.)
A34.
What was the date or week of pregnancy when
the CVS was done?
DATE:
MM
DD
YYYY
OR
WEEKS PREGNANT ..........................................................
DK
❑
PRENATAL SURGERY
IF TAB, SKIP A35 THROUGH A38.
A35.
YES .............................................................................................. 1
NO ................................... (SKIP TO A39) .................................... 2
DK ................................... (SKIP TO A39) ................................... -1
Were any surgical procedures performed on
(NOIB) before birth?
A36.
What was the name of the
prenatal medical
procedure?/Any others? LIST
A37.
What was the date or week of
pregnancy it was done?
A38.
Why was the medical procedure
performed? REFERRING TO
(PROCEDURE)
ALL.
A. _______________________
DK
RF
ASK A37 & A38
DK
ASK A37 & A38
SKIP TO A39
DD
YYYY
________________________________________
REASON
OR
DK
WKS PREG
SKIP TO A39
B. _______________________
RF
MM
DK
MM
DD
RF
YYYY
________________________________________
REASON
OR
DK
WKS PREG
DK
RF
4/6/2010
National Birth Defects Prevention Study—Mother Questionnaire
Page 9
FERTILITY DETAILS
A39.
Did you or ([NOIB]’s/the) father take any medications
or have any procedures to help you become
pregnant for this pregnancy?
YES ................................................................................ 1
NO ......................... (SKIP TO A55) ................................ 2
DK ......................... (SKIP TO A55) ............................... -1
OR IF FATHER UNKNOWN:
Did you take any medications or have any
procedures to help you become pregnant for this
pregnancy?
FERTILITY DETAILS-MOTHER
A40.
Did you have any surgical procedures for this
pregnancy such as: to open or rejoin your fallopian
tubes, to treat uterine fibroids, or to remove
endometriosis? I will ask about IVF later.
YES ................................................................................ 1
NO ......................... (SKIP TO A43) ................................ 2
DK ......................... (SKIP TO A43) ............................... -1
IF NEEDED: IVF (in vitro fertilization) involves extracting a woman’s eggs, fertilizing the eggs in the
laboratory, and then transferring the resulting embryos into the woman’s uterus through the cervix.
A42.
A41.
A.
What was the procedure?/Are there any more
procedures? LIST ALL.
Open fallopian tubes ......................................................................... 1
Rejoin fallopian tubes ........................................................................ 2
Treatment of uterine fibroids ............................................................. 3
Removal of endometriosis ................................................................. 4
Other (SPECIFY): .............................................................................. -5
FOR EACH PROCEDURE, ASK: What was the
date?
MM
DK
DD
YYYY
___________________________________________________
DK........................................... (ASK A42) ................................................... -1
RF ..........................................(SKIP TO A43) ............................................. -2
B.
Open fallopian tubes ......................................................................... 1
Rejoin fallopian tubes ........................................................................ 2
Treatment of uterine fibroids ............................................................. 3
Removal of endometriosis ................................................................. 4
Other (SPECIFY): .............................................................................. -5
MM
DK
DD
YYYY
___________________________________________________
DK........................................... (ASK A42) ................................................... -1
RF ..........................................(SKIP TO A43) ............................................. -2
A43.
In the two months before you became pregnant with
([NOIB]/this pregnancy), did you take any
medications to help you become pregnant?
YES ................................................................................ 1
NO ......................... (SKIP TO A46) ................................ 2
DK ......................... (SKIP TO A46) ............................... -1
4/6/2010
National Birth Defects Prevention Study—Mother Questionnaire
A44.
What medications or injections did you take? / Anything else? IF
MOM DOES NOT KNOW, READ LIST. Was it (READ LIST)? RECORD
ALL BELOW. IF NO OR DK TO ALL, SKIP TO A46.
Bromocriptine
Lupron
Provera
Clomid
Lutrepulse
Serophene
Clomiphene citrate
Metrodin
Synarel
Parlodel
Unknown fertility medication
Danazol
Unknown injection
Danocrine
Pergonal
Depo-Provera
Pregnyl
Unknown vaginal medication
Factrel
Profasi HP
Other medication
(SPECIFY)
Page 10
A45.
From what month and year to what month
and year did you take (MEDICATION)?
FROM: ...............................
MM
_______________________________________________________
YYYY
DK
DK
DK
DK
FIRST MEDICATION / INJECTION
TO: ....................................
DK
ASK A45
RF
SKIP TO A46
FROM: ...............................
MM
_______________________________________________________
YYYY
DK
DK
DK
DK
SECOND MEDICATION / INJECTION
TO: ....................................
DK
ASK A45
RF
SKIP TO A46
FROM: ...............................
MM
_______________________________________________________
YYYY
DK
DK
DK
DK
THIRD MEDICATION / INJECTION
TO: ....................................
DK
ASK A45
RF
SKIP TO A46
FROM: ...............................
MM
_______________________________________________________
YYYY
DK
DK
DK
DK
FOURTH MEDICATION / INJECTION
TO: ....................................
DK
ASK A45
RF
SKIP TO A46
4/6/2010
National Birth Defects Prevention Study—Mother Questionnaire
Page 11
FERTILITY DETAILS-PROCEDURES
A46.
YES .................................................................................1
NO ..........................(SKIP TO A52) .................................2
DK ..........................(SKIP TO A52) ............................... -1
In the 2 months (before your pregnancy with
[NOIB]/before you became pregnant with this
pregnancy), did you have any other procedures to
help you become pregnant?
A47.
Which procedure(s) did you
receive in the 2 months
before ([NOIB]/this pregnancy)
was conceived?/Anything
else?
ARTIFICIAL OR INTRAUTERINE
INSEMINATION ............................ 01
IN VITRO FERTILIZATION—
EMBRYO TRANSFER OR
IVF-ET........................................... 02
GAMETE INTRAFALLOPIAN
TRANSFER OR GIFT.................... 03
ZYGOTE INTRAFALLOPIAN
TRANSFER, OR ZIFT, OR
PRONUCLEAR STAGE
TRANSFER, OR PROST............... 04
TUBAL EMBRYO TRANSFER
OR TET ......................................... 05
INTRACYTOPLASMIC SPERM
INJECTION OR ICSI..(SKIP A48)... 06
OTHER FERTILITY PROCEDURE
(SPECIFY) .................................... -5
SPECIFY_____________________
A48.
IF ANY
PROCEDURE
EXCEPT ICSI:
Did part of that
procedure
involve
intracytoplasmic
sperm injection
or ICSI?
A49.
A50.
A51.
What was the
date of the
last
procedure?
Were donor egg(s),
donor sperm, or donor
embryo(s) used on
(DATE)?
Were frozen egg(s),
frozen sperm, or
frozen embryo(s) used
on (DATE)?
IF NEEDED:
ICSI (intracyto-
plasmic sperm
injection). For
some IVF procedures, fertilization
involves a
specialized
technique known
as intracytoplasmic sperm
injection (ICSI). In
ICSI a single
sperm is injected
directly into the
woman’s egg.
MM
DK
DD
DK
Y
N
DK
Y
N
DK
EGG(S) .......
1
2
-1
EGG(S) .....
1
2
-1
SPERM .......
1
2
-1
SPERM .......
1
2
-1
EMBRYO(S)
1
2
-1
EMBRYO(S)
1
2
-1
EGG(S) ............
1
2
-1
EGG(S) ...........
1
2
-1
SPERM ............
1
2
-1
SPERM ...........
1
2
-1
EMBRYO(S) ....
1
2
-1
EMBRYO(S) ...
1
2
-1
YYYY
DK
________________________________
DK ........... (ASK A48-A51) ............. -1 YES ..................... 1
RF .......... (SKIP TO A52) ............... -2 NO ....................... 2
DK ...................... -1
ARTIFICIAL OR INTRAUTERINE
INSEMINATION ............................ 01
IN VITRO FERTILIZATION—
EMBRYO TRANSFER OR
IVF-ET........................................... 02
GAMETE INTRAFALLOPIAN
TRANSFER OR GIFT.................... 03
ZYGOTE INTRAFALLOPIAN
TRANSFER, OR ZIFT, OR
PRONUCLEAR STAGE
TRANSFER, OR PROST............... 04
TUBAL EMBRYO TRANSFER
OR TET ......................................... 05
INTRACYTOPLASMIC SPERM
INJECTION OR ICSI..(SKIP A48)... 06
OTHER FERTILITY PROCEDURE
(SPECIFY) .................................... -5
MM
DK
DD
DK
YYYY
DK
SPECIFY_____________________
________________________________YES ..................... 1
DK ........... (ASK A48-A51) ............. -1 NO ....................... 2
RF .......... (SKIP TO A52) ............... -2 DK ...................... -1
4/6/2010
National Birth Defects Prevention Study—Mother Questionnaire
A52.
Page 12
IF FATHER UNKNOWN, SKIP TO A55.
Did ([NOIB]’s/the) father have any procedures or
surgeries before this pregnancy to help you become
pregnant?
YES ................................................................................ 1
NO ......................... (SKIP TO A55) ................................ 2
DK ......................... (SKIP TO A55) ............................... -1
A53.
A54.
What was the procedure? PROBE: Are there any more
procedures? LIST ALL.
A.
date? REFERRING TO (PROCEDURE)
____________________________________________________
DK
B.
FOR EACH PROCEDURE, ASK: What was the
ASK A54
RF
MM
SKIP TO A55
DK
____________________________________________________
DK
ASK A54
RF
MM
SKIP TO A55
DK
DD
DD
YYYY
YYYY
COMPLICATIONS PREVENTION MEDICATIONS
A55.
After you became pregnant, did you take any
medications to prevent pregnancy complications or
pregnancy loss such as hormones, steroids or
injections?
YES ................................................................................. 1
NO.......................... (SKIP TO A61) ................................. 2
DK .......................... (SKIP TO A61) ............................... -1
A56.
What did you take?/Did you take anything else? LIST
ALL. IF CAN’T RECALL, READ LIST:
Was it…?
Anti D Globulin............................................................
Brethine .......................................................................
Channel Blockers .......................................................
Depo-Provera .............................................................
Magnesium Sulfate ....................................................
Progesterone ..............................................................
Rhogam .......................................................................
Unknown Steroids ......................................................
RF .............................. (SKIP TO A61) ..........................
1.
_________________________________ DK
2.
_________________________________ DK
3.
_________________________________ DK
4/6/2010
National Birth Defects Prevention Study—Mother Questionnaire
Page 13
FOR EACH MED, ASK A57–A60. IF GET EXACT DATES IN A57 AND A58, SKIP A59. IF GET PARTIAL DATES OR DK
IN A57 AND/OR A58, ASK A59.
A57.
Between (P1) and
([DOIB]/[DOPT]), when did
you start using (MEDICINE)
for this condition?
DRUG
MM
DD
YYYY
A58.
When did you stop using
(MEDICINE)?
OR ASK A59
MM
DD
YYYY
FREQUENCY
DK
DK
2. _________________
DAY(S) ............ 1
WEEK(S) ......... 2
MONTH(S) ....... 3
DK
PER DAY ................ 1
PER WEEK ............. 2
PER MONTH ........... 3
PER YEAR .............. 4
DK
DK
DK
DK
3. _________________
ASK A57-A60
RFSKIP TO A61
DURATION
DK
DK
ASK A57-A60
RFSKIP TO A61
A60.
How often did you
use (MEDICINE)?
SEE SPECIAL
CODES IN
APPENDIX
1. _________________
ASK A57-A60
RFSKIP TO A61
A59.
How long did
you take it?
DAY(S) ............ 1
WEEK(S) ......... 2
MONTH(S) ....... 3
DK
PER DAY ................ 1
PER WEEK ............. 2
PER MONTH ........... 3
PER YEAR .............. 4
DK
DK
DK
DK
DAY(S) ............ 1
WEEK(S) ......... 2
MONTH(S) ....... 3
DK
PER DAY ................ 1
PER WEEK ............. 2
PER MONTH ........... 3
PER YEAR .............. 4
MORNING SICKNESS
Now, I have some questions about morning sickness during (your pregnancy with [NOIB]/your pregnancy).
A61.
During this pregnancy, did you have morning sickness
or nausea?
YES .......................................................................... 1
NO ......................... (SKIP TO A71) .......................... 2
DK ......................... (SKIP TO A71) ......................... -1
4/6/2010
National Birth Defects Prevention Study—Mother Questionnaire
A62.
During which month(s) did you
have nausea or vomiting?
Page 14
A63.
How often during (SPECIFY MONTH)
did you have nausea? Would you say
it was (READ LIST)?
A64.
How often during (SPECIFY MONTH)
did you have vomiting? Would you
say it was (READ LIST)?
MO
YES
(ASK
A63A64)
NO
(NEXT
PERIOD)
DK
(NEXT
PERIOD)
P1
1
2
-1
Never .................................................... 0
Less than once a week ......................... 1
Once a week ........................................ 2
Several days a week ............................ 3
Once per day ........................................ 4
2-3 times per day .................................. 5
More than 3 times per day .................... 6
DK ....................................................... -1
Never ................................................... 0
Less than once a week ........................ 1
Once a week ........................................ 2
Several days a week ............................ 3
Once per day ....................................... 4
2-3 times per day ................................. 5
More than 3 times per day ................... 6
DK ....................................................... -1
P2
1
2
-1
Never .................................................... 0
Less than once a week ......................... 1
Once a week ........................................ 2
Several days a week ............................ 3
Once per day ........................................ 4
2-3 times per day .................................. 5
More than 3 times per day .................... 6
DK ....................................................... -1
Never ................................................... 0
Less than once a week ........................ 1
Once a week ........................................ 2
Several days a week ............................ 3
Once per day ....................................... 4
2-3 times per day ................................. 5
More than 3 times per day ................... 6
DK ....................................................... -1
P3
1
2
-1
Never .................................................... 0
Less than once a week ......................... 1
Once a week ........................................ 2
Several days a week ............................ 3
Once per day ........................................ 4
2-3 times per day .................................. 5
More than 3 times per day .................... 6
DK ....................................................... -1
Never ................................................... 0
Less than once a week ........................ 1
Once a week ........................................ 2
Several days a week ............................ 3
Once per day ....................................... 4
2-3 times per day ................................. 5
More than 3 times per day ................... 6
DK ....................................................... -1
T2
1
2
-1
Never .................................................... 0
Less than once a week ......................... 1
Once a week ........................................ 2
Several days a week ............................ 3
Once per day ........................................ 4
2-3 times per day .................................. 5
More than 3 times per day .................... 6
DK ....................................................... -1
Never ................................................... 0
Less than once a week ........................ 1
Once a week ........................................ 2
Several days a week ............................ 3
Once per day ....................................... 4
2-3 times per day ................................. 5
More than 3 times per day ................... 6
DK ....................................................... -1
T3
1
2
-1
Never .................................................... 0
Less than once a week ......................... 1
Once a week ........................................ 2
Several days a week ............................ 3
Once per day ........................................ 4
2-3 times per day .................................. 5
More than 3 times per day .................... 6
DK ....................................................... -1
Never ................................................... 0
Less than once a week ........................ 1
Once a week ........................................ 2
Several days a week ............................ 3
Once per day ....................................... 4
2-3 times per day ................................. 5
More than 3 times per day ................... 6
DK ....................................................... -1
4/6/2010
National Birth Defects Prevention Study—Mother Questionnaire
A65.
Page 15
YES ...................................................................................... 1
NO ............................... (SKIP TO A71) ................................ 2
DK ............................... (SKIP TO A71) ............................... -1
Did you have any medical treatment or take any
medications for your nausea or vomiting?
FOR EACH MED, ASK A67–A70. IF GET EXACT DATES IN A67 AND A68, SKIP A69. IF GET PARTIAL DATES OR DK IN A67
AND/OR A68, ASK A69.
A66.
What did you
take? PROBE: Did
you take anything
else?
A67.
Between (P1) and
([DOIB]/[DOPT]) when did
you start using (MEDICINE)
for your nausea or
vomiting?
A68
When did you stop using
(MEDICINE)?
A69.
How long did
you take it?
A70.
How often did you
use (MEDICINE)?
SEE SPECIAL
CODES IN APPENDIX
OR ASK A69.
LIST ALL. FOR
EVERY MEDICINE,
ASK A67-A70.
MM
DD
YYYY
MM
DD
YYYY
DURATION
FREQUENCY
1. _________________
DK
__________________
ASK A67-A70
RFSKIP TO A71
DK
DK
DK
DAY(S) ............ 1
WEEK(S) ......... 2
MONTH(S) ....... 3
DK
PER DAY ...................... 1
PER WEEK ................... 2
PER MONTH ................. 3
PER YEAR .................... 4
2. _________________
DK
__________________
ASK A67-A70
RFSKIP TO A71
DK
DK
DK
DAY(S) ............ 1
WEEK(S) ......... 2
MONTH(S) ....... 3
DK
PER DAY ...................... 1
PER WEEK ................... 2
PER MONTH ................. 3
PER YEAR .................... 4
DIARRHEA
A71.
From 3 months before you became pregnant
rd
through your 3 month of pregnancy, which
would be (B3 through P3), did you ever have
diarrhea, that is 3 or more unusually loose stools
in one day?
A72.
On about how many days did you have diarrhea?
YES .................................................................................... 1
NO ......................... (SKIP TO A73) .................................... 2
DK ......................... (SKIP TO A73) ................................... -1
# OF DAYS ........................................................
DK
RF
DIETING
Now I have some questions about weight change before and during the early part of (your pregnancy with [NOIB]/your
pregnancy).
A73.
How much did you weigh before (your pregnancy
with [NOIB]/your pregnancy)?
ENTER NUMBER ..............................................
DK
RF
POUNDS ............................................................................ 1
KG ...................................................................................... 2
4/6/2010
National Birth Defects Prevention Study—Mother Questionnaire
Page 16
A74.
At any time from 3 months before you became
rd
pregnant through your 3 month of pregnancy
did you try to lose weight?
YES ........................................................................................ 1
NO ................................ (SKIP TO A76) ................................. 2
DK ................................ (SKIP TO A76) ................................ -1
RF ................................ (SKIP TO A76) ................................ -2
A75.
Did you try to lose weight by (READ
Eating less food or skipping meals or fasting ........................ 01
Eating foods with lower calories, lower fat or lower
carbohydrates ....................................................................... 02
Exercising ............................................................................. 03
Taking laxatives, water pills or diuretics ................................ 04
Taking other medicines or herbs to help
lose weight................ (SPECIFY IN A75a) ........................... 05
Doing anything else ... (SPECIFY IN A75b) ............................ -5
DK .......................................................................................... -1
RF .......................................................................................... -2
CHOICES)…?
CHOOSE ALL THAT APPLY
A75a. ENTER MEDICINES AND HERBS
A. SPECIFY MEDICINES/HERBS:
_________________________________________________
A75b. ENTER ANY OTHER WEIGHT LOSS
METHODS.
B. SPECIFY OTHER WEIGHT LOSS METHODS:
_________________________________________________
Now I am going to ask you about actual weight change in early pregnancy.
GAIN ...................................................................................... 1
LOSE ...................................................................................... 2
STAY THE SAME ......... (SKIP TO A78) ................................. 3
DK ................................ (SKIP TO A78) ................................ -1
RF ................................ (SKIP TO A78) ................................ -2
A76.
During the first 3 months of your pregnancy,
(P1 through P3) did you gain weight, lose
weight, or stay the same?
A77.
How much weight did you (gain/lose) in that
period?
WEIGHT (GAIN/LOSS) ...........................................
Overall, how much weight did you gain or lose
during the entire pregnancy?
ENTER NUMBER ...................................................
A78.
DK
RF
POUNDS ................................................................................ 1
KG .......................................................................................... 2
DK
RF
POUNDS ................................................................................ 1
KG .......................................................................................... 2
A79.
PROBE: IF NOT VOLUNTEERED, ASK: Was that a
gain or a loss?
ENTER GAIN/LOSS/NO CHANGE.
GAIN ...................................................................................... 1
LOSS ...................................................................................... 2
NO CHANGE .......................................................................... 3
DK ......................................................................................... -1
A80.
What is your height without shoes?
FEET ..................................................................................
DK
RF
INCHES ........................................................................
DK
OR
RF
CENTIMETERS ......................................................
DK
RF
4/6/2010
National Birth Defects Prevention Study—Mother Questionnaire
Page 17
SECTION B: MATERNAL HEALTH—DIABETES
At this time, and at other times during this interview, I will be asking you about illnesses you may have had and
various kinds of medications or remedies you may have used. Please include medications prescribed by a health
care practitioner and medications you might have obtained without a prescription from stores, pharmacies, friends
or relatives, as well as herbal or home remedies. Now I have some questions about your health.
B1.
Were you ever told by a doctor that you had
diabetes (including gestational diabetes),
sometimes called sugar diabetes or diabetes
mellitus?
YES ................................................................................... 1
NO ............................ (SKIP TO B18) ................................ 2
DK ............................ (SKIP TO B18) ............................... -1
B2.
What type of diabetes did you have? Was it
(READ LIST)?
Gestational, that is during pregnancy only ................. 1
Insulin-dependent diabetes, also called Type I
or Juvenile .................................................................. 2
Non-insulin dependent diabetes, also called
Type II or Adult onset ................................................ 3
DK .................................................................................... -1
B3.
What month and year were you first diagnosed?
DATE ............................................
MM
DK
PROBE: How old were you when you were
diagnosed? SEE SPECIAL CODES IN APPENDIX.
OR
YYYY
DK
AGE IN YEARS .....................................................
DK
B4.
Did you ever take insulin?
B5.
At what age did you start taking insulin?
YES ................................................................................... 1
NO ............................. (SKIP TO B8) ................................. 2
DK ............................. (SKIP TO B8) ................................ -1
AGE IN YEARS .......................................................
DK
SEE SPECIAL CODES IN APPENDIX.
B6.
Have you been taking insulin continuously since
that time?
YES ........................... (SKIP TO B8) ................................. 1
NO ..................................................................................... 2
DK ............................. (SKIP TO B8) ................................ -1
B7.
When did you stop taking it?
DATE ............................................
MM
DK
SEE SPECIAL CODES IN APPENDIX.
OR
YYYY
DK
AGE IN YEARS .....................................................
DK
MEMO FIELD FOR MORE COMPLEX INSULIN-TAKING PATTERNS:__________________________________
____________________________________________________________________________
4/6/2010
National Birth Defects Prevention Study—Mother Questionnaire
Page 18
B8.
Did you do anything else to manage your
diabetes or its complications between your first
month of pregnancy and the end of your
pregnancy?
YES ................................................................................................ 1
NO..................................... (SKIP TO B18) .................................... 2
DK ..................................... (SKIP TO B18) ................................... -1
B9.
What did you do? Did you…? READ OPTIONS.
a. Modify your eating habits............. (ASK B10) ...................... 01
b. Control your weight or weight gain ....... (ASK B10)............ 02
c. Take medications or other remedies ........... (ASK B11) ...... 03
d. Do anything else ........................... (ASK B16) ...................... 04
e. DK ................................. (SKIP TO B17) ................................... -1
CHOOSE ALL THAT APPLY.
B10.
IF B9 = a OR b:
In order to modify your eating habits or control
your weight, did you…? READ OPTIONS.
CHOOSE ALL THAT APPLY.
Follow a diet specifically for diabetes ..................................... 01
Eat healthier but no specific diabetes diet ............................. 02
Physical exercise ...................................................................... 03
Other ............................... (SPECIFY) ....................................... -5
DK ................................................................................................. -1
1. _________________________________________ DK
2. _________________________________________ DK
B11.
IF B9 = c, ASK B11-B15 THEN SKIP TO B17.
What medications did you take?/Did you take
anything else? LIST ALL. IF CAN’T RECALL,
READ FROM DRUG LIST: Did you take…?
Diabeta ......................................................................................
Diabinese ..................................................................................
Glucophage...............................................................................
Glucotrol ....................................................................................
Glucotrol XL ..............................................................................
Glynase Prestab .......................................................................
Micronase ..................................................................................
Other ....................... (SPECIFY) ..............................................
RF ........................... (SKIP TO B16) ........................................
1. _________________________________________ DK
2. _________________________________________ DK
3. _________________________________________ DK
4/6/2010
National Birth Defects Prevention Study—Mother Questionnaire
Page 19
FOR EACH MED, ASK B12–B15. IF GET EXACT DATES IN B12 AND B13, SKIP B14. IF GET PARTIAL DATES OR DK IN B12
AND/OR B13, ASK B14.
B12.
Between (B3) and
([DOIB]/[DOPT]), when did
you start using
(MEDICINE) for this
illness?
DRUG
MM
DD
YYYY
B13.
When did you stop using
(MEDICINE)?
MM
DD
YYYY
DK
DK
DK
DK
DK
DK
B16.
DK
DK
IF B9 = d:
What else did you do?/Anything else?
B17.
Day(s) .............. 1
Week(s) ........... 2
Month(s)........... 3
DK
3. __________________
ASK B12-B15
RFSKIP TO B16
Day(s) .............. 1
Week(s) ........... 2
Month(s)........... 3
DK
2. __________________
ASK B12-B15
RFSKIP TO B16
DURATION
DK
DK
How often did (this measure/these measures)
work in controlling your diabetes?
READ OPTIONS
B15.
How often did you
use (MEDICINE)?
SEE SPECIAL CODES
IN APPENDIX
OR ASK B14
1. _______________
ASK B12-B15
RFSKIP TO B16
B14.
How long did
you take it?
Day(s) .............. 1
Week(s) ........... 2
Month(s)........... 3
FREQUENCY
DK
Per Day ............... 1
Per Week ............ 2
Per Month ............ 3
Per Year .............. 4
DK
Per Day ............... 1
Per Week ............ 2
Per Month ............ 3
Per Year .............. 4
DK
Per Day ............... 1
Per Week ............ 2
Per Month ............ 3
Per Year .............. 4
1.
___________________________________ DK
2.
___________________________________ DK
3.
___________________________________ DK
Always ............................................................................... 01
Most of the time ................................................................ 02
Part of the time ................................................................. 03
Never or rarely .................................................................. 04
DK ....................................................................................... -1
RF ....................................................................................... -2
4/6/2010
National Birth Defects Prevention Study—Mother Questionnaire
Page 20
MATERNAL HEALTH-HIGH BLOOD PRESSURE
B18.
Were you ever in your life told by a doctor that
you had high blood pressure, toxemia, preeclampsia or eclampsia?
B19.
What type of high blood pressure did you
have? Was it Pregnancy-related - that is
during pregnancy only? This might also be
called pregnancy-induced toxemia or preeclampsia or eclampsia. Or was it Chronic
high blood pressure or chronic
hypertension? This is high blood pressure
that is not related to your pregnancy. This may
have been diagnosed during pregnancy but did
not go away after the pregnancy ended.
B20.
When were you first diagnosed with high blood
pressure?
YES ........................................................................................... 1
NO .................................... (SKIP TO B29)................................. 2
DK .................................... (SKIP TO B29)................................ -1
PREGNANCY RELATED .... (ASK B20, SKIP B21) .................... 1
CHRONIC HYPERTENSION ..................................................... 2
BOTH ........................................................................................ 3
DK ............................................................................................ -1
DATE ......................................................
MM
DK
B21.
DK
PROBE: How old were you when you were
diagnosed? SEE SPECIAL CODES IN
APPENDIX.
OR
SKIP IF B19 = 1:
YES ........................................................................................... 1
NO ............................................................................................. 2
DK ............................................................................................ -1
RF............................................................................................. -2
Were you pregnant at the time?
B22.
YYYY
Did you have pregnancy-related high blood
pressure when you were pregnant with
([NOIB]/this pregnancy)?
AGE IN YEARS ...............................................................
DK
YES ........................................................................................... 1
NO ............................................................................................. 2
DK ............................................................................................ -1
RF............................................................................................. -2
PROMPT: Pregnancy-related means during
pregnancy only. This might also be called
pregnancy-induced toxemia or pre-eclampsia
or eclampsia.
B23.
Did you take any medications or remedies for
high blood pressure from 3 months before you
became pregnant, which would be (B3), to the
end of your pregnancy?
YES ........................................................................................... 1
NO ...................................... (SKIP TO B29)............................... 2
DK ...................................... (SKIP TO B29).............................. -1
4/6/2010
National Birth Defects Prevention Study—Mother Questionnaire
B24.
What did you take? / Did you take anything
else? LIST ALL. IF CAN’T RECALL, READ FROM
DRUG LIST: Did you take…?
Page 21
Ace Inhibitor (NOS) .........................................................
Aldomet Tablet.................................................................
Antihypertensive (NOS) ..................................................
Atenolol .............................................................................
Beta Blocker (NOS).........................................................
Capoten ............................................................................
Diltiazem HCL ..................................................................
Enalapril Maleate .............................................................
Hydralazine/HCTZ ...........................................................
Lisinopril............................................................................
Metoprolol .........................................................................
Nifedipine..........................................................................
Propranolol .......................................................................
Quinapril HCL ..................................................................
Ramipril .............................................................................
Verapamil .........................................................................
Other ............................. (SPECIFY)..................................
RF............................... (SKIP TO B29) ...............................
1.
____________________________________ DK
2.
____________________________________ DK
3.
____________________________________ DK
FOR EACH MED, ASK B25–B28. IF GET EXACT DATES IN B25 AND B26, SKIP B27. IF GET PARTIAL DATES OR DK IN
B25 AND/OR B26, ASK B27.
B25.
Between (B3) and
([DOIB]/[DOPT]), when did
you start using (MEDICINE)
for this illness?
B26.
When did you stop using
(MEDICINE)?
B27.
How long did
you take it?
OR ASK B27
B28.
How often did
you use
(MEDICINE)?
SEE SPECIAL
CODES IN
APPENDIX
DRUG
MM
DD
YYYY
MM
DD
YYYY
1.__________________
ASK B25-B28
RFSKIP TO B29
DURATION
DK
DK
DK
DK
2.__________________
ASK B25-B28
RFSKIP TO B29
Day(s) .............. 1
Week(s) ........... 2
Month(s)........... 3
DK
DK
DK
DK
3.__________________
ASK B25-B28
RFSKIP TO B29
DK
DK
Day(s) .............. 1
Week(s) ........... 2
Month(s)........... 3
DK
DK
Day(s) .............. 1
Week(s) ........... 2
Month(s)........... 3
FREQUENCY
DK
Per Day ........... 1
Per Week ........ 2
Per Month ........ 3
Per Year .......... 4
DK
Per Day ........... 1
Per Week ........ 2
Per Month ........ 3
Per Year .......... 4
DK
Per Day ........... 1
Per Week ........ 2
Per Month ........ 3
Per Year .......... 4
4/6/2010
National Birth Defects Prevention Study—Mother Questionnaire
Page 22
MATERNAL HEALTH-SEIZURES
B29.
Have you ever had seizures?
YES .................................................................................. 1
NO...............................(SKIP TO B40) ............................. 2
DK ...............................(SKIP TO B40) ............................ -1
B30.
Were you ever told by a doctor that you had
epilepsy?
YES .................................................................................. 1
NO...............................(SKIP TO B38) ............................. 2
DK ...............................(SKIP TO B38) ............................ -1
B31.
How old were you when you were told that you
had epilepsy? SEE SPECIAL CODES IN
AGE IN YEARS ......................................................
DK
APPENDIX.
B32.
Did you take any medications or remedies for
epilepsy from 3 months before you became
pregnant to the end of your pregnancy?
YES .................................................................................. 1
NO...............................(SKIP TO B40) ............................. 2
DK ...............................(SKIP TO B40) ............................ -1
B33.
What did you take? / Did you take anything else?
LIST ALL. IF CAN’T RECALL, READ FROM DRUG
LIST: Did you take…?
Depakene, Depakote, valproic acid.........................
Dilantin, phenytoin .....................................................
Felbatol ........................................................................
Klonopin, clonazepam ...............................................
Lamictal .......................................................................
Phenobarbital .............................................................
Tegretol, Carbatrol .....................................................
Other ..........................(SPECIFY) ................................
RF ...............................(SKIP TO B40) ..........................
1.
2.
3.
_________________________________ DK
_________________________________ DK
_________________________________ DK
4/6/2010
National Birth Defects Prevention Study—Mother Questionnaire
Page 23
FOR EACH MED, ASK B34–B37. IF GET EXACT DATES IN B34 AND B35, SKIP B36. IF GET PARTIAL DATES OR DK IN
B34 AND/OR B35, ASK B36.
B34.
Between (B3) and
([DOIB]/[DOPT]), when did
you start using (MEDICINE)
for this illness?
B35.
When did you stop using
(MEDICINE)?
B36.
How long did
you take it?
B37.
How often did
you use
(MEDICINE)?
OR ASK B36
SEE SPECIAL
CODES IN
APPENDIX
DRUG
MM
DD
YYYY
MM
DD
YYYY
1. __________________
ASK B34-B37
RFSKIP TO B40
DURATION
DK
DK
DK
DK
2. _________________
ASK B34-B37
RFSKIP TO B40
DK
DK
3. _________________
ASK B34-B37
RFSKIP TO B40
Day(s) .............. 1
Week(s) ........... 2
Month(s)........... 3
DK
DK
DK
DK
Day(s) .............. 1
Week(s) ........... 2
Month(s)........... 3
DK
DK
Day(s) .............. 1
Week(s) ........... 2
Month(s)........... 3
FREQUENCY
DK
Per Day ........... 1
Per Week ........ 2
Per Month ........ 3
Per Year .......... 4
DK
Per Day ........... 1
Per Week ........ 2
Per Month ........ 3
Per Year .......... 4
DK
Per Day ........... 1
Per Week ........ 2
Per Month ........ 3
Per Year .......... 4
SKIP TO B40.
B38.
Did you ever have seizures that were not related
to fever?
YES ..................................................................................1
NO .............................. (SKIP TO B40) .............................2
DK .............................. (SKIP TO B40) ........................... -1
B39.
Did you take any medications or remedies for
seizures from 3 months before you became
pregnant to the end of your pregnancy?
YES .......(GO BACK TO B33 AND FILL OUT CHART) .....1
NO ....................................................................................2
DK .................................................................................. -1
4/6/2010
National Birth Defects Prevention Study—Mother Questionnaire
Page 24
MATERNAL HEALTH-RESPIRATORY ILLNESS
B40.
From 3 months before you became pregnant to
the end of your pregnancy, did you have a cold or
flu?
YES .................................................................................. 1
NO .............................. (SKIP TO B53) ............................. 2
DK .............................. (SKIP TO B53) ........................... -1
A. IF YES: How many episodes did you have?
# OF EPISODES ...................................................
IF DK:
How many episodes do you remember?
FOR EACH ILLNESS, ASK B41–B44. IF GET EXACT DATES IN B41 AND B42, SKIP B43. IF GET PARTIAL DATES OR DK IN
B41 AND/OR B42, ASK B43.
B41.
st nd rd
When did your (1 /2 /3 )
cold or flu episode start?
B42.
When did the illness stop?
OR ASK B43
B43.
How long did
the illness
last?
B44.
When you were ill on this occasion,
did you have any of the following?
(READ LIST).
YES
1.
MM
DK
DD
YYYY
MM
DK
DD
YYYY
DK
DAY(S) ............ 1
WEEK(S) ......... 2
MONTH(S) ...... 3
NO
DK
a. Respiratory
symptoms such as
a cough,
congestion or
runny nose ................. 1
2
-1
b. Diarrhea or
vomiting ...................... 1
2
-1
c. Muscle aches ............. 1
2
-1
d. Fever .......................... 1
2
-1
IF YES TO d, ASK B45 AND B46. ALL
OTHERS SKIP TO B47.
2.
MM
DK
DD
YYYY
MM
DK
DD
YYYY
DK
DAY(S) ............ 1
WEEK(S) ......... 2
MONTH(S) ...... 3
a. Respiratory
symptoms such as
a cough,
congestion or
runny nose ................. 1
2
-1
b. Diarrhea or
vomiting ...................... 1
2
-1
c. Muscle aches ............. 1
2
-1
d. Fever .......................... 1
2
-1
IF YES TO d, ASK B45 AND B46. ALL
OTHERS SKIP TO B47.
4/6/2010
National Birth Defects Prevention Study—Mother Questionnaire
B45.
How long did the fever
last?
B46.
What was the highest
temperature recorded
during your fever?
1.
YES ..................................... 1
NO......... (SKIP TO B53) ..... 2
DK ......... (SKIP TO B53) .... -1
.
DK
DK
NOT RECORDED
HOUR(S) ........................... 1
DAY(S)............................... 2
WEEK(S) ........................... 3
MONTH(S) ......................... 4
B47.
Did you take any
medications or remedies
for this illness?
Page 25
B48.
What did you take? / Did you take
anything else? LIST ALL. IF CAN’T
RECALL, READ FROM DRUG LIST:
Did you take…?
Acetaminophen ......................................
Advil .......................................................
Afrin Nasal Spray....................................
Amoxicillin ..............................................
Ampicillin ................................................
FAHRENHEIT ........ F
CENTIGRADE ....... C
Augmentin ..............................................
Erythromycin ..........................................
Ibuprofen ................................................
Motrin .....................................................
Naproxen Sodium ...................................
Nuprin.....................................................
Penicillin (NOS) ......................................
Robitussin ..............................................
Sudafed ..................................................
Tylenol....................................................
Relenza or ..............................................
Zanamivir ...............................................
Tamiflu or ...............................................
Oseltamivir .............................................
Other (SPECIFY) ....................................
RF ................ (SKIP TO B53) ...................
1. ________________________ DK
2. _________________________DK
3. _________________________DK
2.
YES ..................................... 1
NO......... (SKIP TO B53) ..... 2
DK ......... (SKIP TO B53) .... -1
.
DK
DK
NOT RECORDED
HOUR(S) ........................... 1
DAY(S)............................... 2
WEEK(S) ........................... 3
MONTH(S) ......................... 4
FAHRENHEIT ........ F
CENTIGRADE ....... C
Acetaminophen ......................................
Advil .......................................................
Afrin Nasal Spray....................................
Amoxicillin ..............................................
Ampicillin ................................................
Augmentin ..............................................
Erythromycin ..........................................
Ibuprofen ................................................
Motrin .....................................................
Naproxen Sodium ...................................
Nuprin.....................................................
Penicillin (NOS) ......................................
Robitussin ..............................................
Sudafed ..................................................
Tylenol....................................................
Relenza or ..............................................
Zanamivir ...............................................
Tamiflu or ...............................................
Oseltamivir .............................................
Other (SPECIFY) ....................................
RF ................ (SKIP TO B53) ...................
1. ________________________ DK
2. _________________________DK
3. _________________________DK
4/6/2010
National Birth Defects Prevention Study—Mother Questionnaire
Page 26
FOR EACH MEDICINE (BY ILLNESS) ASK B49–B52. IF GET EXACT DATES IN B49 AND B50, SKIP B51. IF GET
PARTIAL DATES OR DK IN B49 AND/OR B50, ASK B51.
B49.
When did you start using
(MEDICINE) for this illness?
B50.
When did you stop using
(MEDICINE)?
B51.
How long did you take
it?
SPECIAL CODES IN
APPENDIX
OR ASK B51
DURATION
1.
DK
MM
MM
DK
DD
YYYY
DK
DD
YYYY
DK
DD
YYYY
DK
DD
YYYY
DK
Per Day ......................... 1
Per Week ...................... 2
Per Month...................... 3
Per Year ........................ 4
Day(s) ................................ 1
Week(s) ............................. 2
Month(s) ............................ 3
DK
Per Day ......................... 1
Per Week ...................... 2
Per Month...................... 3
Per Year ........................ 4
ILLNESS ______________________
DRUG
NAME _______________________
IF DK DRUG ASK B49-B52
IF RF DRUG SKIP TO B53
DK
MM
MM
DK
DD
YYYY
DK
DD
YYYY
Day(s) ................................ 1
Week(s) ............................. 2
Month(s) ............................ 3
DK
Per Day ......................... 1
Per Week ...................... 2
Per Month...................... 3
Per Year ........................ 4
ILLNESS ______________________
DRUG
NAME _______________________
IF DK DRUG ASK B49-B52
IF RF DRUG SKIP TO B53
DK
MM
MM
DK
5.
Day(s) ................................ 1
Week(s) ............................. 2
Month(s) ............................ 3
DK
MM
MM
4.
ILLNESS ______________________
DRUG
NAME _______________________
IF DK DRUG ASK B49-B52
IF RF DRUG SKIP TO B53
3.
FREQUENCY
ILLNESS ______________________
DRUG
NAME _______________________
IF DK DRUG ASK B49-B52
IF RF DRUG SKIP TO B53
2.
B52.
How often did you use
(MEDICINE)? SEE
DD
YYYY
DK
DD
YYYY
Day(s) ................................ 1
Week(s) ............................. 2
Month(s) ............................ 3
DK
Per Day ......................... 1
Per Week ...................... 2
Per Month...................... 3
Per Year ........................ 4
ILLNESS ______________________
DRUG
NAME _______________________
IF DK DRUG ASK B49-B52
IF RF DRUG SKIP TO B53
DK
MM
MM
DK
DD
YYYY
DK
DD
YYYY
Day(s) ................................ 1
Week(s) ............................. 2
Month(s) ............................ 3
DK
Per Day ......................... 1
Per Week ...................... 2
Per Month...................... 3
Per Year ........................ 4
4/6/2010
National Birth Defects Prevention Study—Mother Questionnaire
Page 27
MATERNAL HEALTH-INFECTIONS
B53.
From 3 months before you became pregnant to the end of your pregnancy, did you have any of the following
illnesses…? READ LIST
A.
a kidney, bladder, or urinary tract
infection?
YES ................................................................................ 1
NO .................................................................................. 2
DK ................................................................................. -1
B.
pelvic inflammatory disease or PID?
YES ................................................................................ 1
NO .................................................................................. 2
DK ................................................................................. -1
IF NO TO BOTH A AND B, SKIP TO B65.
FOR EACH YES, ASK B54-B60.
B54.
Was the (infection/
PID) diagnosed by a
doctor?
A. kidney, bladder, or
urinary tract
infection (UTI)
B. PID
B55.
During which months did you have the
illness?
B56.
When you were sick
with (infection/PID),
did you have a fever?
MO
YES
NO
DK
YES ........................... 1
NO ............................. 2
DK ............................ -1
B3
B2
B1
P1
P2
P3
T2
T3
1
1
1
1
1
1
1
1
2
2
2
2
2
2
2
2
-1
-1
-1
-1
-1
-1
-1
-1
YES ................................. 1
NO ....... (SKIP TO B59) ... 2
DK ........ (SKIP TO B59) .. -1
YES ........................... 1
NO ............................. 2
DK ............................ -1
B3
B2
B1
P1
P2
P3
T2
T3
1
1
1
1
1
1
1
1
2
2
2
2
2
2
2
2
-1
-1
-1
-1
-1
-1
-1
-1
YES ................................. 1
NO ....... (SKIP TO B59) ... 2
DK ........ (SKIP TO B59) .. -1
4/6/2010
National Birth Defects Prevention Study—Mother Questionnaire
Page 28
ERNAL HEALTH-INFECTIONS
B57.
How long did the
fever last?
B58.
What was the
highest temperature
recorded during
your fever?
A.
.
DK
DK
NOT RECORDED
HOUR(S) ..................... 1
DAY(S) ........................ 2
WEEK(S) ..................... 3
MONTH(S)................... 4
B59.
Did you take any
medications or remedies
for your (ILLNESS)?
B60.
What did you take? / Did you take
anything else? LIST ALL. IF CAN’T
RECALL, READ FROM DRUG LIST:
Did you take…?
YES ........................................ 1
NO ......... (SKIP TO B65) ......... 2
DK.......... (SKIP TO B65) ....... -1
Amoxicillin, Amoxil, Trimox......................
Augmentin...............................................
Biaxin ......................................................
Cipro .......................................................
Doxycycline, Vibramycin .........................
FAHRENHEIT ........ F
CENTIGRADE........ C
Erythromycin, Erythrocin, EES ................
Levaquin .................................................
Rebetol, Virazole.....................................
Rebetron .................................................
Zithromax ................................................
Other (SPECIFY) ....................................
RF ................ (SKIP TO B65)...................
1. ___________________________ DK
2. ___________________________ DK
3. ___________________________ DK
B.
DK
DK
HOUR(S) ..................... 1
DAY(S) ........................ 2
WEEK(S) ..................... 3
MONTH(S)................... 4
YES ........................................ 1
NO ......... (SKIP TO B65) ......... 2
DK.......... (SKIP TO B65) ....... -1
.
NOT RECORDED
FAHRENHEIT ........ F
CENTIGRADE........ C
Amoxicillin, Amoxil, Trimox......................
Augmentin...............................................
Biaxin ......................................................
Cipro .......................................................
Doxycycline, Vibramycin .........................
Erythromycin, Erythrocin, EES ................
Levaquin .................................................
Rebetol, Virazole.....................................
Rebetron .................................................
Zithromax ................................................
Other (SPECIFY) ....................................
RF ................ (SKIP TO B65)...................
1. ___________________________ DK
2. ___________________________ DK
3. ___________________________ DK
4/6/2010
National Birth Defects Prevention Study—Mother Questionnaire
Page 29
FOR EACH MEDICINE (BY ILLNESS) ASK B61–B64. IF GET EXACT DATES IN B61 AND B62, SKIP B63. IF GET PARTIAL
DATES OR DK IN B61 AND/OR B62, ASK B63.
B61.
When did you start using
(MEDICINE) for this illness?
B62.
When did you stop using
(MEDICINE)?
B63.
How long did you take
it?
B64.
How often did you use
(MEDICINE)?
SEE SPECIAL CODES IN
APPENDIX.
OR ASK B63
DURATION
FREQUENCY
ILLNESS A: KIDNEY, BLADDER,
UTI
IF DK DRUG ASK B61-B64
IF RF DRUG SKIP TO B65
1.
DRUG
NAME _______________________
MM
DK
2.
YYYY
MM
DK
DD
YYYY
DK
DD
YYYY
DK
DD
YYYY
DK
DD
YYYY
Day(s) .............................. 1
Week(s) ........................... 2
Month(s) .......................... 3
DK
MM
DK
DD
DRUG
NAME _______________________
MM
Day(s) .............................. 1
Week(s) ........................... 2
Month(s) .......................... 3
DK
MM
DRUG
NAME _______________________
MM
3.
DD
DK
YYYY
Day(s) .............................. 1
Week(s) ........................... 2
Month(s) .......................... 3
DK
Per Day ........................... 1
Per Week ........................ 2
Per Month........................ 3
Per Year .......................... 4
DK
Per Day ........................... 1
Per Week ........................ 2
Per Month........................ 3
Per Year .......................... 4
DK
Per Day ........................... 1
Per Week ........................ 2
Per Month........................ 3
Per Year .......................... 4
ILLNESS B: PID
IF DK DRUG ASK B61-B64
IF RF DRUG SKIP TO B65
4.
DRUG
NAME _______________________
MM
DK
5.
YYYY
MM
DK
DD
YYYY
DK
DD
YYYY
DK
DD
YYYY
DK
DD
YYYY
Day(s) .............................. 1
Week(s) ........................... 2
Month(s) .......................... 3
DK
MM
DK
DD
DRUG
NAME _______________________
MM
Day(s) .............................. 1
Week(s) ........................... 2
Month(s) .......................... 3
DK
MM
DRUG
NAME _______________________
MM
6.
DD
DK
YYYY
Day(s) .............................. 1
Week(s) ........................... 2
Month(s) .......................... 3
DK
Per Day ........................... 1
Per Week ........................ 2
Per Month........................ 3
Per Year .......................... 4
DK
Per Day ........................... 1
Per Week ........................ 2
Per Month........................ 3
Per Year .......................... 4
DK
Per Day ........................... 1
Per Week ........................ 2
Per Month........................ 3
Per Year .......................... 4
4/6/2010
National Birth Defects Prevention Study—Mother Questionnaire
Page 30
MATERNAL HEALTH-OTHER FEVER
B65.
YES .................................................................................. 1
NO .............................. (SKIP TO B77) ............................. 2
DK .............................. (SKIP TO B77) ............................-1
From 3 months before you became pregnant to
the end of your pregnancy, did you have any
fevers that we haven’t already talked about,
including those due to bronchitis, pneumonia, an
infection, or other illness?
A. IF YES: How many fevers did you have?
B66.
What was the cause
st nd rd
of the (1 /2 /3 )
fever?/Any other
fevers? LIST EACH
EPISODE OF FEVER
EVEN IF CAUSE NOT
KNOWN AND ASK
B67-B76 FOR EACH.
A.
__________________
CAUSE OF FEVER
DK
B.
__________________
CAUSE OF FEVER
DK
C.
__________________
CAUSE OF FEVER
DK
B67.
When you had
(CAUSE OF FEVER),
during which of those
months did you have
a fever?
MO
YES
NO
DK
B3
B2
B1
P1
P2
P3
T2
T3
1
1
1
1
1
1
1
1
2
2
2
2
2
2
2
2
-1
-1
-1
-1
-1
-1
-1
-1
B3
B2
B1
P1
P2
P3
T2
T3
1
1
1
1
1
1
1
1
2
2
2
2
2
2
2
2
-1
-1
-1
-1
-1
-1
-1
-1
B3
B2
B1
P1
P2
P3
T2
T3
1
1
1
1
1
1
1
1
2
2
2
2
2
2
2
2
-1
-1
-1
-1
-1
-1
-1
-1
# OF FEVERS ........................................................
IF DK: How many fevers do you remember?
B68.
How long did
the fever
last?
B69.
What was the
highest
temperature
recorded during
your fever?
.
DK
DK
NOT RECORDED
HOUR(S)........ 1
DAY(S) ........... 2
WEEK(S)........ 3
MONTH(S) ..... 4
DK
YES............ 1
NO ............. 2
DK ............. -1
YES ..................... 1
NO (GO TO NEXT
ILLNESS OR B77).... 2
DK (GO TO NEXT
ILLNESS OR B77) ....-1
YES............ 1
NO ............. 2
DK ............. -1
YES ..................... 1
NO (GO TO NEXT
ILLNESS OR B77).... 2
DK (GO TO NEXT
ILLNESS OR B77) ....-1
FAHRENHEIT........ F
CENTIGRADE ....... C
DK
NOT RECORDED
HOUR(S)........ 1
DAY(S) ........... 2
WEEK(S)........ 3
MONTH(S) ..... 4
YES ..................... 1
NO (GO TO NEXT
ILLNESS OR B77).... 2
DK (GO TO NEXT
ILLNESS OR B77) ....-1
.
DK
YES............ 1
NO ............. 2
DK ............. -1
FAHRENHEIT........ F
CENTIGRADE ....... C
NOT RECORDED
HOUR(S)........ 1
DAY(S) ........... 2
WEEK(S)........ 3
MONTH(S) ..... 4
B71.
Did you take
any medications or
remedies for
(CAUSE OF
FEVER)?
.
DK
B70.
Did you
have a
rash with
this fever?
FAHRENHEIT........ F
CENTIGRADE ....... C
4/6/2010
National Birth Defects Prevention Study—Mother Questionnaire
Page 31
B59.
FOR EACH MEDICINE (BY ILLNESS) ASK B73–B76. IF GET EXACT DATES IN B73 AND B74, SKIP B75. IF GET PARTIAL DATES
OR DK IN B73 AND/OR B74, ASK B75.
B72.
What did you take? Did you take
anything else? CODE ALL THAT
B73.
When did you start using
(MEDICINE) for this illness?
APPLY. IF CAN’T RECALL, READ
FROM DRUG LIST: Did you take…?
B74.
When did you stop using
(MEDICINE)?
OR ASK B75
IF DK DRUG ASK B73-B76
IF RF DRUG SKIP TO B77
A.
B.
C.
Acetaminophen ........................................
Advil .........................................................
Aleve........................................................
Aspirin......................................................
Ibuprofen..................................................
Motrin.......................................................
Naproxen Sodium ....................................
Nuprin ......................................................
Tylenol .....................................................
Other (SPECIFY) .......................................
RF ................ (SKIP TO B77).......................
1._____________________________ DK
2._____________________________ DK
3._____________________________ DK
Acetaminophen ........................................
Advil .........................................................
Aleve........................................................
Aspirin......................................................
Ibuprofen..................................................
Motrin.......................................................
Naproxen Sodium ....................................
Nuprin ......................................................
Tylenol .....................................................
Other (SPECIFY) .......................................
RF ................ (SKIP TO B77).......................
1._____________________________ DK
2._____________________________ DK
3._____________________________ DK
Acetaminophen ........................................
Advil .........................................................
Aleve........................................................
Aspirin......................................................
Ibuprofen..................................................
Motrin.......................................................
Naproxen Sodium ....................................
Nuprin ......................................................
Tylenol .....................................................
Other (SPECIFY) .......................................
RF ................ (SKIP TO B77).......................
1._____________________________ DK
2._____________________________ DK
3._____________________________ DK
DRUG 1 _____________________________
MM
DK
DD
YYYY
MM
DK
DD
YYYY
DRUG 2 _____________________________
MM
DK
DD
YYYY
MM
DK
DD
YYYY
DRUG 3 _____________________________
MM
DK
DD
YYYY
MM
DK
DD
YYYY
DRUG 4 _____________________________
MM
DK
DD
YYYY
MM
DK
DD
YYYY
DRUG 5 _____________________________
MM
DK
DD
YYYY
MM
DK
DD
YYYY
DRUG 6 _____________________________
MM
DK
DD
YYYY
MM
DK
DD
YYYY
4/6/2010
National Birth Defects Prevention Study—Mother Questionnaire
B75.
Page 32
B76.
How long did you take
it?
How often did you use
(MEDICINE)? SEE
SPECIAL CODES IN
APPENDIX
DURATION
A.
DK
DRUG 1 __________________________
Day(s) .................................. 1
Week(s) ............................... 2
Month(s) .............................. 3
DK
DRUG 2 __________________________
Day(s) .................................. 1
Week(s) ............................... 2
Month(s) .............................. 3
B.
DK
DRUG 3 __________________________
Day(s) .................................. 1
Week(s) ............................... 2
Month(s) .............................. 3
DK
DRUG 4 __________________________
C.
Day(s) .................................. 1
Week(s) ............................... 2
Month(s) .............................. 3
DK
DRUG 6 __________________________
Day(s) .................................. 1
Week(s) ............................... 2
Month(s) .............................. 3
DK
DRUG 5 __________________________
Day(s) .................................. 1
Week(s) ............................... 2
Month(s) .............................. 3
FREQUENCY
DK
Per Day .............................. 1
Per Week ............................ 2
Per Month ........................... 3
Per Year ............................. 4
DK
Per Day .............................. 1
Per Week ............................ 2
Per Month ........................... 3
Per Year ............................. 4
DK
Per Day .............................. 1
Per Week ............................ 2
Per Month ........................... 3
Per Year ............................. 4
DK
Per Day .............................. 1
Per Week ............................ 2
Per Month ........................... 3
Per Year ............................. 4
DK
Per Day .............................. 1
Per Week ............................ 2
Per Month ........................... 3
Per Year ............................. 4
DK
Per Day .............................. 1
Per Week ............................ 2
Per Month ........................... 3
Per Year ............................. 4
4/6/2010
National Birth Defects Prevention Study—Mother Questionnaire
Page 33
MATERNAL HEALTH-OTHER DISEASES
B77.
YES .............................................................1
NO ....................... (SKIP TO B87)................2
DK ....................... (SKIP TO B87).............. -1
From 3 months before you became pregnant to the end of
your pregnancy, did you have any other illnesses that we
haven't already talked about such as infectious diseases
including sexually transmitted diseases, or chickenpox?
B78.
What did you
have? / Did you
have anything
else? LIST ALL. FOR
EACH ILLNESS ASK
B79-B86.
B79.
When was it first
diagnosed?
REFERRING TO
(CONDITION)
ILLNESS
DK
MM
ASK B79-B82
YYYY
OR
AGE IN YEARS
RF
B81.
Did you take any
medications or
remedies for (ILLNESS)?
PROBE: How old
were you when you
were diagnosed?
A.
______________
B80.
Between (B3) and
([DOIB]/[DOPT]), when did
you have symptoms?
DK
SKIP TO B87
LIST ALL
MO
YES
NO
DK
B3
B2
B1
P1
P2
P3
T2
T3
1
1
1
1
1
1
1
1
2
2
2
2
2
2
2
2
-1
-1
-1
-1
-1
-1
-1
-1
YES ................................. 1
NO ....... (SKIP TO B87) ... 2
DK ....... (SKIP TO B87) .. -1
______________
B3
B2
B1
P1
P2
P3
T2
T3
1
1
1
1
1
1
1
1
2
2
2
2
2
2
2
2
-1
-1
-1
-1
-1
-1
-1
-1
YES ................................. 1
NO ....... (SKIP TO B87) ... 2
DK ....... (SKIP TO B87) .. -1
ILLNESS
DK
MM
ASK B79-B82
YYYY
OR
AGE IN YEARS
RF
DK
SKIP TO B87
______________
B3
B2
B1
P1
P2
P3
T2
T3
1
1
1
1
1
1
1
1
2
2
2
2
2
2
2
2
-1
-1
-1
-1
-1
-1
-1
-1
YES ................................. 1
NO ....... (SKIP TO B87) ... 2
DK ....... (SKIP TO B87) .. -1
ILLNESS
DK
ASK B79-B82
MM
YYYY
OR
AGE IN YEARS
RF
SKIP TO B87
DK
SEE SPECIAL CODES
IN APPENDIX.
2. ____________________
4. ____________________
ASK B83-B86
RF SKIP TO B87
DK
1. ____________________
2. ____________________
3. ____________________
4. ____________________
ASK B83-B86
RF SKIP TO B87
DK
SEE SPECIAL CODES
IN APPENDIX.
C.
1. ____________________
3. ____________________
SEE SPECIAL CODES
IN APPENDIX.
B.
B82.
What did you take? Did
you take anything else?
1. ____________________
2. ____________________
3. ____________________
4. ____________________
ASK B83-B86
RF SKIP TO B87
DK
4/6/2010
National Birth Defects Prevention Study—Mother Questionnaire
Page 34
FOR EACH MEDICINE, ASK B83–B86. IF GET EXACT DATES IN B83 AND B84, SKIP B85. IF GET PARTIAL DATES OR DK
IN B83 AND/OR B84, ASK B85.
B83.
When did you start using
(MEDICINE) for this illness?
B84.
When did you stop using
(MEDICINE)?
B85.
How long did you take it?
SEE SPECIAL CODES IN
APPENDIX
OR ASK B85
DURATION
A.
DRUG 1 _______________________
MM
DK
DD
YYYY
DK
MM
DK
DD
YYYY
DRUG 2 _______________________
MM
DK
B.
DD
YYYY
DK
DD
YYYY
DRUG 3 _______________________
MM
DK
DD
YYYY
DK
DD
YYYY
DRUG 4 _______________________
MM
DK
C.
DD
YYYY
DK
DD
YYYY
DRUG 5 _______________________
MM
DK
DD
YYYY
DK
DD
YYYY
DRUG 6 _______________________
MM
DK
DD
YYYY
DK
DD
YYYY
Day(s) .................................. 1
Week(s) ............................... 2
Month(s) .............................. 3
DK
MM
Day(s) .................................. 1
Week(s) ............................... 2
Month(s) .............................. 3
DK
MM
Day(s) .................................. 1
Week(s) ............................... 2
Month(s) .............................. 3
DK
MM
Day(s) .................................. 1
Week(s) ............................... 2
Month(s) .............................. 3
DK
MM
Day(s) .................................. 1
Week(s) ............................... 2
Month(s) .............................. 3
DK
MM
B86.
How often did you use
(MEDICINE)?
Day(s) .................................. 1
Week(s) ............................... 2
Month(s) .............................. 3
FREQUENCY
DK
Per Day .......................... 1
Per Week ....................... 2
Per Month....................... 3
Per Year ......................... 4
DK
Per Day .......................... 1
Per Week ....................... 2
Per Month....................... 3
Per Year ......................... 4
DK
Per Day .......................... 1
Per Week ....................... 2
Per Month....................... 3
Per Year ......................... 4
DK
Per Day .......................... 1
Per Week ....................... 2
Per Month....................... 3
Per Year ......................... 4
DK
Per Day .......................... 1
Per Week ....................... 2
Per Month....................... 3
Per Year ......................... 4
DK
Per Day .......................... 1
Per Week ....................... 2
Per Month....................... 3
Per Year ......................... 4
4/6/2010
National Birth Defects Prevention Study—Mother Questionnaire
B87.
Page 35
YES ...................................................................... 1
NO ....................... (SKIP TO B97)......................... 2
DK ....................... (SKIP TO B97)........................ -1
Have you ever been diagnosed with any other chronic
diseases or illnesses that we haven't talked about such as
asthma, thyroid disease, an autoimmune disease, or other
chronic or long-term diseases?
PROBE: Such as rheumatoid arthritis, psoriasis, alopecia, lupus, Addison’s disease, pernicious anemia,
celiac disease, multiple sclerosis, myasthenia gravis or Guillain-Barre Syndrome.
B88.
What did you have?
/ Did you have
anything else? LIST
ALL. FOR EACH
ILLNESS ASK B89B96.
A.
B89.
When was it first
diagnosed?
REFERRING TO
(CONDITION)
DK
RF
MM
ASK B89-B92
SKIP TO B97
B91.
B92.
Did you take any
medications or
remedies for (ILLNESS)?
What did you take? Did
you take anything else?
PROBE: How old
were you when you
were diagnosed?
______________
ILLNESS
B90.
Between (B3) and
([DOIB]/[DOPT]) when did
you have symptoms?
YYYY
OR
AGE IN YEARS
DK
LIST ALL
MO
YES
NO
DK
B3
B2
B1
P1
P2
P3
T2
T3
1
1
1
1
1
1
1
1
2
2
2
2
2
2
2
2
-1
-1
-1
-1
-1
-1
-1
-1
B3
B2
B1
P1
P2
P3
T2
T3
1
1
1
1
1
1
1
1
2
2
2
2
2
2
2
2
-1
-1
-1
-1
-1
-1
-1
-1
B3
B2
B1
P1
P2
P3
T2
T3
1
1
1
1
1
1
1
1
2
2
2
2
2
2
2
2
-1
-1
-1
-1
-1
-1
-1
-1
YES .................................1
NO ....... (SKIP TO B97) ... 2
DK ....... (SKIP TO B97) .. -1
______________
ILLNESS
DK
RF
ASK B89-B92
SKIP TO B97
MM
YYYY
OR
AGE IN YEARS
DK
4. ___________________
ASK B93-B96
RF SKIP TO B97
DK
YES .................................1
NO ....... (SKIP TO B97) ... 2
DK ....... (SKIP TO B97) .. -1
______________
ILLNESS
DK
RF
ASK B89-B92
SKIP TO B97
MM
YYYY
OR
AGE IN YEARS
DK
SEE SPECIAL CODES
IN APPENDIX.
1. ___________________
2. ___________________
3. ___________________
4. ___________________
ASK B93-B96
RF SKIP TO B97
DK
SEE SPECIAL CODES
IN APPENDIX.
C.
2. ___________________
3. ___________________
SEE SPECIAL CODES
IN APPENDIX.
B.
1. ___________________
YES .................................1
NO ....... (SKIP TO B97) ... 2
DK ....... (SKIP TO B97) .. -1
1. ___________________
2. ___________________
3. ___________________
4. ___________________
ASK B93-B96
RF SKIP TO B97
DK
4/6/2010
National Birth Defects Prevention Study—Mother Questionnaire
Page 36
FOR EACH MEDICINE, ASK B93–B96. IF GET EXACT DATES IN B93 AND B94, SKIP B95. IF GET PARTIAL DATES OR
DK IN B93 AND/OR B94, ASK B95.
B93.
B94.
When did you start using
(MEDICINE) for this illness?
B95.
When did you stop using
(MEDICINE)?
B96.
How long did you take it?
OR ASK B95
DURATION
How often did you use
(MEDICINE)?
SEE SPECIAL CODES IN
APPENDIX
FREQUENCY
A.
DRUG 1 ____________________
MM
DK
DD
YYYY
DK
MM
DK
DD
YYYY
Day(s) .................................. 1
Week(s) ............................... 2
Month(s) .............................. 3
DRUG 2 ____________________
DK
MM
DK
DD
YYYY
MM
DK
DD
YYYY
Day(s) .................................. 1
Week(s) ............................... 2
Month(s) .............................. 3
DK
Per Day .............................. 1
Per Week ........................... 2
Per Month .......................... 3
Per Year ............................. 4
DK
Per Day .............................. 1
Per Week ........................... 2
Per Month .......................... 3
Per Year ............................. 4
B.
DRUG 3 ____________________
MM
DK
DD
YYYY
DK
MM
DK
DD
YYYY
Day(s) .................................. 1
Week(s) ............................... 2
Month(s) .............................. 3
DRUG 4 ____________________
DK
MM
DK
DD
YYYY
MM
DK
DD
YYYY
Day(s) .................................. 1
Week(s) ............................... 2
Month(s) .............................. 3
DK
Per Day .............................. 1
Per Week ........................... 2
Per Month .......................... 3
Per Year ............................. 4
DK
Per Day .............................. 1
Per Week ........................... 2
Per Month .......................... 3
Per Year ............................. 4
C.
DRUG 5 ____________________
MM
DK
DD
YYYY
DK
MM
DK
DD
YYYY
Day(s) .................................. 1
Week(s) ............................... 2
Month(s) .............................. 3
DRUG 6 ____________________
DK
MM
DK
DD
YYYY
MM
DK
DD
YYYY
Day(s) .................................. 1
Week(s) ............................... 2
Month(s) .............................. 3
DK
Per Day .............................. 1
Per Week ........................... 2
Per Month .......................... 3
Per Year ............................. 4
DK
Per Day .............................. 1
Per Week ........................... 2
Per Month .......................... 3
Per Year ............................. 4
4/6/2010
National Birth Defects Prevention Study—Mother Questionnaire
Page 37
THIS PAGE INTENTIONALLY LEFT BLANK
4/6/2010
National Birth Defects Prevention Study—Mother Questionnaire
Page 38
MATERNAL HEALTH-INJURIES
B97.
From 3 months before you became pregnant to
the end of your pregnancy, were you injured by,
for example, a car accident, fall, or being hurt by
another person?
B98.
What was the cause and
what injuries did you
have? / Anything else?
B99.
What was the date of your
(INJURY)?
YES .................................................................................. 1
NO.............................. (SKIP TO B106) ........................... 2
DK .............................. (SKIP TO B106) .......................... -1
B100.
Did you take any medicine or
receive any injections
because of the injury(s)?
B101.
What did you take? Did you
take anything else? LIST
ALL.
YES ................................................. 1
NO......... (NEXT INJURY OR SKIP
TO B106)......................................... 2
DK ......... (NEXT INJURY OR SKIP
TO B106)....................................... -1
1. ______________________
ASK B99-B105 FOR EACH.
A.
_____________________
INJURY
_____________________
MM
DK
DD
YYYY
CAUSE
ASK B102-B105
RF SKIP TO B106
DK
ASK B99-B101
RF SKIP TO B106
B.
_____________________
_____________________
MM
DK
DD
YYYY
YES ................................................. 1
NO......... (NEXT INJURY OR SKIP
TO B106)......................................... 2
DK ......... (NEXT INJURY OR SKIP
TO B106)....................................... -1
CAUSE
_____________________
ASK B99-B101
RF SKIP TO B106
DK
3. ______________________
ASK B102-B105
RF SKIP TO B106
C.
CAUSE
2. ______________________
DK
ASK B99-B101
RF SKIP TO B106
_____________________
1. ______________________
4. ______________________
DK
INJURY
3. ______________________
4. ______________________
DK
INJURY
2. ______________________
MM
DK
DD
YYYY
YES ................................................. 1
NO......... (NEXT INJURY OR SKIP
TO B106)......................................... 2
DK ......... (NEXT INJURY OR SKIP
TO B106)....................................... -1
1. ______________________
2. ______________________
3. ______________________
4. ______________________
ASK B102-B105
RF SKIP TO B106
DK
4/6/2010
National Birth Defects Prevention Study—Mother Questionnaire
Page 39
FOR EACH MEDICINE (BY INJURY), ASK B102–B105. IF GET EXACT DATES IN B102 AND B103, SKIP B104. IF GET
PARTIAL DATES OR DK IN B102 AND/OR B103, ASK B104.
B102.
When did you start using
(MEDICINE) for this injury?
B103.
When did you stop using
(MEDICINE)?
B104.
How long did you take
it?
OR ASK B104
DURATION
A.
MM
DK
DD
YYYY
DK
MM
DK
DD
YYYY
DRUG 2 _______________________
MM
DK
DD
YYYY
MM
DK
DD
YYYY
Day(s) ................................. 1
Week(s)............................... 2
Month(s) .............................. 3
DK
Day(s) ................................. 1
Week(s)............................... 2
Month(s) .............................. 3
DK
Per Day............................... 1
Per Week ............................ 2
Per Month ........................... 3
Per Year ............................. 4
DK
Per Day............................... 1
Per Week ............................ 2
Per Month ........................... 3
Per Year ............................. 4
INJURY ______________________
DRUG 3 _______________________
MM
DK
DD
YYYY
DK
MM
DK
DD
YYYY
DRUG 4 _______________________
MM
DK
C.
SEE SPECIAL CODES IN
APPENDIX
FREQUENCY
INJURY ______________________
DRUG 1 _______________________
B.
B105.
How often did you use
(MEDICINE)?
DD
YYYY
Day(s) ................................. 1
Week(s)............................... 2
Month(s) .............................. 3
DK
MM
DK
DD
YYYY
Day(s) ................................. 1
Week(s)............................... 2
Month(s) .............................. 3
DK
Per Day............................... 1
Per Week ............................ 2
Per Month ........................... 3
Per Year ............................. 4
DK
Per Day............................... 1
Per Week ............................ 2
Per Month ........................... 3
Per Year ............................. 4
INJURY ______________________
DRUG 5 _______________________
MM
DK
DD
YYYY
DK
MM
DK
DD
YYYY
DRUG 6 _______________________
MM
DK
DD
YYYY
Day(s) ................................. 1
Week(s)............................... 2
Month(s) .............................. 3
DK
MM
DK
DD
YYYY
Day(s) ................................. 1
Week(s)............................... 2
Month(s) .............................. 3
DK
Per Day............................... 1
Per Week ............................ 2
Per Month ........................... 3
Per Year ............................. 4
DK
Per Day............................... 1
Per Week ............................ 2
Per Month ........................... 3
Per Year ............................. 4
4/6/2010
National Birth Defects Prevention Study—Mother Questionnaire
Page 40
MATERNAL HEALTH-SURGERY
B106.
YES ........................................................................................1
NO .............................. (SKIP TO B116) .................................2
DK .............................. (SKIP TO B116) ............................... -1
From 3 months before you became
pregnant to the end of your pregnancy, did
you have any surgical procedures?
B107.
What was done? /
Anything else? ASK
B108- B115 FOR
EACH.
B108.
Did you have
general
anesthesia or
local
anesthesia?
B109.
What month did the
procedure take place?
B110.
Did you take any
medicine or receive
any injections
because of the
surgery?
REFERRING TO
(PROCEDURE)
GENERAL
ANESTHESIA?
_____________________
SURGERY
ASK B108-B111
RF SKIP TO B116
DK
YES ..................... 1
NO....................... 2
DK ...................... -1
LOCAL
ANESTHESIA?
YES ..................... 1
NO....................... 2
DK ...................... -1
GENERAL
ANESTHESIA?
_____________________
YES ..................... 1
SURGERY
ASK B108-B111
RF SKIP TO B116
DK
NO....................... 2
DK ...................... -1
LOCAL
ANESTHESIA?
YES ..................... 1
NO....................... 2
DK ...................... -1
B111.
What did you take?/ Did
you take anything else?
LIST ALL.
MO
YES
NO
DK
B3
B2
B1
P1
P2
P3
T2
T3
1
1
1
1
1
1
1
1
2
2
2
2
2
2
2
2
-1
-1
-1
-1
-1
-1
-1
-1
B3
B2
B1
P1
P2
P3
T2
T3
1
1
1
1
1
1
1
1
2
2
2
2
2
2
2
2
-1
-1
-1
-1
-1
-1
-1
-1
YES ................................. 1
NO ....... (SKIP TO B116) . 2
DK ....... (SKIP TO B116) -1
1. ______________________
2. ______________________
3. ______________________
4. ______________________
ASK B112-B115
RF SKIP TO B116
DK
YES ................................. 1
NO ....... (SKIP TO B116) . 2
DK ....... (SKIP TO B116) -1
1. ______________________
2. ______________________
3. ______________________
4. ______________________
ASK B112-B115
RF SKIP TO B116
DK
4/6/2010
National Birth Defects Prevention Study—Mother Questionnaire
Page 41
FOR EACH MEDICINE (BY SURGERY) ASK B112–B115. IF GET EXACT DATES IN B112 AND B113, SKIP B114. IF GET
PARTIAL DATES OR DK IN B112 AND/OR B113, ASK B114.
B112.
When did you start using
(MEDICINE) for this surgery?
B113.
When did you stop using
(MEDICINE)?
B114.
How long did you take
it?
OR ASK B114
DURATION
A.
SEE SPECIAL CODES IN
APPENDIX
FREQUENCY
SURGERY _____________________
DRUG 1 _______________________
MM
DK
DD
DK
YYYY
MM
DK
DD
YYYY
DRUG 2 _______________________
MM
DK
B.
B115.
How often did you use
(MEDICINE)?
DD
Day(s) .................................. 1
Week(s) ............................... 2
Month(s) .............................. 3
DK
YYYY
MM
DK
DD
YYYY
Day(s) .................................. 1
Week(s) ............................... 2
Month(s) .............................. 3
DK
Per Day .............................. 1
Per Week ........................... 2
Per Month .......................... 3
Per Year ............................. 4
DK
Per Day .............................. 1
Per Week ........................... 2
Per Month .......................... 3
Per Year ............................. 4
SURGERY _____________________
DRUG 3 _______________________
MM
DK
DD
DK
YYYY
MM
DK
DD
YYYY
DRUG 4 _______________________
MM
DK
DD
Day(s) .................................. 1
Week(s) ............................... 2
Month(s) .............................. 3
DK
YYYY
MM
DK
DD
YYYY
Day(s) .................................. 1
Week(s) ............................... 2
Month(s) .............................. 3
DK
Per Day .............................. 1
Per Week ........................... 2
Per Month .......................... 3
Per Year ............................. 4
DK
Per Day .............................. 1
Per Week ........................... 2
Per Month .......................... 3
Per Year ............................. 4
4/6/2010
National Birth Defects Prevention Study—Mother Questionnaire
Page 42
MATERNAL HEALTH-X-RAY OR SCANS
B116.
From 3 months before you became pregnant to the end
of your pregnancy, did you have any x-rays or scans, not
related to your pregnancy?
B117.
Did you have: / Did you have anything else?
YES ........................................................................ 1
NO ...................... (SKIP TO SECTION C) ............... 2
DK ...................... (SKIP TO SECTION C) .............. -1
B118.
What part of your body was tested?
REFERRING TO (PROCEDURE)
YES
(ASK
B118B120)
A. X-rays,
including
dental,
1
mammogram,
upper GI or
IVP
(Intravenous
Pyelogram), ................
B. CT or CAT
2
scans,..........................
C. MRI (or
3
magnetic
resonance
imaging), .....................
D. Radionuclide
4
study or scan, .............
NO
(NXT)
0
0
0
0
DK
(ASK
B118B120)
-1
-1
-1
-1
RF
(ASK
B118B120)
-2
-2
-2
-2
ABDOMEN = 01
ADRENAL GLAND = 02
ARM/ELBOW = 03
BACK = 04
BLADDER = 05
BODY, TOTAL = 06
BONE = 07
BRAIN = 08
BREAST = 09
CHEST = 10
DENTAL/TEETH = 35
FOOT = 11
GALLBLADDER = 12
HAND = 13
HEAD/SKULL/FACE = 14
HEART = 15
HIP = 16
INTESTINES = 17
KIDNEY = 18
LEG/KNEE = 19
LIVER = 20
LOWER GI = 21
LUNGS = 22
MOUTH = 23
NECK = 24
PELVIS = 25
SHOULDER = 26
SPINE = 27
SPLEEN = 28
STOMACH = 29
THYROID = 30
UPPER GI = 31
URINARY TRACT = 32
UTERUS (INCLUDES TUBES
& OVARIES) = 33
VASCULAR SYSTEM = 34
WRIST = 36
OTHER (SPECIFY) = -5
SPECIFY:
________________________
BODY PART
E. Other x-ray or
scan?
-5
SPECIFY TEST: _____________
__________________________
0
-1
DK
ASK B119B121
RF
ASK B119B121
DK
ASK B119B121
RF
ASK B119B121
DK
ASK B119B121
RF
ASK B119B120
DK
ASK B119B121
RF
ASK B119B120
-2
DK
ASK B119B121
RF
ASK B119B121
B119.
What month was the
test done?
MO
B3
B2
B1
P1
P2
P3
T2
T3
YES
1
1
1
1
1
1
1
1
NO
2
2
2
2
2
2
2
2
DK
-1
-1
-1
-1
-1
-1
-1
-1
B3
B2
B1
P1
P2
P3
T2
T3
1
1
1
1
1
1
1
1
2
2
2
2
2
2
2
2
-1
-1
-1
-1
-1
-1
-1
-1
B3
B2
B1
P1
P2
P3
T2
T3
1
1
1
1
1
1
1
1
2
2
2
2
2
2
2
2
-1
-1
-1
-1
-1
-1
-1
-1
B3
B2
B1
P1
P2
P3
T2
T3
1
1
1
1
1
1
1
1
2
2
2
2
2
2
2
2
-1
-1
-1
-1
-1
-1
-1
-1
B3
B2
B1
P1
P2
P3
T2
T3
1
1
1
1
1
1
1
1
2
2
2
2
2
2
2
2
-1
-1
-1
-1
-1
-1
-1
-1
4/6/2010
National Birth Defects Prevention Study—Mother Questionnaire
Page 43
FOR EACH MONTH WITH ‘YES’ RESPONSE IN B119, ASK B120.
B120.
How many (TESTS) did you have in (MONTH)?
B121.
IF B117 = A, B OR E:
Was your pelvis shielded with a
lead apron?
TEST 1 TYPE:
__________________________
TEST 2 TYPE:
__________________________
TEST 3 TYPE:
__________________________
DK
YES................................................. 1
NO .................................................. 2
DK .................................................. -1
NUMBER OF TESTS ........................
DK
DK
DK
DK
DK
DK
DK
B3
NUMBER OF TESTS ........................
DK
B2
NUMBER OF TESTS ........................
YES................................................. 1
NO .................................................. 2
DK .................................................. -1
B1
NUMBER OF TESTS ........................
P1
NUMBER OF TESTS ........................
P2
NUMBER OF TESTS ........................
P3
NUMBER OF TESTS ........................
T2
NUMBER OF TESTS ........................
T3
NUMBER OF TESTS ........................
DK
DK
DK
DK
DK
DK
DK
B3
NUMBER OF TESTS ........................
DK
B2
NUMBER OF TESTS ........................
YES................................................. 1
NO .................................................. 2
DK .................................................. -1
B1
NUMBER OF TESTS ........................
P1
NUMBER OF TESTS ........................
P2
NUMBER OF TESTS ........................
P3
NUMBER OF TESTS ........................
T2
NUMBER OF TESTS ........................
T3
NUMBER OF TESTS ........................
DK
DK
DK
DK
DK
DK
DK
B3
NUMBER OF TESTS ........................
B2
NUMBER OF TESTS ........................
B1
NUMBER OF TESTS ........................
P1
NUMBER OF TESTS ........................
P2
NUMBER OF TESTS ........................
P3
NUMBER OF TESTS ........................
T2
NUMBER OF TESTS ........................
T3
4/6/2010
National Birth Defects Prevention Study—Mother Questionnaire
Page 44
SECTION C: MEDICATION
C1.
We are interested in some medicines that you may have taken from 3 months before you became pregnant,
which would be (B3), to the end of your pregnancy. These would include prescription and nonprescription
medicines. Some of these medicines we may have already discussed. I will read you a list of medications. As I
read the list, please tell me Yes or No whether you took the medicine. During this time period, did you take any of
the following medications? READ CHOICES
FOR EACH YES, ASK C2-C5.
YES
NO
DK
a.
Tylenol, or .................................................................
1
2
-1
b.
Datril, or ....................................................................
1
2
-1
c.
Acetaminophen .........................................................
1
2
-1
d.
Advil, or .....................................................................
1
2
-1
e.
Motrin, or ...................................................................
1
2
-1
f.
Nuprin, or ..................................................................
1
2
-1
g.
Ibuprofen. ..................................................................
1
2
-1
h.
Aleve .........................................................................
1
2
-1
i.
Aspirin. ......................................................................
1
2
-1
j.
Prozac .......................................................................
1
2
-1
k.
Wellbutrin, or. ............................................................
1
2
-1
l.
Zyban ........................................................................
1
2
-1
m.
Paxil ..........................................................................
1
2
-1
n.
Zoloft .........................................................................
1
2
-1
o.
Effexor. ......................................................................
1
2
-1
p.
Celexa .......................................................................
1
2
-1
q.
Levofloxacin ..............................................................
1
2
-1
r.
Amoxicillin .................................................................
1
2
-1
s.
Augmentin .................................................................
1
2
-1
t.
Bactrim ......................................................................
1
2
-1
u.
Septra .......................................................................
1
2
-1
v.
Cipro..........................................................................
1
2
-1
w.
Doxycycline ...............................................................
1
2
-1
x.
Zithromax ..................................................................
1
2
-1
y.
Thalidomide ..............................................................
1
2
-1
z.
Nicotine Patch ...........................................................
1
2
-1
aa. Nicotine Gum ............................................................
1
2
-1
bb. Cytotec, or .................................................................
1
2
-1
cc. Misoprostol ................................................................
1
2
-1
dd. Accutane ...................................................................
1
2
-1
ee. Methotrexate .............................................................
1
2
-1
ff.
Claritin .......................................................................
1
2
-1
gg. Allegra .......................................................................
1
2
-1
hh. Zyrtec ........................................................................
1
2
-1
ii.
Cellcept .....................................................................
1
2
-1
jj.
Myfortic .....................................................................
1
2
-1
kk. An antiviral such as Relenza ....................................
1
2
-1
ll.
1
2
-1
Zanamivir ..................................................................
4/6/2010
National Birth Defects Prevention Study—Mother Questionnaire
FOR EACH YES, ASK C2-C5.
Page 45
YES
NO
DK
mm. Tamiflu ......................................................................
1
2
-1
nn. Oseltamivir ................................................................
1
2
-1
1
2
-1
1
2
-1
oo. Some other antiviral medication? __________________
pp. During this time period, did you take any medications,
remedies, or treatments that we haven’t already talked
about? For example, flu or allergy shots or medications for
asthma, allergies, infections, STDs or HIV/AIDS? What
drug?/Any others? 1. ____________________________
4/6/2010
National Birth Defects Prevention Study—Mother Questionnaire
IF MORE THAN ONE
EPISODE OF USE,
REPEAT DRUG NAME ON
NEXT RECORD AND FILL
OUT ADDITIONAL
RECORD FOR EACH
PERIOD OF USE.
TYPE OF MEDICINE
C2.
1. _____________________
2. _____________________
3. _____________________
4. _____________________
5. _____________________
6. _____________________
C3.
During this time period,
when did you start using
(MEDICINE)?
IF A MEDICINE ON THE
LIST WAS ALREADY
REPORTED, ASK: At what
other times besides (USE
DATE TO DATE) did you
use (MEDICINE)?
MM
DD
YYYY
MM
YYYY
DK
DD
MM
YYYY
DK
DD
MM
YYYY
DK
DD
MM
YYYY
DK
DD
MM
YYYY
DK
DK
DD
Page 46
C4.
When did you stop using
(MEDICINE)?
OR ASK C4
IF GET EXACT DATES IN
C2 AND C3, SKIP C4. IF
GET PARTIAL DATES OR
DK IN C2 AND/OR C3, ASK
C4.
MM
DD
YYYY
MM
YYYY
DK
DD
MM
YYYY
DK
DD
MM
YYYY
DK
DD
MM
YYYY
DK
DD
MM
YYYY
DK
DK
DD
C5.
How long did
you take it?
How often did
you use
(MEDICINE)?
SEE SPECIAL
CODES IN
APPENDIX
DURATION
DK
DAY(S)................. 1
WEEK(S) ............. 2
MONTH(S) ........... 3
DK
DAY(S)................. 1
WEEK(S) ............. 2
MONTH(S) ........... 3
DK
DAY(S)................. 1
WEEK(S) ............. 2
MONTH(S) ........... 3
DK
DAY(S)................. 1
WEEK(S) ............. 2
MONTH(S) ........... 3
DK
DAY(S)................. 1
WEEK(S) ............. 2
MONTH(S) ........... 3
DK
DAY(S)................. 1
WEEK(S) ............. 2
MONTH(S) ........... 3
FREQUENCY
DK
PER DAY ............. 1
PER WEEK .......... 2
PER MONTH ....... 3
PER YEAR ........... 4
DK
PER DAY ............. 1
PER WEEK .......... 2
PER MONTH ....... 3
PER YEAR ........... 4
DK
PER DAY ............. 1
PER WEEK .......... 2
PER MONTH ....... 3
PER YEAR ........... 4
DK
PER DAY ............. 1
PER WEEK .......... 2
PER MONTH ....... 3
PER YEAR ........... 4
DK
PER DAY ............. 1
PER WEEK .......... 2
PER MONTH ....... 3
PER YEAR ........... 4
DK
PER DAY ............. 1
PER WEEK .......... 2
PER MONTH ....... 3
PER YEAR ........... 4
4/6/2010
National Birth Defects Prevention Study—Mother Questionnaire
IF MORE THAN ONE
EPISODE OF USE,
REPEAT DRUG NAME ON
NEXT RECORD AND FILL
OUT ADDITIONAL
RECORD FOR EACH
PERIOD OF USE.
TYPE OF MEDICINE
C2.
8. ____________________
9. ____________________
10. ___________________
C3.
During this time period,
when did you start using
(MEDICINE)?
IF A MEDICINE ON THE
LIST WAS ALREADY
REPORTED, ASK: At what
other times besides (USE
DATE TO DATE) did you
use (MEDICINE)?
MM
7. ____________________
DD
YYYY
MM
YYYY
DK
DD
MM
YYYY
DK
DD
MM
YYYY
DK
DK
DD
Page 47
C4.
When did you stop using
(MEDICINE)?
OR ASK C4
IF GET EXACT DATES IN
C2 AND C3, SKIP C4. IF
GET PARTIAL DATES OR
DK IN C2 AND/OR C3, ASK
C4.
MM
DD
YYYY
MM
YYYY
DK
DD
MM
YYYY
DK
DD
MM
YYYY
DK
DK
DD
C5.
How long did
you take it?
How often did
you use
(MEDICINE)?
SEE SPECIAL
CODES IN
APPENDIX
DURATION
DK
DAY(S)................. 1
WEEK(S) ............. 2
MONTH(S) ........... 3
DK
DAY(S)................. 1
WEEK(S) ............. 2
MONTH(S) ........... 3
DK
DAY(S)................. 1
WEEK(S) ............. 2
MONTH(S) ........... 3
DK
DAY(S)................. 1
WEEK(S) ............. 2
MONTH(S) ........... 3
FREQUENCY
DK
PER DAY ............. 1
PER WEEK .......... 2
PER MONTH ....... 3
PER YEAR ........... 4
DK
PER DAY ............. 1
PER WEEK .......... 2
PER MONTH ....... 3
PER YEAR ........... 4
DK
PER DAY ............. 1
PER WEEK .......... 2
PER MONTH ....... 3
PER YEAR ........... 4
DK
PER DAY ............. 1
PER WEEK .......... 2
PER MONTH ....... 3
PER YEAR ........... 4
4/6/2010
National Birth Defects Prevention Study—Mother Questionnaire
Page 48
HERBAL REMEDIES
C6.
YES ..................................................................................1
NO .............................. (SKIP TO D1) ...............................2
DK .............................. (SKIP TO D1) ............................. -1
From 3 months before you became pregnant to
the end of your pregnancy, did you use any
herbs or folk medicines to treat any medical
conditions, to lose weight, or just to keep you
healthy?
C6a.
C7.
C8.
C9.
C10.
Between (B3) and
([DOIB]/[DOPT]), what herbs
Between (B3) and
([DOIB]/[DOPT]), when did
you start using
(REMEDY)?
When did you stop using
How long did
you take it?
How often did
you use
(REMEDY)?
or folk medicine did you
take?/Anything else?
(REMEDY)? OR ASK C9
IF GET EXACT DATES IN
C7 AND C8, SKIP C9. IF
GET PARTIAL DATES OR
DK IN C7 AND/OR C8, ASK
C9.
SPECIFY HERBAL OR FOLK
REMEDY
SEE SPECIAL
CODES IN
APPENDIX
DURATION
1. ______________________
ASK C7-C10
RF SKIP TO D1
DK
MM
DD
YYYY
MM
YYYY
DK
MM
DD
YYYY
MM
YYYY
DK
DK
DAY(S) .................1
WEEK(S) ..............2
MONTH(S) ...........3
2. ______________________
ASK C7-C10
RF SKIP TO D1
DK
DD
MM
YYYY
DK
DD
MM
YYYY
DK
DK
ASK C7-C10
RF SKIP TO D1
DK
MM
YYYY
DK
DD
MM
YYYY
DK
DK
ASK C7-C10
RF SKIP TO D1
DK
MM
YYYY
DK
DD
MM
YYYY
DK
DK
ASK C7-C10
RF SKIP TO D1
DK
MM
YYYY
DK
DD
MM
YYYY
DK
DK
ASK C7-C10
RF SKIP TO D1
DK
DK
DK
DD
DAY(S) .................1
WEEK(S) ..............2
MONTH(S) ...........3
6. ______________________
DD
DAY(S) .................1
WEEK(S) ..............2
MONTH(S) ...........3
5. ______________________
DD
DAY(S) .................1
WEEK(S) ..............2
MONTH(S) ...........3
4. ______________________
DD
DAY(S) .................1
WEEK(S) ..............2
MONTH(S) ...........3
3. ______________________
DD
DK
DAY(S) .................1
WEEK(S) ..............2
MONTH(S) ...........3
FREQUENCY
DK
PER DAY ............. 1
PER WEEK .......... 2
PER MONTH ....... 3
PER YEAR ........... 4
DK
PER DAY ............. 1
PER WEEK .......... 2
PER MONTH ....... 3
PER YEAR ........... 4
DK
PER DAY ............. 1
PER WEEK .......... 2
PER MONTH ....... 3
PER YEAR ........... 4
DK
PER DAY ............. 1
PER WEEK .......... 2
PER MONTH ....... 3
PER YEAR ........... 4
DK
PER DAY ............. 1
PER WEEK .......... 2
PER MONTH ....... 3
PER YEAR ........... 4
DK
PER DAY ............. 1
PER WEEK .......... 2
PER MONTH ....... 3
PER YEAR ........... 4
4/6/2010
National Birth Defects Prevention Study—Mother Questionnaire
Page 49
SECTION D: PRENATAL VITAMINS
D1.
YES .......................................................................................... 1
NO .....................................(SKIP TO D7) ................................. 2
DK .....................................(SKIP TO D7) ................................ -1
From 3 months before you became pregnant,
which would be (B3), to the end of your
pregnancy, did you take any prenatal vitamins,
which are special vitamin supplements
sometimes taken by pregnant women or women
trying to get pregnant?
FOR EACH VITAMIN ASK D2 TO D6. IF YOU GET EXACT DATES IN D3 AND D4, SKIP D5. IF GET PARTIAL DATES
OR DK IN D3 AND/OR D4, ASK D5.
D3.
D2.
What did you take? /
Anything else?
D4.
During this time period,
when did you start using
(PRENATAL VITAMIN)?
PROBE WITH LIST
BELOW . LIST ALL.
D5.
When did you stop using
(PRENATAL VITAMIN)?
D6.
How long did
you take it?
OR ASK D5
SEE SPECIAL
CODES IN
APPENDIX
DURATION
1. _____________________
ASK D3-D6
RF SKIP TO D7
DK
2. _____________________
ASK D3-D6
RF SKIP TO D7
DK
3. _____________________
ASK D3-D6
RF SKIP TO D7
DK
How often did
you use the
prenatal
vitamin?
MM
DD
YYYY
MM
YYYY
DK
DD
MM
YYYY
DK
DK
DD
MM
DD
YYYY
MM
YYYY
DK
DD
MM
YYYY
DK
DK
DD
DK
DAY(S) ................. 1
WEEK(S) .............. 2
MONTH(S) ........... 3
DK
DAY(S) ................. 1
WEEK(S) .............. 2
MONTH(S) ........... 3
DK
DAY(S) ................. 1
WEEK(S) .............. 2
MONTH(S) ........... 3
FREQUENCY
DK
PER DAY ............. 1
PER WEEK .......... 2
PER MONTH........ 3
PER YEAR ........... 4
DK
PER DAY ............. 1
PER WEEK .......... 2
PER MONTH........ 3
PER YEAR ........... 4
DK
PER DAY ............. 1
PER WEEK .......... 2
PER MONTH........ 3
PER YEAR ........... 4
PROBE FOR D2:
IF CANNOT RECALL, READ LIST: Was it (READ LIST)?
Duet by Stuart Natal
Materna (new form 97)
Natafort
Prenate Advance
Prenate GT
Prenate 90
Prenate Ultra
Spring Valley Prenatal (New)
Stuartnatal Plus 3
Stuartnatal Plus w/ 27 mg iron
Ultra Natal Care
Prenatal Vitamin (NOS)
4/6/2010
National Birth Defects Prevention Study—Mother Questionnaire
Page 50
MULTIVITAMINS
D7.
YES ............................................................................... 1
NO .............................. (SKIP TO D13)........................... 2
DK............................... (SKIP TO D13).......................... -1
Other than prenatal vitamins, from 3 months before you
became pregnant to the end of your pregnancy, did
you take any multivitamins or vitamin complexes?
FOR EACH VITAMIN ASK D9 TO D12. IF GET EXACT DATES IN D9 AND D10, SKIP D11. IF GET PARTIAL DATES
OR DK IN D9 AND/OR D10, ASK D11.
D8.
What did you take?
PROBE: Anything else?
Do you remember the
brand name?
D10.
D9.
During this time period,
when did you start using
(VITAMIN)?
D11.
When did you stop using
(VITAMIN)?
How long did
you take it?
OR ASK D11
D12.
How often did
you use the
vitamin? SEE
SPECIAL CODES
IN APPENDIX
LIST ALL.
DURATION
1. _____________________
ASK D9-D12
RF SKIP TO D13
DK
2. _____________________
ASK D9-D12
RF SKIP TO D13
DK
3. _____________________
ASK D9-D12
RF SKIP TO D13
DK
MM
DD
YYYY
MM
YYYY
DK
DD
MM
YYYY
DK
DK
DD
MM
DD
YYYY
MM
YYYY
DK
DD
MM
YYYY
DK
DK
DD
DK
DAY(S) ................ 1
WEEK(S) ............. 2
MONTH(S) .......... 3
DK
DAY(S) ................ 1
WEEK(S) ............. 2
MONTH(S) .......... 3
DK
DAY(S) ................ 1
WEEK(S) ............. 2
MONTH(S) .......... 3
FREQUENCY
DK
PER DAY ............. 1
PER WEEK .......... 2
PER MONTH........ 3
PER YEAR ........... 4
DK
PER DAY ............. 1
PER WEEK .......... 2
PER MONTH........ 3
PER YEAR ........... 4
DK
PER DAY ............. 1
PER WEEK .......... 2
PER MONTH........ 3
PER YEAR ........... 4
4/6/2010
National Birth Defects Prevention Study—Mother Questionnaire
Page 51
SINGLE VITAMINS
D13.
Now I want to ask you about some single
vitamins and minerals. From 3 months before
you became pregnant to the end of your
pregnancy, did you take any of the following
single vitamins or minerals?
READ ALL
YES
NO
DK
a. Vitamin A ............................................................
1
2
-1
b. Retinol ................................................................
1
2
-1
c. Beta carotene .....................................................
1
2
-1
d. B complexes .......................................................
1
2
-1
e. B6 .......................................................................
1
2
-1
f. B12 .....................................................................
1
2
-1
g. Folic acid ............................................................
1
2
-1
h. Vitamin C ............................................................
1
2
-1
i.
Vitamin D ............................................................
1
2
-1
j.
Vitamin E ............................................................
1
2
-1
k. Iron .....................................................................
1
2
-1
l.
Calcium ..............................................................
1
2
-1
m. Zinc .....................................................................
1
2
-1
n. Selenium ............................................................
1
2
-1
FOR EACH YES, ASK D14-D17. IF ALL NO OR DK, SKIP TO D18.
4/6/2010
National Birth Defects Prevention Study—Mother Questionnaire
Page 52
FOR EACH VITAMIN ASK D14 TO D17. IF GET EXACT DATES IN D14 AND D15, SKIP D16. IF
GET PARTIAL DATES OR DK IN D14 AND/OR D15, ASK D16.
D14.
D15.
During this time period,
when did you start using
(VITAMIN)?
D16.
When did you stop using
(VITAMIN)?
D17.
How long did
you take it?
OR ASK D16
SPECIAL CODES
IN APPENDIX
DURATION
1. _____________________
FIRST VITAMIN
2. _____________________
SECOND VITAMIN
3. _____________________
THIRD VITAMIN
4. _____________________
FOURTH VITAMIN
MM
DD
YYYY
MM
YYYY
DK
DD
MM
YYYY
DK
DD
MM
YYYY
DK
DK
DD
MM
DD
YYYY
MM
YYYY
DK
DD
MM
YYYY
DK
DD
MM
YYYY
DK
DK
DD
How often did
you use the
vitamin? SEE
DK
DAY(S)................. 1
WEEK(S) ............. 2
MONTH(S) ........... 3
DK
DAY(S)................. 1
WEEK(S) ............. 2
MONTH(S) ........... 3
DK
DAY(S)................. 1
WEEK(S) ............. 2
MONTH(S) ........... 3
DK
DAY(S)................. 1
WEEK(S) ............. 2
MONTH(S) ........... 3
FREQUENCY
DK
PER DAY ............. 1
PER WEEK .......... 2
PER MONTH ....... 3
PER YEAR ........... 4
DK
PER DAY ............. 1
PER WEEK .......... 2
PER MONTH ....... 3
PER YEAR ........... 4
DK
PER DAY ............. 1
PER WEEK .......... 2
PER MONTH ....... 3
PER YEAR ........... 4
DK
PER DAY ............. 1
PER WEEK .......... 2
PER MONTH ....... 3
PER YEAR ........... 4
4/6/2010
National Birth Defects Prevention Study—Mother Questionnaire
Page 53
OTHER VITAMINS, MINERALS
D18.
YES ............................................................................................. 1
NO ...................................... (SKIP TO D24) ................................ 2
DK ...................................... (SKIP TO D24) ............................... -1
From 3 months before you became pregnant to
the end of your pregnancy, did you take any
other vitamins, minerals, amino acids,
antioxidants, or other nutrients that we haven’t
already talked about?
FOR EACH PRODUCT, ASK D20 TO D23. IF GET EXACT DATES IN D20 AND D21, SKIP D22. IF GET PARTIAL DATES
OR DK IN D20 AND/OR D21, ASK D22.
D19.
What did you take?
D21.
D20.
During this time period,
when did you start using
(VITAMIN)?
PROBE: Anything else?
LIST ALL.
D22.
When did you stop using
(VITAMIN)?
How long did
you take it?
OR ASK D22
ASK D20-D23
RF SKIP TO D24
DK
2. _____________________
ASK D20-D23
RF SKIP TO D24
DK
3. _____________________
ASK D20-D23
RF SKIP TO D24
DK
How often did
you use the
supplement?
SEE SPECIAL
CODES IN
APPENDIX.
DURATION
1. _____________________
D23.
MM
DD
YYYY
MM
YYYY
DK
DD
MM
YYYY
DK
DK
DD
MM
DD
YYYY
MM
YYYY
DK
DD
MM
YYYY
DK
DK
DD
DK
DAY(S) ................ 1
WEEK(S) ............. 2
MONTH(S) .......... 3
DK
DAY(S) ................ 1
WEEK(S) ............. 2
MONTH(S) .......... 3
DK
DAY(S) ................ 1
WEEK(S) ............. 2
MONTH(S) .......... 3
FREQUENCY
DK
PER DAY ............. 1
PER WEEK .......... 2
PER MONTH........ 3
PER YEAR ........... 4
DK
PER DAY ............. 1
PER WEEK .......... 2
PER MONTH........ 3
PER YEAR ........... 4
DK
PER DAY ............. 1
PER WEEK .......... 2
PER MONTH........ 3
PER YEAR ........... 4
4/6/2010
National Birth Defects Prevention Study—Mother Questionnaire
Page 54
SUPPLEMENTS-(CEREALS)
D24.
YES ..................................................................................... 1
NO .............................. (SKIP TO D28) ................................ 2
DK .............................. (SKIP TO D28) ............................... -1
From 3 months before you became pregnant to the
end of your pregnancy, did you eat cereal?
FOR EACH CEREAL, ASK D26 AND D27.
D25.
What were the names of the cereals you ate
most often between (B3) and ([DOIB]/[DOPT])?
/ Anything else? LIST ALL. USE RESPONSE
D26.
Which months did you eat
(CEREAL)?
OPTIONS IN CATI OR APPENDIX TO PROBE.
1.
____________________________________________
ASK D26 & D27
RF SKIP TO D28
OTHER ASK D26 & D27
DK
2.
____________________________________________
ASK D26 & D27
RF SKIP TO D28
OTHER ASK D26 & D27
DK
MO
YES
NO
DK
B3
1
2
-1
B2
1
2
-1
B1
1
2
-1
P1
1
2
-1
P2
1
2
-1
P3
1
2
-1
T2
1
2
-1
T3
1
2
-1
B3
1
2
-1
B2
1
2
-1
B1
1
2
-1
P1
1
2
-1
P2
1
2
-1
P3
1
2
-1
T2
1
2
-1
T3
1
2
-1
D27.
How often, on average, did you
eat (CEREAL) during that time?
You may use the food frequency
choices list which was sent to you
in the mail to help you respond to
this question.
NEVER OR < ONCE PER MONTH ......... 0
1 PER MONTH .................................... 1M
2 PER MONTH .................................... 2M
3 PER MONTH .................................... 3M
1 PER WEEK ....................................... 1W
2 PER WEEK ....................................... 2W
3 PER WEEK ....................................... 3W
4 PER WEEK ....................................... 4W
5 PER WEEK ....................................... 5W
6 PER WEEK ....................................... 6W
1 PER DAY .......................................... 1D
2 PER DAY .......................................... 2D
3 PER DAY .......................................... 3D
4 PER DAY .......................................... 4D
5 PER DAY .......................................... 5D
6+ PER DAY ........................................ 6D
DK.......................................................... -1
RF .......................................................... -2
NEVER OR < ONCE PER MONTH ......... 0
1 PER MONTH .................................... 1M
2 PER MONTH .................................... 2M
3 PER MONTH .................................... 3M
1 PER WEEK ....................................... 1W
2 PER WEEK ....................................... 2W
3 PER WEEK ....................................... 3W
4 PER WEEK ....................................... 4W
5 PER WEEK ....................................... 5W
6 PER WEEK ....................................... 6W
1 PER DAY .......................................... 1D
2 PER DAY .......................................... 2D
3 PER DAY .......................................... 3D
4 PER DAY .......................................... 4D
5 PER DAY .......................................... 5D
6+ PER DAY ........................................ 6D
DK.......................................................... -1
RF .......................................................... -2
4/6/2010
National Birth Defects Prevention Study—Mother Questionnaire
Page 55
SUPPLEMENTS-(FOOD)
YES ............................................................................ 1
NO .............................. (SKIP TO D32) ....................... 2
DK .............................. (SKIP TO D32) ..................... -1
D28.
Now, I’d like to ask you about food supplements,
which includes power and energy bars, and
products mixed into drinks, like Slim Fast, Instant
Breakfast, protein powder, or Brewer’s yeast. From
3 months before you became pregnant to the end
of your pregnancy, did you eat or drink any food
supplements?
D29.
What was the name of the food supplement?/ Anything else? USE RESPONSE OPTIONS TO PROBE.
Atkins Shakes
Boost Drink
Boost High Protein Drink
Brewer’s Yeast
Carnation Instant Breakfast
Chocomilk
Citrucel Fiber
Ensure
Instant Breakfast
Luna Bar
Myoplex
Nesquik Chocolate
FOR EACH SUPPLEMENT, ASK
D30 AND D31.
1.
D30.
Which month(s) did you use
(FOOD SUPPLEMENT)?
YES
NO
DK
B3
1
2
-1
B2
1
2
-1
B1
1
2
-1
P1
1
2
-1
P2
1
2
-1
P3
1
2
-1
T2
1
2
-1
T3
1
2
-1
B3
1
2
-1
B2
1
2
-1
B1
1
2
-1
P1
1
2
-1
P2
1
2
-1
P3
1
2
-1
T2
1
2
-1
T3
1
2
-1
____________________________________________
ASK D30 & D31
RF SKIP TO D32
OTHER ASK D30 & D31
____________________________________________
ASK D30 & D31
RF SKIP TO D32
OTHER ASK D30 & D31
DK
Slim-Fast Shakes
Soy Protein NOS
Spiru-tein
Wheat Germ
Whey Protein NOS
Other, SPECIFY
D31.
How often, on average, did you use
(FOOD SUPPLEMENT) during that time?
You may use the food frequency
choices list which was sent to you in the
mail to help you respond to this
question.
MO
DK
2.
Nestle’s Sweet Success
Nutriment
Ovaltine
Protein Powder NOS
Shaklee Instant Protein
Slim-Fast Bars
NEVER OR < ONCE PER MONTH ................... 0
1 PER MONTH ...............................................1M
2 PER MONTH ...............................................2M
3 PER MONTH ...............................................3M
1 PER WEEK ................................................. 1W
2 PER WEEK ................................................. 2W
3 PER WEEK ................................................. 3W
4 PER WEEK ................................................. 4W
5 PER WEEK ................................................. 5W
6 PER WEEK ................................................. 6W
1 PER DAY ..................................................... 1D
2 PER DAY ..................................................... 2D
3 PER DAY ..................................................... 3D
4 PER DAY ..................................................... 4D
5 PER DAY ..................................................... 5D
6+ PER DAY ................................................... 6D
DK ................................................................... -1
RF.................................................................... -2
NEVER OR < ONCE PER MONTH ................... 0
1 PER MONTH ...............................................1M
2 PER MONTH ...............................................2M
3 PER MONTH ...............................................3M
1 PER WEEK ................................................. 1W
2 PER WEEK ................................................. 2W
3 PER WEEK ................................................. 3W
4 PER WEEK ................................................. 4W
5 PER WEEK ................................................. 5W
6 PER WEEK ................................................. 6W
1 PER DAY ..................................................... 1D
2 PER DAY ..................................................... 2D
3 PER DAY ..................................................... 3D
4 PER DAY ..................................................... 4D
5 PER DAY ..................................................... 5D
6+ PER DAY ................................................... 6D
DK ................................................................... -1
RF.................................................................... -2
4/6/2010
National Birth Defects Prevention Study—Mother Questionnaire
Page 56
DIETARY ASSESSMENT-INTRODUCTION
Next I will read a list of food items, and for each one I would like to know how often you ate that food on average during the year before you became pregnant
with ([NOIB]/this pregnancy). You may use the list of Food Frequency Choices that was sent to you in the mail to help you answer these questions. You do not
have to remember exactly what you ate, we are only trying to determine what your usual diet was like before you were pregnant. For seasonal foods, such as
fruits and vegetables, you can average over the six months prior to pregnancy. For foods that you ate less than once a month, you can report as never or none.
D32.
How often, on average, did you use (READ LIST)?
0
NEVER
OR < 1
PER
MONTH
1M
2M
3M
1W
2W
3W
4W
5W
6W
1D
2D
3D
4D
5D
6D
-2
-1
1 PER
MONTH
2 PER
MONTH
3 PER
MONTH
1 PER
WEEK
2 PER
WEEK
3 PER
WEEK
4 PER
WEEK
5 PER
WEEK
6 PER
WEEK
1 PER
DAY
2 PER
DAY
3 PER
DAY
4 PER
DAY
5 PER
DAY
6+ PER
DAY
RF
DK
-1
a.
Skim or lowfat milk (8 oz glass)
0
1M
2M
3M
1W
2W
3W
4W
5W
6W
1D
2D
3D
4D
5D
6D
-2
b.
Whole milk (8 oz glass) ............
0
1M
2M
3M
1W
2W
3W
4W
5W
6W
1D
2D
3D
4D
5D
6D
-2
-1
c.
Yogurt (1cup) ...........................
0
1M
2M
3M
1W
2W
3W
4W
5W
6W
1D
2D
3D
4D
5D
6D
-2
-1
d.
Soy milk or soy yogurt (8 oz) ....
0
1M
2M
3M
1W
2W
3W
4W
5W
6W
1D
2D
3D
4D
5D
6D
-2
-1
e.
Ice cream(1/2 cup) ...................
0
1M
2M
3M
1W
2W
3W
4W
5W
6W
1D
2D
3D
4D
5D
6D
-2
-1
f.
Cottage or Ricotta cheese (1/2 cup)
0
1M
2M
3M
1W
2W
3W
4W
5W
6W
1D
2D
3D
4D
5D
6D
-2
-1
g.
Other cheese e.g., American,
cheddar, etc., plain or part of a dish
(1 slice or 1 oz serving)
0
1M
2M
3M
1W
2W
3W
4W
5W
6W
1D
2D
3D
4D
5D
6D
-2
-1
h.
Margarine (pat), added to food or
bread; exclude use in cooking ..
0
1M
2M
3M
1W
2W
3W
4W
5W
6W
1D
2D
3D
4D
5D
6D
-2
-1
i.
Butter (pat), added to food or bread;
exclude use in cooking ............
0
1M
2M
3M
1W
2W
3W
4W
5W
6W
1D
2D
3D
4D
5D
6D
-2
-1
j.
Fresh apples or pears (1) .........
0
1M
2M
3M
1W
2W
3W
4W
5W
6W
1D
And again, in the year before your pregnancy, how often on average did you use…
2D
3D
4D
5D
6D
-2
-1
k.
Oranges (1) ..............................
0
1M
2M
3M
1W
2W
3W
4W
5W
6W
1D
2D
3D
4D
5D
6D
-2
-1
l.
Orange juice (small glass) ........
0
1M
2M
3M
1W
2W
3W
4W
5W
6W
1D
2D
3D
4D
5D
6D
-2
-1
m.
Hawaiian Punch, lemonade, or other
fruit drinks (small glass) ............
0
1M
2M
3M
1W
2W
3W
4W
5W
6W
1D
2D
3D
4D
5D
6D
-2
-1
n.
Peaches, apricots, plums, or
nectarines (1 fresh or ½ cup canned)
0
1M
2M
3M
1W
2W
3W
4W
5W
6W
1D
2D
3D
4D
5D
6D
-2
-1
o.
Bananas (1)..............................
0
1M
2M
3M
1W
2W
3W
4W
5W
6W
1D
2D
3D
4D
5D
6D
-2
-1
p.
Cantaloupe (1/4 melon) ............
0
1M
2M
3M
1W
2W
3W
4W
5W
6W
1D
2D
3D
4D
5D
6D
-2
-1
q.
Avocado (1) or guacamole (1 cup)
0
1M
2M
3M
1W
2W
3W
4W
5W
6W
1D
2D
3D
4D
5D
6D
-2
-1
r.
Other fruits fresh, frozen, or canned
(1/2 cup) ...................................
0
1M
2M
3M
1W
2W
3W
4W
5W
6W
1D
2D
3D
4D
5D
6D
-2
-1
s.
Tomatoes (1) or tomato juice (small
glass) .......................................
0
1M
2M
3M
1W
2W
3W
4W
5W
6W
1D
2D
3D
4D
5D
6D
-2
-1
4/6/2010
National Birth Defects Prevention Study—Mother Questionnaire
D32.
Page 57
How often, on average, did you use (READ LIST)?
0
NEVER
OR < 1
PER
MONTH
1M
2M
3M
1W
2W
3W
4W
5W
6W
1D
2D
3D
4D
5D
6D
-2
-1
1 PER
MONTH
2 PER
MONTH
3 PER
MONTH
1 PER
WEEK
2 PER
WEEK
3 PER
WEEK
4 PER
WEEK
5 PER
WEEK
6 PER
WEEK
1 PER
DAY
2 PER
DAY
3 PER
DAY
4 PER
DAY
5 PER
DAY
6+ PER
DAY
RF
DK
t.
String beans (1/2 cup) ..............
0
1M
2M
3M
1W
2W
3W
4W
5W
6W
1D
2D
3D
4D
5D
6D
-2
-1
u.
Broccoli (1/2 cup) .....................
0
1M
2M
3M
1W
2W
3W
4W
5W
6W
1D
2D
3D
4D
5D
6D
-2
-1
v.
Cabbage, cauliflower, or brussel
sprouts (1/2 cup) ......................
0
1M
2M
3M
1W
2W
3W
4W
5W
6W
1D
2D
3D
4D
5D
6D
-2
-1
w.
Carrots, raw (1/2 carrot or 2-4 sticks)
.................................................
0
1M
2M
3M
1W
2W
3W
4W
5W
6W
1D
2D
3D
4D
5D
6D
-2
-1
x.
Carrots, cooked (1/2 cup) .........
0
1M
2M
3M
1W
2W
3W
4W
5W
6W
1D
2D
3D
4D
5D
6D
-2
-1
y.
Corn (1 ear or ½ cup frozen, canned)
.................................................
0
1M
2M
3M
1W
2W
3W
4W
5W
6W
1D
2D
3D
4D
5D
6D
-2
-1
z.
Peas or lima beans (1/2 cup frozen,
canned) ....................................
0
1M
2M
3M
1W
2W
3W
4W
5W
6W
1D
2D
3D
4D
5D
6D
-2
-1
aa. Yams or sweet potatoes (1/2 cup)
0
1M
2M
3M
1W
2W
3W
4W
5W
6W
1D
2D
3D
4D
5D
6D
-2
-1
bb. Spinach or collard greens, cooked
(1/2 cup) ...................................
0
1M
2M
3M
1W
2W
3W
4W
5W
6W
1D
2D
3D
4D
5D
6D
-2
-1
cc. Refried beans (1 cup) ...............
0
1M
2M
3M
1W
2W
3W
4W
5W
6W
1D
2D
3D
4D
5D
6D
-2
-1
dd. Beans or lentils, baked or dried (1/2
cup) ..........................................
0
1M
2M
3M
1W
2W
3W
4W
5W
6W
1D
And again, in the year before your pregnancy, how often on average did you use…
2D
3D
4D
5D
6D
-2
-1
ee.
Squash (1/2 cup) .....................
0
1M
2M
3M
1W
2W
3W
4W
5W
6W
1D
2D
3D
4D
5D
6D
-2
-1
ff.
Raw Chile peppers, Jalapeño (1)
0
1M
2M
3M
1W
2W
3W
4W
5W
6W
1D
2D
3D
4D
5D
6D
-2
-1
gg. Salsa (1 cup) (fruit or tomato) ...
0
1M
2M
3M
1W
2W
3W
4W
5W
6W
1D
2D
3D
4D
5D
6D
-2
-1
hh. Eggs (1) ...................................
0
1M
2M
3M
1W
2W
3W
4W
5W
6W
1D
2D
3D
4D
5D
6D
-2
-1
ii1. Chicken or Turkey with skin (4-6 oz)
0
1M
2M
3M
1W
2W
3W
4W
5W
6W
1D
2D
3D
4D
5D
6D
-2
-1
ii2. Chicken or Turkey without skin (4-6
oz) ............................................
0
1M
2M
3M
1W
2W
3W
4W
5W
6W
1D
2D
3D
4D
5D
6D
-2
-1
jj.
Bacon (2 slices) ........................
0
1M
2M
3M
1W
2W
3W
4W
5W
6W
1D
2D
3D
4D
5D
6D
-2
-1
kk. Hot dogs (1) .............................
0
1M
2M
3M
1W
2W
3W
4W
5W
6W
1D
2D
3D
4D
5D
6D
-2
-1
ll.
Processed meats, e.g. sausage,
salami, bologna, chorizo, etc. (piece
or slice).
0
1M
2M
3M
1W
2W
3W
4W
5W
6W
1D
2D
3D
4D
5D
6D
-2
-1
mm. Liver (3-4 oz) ............................
0
1M
2M
3M
1W
2W
3W
4W
5W
6W
1D
2D
3D
4D
5D
6D
-2
-1
nn. Chicken livers (1 oz) .................
0
1M
2M
3M
1W
2W
3W
4W
5W
6W
1D
2D
3D
4D
5D
6D
-2
-1
4/6/2010
National Birth Defects Prevention Study—Mother Questionnaire
D32.
Page 58
How often, on average, did you use (READ LIST)?
0
NEVER
OR < 1
PER
MONTH
1M
2M
3M
1W
2W
3W
4W
5W
6W
1D
2D
3D
4D
5D
6D
-2
-1
1 PER
MONTH
2 PER
MONTH
3 PER
MONTH
1 PER
WEEK
2 PER
WEEK
3 PER
WEEK
4 PER
WEEK
5 PER
WEEK
6 PER
WEEK
1 PER
DAY
2 PER
DAY
3 PER
DAY
4 PER
DAY
5 PER
DAY
6+ PER
DAY
RF
DK
oo. Organ meats Barbacoa, Menudo,
sweetbreads, tongue, intestines (3-4
oz) ............................................
0
1M
2M
3M
1W
2W
3W
4W
5W
6W
1D
2D
3D
4D
5D
6D
-2
-1
pp. Hamburger (1 patty) .................
0
1M
2M
3M
1W
2W
3W
4W
5W
6W
1D
2D
3D
4D
5D
6D
-2
-1
qq. Beef, pork, lamb or cabrito as a
sandwich or mixed dish, e.g. stew,
casserole, lasagna, etc. ............
0
1M
2M
3M
1W
2W
3W
4W
5W
6W
1D
2D
3D
4D
5D
6D
-2
-1
rr.
Beef, pork, lamb or cabrito as a main
dish, e.g. steak, roast, ham, etc. (4-6
oz) ............................................
0
1M
2M
3M
1W
2W
3W
4W
5W
6W
1D
2D
3D
4D
5D
6D
-2
-1
ss. Fish (3-5 oz) .............................
0
1M
2M
3M
1W
2W
3W
4W
5W
6W
1D
2D
3D
4D
5D
6D
-2
-1
tt.
0
1M
2M
3M
1W
2W
3W
4W
5W
6W
1D
2D
3D
4D
5D
6D
-2
-1
Tofu, tempeh or soy burgers (4 oz)
uu. Chocolate (1 oz) .......................
0
1M
2M
3M
1W
2W
3W
4W
5W
6W
1D
2D
3D
4D
5D
6D
-2
-1
vv. Candy without chocolate (1 oz).
0
1M
2M
3M
1W
2W
3W
4W
5W
6W
1D
2D
3D
4D
5D
6D
-2
-1
ww. Pie (slice) .................................
0
1M
2M
3M
1W
2W
3W
4W
5W
6W
1D
And again, in the year before your pregnancy, how often on average did you use…
2D
3D
4D
5D
6D
-2
-1
xx. Cake (slice) or donut (1) ...........
0
1M
2M
3M
1W
2W
3W
4W
5W
6W
1D
2D
3D
4D
5D
6D
-2
-1
yy. Cookies (1) ...............................
0
1M
2M
3M
1W
2W
3W
4W
5W
6W
1D
2D
3D
4D
5D
6D
-2
-1
zz. White bread (slice), including pita
bread, bagels and crackers ......
0
1M
2M
3M
1W
2W
3W
4W
5W
6W
1D
2D
3D
4D
5D
6D
-2
-1
aaa. Biscuits, scones, croissants and
muffins (1) ...............................
0
1M
2M
3M
1W
2W
3W
4W
5W
6W
1D
2D
3D
4D
5D
6D
-2
-1
bbb. Dark bread (slice) including wheat
pita bread .................................
0
1M
2M
3M
1W
2W
3W
4W
5W
6W
1D
2D
3D
4D
5D
6D
-2
-1
ccc. French fried potatoes (4 oz)......
0
1M
2M
3M
1W
2W
3W
4W
5W
6W
1D
2D
3D
4D
5D
6D
-2
-1
ddd. Potatoes baked, boiled (1) or mashed
(1 cup) ......................................
0
1M
2M
3M
1W
2W
3W
4W
5W
6W
1D
2D
3D
4D
5D
6D
-2
-1
eee. Rice or pasta e.g. Spanish rice,
spaghetti, noodles, etc. (1 cup) .
0
1M
2M
3M
1W
2W
3W
4W
5W
6W
1D
2D
3D
4D
5D
6D
-2
-1
fff.
Tortilla (1) .................................
0
1M
2M
3M
1W
2W
3W
4W
5W
6W
1D
2D
3D
4D
5D
6D
-2
-1
ggg. Potato chips or corn chips (small bag
or 1 oz) .......................
0
1M
2M
3M
1W
2W
3W
4W
5W
6W
1D
2D
3D
4D
5D
6D
-2
-1
hhh. Nuts (small packet or 1 oz) .......
0
1M
2M
3M
1W
2W
3W
4W
5W
6W
1D
2D
3D
4D
5D
6D
-2
-1
iii.
Peanut butter (1tbs)..................
0
1M
2M
3M
1W
2W
3W
4W
5W
6W
1D
2D
3D
4D
5D
6D
-2
-1
jjj.
Oil and vinegar dressing e.g., Italian
(1 tbs) .......................................
0
1M
2M
3M
1W
2W
3W
4W
5W
6W
1D
2D
3D
4D
5D
6D
-2
-1
4/6/2010
National Birth Defects Prevention Study—Mother Questionnaire
Page 59
We have just a few more dietary questions about your average habits during the year before you became
pregnant with ([NOIB]/this pregnancy).
D33.
D34.
How many teaspoons of sugar did you add to your
beverages (including tea and coffee) and foods
(including cereal and fruit) in total per day?
# OF TEASPOONS .........................................
How much of the visible fat on your beef, pork or
lamb was removed before eating?
Would you say…
All visible fat removed ......................................................... 1
Most fat was removed ......................................................... 2
Small part of fat was removed ............................................. 3
None was removed ............................................................. 4
Don’t eat meat .................................................................... 5
DK ..................................................................................... -1
RF...................................................................................... -2
READ CHOICES.
D35.
What kind of fat did you usually use for frying and
sautéing at home? Exclude “Pam” type spray.
READ CHOICES. SELECT ONE.
PROBE: Which did you use most often or most of?
D36.
What kind of fat did you usually use for baking at
home? READ CHOICES. SELECT ONE.
D37.
How often did you eat food that is fried at home?
Exclude “Pam” type spray. READ CHOICES.
D38.
How often did you eat fried food away from home?
(e.g. French fries, fried chicken, fried fish, fried
tortilla chips) READ CHOICES.
D39a.
What type of cooking oil did you usually use at
home (e.g. Corn Oil)? (Which did you use the
most?)
PROBE: Some companies, sell many types of oil,
such as corn, canola, soybean or olive. What type
of [brand name] oil did you use?
DK
Real butter (light butter) ...................................................... 1
Margarine ........................................................................... 2
Vegetable oil (olive oil, canola oil) ....................................... 3
Vegetable shortening .......................................................... 4
Lard .................................................................................... 5
NA ................................................................................... -10
DK ..................................................................................... -1
RF...................................................................................... -2
Real butter (light butter) ...................................................... 1
Margarine ........................................................................... 2
Vegetable oil (olive oil, canola oil) ....................................... 3
Vegetable shortening .......................................................... 4
Lard .................................................................................... 5
NA ................................................................................... -10
DK ..................................................................................... -1
RF...................................................................................... -2
Never or less than once per week ..................................... 01
1 - 3 times per week ......................................................... 02
4 – 6 times per week ......................................................... 03
Daily ................................................................................. 04
DK ..................................................................................... -1
RF...................................................................................... -2
Never or less than once per week ..................................... 01
1 - 3 times per week ......................................................... 02
4 – 6 times per week ......................................................... 03
Daily ................................................................................. 04
DK ..................................................................................... -1
RF...................................................................................... -2
SPECIFY TYPE:
_____________________________________________________
NONE
DK
RF
PROMPT: Only include oils, not fats, such as butter or
lard.
PROMPT: During the year before you became pregnant
4/6/2010
National Birth Defects Prevention Study—Mother Questionnaire
Page 60
CAFFEINE
The next questions are about caffeine. We will be asking you about your average use of coffee, tea and soda during the
year before you became pregnant with ([NOIB]/this pregnancy), and during your first trimester. You may use the list of
food frequency choices again.
D40.
During the year before you became
pregnant with ([NOIB]/this pregnancy),
how many cups of caffeinated or regular
coffee, hot or iced, did you usually
drink?
NEVER OR < ONCE PER MONTH ............................................................. 0
1 PER MONTH .......................................................................................... 1M
2 PER MONTH .......................................................................................... 2M
3 PER MONTH .......................................................................................... 3M
1 PER WEEK ............................................................................................ 1W
2 PER WEEK ............................................................................................ 2W
3 PER WEEK ............................................................................................ 3W
4 PER WEEK ............................................................................................ 4W
5 PER WEEK ............................................................................................ 5W
6 PER WEEK ............................................................................................ 6W
1 PER DAY................................................................................................. 1D
2 PER DAY................................................................................................. 2D
3 PER DAY................................................................................................. 3D
4 PER DAY................................................................................................. 4D
5 PER DAY................................................................................................. 5D
6+ PER DAY............................................................................................... 6D
DK ............................................................................................................... -1
RF ............................................................................................................... -2
D41.
During the first trimester, how many
cups of caffeinated or regular coffee,
hot or iced, did you usually drink?
NEVER OR < ONCE PER MONTH ............................................................. 0
1 PER MONTH .......................................................................................... 1M
2 PER MONTH .......................................................................................... 2M
3 PER MONTH .......................................................................................... 3M
1 PER WEEK ............................................................................................ 1W
2 PER WEEK ............................................................................................ 2W
3 PER WEEK ............................................................................................ 3W
4 PER WEEK ............................................................................................ 4W
5 PER WEEK ............................................................................................ 5W
6 PER WEEK ............................................................................................ 6W
1 PER DAY................................................................................................. 1D
2 PER DAY................................................................................................. 2D
3 PER DAY................................................................................................. 3D
4 PER DAY................................................................................................. 4D
5 PER DAY................................................................................................. 5D
6+ PER DAY............................................................................................... 6D
DK ............................................................................................................... -1
RF ............................................................................................................... -2
(IF BOTH D40 AND D41 = NEVER, RF OR DK, SKIP TO D43)
D42.
What size cup did you usually have for
your coffee? Was it small, medium,
large or extra large?
SMALL (< 8 OUNCE, TEACUP) ................................................................... 1
MEDIUM (8 OUNCES TO LESS THAN 12 OUNCES, MEDIUM MUG) ......... 2
LARGE (12 OUNCE, LARGE MUG) ............................................................. 3
EXTRA LARGE (> 12 OUNCE, LARGE TAKE-OUT) .................................... 4
DK ............................................................................................................... -1
RF ............................................................................................................... -2
4/6/2010
National Birth Defects Prevention Study—Mother Questionnaire
Page 61
D43.
During the year before you became
pregnant with ([NOIB]/this pregnancy),
how many cups or glasses of caffeinated
tea, hot or iced, did you usually drink?
NEVER OR < ONCE PER MONTH ................................ 0
1 PER MONTH ........................................................... 1M
2 PER MONTH ........................................................... 2M
3 PER MONTH ........................................................... 3M
1 PER WEEK .............................................................. 1W
2 PER WEEK .............................................................. 2W
3 PER WEEK .............................................................. 3W
4 PER WEEK .............................................................. 4W
5 PER WEEK .............................................................. 5W
6 PER WEEK .............................................................. 6W
1 PER DAY .................................................................. 1D
2 PER DAY .................................................................. 2D
3 PER DAY .................................................................. 3D
4 PER DAY .................................................................. 4D
5 PER DAY .................................................................. 5D
6+ PER DAY ................................................................ 6D
DK................................................................................. -1
RF ................................................................................. -2
D44.
During the first trimester, how many cups
or glasses of caffeinated tea, hot or iced,
did you usually drink?
NEVER OR < ONCE PER MONTH ................................ 0
1 PER MONTH ........................................................... 1M
2 PER MONTH ........................................................... 2M
3 PER MONTH ........................................................... 3M
1 PER WEEK .............................................................. 1W
2 PER WEEK .............................................................. 2W
3 PER WEEK .............................................................. 3W
4 PER WEEK .............................................................. 4W
5 PER WEEK .............................................................. 5W
6 PER WEEK .............................................................. 6W
1 PER DAY .................................................................. 1D
2 PER DAY .................................................................. 2D
3 PER DAY .................................................................. 3D
4 PER DAY .................................................................. 4D
5 PER DAY .................................................................. 5D
6+ PER DAY ................................................................ 6D
DK................................................................................. -1
RF ................................................................................. -2
D45.
During the year before you became
pregnant with ([NOIB]/this pregnancy),
and during the first trimester, did you
drink sodas or soft drinks?
YES ................................................................................ 1
NO .............................. (SKIP TO SECTION E) ............... 2
DK............................... (SKIP TO SECTION E) ............. -1
FOR EVERY BRAND ANSWERED IN D46, ASK D47 – D50:
7 up = 01
A&W cream soda = 02
A&W root beer = 03
After the Fall spritzers = 04
Barq’s root beer = 05
Black cherry soda = 06
Cheerwine = 07
Cherry 7-up = 08
Cherry coke = 09
Cherry soda = 10
Clearly Canadian = 11
Club soda = 12
Coke = 13
Cola , NOS = 14
Cranberry ginger ale = 15
Cream soda, NOS = 16
Diet Rite cola = 17
Diet Rite (fruit flavors) = 18
Dr. Brown’s(all flavors) = 19
Dr. Pepper = 20
Fanta (all flavors) = 21
Fresca = 22
Ginger ale = 23
Ginger beer soda, NOS = 24
Grapefruit soda, NOS = 25
Hires root beer = 26
IBC black cherry = 27
IBC cherry cola = 28
IBC cream soda = 29
IBC root beer = 30
Jarritos sodas (all flavors) = 31
Jolt cola = 32
Josta = 33
Knudsen sparkling juices = 34
Lemon/lime soda, NOS = 35
Mellow Yellow = 36
Mountain Dew = 37
Mr. Pibb = 38
Nugrape = 39
Orange Crush = 40
Orange soda, NOS = 41
Pepsi = 42
Quinine water = 43
RC Cola = 44
Root beer, NOS = 45
Sierra Mist = 181
Slice = 46
Sparkling water flavors = 47
Sprite = 48
Squirt (both flavors) = 49
Strawberry soda = 50
Sun-Drop = 51
Sunkist fruit punch = 52
Sunkist orange = 53
Surge = 54
Tab = 55
Tahitian Treat = 56
Tonic water = 57
Wild cherry Pepsi = 58
Wink = 59
Yoohoo Chocolate = 60
Other, specify = -5
4/6/2010
National Birth Defects Prevention Study—Mother Questionnaire
D46.
What brand(s) or
types did you
usually
drink?/Anything
else?
D47.
D48.
Was (BRAND)
diet?
Was (BRAND)
caffeine free?
Page 62
D49.
D50.
How many 12 ounce
(cans/glasses/bottles) of
(BRAND) did you usually
drink in the year before you
became pregnant with
([NOIB]/this pregnancy)?
During the first trimester,
how many 12 ounce
(cans/glasses/bottles) of
(BRAND) did you usually
drink?
NEVER OR LESS THAN
1 PER MONTH ........................... 0
1 PER MONTH ......................... 1M
2 PER MONTH ......................... 2M
3 PER MONTH ......................... 3M
1 PER WEEK............................ 1W
2 PER WEEK............................ 2W
3 PER WEEK............................ 3W
4 PER WEEK............................ 4W
5 PER WEEK............................ 5W
6 PER WEEK............................ 6W
1 PER DAY ............................... 1D
2 PER DAY ............................... 2D
3 PER DAY ............................... 3D
4 PER DAY ............................... 4D
5 PER DAY ............................... 5D
6+ PER DAY............................. 6D
DK .............................................. -1
RF .............................................. -2
NEVER OR LESS THAN
1 PER MONTH ........................... 0
1 PER MONTH ......................... 1M
2 PER MONTH ......................... 2M
3 PER MONTH ......................... 3M
1 PER WEEK ........................... 1W
2 PER WEEK ........................... 2W
3 PER WEEK ........................... 3W
4 PER WEEK ........................... 4W
5 PER WEEK ........................... 5W
6 PER WEEK ........................... 6W
1 PER DAY................................ 1D
2 PER DAY................................ 2D
3 PER DAY................................ 3D
4 PER DAY................................ 4D
5 PER DAY................................ 5D
6+ PER DAY ............................. 6D
DK .............................................. -1
RF .............................................. -2
B.
NEVER OR LESS THAN
1 PER MONTH ........................... 0
1 PER MONTH ......................... 1M
2 PER MONTH ......................... 2M
3 PER MONTH ......................... 3M
1 PER WEEK............................ 1W
2 PER WEEK............................ 2W
3 PER WEEK............................ 3W
4 PER WEEK............................ 4W
5 PER WEEK............................ 5W
6 PER WEEK............................ 6W
1 PER DAY ............................... 1D
2 PER DAY ............................... 2D
3 PER DAY ............................... 3D
4 PER DAY ............................... 4D
5 PER DAY ............................... 5D
6+ PER DAY............................. 6D
DK .............................................. -1
RF .............................................. -2
NEVER OR LESS THAN
1 PER MONTH ........................... 0
1 PER MONTH ......................... 1M
2 PER MONTH ......................... 2M
3 PER MONTH ......................... 3M
1 PER WEEK ........................... 1W
2 PER WEEK ........................... 2W
3 PER WEEK ........................... 3W
4 PER WEEK ........................... 4W
5 PER WEEK ........................... 5W
6 PER WEEK ........................... 6W
1 PER DAY................................ 1D
2 PER DAY................................ 2D
3 PER DAY................................ 3D
4 PER DAY................................ 4D
5 PER DAY................................ 5D
6+ PER DAY ............................. 6D
DK .............................................. -1
RF .............................................. -2
C.
NEVER OR LESS THAN
1 PER MONTH ........................... 0
1 PER MONTH ......................... 1M
2 PER MONTH ......................... 2M
3 PER MONTH ......................... 3M
1 PER WEEK............................ 1W
2 PER WEEK............................ 2W
3 PER WEEK............................ 3W
4 PER WEEK............................ 4W
5 PER WEEK............................ 5W
6 PER WEEK............................ 6W
1 PER DAY ............................... 1D
2 PER DAY ............................... 2D
3 PER DAY ............................... 3D
4 PER DAY ............................... 4D
5 PER DAY ............................... 5D
6+ PER DAY............................. 6D
DK .............................................. -1
RF .............................................. -2
NEVER OR LESS THAN
1 PER MONTH ........................... 0
1 PER MONTH ......................... 1M
2 PER MONTH ......................... 2M
3 PER MONTH ......................... 3M
1 PER WEEK ........................... 1W
2 PER WEEK ........................... 2W
3 PER WEEK ........................... 3W
4 PER WEEK ........................... 4W
5 PER WEEK ........................... 5W
6 PER WEEK ........................... 6W
1 PER DAY................................ 1D
2 PER DAY................................ 2D
3 PER DAY................................ 3D
4 PER DAY................................ 4D
5 PER DAY................................ 5D
6+ PER DAY ............................. 6D
DK .............................................. -1
RF .............................................. -2
LIST ALL. USE PRECODED SODA LIST TO PROBE.
______________________
ASK D47-D50
RF SKIP TO E1
YES ................. 1
NO ................... 2
DK ..................-1
YES.................. 1
NO ................... 2
DK .................. -1
DK
A.
______________________
ASK D47-D50
RF SKIP TO E1
YES ................. 1
NO ................... 2
DK ..................-1
YES.................. 1
NO ................... 2
DK .................. -1
DK
______________________
ASK D47-D50
RF SKIP TO E1
DK
YES ................. 1
NO ................... 2
DK ..................-1
YES.................. 1
NO ................... 2
DK .................. -1
4/6/2010
National Birth Defects Prevention Study—Mother Questionnaire
Page 63
SECTION E: STRESS
The next series of questions will be about events that may have occurred in your life from 3 months before you
rd
became pregnant through your 3 month of pregnancy, which would be (B3) through (P3). Most people experience
periods of stress in their lives, caused by major events and daily life. We will be asking whether or not an event
happened during that time period, but we will not be asking for further details.
E1.
From 3 months before you became pregnant through your
rd
3 month of pregnancy, did you experience any serious
relationship difficulties with your husband or partner or
become separated or divorced?
YES .......................................................................... 1
NO ............................................................................ 2
DK............................................................................ -1
RF ............................................................................ -2
NA.......................................................................... -10
E2.
During this same time period, did you or your husband or
partner have any serious legal or financial problems?
YES .......................................................................... 1
NO ............................................................................ 2
DK............................................................................ -1
RF ............................................................................ -2
E3.
During this same time period, were you or someone close to
you a victim of abuse, violence, or crime? Remember, you
just have to indicate yes or no.
YES .......................................................................... 1
NO ............................................................................ 2
DK............................................................................ -1
RF ............................................................................ -2
MOTHER MUST USE HER OWN JUDGEMENT ON WHAT SHE
THINKS IS MEANT BY “SOMEONE CLOSE TO YOU”.
E4.
During this same time period, did you or someone close to
you have a serious illness or injury?
MOTHER MUST USE HER OWN JUDGEMENT ON WHAT SHE
THINKS IS MEANT BY “SOMEONE CLOSE TO YOU”.
E5.
During this same time period, did someone close to you die?
MOTHER MUST USE HER OWN JUDGEMENT ON WHAT SHE
THINKS IS MEANT BY “SOMEONE CLOSE TO YOU”.
YES .......................................................................... 1
NO ............................................................................ 2
DK............................................................................ -1
RF ............................................................................ -2
YES .......................................................................... 1
NO ............................................................................ 2
DK............................................................................ -1
RF ............................................................................ -2
E6.
During this same time period, could you count on anyone to
provide you with emotional support such as talking over a
problem or helping with a difficult decision, if you had
needed it?
YES .......................................................................... 1
NO ............................................................................ 2
DK............................................................................ -1
RF ............................................................................ -2
E7.
During this same time period, could you count on anyone to
provide you with help financially such as paying bills or
providing food or clothes, if you had needed it?
YES .......................................................................... 1
NO ............................................................................ 2
DK............................................................................ -1
RF ............................................................................ -2
E8.
During this same time period, could you count on anyone to
provide you with help with daily tasks such as grocery
shopping, child care, or cooking, if you had needed it?
YES .......................................................................... 1
NO ............................................................................ 2
DK............................................................................ -1
RF ............................................................................ -2
E9.
During this same time period, how often did you feel
nervous and stressed? Would you say…READ CHOICES
Never................................................................. 0
Almost Never..................................................... 1
Sometimes ........................................................ 2
Somewhat Often ............................................... 3
Very Often ......................................................... 4
DK............................................................................ -1
RF ............................................................................ -2
4/6/2010
National Birth Defects Prevention Study—Mother Questionnaire
Page 64
SECTION F: TOBACCO-MOTHER
F1.
The next questions are about tobacco use. Did you
ever smoke cigarettes?
YES ........................................................................................ 1
NO ................................. (SKIP TO F5) .................................. 2
DK ................................. (SKIP TO F5) ................................. -1
F2.
From 3 months before you became pregnant to the
end of your pregnancy, did you smoke cigarettes?
YES ........................................................................................ 1
NO ................................. (SKIP TO F5) .................................. 2
DK ................................. (SKIP TO F5) ................................. -1
(CONTINUED ON NEXT PAGE)
4/6/2010
National Birth Defects Prevention Study—Mother Questionnaire
F3.
During which months did you
smoke?
CIRCLE FOR EACH MONTH. DO
NOT CODE SHADED AREA.
MO
B3
B2
B1
P1
P2
P3
T2
T3
YES
(ASK F4)
1
1
1
1
1
1
1
1
NO
2
2
2
2
2
2
2
2
DK
-1
-1
-1
-1
-1
-1
-1
-1
Page 65
F4.
During (SPECIFY MONTH) about how many
cigarettes did you smoke a day?/Did you continue
to smoke that many cigarettes through (LAST
MONTH STATED)?
<1/DAY ................................................01
1/DAY ..................................................02
2-4/DAY ...............................................03
½ PACK (5-14).....................................04
1 PACK(15-24).....................................05
1 ½ PACK (25-34)................................06
2 PACK (35-44)....................................07
>2 PACK ..............................................08
<1/DAY ................................................01
1/DAY ..................................................02
2-4/DAY ...............................................03
½ PACK (5-14).....................................04
1 PACK(15-24).....................................05
1 ½ PACK (25-34)................................06
2 PACK (35-44)....................................07
>2 PACK ..............................................08
<1/DAY ................................................01
1/DAY ..................................................02
2-4/DAY ...............................................03
½ PACK (5-14).....................................04
1 PACK(15-24).....................................05
1 ½ PACK (25-34)................................06
2 PACK (35-44)....................................07
>2 PACK ..............................................08
<1/DAY ................................................01
1/DAY ..................................................02
2-4/DAY ...............................................03
½ PACK (5-14).....................................04
1 PACK(15-24).....................................05
1 ½ PACK (25-34)................................06
2 PACK (35-44)....................................07
>2 PACK ..............................................08
<1/DAY ................................................01
1/DAY ..................................................02
2-4/DAY ...............................................03
½ PACK (5-14).....................................04
1 PACK(15-24).....................................05
1 ½ PACK (25-34)................................06
2 PACK (35-44)....................................07
>2 PACK ..............................................08
<1/DAY ................................................01
1/DAY ..................................................02
2-4/DAY ...............................................03
½ PACK (5-14).....................................04
1 PACK(15-24).....................................05
1 ½ PACK (25-34)................................06
2 PACK (35-44)....................................07
>2 PACK ..............................................08
<1/DAY ................................................01
1/DAY ..................................................02
2-4/DAY ...............................................03
½ PACK (5-14).....................................04
1 PACK(15-24).....................................05
1 ½ PACK (25-34)................................06
2 PACK (35-44)....................................07
>2 PACK ..............................................08
<1/DAY ................................................01
1/DAY ..................................................02
2-4/DAY ...............................................03
½ PACK (5-14).....................................04
1 PACK(15-24).....................................05
1 ½ PACK (25-34)................................06
2 PACK (35-44)....................................07
>2 PACK ..............................................08
DK
RF
DK
RF
DK
RF
DK
RF
DK
RF
DK
RF
DK
RF
DK
RF
4/6/2010
National Birth Defects Prevention Study—Mother Questionnaire
Page 66
TOBACCO-HOUSEHOLD
YES........................................................................... 1
NO ........................... (SKIP TO F7) ........................... 2
DK ............................ (SKIP TO F7) .......................... -1
F5.
Did anyone in your household smoke cigarettes in your
home between 3 months before you became pregnant to
the end of your pregnancy?
MO
YES
NO
DK
F6.
During which months did someone smoke in your
home?
B3
1
2
-1
CIRCLE FOR EACH MONTH.
DO NOT CODE SHADED AREA.
B2
1
2
-1
B1
1
2
-1
P1
1
2
-1
P2
1
2
-1
P3
1
2
-1
T2
1
2
-1
T3
1
2
-1
TOBACCO-WORKPLACE
YES .......................................................................... 1
NO ........................... (SKIP TO F9) .......................... 2
DK ........................... (SKIP TO F9) ......................... -1
F7.
Did anyone smoke cigarettes near you at a
workplace or school you may have attended during
that year?
MO
YES
NO
DK
F8.
During which months did someone smoke near you
at work/school?
B3
1
2
-1
CIRCLE FOR EACH MONTH.
DO NOT CODE SHADED AREA.
B2
1
2
-1
B1
1
2
-1
P1
1
2
-1
P2
1
2
-1
P3
1
2
-1
T2
1
2
-1
T3
1
2
-1
4/6/2010
National Birth Defects Prevention Study—Mother Questionnaire
Page 67
ALCOHOL
F9.
YES.................................................................................. 1
NO ............................ (SKIP TO F15) .............................. 2
DK ............................. (SKIP TO F15) ............................. -1
RF ............................. (SKIP TO F15) ............................. -2
Now I’m going to ask you some questions about
drinking alcoholic beverages. We define an
alcoholic drink as one beer, one glass of wine, one
mixed drink, or one shot of liquor. From 3 months
before you became pregnant to the end of your
pregnancy, did you drink any wine, beer, mixed
drinks or shots of liquor?
F10.
During which months did you
drink any alcoholic beverages?
CIRCLE FOR EACH MONTH. DO
NOT CODE SHADED AREA.
MO
YES
NO
(ASK F11F13)
(NEXT)
B3
1
2
-1
B2
1
2
-1
B1
1
2
-1
P1
1
2
-1
P2
1
2
-1
P3
1
2
-1
T2
1
2
-1
T3
1
2
-1
F14.
F11.
rd nd
In the (3 /2 /1st month
st nd rd
before pregnancy, 1 /2 /3
nd rd
month of pregnancy, 2 /3
trimester), on average, how
many days [FOR T2 AND
T3, ASK: days/month]did
you drink alcoholic
beverages?
F12.
On those days that you
drank alcoholic
beverages, on average,
how many drinks did
you have per day?
# DAYS
# DRINKS
DK
(NEXT)
RF
DK RF
DK RF
DK RF
DK RF
DK RF
DK RF
DK RF
# DRINKS
RF
DK RF
DK RF
DK RF
DK RF
DK RF
DK RF
DK RF
DK
F13.
What was the
greatest number of
drinks you had on
one occasion in
(MONTH)?
DK
RF
DK RF
DK RF
DK RF
DK RF
DK RF
DK RF
DK RF
DK
On the days that you drank alcohol, what
type(s) of alcohol did you usually drink?
READ CHOICES.
YES
NO
DK
RF
a.
Beer ................................................................
1
2
-1
-2
b.
Wine or wine cooler or champagne ................
1
2
-1
-2
c.
Mixed drink or shot liquor ................................
1
2
-1
-2
d.
Other alcohol ...................................................
1
2
-1
-2
-1
-2
SPECIFY: _______________________________
4/6/2010
National Birth Defects Prevention Study—Mother Questionnaire
Page 68
TOBACCO AND SUBSTANCE ABUSE-FATHER
IF FATHER UNKNOWN, SKIP TO F19.
Now I’m going to ask you about some exposures that ([NOIB]’s/the) father may have had around the time
you became pregnant. These include questions about smoking and recreational drug use.
YES ............................................................................ 1
NO ..........................(SKIP TO F17) ............................ 2
DK ..........................(SKIP TO F17) ...........................-1
RF...........................(SKIP TO F17) ...........................-2
F15.
At any time from 1 month before you became
pregnant through the first month of your pregnancy,
which would be (B1) through (P1), did ([NOIB]’s/the)
biologic or natural father smoke cigarettes?
F16.
From 1 month before you became pregnant through
the first month of your pregnancy, about how many
cigarettes did he smoke per day?
F17.
In the 3 months before pregnancy, which would be
(B3) through (B1), did ([NOIB]’s/the) father use any
of the following recreational or street drugs? READ
CHOICES.
YES
NO
DK
RF
a. Marijuana ............................................................
1
2
-1
-2
b. Cocaine ...............................................................
1
2
-1
-2
c. Ecstasy ...............................................................
1
2
-1
-2
d. Methamphetamines or crank or ice ....................
1
2
-1
-2
e. Anything else? ....................................................
1
2
-1
-2
<1/DAY ..................................................................... 01
1/DAY ....................................................................... 02
2-4/DAY .................................................................... 03
½ PACK (5-14) ......................................................... 04
1 PACK(15-24) ......................................................... 05
1 ½ PACK (25-34)..................................................... 06
2 PACK (35-44) ........................................................ 07
>2 PACK ................................................................... 08
DK .............................................................................-1
IF YES TO F17E:
F18.
What did he use? / Anything else?
SPECIFY: ______________________________________________________________________ DK
4/6/2010
National Birth Defects Prevention Study—Mother Questionnaire
Page 69
SUBSTANCE ABUSE-MOTHER
Now I would like to ask you about any recreational drugs you may have used.
F19.
From 3 months before you became pregnant to the
end of your pregnancy, did you use any of the
following recreational or street drugs? READ
CHOICES.
YES
NO
DK
RF
a. Marijuana ............................................................
1
2
-1
-2
b. Cocaine ...............................................................
1
2
-1
-2
c. Ecstasy ...............................................................
1
2
-1
-2
d. Methamphetamines or crank or ice ....................
1
2
-1
-2
e. Anything else? ....................................................
1
2
-1
-2
IF YES TO F19E:
F20.
What did you use? / Anything else?
SPECIFY: ______________________________________________ DK
ASK F21& F22
RF
SKIP TO G1
4/6/2010
National Birth Defects Prevention Study—Mother Questionnaire
F21.
MOTHER’S RECREATIONAL/ STREET
DRUG. LIST EACH “YES” FROM F19
AND F20.
Page 70
F22.
How often did you take/use
Which month(s) did you
take/use (SUBSTANCE)?
(SUBSTANCE)?
MO
YES
NO
DK
B3
1
2
-1
FREQUENCY
DK
______________________________
RF
PER DAY .............................................1
PER WEEK ..........................................2
PER MONTH .......................................3
PER YEAR...........................................4
FIRST SUBSTANCE
B2
1
2
-1
DK
RF
PER DAY .............................................1
PER WEEK ..........................................2
PER MONTH .......................................3
PER YEAR...........................................4
B1
1
2
-1
DK
RF
PER DAY .............................................1
PER WEEK ..........................................2
PER MONTH .......................................3
PER YEAR...........................................4
P1
1
2
-1
DK
RF
PER DAY .............................................1
PER WEEK ..........................................2
PER MONTH .......................................3
PER YEAR...........................................4
P2
1
2
-1
DK
RF
PER DAY .............................................1
PER WEEK ..........................................2
PER MONTH .......................................3
PER YEAR...........................................4
P3
1
2
-1
DK
RF
PER DAY .............................................1
PER WEEK ..........................................2
PER MONTH .......................................3
PER YEAR...........................................4
T2
1
2
-1
DK
RF
PER DAY .............................................1
PER WEEK ..........................................2
PER MONTH .......................................3
PER YEAR...........................................4
T3
1
2
-1
DK
RF
PER DAY .............................................1
PER WEEK ..........................................2
PER MONTH .......................................3
PER YEAR...........................................4
4/6/2010
National Birth Defects Prevention Study—Mother Questionnaire
F21.
MOTHER’S RECREATIONAL/ STREET
DRUG. LIST EACH “YES” FROM F19
AND F20.
Which month(s) did you
take/use (SUBSTANCE)?
MO
YES
NO
DK
B3
1
2
-1
Page 71
F22.
How often did you take/use
(SUBSTANCE)?
FREQUENCY
DK
______________________________
RF
PER DAY ............................................ 1
PER WEEK ......................................... 2
PER MONTH....................................... 3
PER YEAR .......................................... 4
SECOND SUBSTANCE
B2
1
2
-1
DK
RF
PER DAY ............................................ 1
PER WEEK ......................................... 2
PER MONTH....................................... 3
PER YEAR .......................................... 4
B1
1
2
-1
DK
RF
PER DAY ............................................ 1
PER WEEK ......................................... 2
PER MONTH....................................... 3
PER YEAR .......................................... 4
P1
1
2
-1
DK
RF
PER DAY ............................................ 1
PER WEEK ......................................... 2
PER MONTH....................................... 3
PER YEAR .......................................... 4
P2
1
2
-1
DK
RF
PER DAY ............................................ 1
PER WEEK ......................................... 2
PER MONTH....................................... 3
PER YEAR .......................................... 4
P3
1
2
-1
DK
RF
PER DAY ............................................ 1
PER WEEK ......................................... 2
PER MONTH....................................... 3
PER YEAR .......................................... 4
T2
1
2
-1
DK
RF
PER DAY ............................................ 1
PER WEEK ......................................... 2
PER MONTH....................................... 3
PER YEAR .......................................... 4
T3
1
2
-1
DK
RF
PER DAY ............................................ 1
PER WEEK ......................................... 2
PER MONTH....................................... 3
PER YEAR .......................................... 4
4/6/2010
National Birth Defects Prevention Study—Mother Questionnaire
Page 72
IF MOTHER DID NOT PROVIDE DATES IN THE RESIDENCE HISTORY (A17 AND A18) THAT OVERLAP WITH THE
DOC, SKIP TO SECTION H. OTHERWISE, CONTINUE.
SECTION G: WATER
These questions relate to your use of water in your place at [RESIDENCE AT DOC], where you lived at the
time you got pregnant.
G1.
Did your drinking water come from your own private
well or were you on a public water supply around
the time you got pregnant?
WELLS CAN BE PUBLIC OR PRIVATE.
PRIVATE WELL..................................................................1
PUBLIC SUPPLY INCLUDING COMMUNITY WATER
SYSTEM….. ..................... (SKIP TO G3) ..........................2
OTHER .............................. (SKIP TO G3) ........................ -5
DK ..................................... (SKIP TO G3) ........................ -1
RF...................................... (SKIP TO G3) ........................ -2
NA ..................................... (SKIP TO G3) ...................... -10
G2.
Was your well water chemically disinfected around
the time you got pregnant?
YES .................................................................................... 1
NO ...................................................................................... 2
DK ..................................................................................... -1
G3.
Was your home tap water filtered? PROMPT: Around
the time you got pregnant.
All drinking water was filtered .....................................1
Some drinking water was filtered................................2
All water other than drinking water was filtered. .........3
Some water other than drinking water was filtered .....4
No, none of the tap water was filtered ........................5
DK ..............................................................................-1
RF ..............................................................................-2
NA ............................................................................ -10
READ CHOICES
CHOOSE ALL THAT APPLY.
G4.
G5.
Including water used for mixed drinks such as koolaid, how many 8-oz. glasses of cold tap water did
you drink at your home, each day, around the time
you became pregnant? PROMPT: Around the time
you became pregnant means the month before
pregnancy through the first trimester of pregnancy.
# GLASSES .............................................................
How many 8-oz. glasses of water, heated after it
comes out of the tap, such as coffee, brewed iced
tea, and hot chocolate did you drink at your home,
each day, around the time you got pregnant?
# GLASSES .............................................................
DK
RF
(DK OR RF SKIP TO G5)
Per:
DAY ................................................................................... 1
WEEK ................................................................................ 2
MONTH ............................................................................. 3
DK
RF
(DK OR RF SKIP TO G6)
Per:
DAY ................................................................................... 1
WEEK ................................................................................ 2
MONTH ............................................................................. 3
Now think about when you were away from your
residence.
G6.
G7.
Around the time you became pregnant, how many
8-oz. glasses of cold and hot tap water did you
usually drink each day from a tap other than at your
residence?
# GLASSES .............................................................
Around the time you became pregnant, how many
8-oz. glasses of bottled water did you usually drink
each day?
# GLASSES OF BOTTLED WATER ........................
(ROUND 1 12-OZ. BOTTLE DOWN)
DK
RF
(DK OR RF SKIP TO G7)
Per:
DAY ................................................................................... 1
WEEK ................................................................................ 2
MONTH ............................................................................. 3
DK
RF
(DK OR RF SKIP TO G8)
Per:
DAY ................................................................................... 1
WEEK ................................................................................ 2
MONTH ............................................................................. 3
4/6/2010
National Birth Defects Prevention Study—Mother Questionnaire
NOTE: RESPONSE OPTIONS FOR G8 AND G10 ARE:
Page 73
0 = NEVER OR LESS THAN ONCE PER MONTH
1M = 1 PER MONTH
2M = 2 PER MONTH
3M = 3 PER MONTH
1W = 1 PER WEEK
2W = 2 PER WEEK
3W = 3 PER WEEK
4W = 4 PER WEEK
5W = 5 PER WEEK
6W = 6 PER WEEK
1D = 1 PER DAY
2D = 2 PER DAY
3D = 3 PER DAY
4D = 4 PER DAY
5D = 5 PER DAY
6D = 6 PER DAY OR MORE
DK = -1
RF = -2
Now I would like to ask you some questions about activities at your home that involve water.
G8.
Around the time you got pregnant, how often did
you take showers at home?
RECORD CODE .......................................................
DK
RF
IF = 00, SKIP TO G10.
G9.
Approximately how many minutes did you shower
each time?
# MINUTES SHOWERING ......................................
DK
G10.
Around the time you got pregnant, how often did
you take baths at home?
RF
RECORD CODE .......................................................
DK
RF
IF = 00, SKIP TO G12.
G11.
Approximately how many minutes did you bathe
each time?
# MINUTES BATHING .............................................
DK
RF
4/6/2010
National Birth Defects Prevention Study—Mother Questionnaire
G12.
From 3 months before you became pregnant to the end
of your pregnancy, did you use a hot tub, Jacuzzi or
sauna?
Page 74
YES ................................................................................ 1
NO ................................. (SKIP TO H1).......................... 2
DK .................................. (SKIP TO H1)......................... -1
RF .................................. (SKIP TO H1)......................... -2
IF RESPONDENT USES MORE THAN ONE OF THESE, ADD ALL TIMES IN
G14, AND CALCULATE AN AVERAGE DURATION IN MINUTES FOR ALL
TYPES COMBINED FOR G15.
G13.
During which month(s) did you use the
hot tub, Jacuzzi or sauna?
CIRCLE FOR EACH MONTH. DO NOT
CODE SHADED AREA.
MO
YES
(ASK
G14-G15)
NO
DK
RF
(NEXT)
(NEXT)
(NEXT)
B3
1
2
-1
-2
B2
1
2
-1
-2
B1
1
2
-1
-2
P1
1
2
-1
-2
P2
1
2
-1
-2
P3
1
2
-1
-2
P4
1
2
-1
-2
P5
1
2
-1
-2
P6
1
2
-1
-2
P7
1
2
-1
-2
P8
1
2
-1
-2
P9
1
2
-1
-2
P10
1
2
-1
-2
G14.
During (SPECIFY MONTH) how many
times per month did you use the hot
tub, Jacuzzi or sauna?
G15.
On average, for how many
minutes each time?
INDICATE # TIMES FOR EACH MONTH.
COMBINE ALL TYPES.
INDICATE HOW MANY
MINUTES EACH TIME.
# TIMES
RF
DK RF
DK RF
DK RF
DK RF
DK RF
DK RF
DK RF
DK RF
DK RF
DK RF
DK RF
DK RF
DK
# MINUTES
RF
DK RF
DK RF
DK RF
DK RF
DK RF
DK RF
DK RF
DK RF
DK RF
DK RF
DK RF
DK RF
DK
G15a.
Which one did you use the most?
HOT TUB/JACUZZI ............................................................ 1
SAUNA….. ........................ (SKIP TO H1) .......................... 2
NEITHER – USED ABOUT SAME ..................................... 3
DK ..................................... (SKIP TO H1) ......................... -1
RF...................................... (SKIP TO H1) ......................... -2
G16.
Was the source of the water for the hot
tub/Jacuzzi chemically disinfected?
YES .................................................................................... 1
NO ...................................................................................... 2
DK ..................................................................................... -1
RF...................................................................................... -2
4/6/2010
National Birth Defects Prevention Study—Mother Questionnaire
Page 75
SECTION H: MOTHER’S OCCUPATION
H1.
The next section is a series of questions about your
work experiences—paid, volunteer, or military
service. This includes part-time and full-time jobs,
jobs at home, and jobs on a farm or outside your
home that lasted one month or more. From 3
months before you became pregnant to the end of
your pregnancy, did you have a job?
YES ............................... (SKIP TO H3) .......................... 1
NO .................................................................................. 2
DK ................................................................................. -1
RF .................................................................................. -2
H2.
Were you (READ CHOICES) or did you do something
else?
A homemaker/parent .... (SKIP TO H12) .................... 1
A student......................... (SKIP TO H3)....................... 2
Disabled .......................... (SKIP TO H12) .................... 3
Unemployed/in
between Jobs .............. (SKIP TO H12) .................... 4
OTHER ................ (SPECIFY THEN SKIP TO H12) ...... -5
DK .................................... (SKIP TO H12) ................... -1
RF ..................................... (SKIP TO H12) ................... -2
SPECIFY: _______________________________________________________________________________ DK
H3.
What were the names of the companies or organizations you worked for between (B3) and ([DOIB]/[DOPT])?
/ What other companies did you work for? LIST ALL EMPLOYERS, INCLUDING “SELF-EMPLOYED.” IF
STUDENT, CATI FILLS IN “SCHOOL” HERE.
COMPANY/ORGANIZATION: _____________________________________________________________________
DK
H4.
ASK H4 – H11
SKIP TO H12
RF
What was your job title there? IF STUDENT, CATI FILLS IN “STUDENT” HERE AND SKIPS H5 & H6.
JOB TITLE: _______________________________________________________________________ DK
H5.
RF
What did they make or do? IF CONGLOMERATE: What did your division make or do?
SPECIFY: _________________________________________________________________________________
_________________________________________________________________________________ DK
H6.
RF
Describe what you did and how you did it. What were your main activities or duties? Anything else?
MAIN ACTIVITIES/DUTIES: ___________________________________________________________________
__________________________________________________________________________________________
_________________________________________________________________________________ DK
H7.
RF
Describe any chemicals or substances you handled or machines that you used or worked in the same room
with. Anything else?
CHEMICALS/SUBSTANCES/MACHINES USED: ______________________________________________________
________________________________________________________ NONE
DK RF IF NONE, DK OR RF, SKIP TO H8.
4/6/2010
National Birth Defects Prevention Study—Mother Questionnaire
H8.
What month and year did you start that
job/school?
Page 76
DATE: ....................................
MM
DK
H9.
What month and year did you end that job/school?
YYYY
DK
DATE: ....................................
MM
YYYY
DK
DK
CURRENTLY WORKING = DATE OF INTERVIEW
H10.
H11.
How many days per week did you usually work?
IF STUDENT: How many days per week did you go
to school?
DAYS PER WEEK ....................................................
DK
How many hours per day did you usually work?
IF STUDENT: How many hours per day did you
spend either at school or studying?
RF
HOURS PER DAY ..............................................
DK
RF
PAPER COPY INTERVIEWER INSTRUCTION: IF RESPONDENT HAS HAD MORE THAN ONE JOB BETWEEN (B3)
AND ([DOIB]/[DOPT]), USE SUPPLEMENT SHEET FOR EACH ADDITIONAL JOB. (REPEAT H3 –H11.)
MOTHER’S OCCUPATION-MILITARY
H12.
YES ................................................................................ 1
NO .................................. (SKIP TO I1) ........................... 2
DK .................................. (SKIP TO I1) .......................... -1
RF ................................... (SKIP TO I1) .......................... -2
Have you served in active duty in the U.S. armed
forces since 1990?
H13.
In which country did you serve?
Any other?
A. __________________________
ASK H14 & H15
RF SKIP TO I1
H14.
From which month and year?
(IF STILL SERVING ENTER CURRENT
DATE)
FROM:
ASK H14 & H15
RF SKIP TO I1
DK
TO:
MM
DK
B. __________________________
H15.
To which month and year?
DK
YYYY
DK
MM
FROM:
DK
YYYY
DK
TO:
MM
DK
YYYY
DK
MM
DK
YYYY
DK
4/6/2010
National Birth Defects Prevention Study—Mother Questionnaire
Page 77
SECTION I: FATHER’S OCCUPATION
IF FATHER UNKNOWN (CHECK HERE IF PAPER COPY ), THEN SKIP TO I16.
I1.
Next I’m going to ask about ([NOIB]’s/the) father’s
work experiences. This includes paid, volunteer, or
military service, part-time and full-time jobs, jobs at
home, and jobs on a farm or outside his home that
lasted one month or more. From 3 months before
you became pregnant to the end of your
pregnancy, did ([NOIB]’s/the) father have a job?
YES ................................ (SKIP TO I3) ............................. 1
NO .................................................................................... 2
DK .................................................................................. -1
RF................................................................................... -2
I2.
Was he (READ CHOICES) or did he do something
else?
A homemaker/parent ....... (SKIP TO I12) ...................... 1
A student............................. (SKIP TO I3) ....................... 2
Disabled ............................. (SKIP TO I12) ...................... 3
Unemployed/in
between Jobs ................. (SKIP TO I12) ...................... 4
OTHER ................... (SPECIFY THEN SKIP TO I12) ....... -5
DK ....................................... (SKIP TO I12) .................... -1
RF........................................ (SKIP TO I12) .................... -2
SPECIFY: _______________________________________________________________________________ DK
I3.
What were the names of the companies or organizations he worked for between (B3) and ([DOIB]/[DOPT])? /
What other companies did he work for? LIST ALL EMPLOYERS, INCLUDING “SELF-EMPLOYED.” IF STUDENT,
CATI FILLS IN SCHOOL HERE.
COMPANY/ORGANIZATION: ___________________________________________________________________
DK
I4.
ASK I4 – I11
RF
SKIP TO I12
What was his job title there? IF STUDENT, CATI FILLS IN “STUDENT” HERE AND SKIPS I5 & I6.
JOB TITLE: ________________________________________________________________________DK
I5.
RF
What did they make or do? (IF CONGLOMERATE:) What did his division make or do?
SPECIFY: _____________________________________________________________________________________
_________________________________________________________________________________DK
I6.
RF
Describe what he did and how he did it. What were his main activities or duties?
MAIN ACTIVITIES/DUTIES: _______________________________________________________________________
_________________________________________________________________________________DK
I7.
RF
Describe any chemicals or substances he handled or machines that he used or worked in the same room
with. Anything else?
CHEMICALS/SUBSTANCES/MACHINES USED: _____________________________________________________
________________________________________________________ NONE
DK RF IF NONE, DK OR RF, SKIP TO I8.
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National Birth Defects Prevention Study—Mother Questionnaire
I8.
What month and year did he start that job/school?
Page 78
DATE: ....................................
MM
DK
I9.
What month and year did he end that job/school?
YYYY
DK
DATE: .....................................
MM
YYYY
DK
DK
CURRENTLY WORKING = DATE OF INTERVIEW
I10.
I11.
How many days per week did he usually work?
IF STUDENT: How many days per week did he go to
school?
DAYS PER WEEK ....................................................
DK
How many hours per day did he usually work?
IF STUDENT: How many hours per day did he
spend either at school or studying?
RF
RF
HOURS PER DAY ..............................................
DK
PAPER COPY INTERVIEWER INSTRUCTION: IF FATHER HAS HAD MORE THAN ONE JOB BETWEEN (B3) AND
([DOIB]/[DOPT]), USE SUPPLEMENT SHEET FOR EACH ADDITIONAL JOB. (REPEAT I3 – I11.)
FATHER’S OCCUPATION-MILITARY
I12.
YES.................................................................................... 1
NO .......................... (SKIP TO I16) .................................... 2
DK ........................... (SKIP TO I16) ................................... -1
Has ([NOIB]’s/the) father served in active duty in
the U.S. armed forces since 1990?
I13.
In which country did he serve?
Any other?
A. __________________________
ASK I14 & I15
RF SKIP TO I16
I14.
From which month and year?
ASK I14 & I15
RF SKIP TO I16
DK
To which month and year?
(IF STILL SERVING ENTER CURRENT DATE)
TO:
FROM:
MM
DK
B. __________________________
I15.
DK
YYYY
DK
MM
DK
FROM:
YYYY
DK
TO:
MM
DK
YYYY
DK
MM
DK
YYYY
DK
OCCUPATION—PESTICIDES
I16.
From 3 months before you became pregnant to the
end of your pregnancy, did anyone in your
household apply pesticides as an occupation or as
part of their work?
I17.
How many times per day, week, or month did you
personally wash clothes that had been worn during
pesticide mixing or application? We are interested
in clothes that may have gotten pesticide on them
from spills or drift during spray application.
YES .................................................................................... 1
NO .................................. (SKIP TO J1)............................... 2
DK .................................. (SKIP TO J1).............................. -1
# TIMES
DK
NEVER = 00
PER DAY ............................................................................ 1
PER WEEK......................................................................... 2
PER MONTH ...................................................................... 3
PER YEAR ......................................................................... 4
OTHER ............................ (SPECIFY) ............................... -5
DK ..................................................................................... -1
RF ..................................................................................... -2
SPECIFY: _______________________________ DK
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SECTION P: PHYSICAL ACTIVITY
I am going to ask you about the time you spent being physically active in the three months before you became pregnant.
Please answer each question even if you do not consider yourself to be an active person. Think about the activities you
do at work, as part of your house and yard work, to get from place to place, and in your spare time for recreation, exercise
or sport.
Now, think about all the vigorous activities which take hard physical effort that you did in the three months before you
became pregnant. Vigorous activities make you breathe much harder than normal and may include heavy lifting, digging,
aerobics, running, or fast bicycling. Think only about those physical activities that you did for at least 10 minutes at a
time.
P1.
During the three months before you became
pregnant, in a typical week on how many days did
you do vigorous physical activities?
PROBE: Think only about those physical activities
P2.
DAYS PER WEEK ...............................................
RANGE: 0-7
DON’T KNOW/NOT SURE ............................................ -1
REFUSED ..................................................................... -2
that you do for at least 10 minutes at a time.
IF 0, DK, OR RF, SKIP TO P3.
How much time did you usually spend doing
vigorous physical activities on one of those days?
HOURS PER DAY ...............................................
RANGE: 0-16
PROBE: Think only about those physical activities
MINUTES PER DAY ......................................
RANGE: 0-960
that you do for at least 10 minutes at a time.
OR
In the three months before you became
pregnant, how much time in total would you
spend in a typical week doing vigorous
physical activities?
HOURS PER WEEK ............................................
RANGE: 0-112
MINUTES PER WEEK ....................................
RANGE: 0-6720
DON’T KNOW/NOT SURE ............................................ -1
REFUSED ..................................................................... -2
Now think about activities which take moderate physical effort that you did in the three months before you became
pregnant. Moderate physical activities make you breathe somewhat harder than normal and may include child care while
standing, carrying light loads at home or work, scrubbing or mopping floors, or bicycling at a regular pace. Do not include
walking. Again, think about only those physical activities that you did for at least 10 minutes at a time.
P3.
During the three months before you became
pregnant, in a typical week on how many days did
you do moderate physical activities?
PROBE: Think only about those physical activities
DAYS PER WEEK ...............................................
RANGE: 0-7
that you do for at least 10 minutes at a time.
DON’T KNOW/NOT SURE ............................................ -1
REFUSED ..................................................................... -2
PROBE: Child care includes dressing, bathing,
IF 0, DK, OR RF, SKIP TO P5
grooming, feeding, or occasional lifting.
4/6/2010
National Birth Defects Prevention Study—Mother Questionnaire
P4.
How much time did you usually spend doing
moderate physical activities on one of those days?
HOURS PER DAY ...............................................
RANGE: 0-16
PROBE: Think only about those physical activities
MINUTES PER DAY ......................................
RANGE: 0-960
that you do for at least 10 minutes at a time.
Page 80
OR
In the three months before you became
pregnant, what is the total amount of time you
spent in a typical week doing moderate
physical activities?
HOURS PER WEEK ......................................
RANGE: 0-112
MINUTES PER WEEK ...................................
RANGE: 0-6720
DON’T KNOW/NOT SURE ............................................ -1
REFUSED ..................................................................... -2
Now think about the time you spent walking in the three months before you became pregnant. This includes at
work and at home, walking to travel from place to place, and any other walking that you might do solely for
recreation, sport, exercise, or leisure.
P5.
During the three months before you became
pregnant, in a typical week on how many days did
you walk for at least 10 minutes at a time?
PROBE: Think only about the walking that you do
for at least 10 minutes at a time.
DAYS PER WEEK ...............................................
RANGE: 0-7
DON’T KNOW/NOT SURE ............................................ -1
REFUSED ..................................................................... -2
IF 0, DK, OR RF, SKIP TO P7
P6.
How much time did you usually spend walking on
one of those days?
HOURS PER DAY ...............................................
RANGE: 0-16
MINUTES PER DAY ......................................
RANGE: 0-960
OR
In the three months before you became
pregnant, what is the total amount of time you
spent walking in a typical week?
HOURS PER WEEK ......................................
RANGE: 0-112
MINUTES PER WEEK ...................................
RANGE: 0-6720
DON’T KNOW/NOT SURE ............................................ -1
REFUSED ..................................................................... -2
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Page 81
Now think about the time you spent sitting on week days in the three months before you became pregnant. Include time
spent at work, at home, while doing course work, and during leisure time. This may include time spent sitting at a desk,
visiting friends, reading or sitting or lying down to watch television.
P7.
In the three months before you became pregnant, in
a typical week, how much time did you usually
spend sitting on a week day?
PROBE: Include time spent lying down (awake) as
well as sitting.
HOURS PER DAY ...............................................
RANGE: 0-16
MINUTES PER DAY
RANGE: 0-960
OR
What is the total amount of time you spent
sitting on a typical Wednesday?
HOURS ON WEDNESDAY ..................................
RANGE: 0-16
MINUTES ON WEDNESDAY .........................
RANGE: 0-960
DON’T KNOW/NOT SURE ............................................ -1
REFUSED ..................................................................... -2
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SECTION J: FAMILY DEMOGRAPHICS-MOTHER
Now I will be asking about your ethnic background and education.
J1.
Were you born in the U.S.?
J2.
Where were you born?
YES............................ (SKIP TO J3) .............................. 1
NO ................................................................................. 2
DK .............................. (SKIP TO J3) ............................. -1
RF .............................. (SKIP TO J3) ............................. -2
SPECIFY: _______________________________________________________________________________ DK
J2a. How many years have you lived in the U.S.?
J3.
YEARS......................................................
DK
What language do you usually speak at home?
SPECIFY LANGUAGE: _______________________________________________________________________
J4.
What is your race or ethnic group? I’m going to read
you a list and then please tell me all categories that
apply to you. You can select more than one
category.
SKIP PATTERNS DEPENDENT ON MULTIPLE
CHOICES. FOR EXAMPLE, “BLACK” WON’T SKIP TO
J6 IF ALSO ANSWERED ASIAN OR HISPANIC.
American Indian or
Alaska Native ............................... (ASK J4b) ...............4
Asian ............................................... (ASK J4a) ........... 103
Black or African American ............... (SKIP TO J6) ..........2
Hispanic or Latina ............................. (ASK J5) ...............6
Native Hawaiian or
Other Pacific Islander ................... (ASK J4a) ........... 155
White............................................... (SKIP TO J6) ..........1
DK ................................................... (SKIP TO J6) ........ -1
RF ................................................... (SKIP TO J6) ........ -2
J4a. What country? PROMPT: Referring to Asian, Native Hawaiian or other Pacific Island countries.
________________________________________________________________________________ DK
(SKIP TO J6 UNLESS J4 ALSO = 4 OR 6)
J4b. What tribe do you consider yourself a member of? ____________________________________ DK
(SKIP TO J6 UNLESS J4 ALSO = 6)
J5.
Which Hispanic or Spanish group do you consider yourself a member of? PROMPT: Mexican, Puerto
Rican, Salvadoran, Honduran, Colombian, Peruvian, Guatemalan, Spanish, Central American, South
American, etc?
SPECIFY: _______________________________________________________________________________ DK
J6.
What was the highest grade or year of school or
college that you had completed (at the time [NOIB]
was born/by [DOPT])?
IF RESPONDENT HESITATES, BEGIN READING
CATEGORIES.
No formal schooling....................................................... 01
1-6 years ....................................................................... 02
7-8 years ....................................................................... 03
9-11 years ..................................................................... 04
12 years, completed high school or
equivalent..................................................................... 05
1-3 years college ........................................................... 06
Completed technical college.......................................... 07
4 years college or Bachelor’s degree............................. 08
Master’s degree ............................................................ 09
Advanced degree (MD, PhD, JD) .................................. 10
DK ................................................................................. -1
RF ................................................................................. -2
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Page 83
FAMILY DEMOGRAPHICS-FATHER
IF FATHER UNKNOWN, SKIP TO J14.
The next few questions are about ([NOIB]’s/the) biologic or natural father.
J7.
Was he born in the U.S.?
J8.
Where was he born?
YES .........................(SKIP TO J9).................................. 1
NO .................................................................................. 2
DK ...........................(SKIP TO J9)................................. -1
SPECIFY: ______________________________________________________________________________ DK
J8a. How many years has he lived in the U.S.?
J9.
What is his race or ethnic group? I’m going to read
you a list and then please tell me all categories that
apply to him. You can select more than one
category.
SKIP PATTERNS DEPENDENT ON MULTIPLE
CHOICES. FOR EXAMPLE, “BLACK” WON’T SKIP TO
J11 IF ALSO ANSWERED ASIAN OR HISPANIC.
YEARS ......................................................
DK
American Indian or
Alaska Native ............................... (ASK J9b) ............... 4
Asian .............................................. (ASK J9a) ........... 103
Black or African American ............... (SKIP TO J11) ........ 2
Hispanic or Latino ............................. (ASK J10) ............. 6
Native Hawaiian or
Other Pacific Islander ................... (ASK J9a) ........... 155
White .............................................. (SKIP TO J11) ........ 1
DK .................................................. (SKIP TO J11) ....... -1
RF .................................................. (SKIP TO J11) ....... -2
J9a. What country? PROMPT: Referring to Asian, Native Hawaiian or other Pacific Island countries.
_______________________________________________________________________________ DK
(SKIP TO J11 UNLESS J9 ALSO = 4 OR 6)
J9b. What tribe does he consider himself a member of?
_______________________________________________________________________________ DK
(SKIP TO J11 UNLESS J9 ALSO = 6)
J10.
Which Hispanic or Spanish group do you consider yourself a member of? PROMPT: Mexican, Puerto
Rican, Salvadoran, Honduran, Colombian, Peruvian, Guatemalan, Spanish, Central American, South
American, etc?
SPECIFY: ______________________________________________________________________________ DK
J11.
What was the highest grade or year of school or
college that he had completed (at the time [NOIB]
was born/by [DOPT])?
IF RESPONDENT HESITATES, BEGIN READING
CATEGORIES.
No formal schooling ...................................................... 01
1-6 years....................................................................... 02
7-8 years....................................................................... 03
9-11 years..................................................................... 04
12 years, completed high school or
equivalent .................................................................... 05
1-3 years college .......................................................... 06
Completed technical college ......................................... 07
4 years college or Bachelor’s degree ............................ 08
Master’s degree ............................................................ 09
Advanced degree (MD, PhD, JD) .................................. 10
DK ................................................................................. -1
RF ................................................................................. -2
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FAMILY INFORMATION
J12.
Are you related to ([NOIB]’s/the) biologic or natural
father by blood?
YES ..................................................................................... 1
NO........................... (SKIP TO J14)..................................... 2
DK ........................... (SKIP TO J14)................................... -1
RF ........................... (SKIP TO J14)................................... -2
J13.
What is/was your blood relationship to him?
1ST COUSIN ...................................................................... 01
2ND COUSIN ...................................................................... 02
3RD COUSIN ...................................................................... 03
4TH COUSIN ...................................................................... 04
5TH COUSIN ...................................................................... 05
1ST COUSIN, ONCE REMOVED........................................ 06
2ND COUSIN, ONCE REMOVED ....................................... 07
DISTANT COUSINS, NOS ................................................ 08
OTHER.................... (SPECIFY) ........................................ -5
DK ..................................................................................... -1
RF ..................................................................................... -2
SPECIFY: __________________________________ DK
J14.
J15.
J16.
Did you have a health problem at birth or a birth
defect that was diagnosed in childhood?
YES ..................................................................................... 1
NO.......................... (SKIP TO J15) ..................................... 2
DK .......................... (SKIP TO J15) ................................... -1
RF .......................... (SKIP TO J15) ................................... -2
J14a. What was it?/Anything else?
PROBLEM: ___________________________ DK
IF FATHER UNKNOWN, SKIP TO J16.
Did ([NOIB]’s/the) biologic or natural father have a
health problem at birth or a birth defect that was
diagnosed in childhood?
YES ..................................................................................... 1
NO........................... (SKIP TO J16)..................................... 2
DK ........................... (SKIP TO J16)................................... -1
RF ........................... (SKIP TO J16)................................... -2
J15a. What was it?/Anything else?
PROBLEM: ___________________________ DK
Did any of ([NOIB]’s/the) grandparents, uncles,
aunts, cousins, half brothers or half sisters or
younger brothers or sisters have a health problem
at birth or a birth defect that was diagnosed in
childhood?
YES ..................................................................................... 1
NO........................... (SKIP TO J20)..................................... 2
DK ........................... (SKIP TO J20)................................... -1
RF ........................... (SKIP TO J20)................................... -2
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National Birth Defects Prevention Study—Mother Questionnaire
J18.
J19.
ASK ABOUT SEX ONLY IF IT IS NOT
OBVIOUS, OTHERWISE FILL IN
ANSWER.
What problem or birth defect did
(he/she) have?
J17.
What is this person’s relationship
to ([NOIB]/the baby)?/ Anyone
else?
Page 85
Is this person male or female?
_______________________________
A.
PROBE:
Aunt, cousin; grandfather, grandmother,
great grandfather, great grandmother,
great aunt, great uncle, half brother, half
sister, uncle, other,
MALE ...................................................... 1
FEMALE.................................................. 2
DK .......................................................... -1
RF .......................................................... -2
PROBLEM: ____________________
MALE ...................................................... 1
FEMALE.................................................. 2
DK .......................................................... -1
RF .......................................................... -2
PROBLEM: ____________________
DK
SPECIFY:______________________
DK
_______________________________
B.
PROBE:
Aunt, cousin; grandfather, grandmother,
great grandfather, great grandmother,
great aunt, great uncle, half brother, half
sister, uncle, other,
DK
SPECIFY:______________________
DK
HOUSEHOLD INCOME
J20.
J20a.
In the year before you became pregnant with
([NOIB]/this pregnancy), what was your total
household income? Please include income such as
Medicaid, Social Security, and Unemployment
payments. Was it…READ CHOICES.
Would you say it was…
IF THE ANSWER IS 20,000, FOR EXAMPLE, ROUND UP TO
THE HIGH RANGE, 20-30,000.
Less than Ten Thousand .... (SKIP TO J21) ................... 1
More then Fifty Thousand... (SKIP TO J21) ................... 2
In Between ....................................................................... 3
DK ..................................... (SKIP TO J22) ........................ -1
RF ..................................... (SKIP TO J22) ........................ -2
10 to 20 Thousand Dollars ............................................ 1
20 to 30 Thousand Dollars ............................................ 2
30 to 40 Thousand Dollars, or....................................... 3
40 to 50 Thousand Dollars ............................................ 4
DK ..................................................................................... -1
RF ..................................................................................... -2
J21.
J22.
How many people were supported by this income
including both adults and children? HINT: In the
year before you became pregnant with [NOIB].
Were you married at the time ([NOIB] was born/of
[DOPT])?
HINT: “SEPARATED” AND “COMMON-LAW” ARE
CONSIDERED “MARRIED” HERE.
# OF PEOPLE ..........................................................
DK
RF
YES .................................................................................... 1
NO ...................................................................................... 2
DK ..................................................................................... -1
RF...................................................................................... -2
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National Birth Defects Prevention Study—Mother Questionnaire
Page 86
SECTION K: CLOSING
K1.
As I said at the beginning, we do not know what causes
most birth defects and that is why we asked about many
things. Is there anything, including some of the factors
we’ve talked about, that you think might be a cause of
birth defects?
K2.
Can you tell me about some of those factors?
YES .......................................................................... 1
NO ........................... (SKIP TO K3) ........................... 2
DK ........................... (SKIP TO K3) .......................... -1
___________________________________________________________________________________
___________________________________________________________________________________
___________________________________________________________________________________
DEBRIEFING STATEMENT
K3.
In case we need to get in touch with you in the future,
would you be willing to give us the name and address of
someone who would always know where you are? This
information will be kept separate from your
questionnaire. It will be locked except when needed by
the research team, and will be destroyed when the study
is finished.
K4.
NAME OF CONTACT:
PREFIX:
YES .......................................................................... 1
NO ........................... (SKIP TO K5) ........................... 2
DK ........................... (SKIP TO K5) .......................... -1
RF ............................ (SKIP TO K5) .......................... -2
MS/MRS./MR./DR
FIRST NAME: ________________________________________
LAST NAME: _______________________________________
STREET/APARTMENT: ________________________________________________________________________________ DK
CITY, STATE: _____________________________________________________ DK
HOME PHONE:
DK
/
-
WORK PHONE:
DK
ZIP CODE:
/
DK
-
RELATIONSHIP:
K5.
DK
That completes the interview, but as you read in the advance letter, there are two parts to the study. You just
completed the first part, the interview, that will help us understand the environmental causes of birth defects. The
second part of the study will help us understand the genetics of birth defects. We will mail a kit to you with small,
soft brushes to collect cell samples from the inside of your mouth, SKIP IF TAB/STILLBIRTH/BABY DECEASED:
(NOIB)’s mouth, SKIP IF FATHER UNKNOWN: and ([NOIB]’s/the) father’s mouth. We will enclose $20.00 per family
in the kit to provide for any inconvenience. You can decide whether to take part in the second part of the study
after you receive the kit. What is your current mailing address?
___________________________________________________________________________________
STREET
APT
___________________________________________________________________________________
CITY
STATE
ZIP
4/6/2010
National Birth Defects Prevention Study—Mother Questionnaire
K6.
Page 87
□
CHECK THIS BOX IF PARTICIPANT DOES NOT WANT TO RECEIVE BUCCAL KIT.
IF FATHER UNKNOWN, SKIP K7a AND K7c.
K7a.
Does the biologic or natural father of
([NOIB]/this pregnancy) live at the same
address?
YES ..................... (SKIP TO FINAL REMARK)........................... 1
NO .............................................................................................. 2
(IF CENTER REQUESTS ADDRESS OF FATHER, ASK K7c.
OTHERWISE SKIP TO K7d)
NO, BUT MOTHER WILL TRY TO COLLECT BUCCAL
CELLS ................ (SKIP TO FINAL REMARK)........................... 3
DK ....................... (SKIP TO FINAL REMARK).......................... -1
RF ....................... (SKIP TO FINAL REMARK).......................... -2
K7b.
CHECK YES IF CENTER REQUESTS ADDRESS
OF FATHER.
YES ............................................................................................ 1
NO ................................. (SKIP TO K7d) .................................... 2
K7c.
We would like to mail a kit and a $10 money
order to his current address. What is his
current mailing address?
FATHER’S ADDRESS:
DK
□
RF
□
___________________________________________________________________________________
STREET
APT
___________________________________________________________________________________
CITY
K7d.
KIT NOT BEING SENT TO FATHER BECAUSE:
IF FATHER UNKNOWN, CATI AUTOFILL = 9.
STATE
ZIP
CENTER DOES NOT COLLECT FATHER’S ADDRESS ............ 1
MOTHER REFUSED TO GIVE INFORMATION ........................ -2
MOTHER DOES NOT KNOW WHERE FATHER LIVES ............ -1
MOTHER DOES NOT KNOW WHO FATHER IS ........................ 9
DOES NOT APPLY – KIT TO BE SENT .................................... -6
FINAL REMARK
In closing, we would like to sincerely thank you for your time and efforts. Your contribution to this important
study will help us greatly in our efforts to better understand the causes of birth defects. Thank you.
INTERVIEWER STATUS
K8.
INTERVIEWER ID
ID#: ...........................................................................
K9.
WAS THE INTERVIEW A PHONE OR IN-PERSON
INTERVIEW ?
PHONE INTERVIEW ................................................................ 1
IN-PERSON INTERVIEW ......................................................... 2
K10.
STATUS OF INTERVIEW :
COMPLETE .............................................................................. 1
TO BE CONTINUED (GO TO CALL SCHEDULE
UPON EXIT) ........................................................................... 2
REFUSAL/PERMANENT BREAK-OFF ..................................... 3
K11.
DATE INTERVIEW COMPLETED/
REFUSED/BROKE-OFF:
DATE .................................
MM
DD
YYYY
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National Birth Defects Prevention Study—Mother Questionnaire
Page 88
INTERVIEWER REMARKS
K12.
THE OVERALL QUALITY OF THIS INTERVIEW
WAS:
HIGH QUALITY .......................................................................... 1
GENERALLY RELIABLE ............................................................ 2
QUESTIONABLE ........................................................................ 3
UNSATISFACTORY ................................................................... 4
K13.
DID THE FATHER (NOIB’s) CONTRIBUTE TO
THE MOTHER’S ANSWERS?
YES ............................................................................................ 1
NO .............................................................................................. 2
DK ............................................................................................. -1
K14.
DID SOME OTHER PERSON CONTRIBUTE TO
THE MOTHER’S ANSWERS?
YES ............................................................................................ 1
NO .............................................................................................. 2
DK ............................................................................................. -1
A. WHO WAS IT? __________________________________________________________________________ DK
K15.
IF CODE 3 OR 4 AT K12, ANSWER:
THE MAIN REASON FOR QUESTIONABLE OR
UNSATISFACTORY QUALITY OF
INFORMATION WAS BECAUSE THE
RESPONDENT:
DID NOT KNOW ENOUGH INFORMATION
REGARDING THE TOPIC ....................................................... 01
DID NOT WANT TO BE MORE SPECIFIC ............................... 02
SOUNDED BORED OR UNINTERESTED................................ 03
SOUNDED UPSET, DEPRESSED, OR ANGRY....................... 04
HAD POOR HEARING OR SPEECH ........................................ 05
SOUNDED CONFUSED OR DISTRACTED BY
FREQUENT INTERRUPTIONS ............................................... 06
SOUNDED INHIBITED BY OTHERS AROUND
HER......................................................................................... 07
SOUNDED EMBARRASSED BY THE SUBJECT
MATTER.................................................................................. 08
SOUNDED EMOTIONALLY UNSTABLE .................................. 09
SOUNDED PHYSICALLY ILL ................................................... 10
NOT COMFORTABLE WITH LANGUAGE OF
THE QUESTIONNAIRE ........................................................... 12
DOESN’T HAVE THE TIME ...................................................... 13
FELT INTERVIEW TOO LONG................................................. 14
OTHER (SPECIFY) ................................................................... -5
SPECIFY: ____________________________________________________________________________________
K16.
WAS THE MAJORITY OF THE INTERVIEW
DONE IN ENGLISH OR IN SPANISH?
ENGLISH.................................................................................... 1
SPANISH.................................................................................... 2
HALF ENGLISH/HALF SPANISH ............................................... 3
K17.
WAS THIS INTERVIEW TRANSLATED BY
ANOTHER PERSON?
YES ............................................................................................ 1
NO .............................................................................................. 2
4/6/2010
National Birth Defects Prevention Study—Mother Questionnaire
K18.
Page 89
USE THIS SPACE FOR ANY OTHER COMMENTS YOU HAVE WHICH MAY AFFECT THE INTERPRETATION OF
THIS RESPONDENT’S ANSWERS.
___________________________________________________________________________________________
___________________________________________________________________________________________
___________________________________________________________________________________________
___________________________________________________________________________________________
___________________________________________________________________________________________
___________________________________________________________________________________________
___________________________________________________________________________________________
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National Birth Defects Prevention Study—Mother Questionnaire
Page 90
Appendix
National Birth Defects Prevention Study
Mother Questionnaire
This interview was conducted with CATI (computer-assisted telephone interview). This hard copy questionnaire serves
as a documentation of the computer interview. It can also be used in “emergency” situations to continue an interview
during a computer failure with the precaution that the hard copy is not ideal for conducting interviews as it does not have
the range checks, automatic skip patterns, dropdown coding lists, automatic text and date insertions and electronic
consistency checks built in. The interviews should be conducted and documented in accordance with the specific
instructions provided in the Question-by-Question Interviewer Manual.
To save on the number of pages created for this hard copy, repetitive response lists and special code options are printed
here in the appendix, rather than in the body of the questionnaire.
Investigators should note that this document is not a “codebook” for the CATI database. Every effort has been made to
match the response codes in the hard copy questionnaire with the data codes in the CATI database and in analytic
databases, however, there are some limitations. This hard copy does not show codes for open-ended text fields. As
codes are created, altered and added, the updated coding lists are posted on the Centers’ study website. That would
be the definitive source for all codes.
There are also some conventions possible with the computerized format that are not practical for listing in the hard copy
such as special buttons allowing the interviewer to automatically select the same response for a number of months.
Those are not captured in this hard copy.
TABS:
In cases where the mother had a therapeutic abortion, the CATI automatically substitutes terms such as “the (NOIB)”, or
name of index baby, with other terms such as “the affected pregnancy”, or “the pregnancy”.
Other Response Options and Codes:
Refused and Don’t Know options are allowed at almost every field in the CATI. The Don’t Know option will show at
most fields in the hard copy, but the Refused option was not repeated at each response, to save paper. Don’t Know
check boxes have been added to certain fields when DK isn’t an option in a response list, such as in text fields. When
subjects refuse to respond, the interviewer should circle the RF option, or check the RF check box. If neither are
available, she should write RF next to the other response codes or in the open fields or next to any date fields on the
hard copy. Skip instructions for refusals (RF) and don’t knows (DK) should follow the skip patterns for NO responses at
gateways. In drop down lists, RF may skip over subsequent questions and DK may lead to the next questions. Those
instructions are shown in the hard copy.
The first version of the hard copy used 7, 8, 97, and 98 for RF and DK codes. Those were replaced in this version with
the following codes, to be consistent with the values in the analytic database:
DK = -1
RF = -2
Other = -5
N/A = -10
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Ages:
Some questions ask for ages, such as when a condition was diagnosed. In addition to being able to enter a specific age,
the interviewer can select one of the following age group responses listed in the CATI:
infancy (<1 yr)
childhood (1-12)
teenage (13-19)
young adult (20-25)
adult
Time Periods:
Many questions are asked by month of pregnancy or trimester, and for each of the three months prior to pregnancy. The
CATI actually shows a reference date for each of these time periods. The designations are:
B3 (3 months before pregnancy)
B2 (2 months before pregnancy)
B1 (1 month before pregnancy)
P1 (month 1 of pregnancy)
P2 (month 2 of pregnancy)
P3 (month 3 of pregnancy)
nd
T2 (2 trimester)
rd
T3 (3 trimester)
In some questions asking about events in the past, in addition to listing a particular calendar month, these following
response options are listed:
B3
B2
B1
P1
P2
P3
P4
P5
P6
P7
P8
P9
P10
Beginning of year
Middle of year
End of year
When asking about a particular week of the pregnancy in which an event occurred, in addition to weeks, other response
options are:
T1, T2, T3
A few questions only ask about the period two months prior to pregnancy. Although other response options are listed in
the CATI, they may be blocked.
Many of the open-ended fields contain a dropdown list of choices available to the interviewer in the CATI. The interviewer
can select one of these responses by typing in the first few letters. The response is linked to a code internally. If the
response is not on the list, she enters the appropriate response in the text specify field. Most responses entered this way
are coded later. These lists are not all inclusive, so that is why other responses can be written in.
See the latest coding lists on the Centers’ study website. There are 14 coding lists created as new responses were
encountered, and 5 standardized coding lists used: ICD-9-CM, CPT, NAICS, SOC and the Slone Drug Dictionary.
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Medication Frequency:
Questions that ask for the frequency of medicine use (in sections A, B, C and D) can be answered with these additional
codes as needed:
90 = IV (any)
92 = Patch (worn continuously)
93 = Schedule varied/ as needed
94 = Tapering frequency
95 = Per time period (this refers to the number of times she took a drug between the dates she listed)
When these codes are used, the “per day/per week/per month/per year” is skipped.
Food Frequency:
For items using the Food Frequency response choices, the CATI screen employs the codes 0 through 6D (middle
column below). However, the background CATI database designates these codes numerically as shown under
Database. This response list is also available for some other fields, such as frequency of pesticide use.
CATI RESPONSE
CATI
SCREEN
CODE
NEVER OR < ONCE PER MONTH......... 0
1 PER MONTH .................................... 1M
2 PER MONTH .................................... 2M
3 PER MONTH .................................... 3M
1 PER WEEK....................................... 1W
2 PER WEEK....................................... 2W
3 PER WEEK....................................... 3W
4 PER WEEK....................................... 4W
5 PER WEEK....................................... 5W
6 PER WEEK....................................... 6W
1 PER DAY ........................................... 1D
2 PER DAY ........................................... 2D
3 PER DAY ........................................... 3D
4 PER DAY ........................................... 4D
5 PER DAY ........................................... 5D
6+ PER DAY......................................... 6D
DK ............................................................
RF ............................................................
DATABASE
0
1
2
3
11
12
13
14
15
16
21
22
23
24
25
26
-1
-2
Electronic Drug Dictionary:
The electronic CATI contains an embedded Drug Dictionary developed by the Slone Epidemiology Center of Boston
University School of Medicine. This is updated on a regular basis and replaces the older version in the CATI and in the
electronic coding program. Permission to use the SEC Drug Dictionary may be obtained from:
Allen Mitchell, MD
Director, SEC
Slone Epidemiology Center
Boston University
1010 Commonwealth Ave, 4th Floor
Boston MA 02215
617-734-6006
4/6/2010
| File Type | application/pdf |
| File Title | Microsoft Word - NBDPS CATI Qx English version 5 1 REV 04-05-10.doc |
| Author | tay7 |
| File Modified | 2010-04-07 |
| File Created | 2010-04-07 |