Form 1 RME-Repro and Medical History-Eng

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the completed form to this address.

OMB#: 0925-0584
Exp. xx/xx/xxxx

HCHS/SOL Visit 2- Reproductive and Medical History
Contact
Occasion

FORM CODE: RME
VERSION: 1, 12/10/2013

ID NUMBER:

0

2

SEQ #

ADMINISTRATIVE INFORMATION
0a.

Completion Date:

/

/

0b.

Staff ID:

Instructions:Enter the answer given by the participant for each response. Use the CDART Notelog window to code 'Don’t
know/refused, Missing, etc.' for those questions that do not list these as an option.

A. HORMONE AND MENSTRUAL HISTORY QUESTIONS
1. Which of the following hormonal birth control treatments have you ever used?
{If ever used then} Are you currently using these treatments? Choose all that apply.
Never used any of these treatments 0

GO TO QUESTION 3
Ever Current

a. Birth control pills

1

2

b. Birth control ring (Nuvaring) or patch (OrthoEvra)

1

2

c. DepoProvera Shots

1

2

d. Birth control implant (Norplant, Implanon, or Nexplanon)

1

2

e. Intrauterine device (IUD) with hormones (Mirena)
(This is the five-year IUD and it makes your periods lighter)

1

2

2. If yes to any, what is the reason you used this/these hormonal treatment(s)? Choose all that apply.
No

Yes

a. Birth control

0

1

b. Acne

0

1

c. Menstrual cramps or painful periods 0

1

d. To regulate periods

0

1

e. To treat vaginal bleeding

0

1

f.

0

1

Other

3. Have you ever tried to become pregnant for more than 1 year without becoming pregnant?
Go to question 4
No 0
Yes 1
Unsure 9

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FORM CODE: RME
VERSION: 1, 12/10/2013

ID NUMBER:

3a.

Contact
Occasion

0

2

SEQ #

What was the reason that you did not become pregnant? (Check one)
Medical problem with you? 0
Medical problem with your partner? 1
Medical problems with both you and your partner? 2
Don’t know or unknown cause 9

4. Have your natural periods ceased PERMANENTLY?
No 0
Yes, I have no menstrual periods 1

GO TO QUESTION 5

Yes, but I have periods induced by hormones 2

GO TO QUESTION 5

Unsure 9
4a.

IF UNSURE or NO: What was the date that you started your most recent menstrual
bleeding? [Prompt for month and year, even if day is unknown. ]

/
mm

/

GO TO QUESTION 8

/dd

/yyyy

5. At what age did your natural periods stop?

age in years

6. For what reason did you periods stop (check one)?
Natural

1

Surgery

2

Endometrial ablation 3
Radiation/chemo

4

Unsure

9

7. Have you had a hysterectomy? (This is an operation to take out your uterus or womb)
No 0 GO TO QUESTION 8
Yes 1
Unsure 9 GO TO QUESTION 8
7a.

Age at surgery?

Age in years

8. Have you ever had either of your ovaries surgically removed?
Go to question 9
No 0
Yes, one removed 1
Yes, both removed 2
Go to question 9
Unsure / Refused 9
8a.

Age at surgery?

RME-Repro and Medical Hx_12-10-13.docx

Age in years

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FORM CODE: RME
VERSION: 1, 12/10/2013

ID NUMBER:

Contact
Occasion

0

2

SEQ #

For the next question, I would like to ask you to think about your menstrual periods when you were
not using birth control pills or other hormone medications and were not pregnant or breastfeeding. [IF
UNDER 40: Since you turned 20;IF 40 OR OLDER: In your 20s or 30s]
9. How many days were there in a typical menstrual cycle, that is, from the beginning of one menstrual
period to the beginning of bleeding of the next period?
Less than 24 days 0
24-35 days 1
More than 35 days 2
Too variable or irregular to say 3
Don’t know 9
10. Has a health care provider ever told you that you have polycystic ovary syndrome (PCOS)?
No
0
Yes
1
Unsure 9
B. PREGNANCY HISTORY QUESTIONS
11. Are you currently pregnant?
No
0
Yes
1
Reschedule Study Visit
Unsure 9
12. How many times have you been pregnant? Please include live births, still births, miscarriages and
abortions.[If none, enter 00]
Pregnancies if None End Questionnaire
13. How many miscarriages have you had?
14. How many tubal or ectopic pregnancies have you had?
[An ectopic pregnancy is a pregnancy that grows in one of the tubes instead of in the uterus or womb.]

15. How many abortions have you had? [I understand that you may not want to answer this question.]

16. How many pregnancies have you had that lasted more than six months?
if None End Questionnaire
17. How many live births have you had?
18. For pregnancies lasting more than six months, how many stillbirths have you had?

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FORM CODE: RME
VERSION: 1, 12/10/2013

ID NUMBER:

Contact
Occasion

0

2

SEQ #

19. Did you ever have any of these illnesses or complications during these pregnancies?
No

Yes

Unsure

19a. High blood pressure or hypertension?

0

1

9

19b. Preeclampsia or toxemia?

0

1

9

19c. Seizures, convulsions or eclampsia?

0

1

9

19d. Diabetes?

0

1

9

19e. Birth of an infant weighing less than 5.5 lbs (2.5kg)?

0

1

9

19f. Birth of an infant weighing more than 9 lbs (4.09kg)?

0

1

9

19g. Birth of a preterm infant, or infant born at 36 weeks or earlier? 0

1

9

19h. How many of these pregnancies ended with a vaginal birth?

pregnancies

19i. How many of these pregnancies ended with a cesarean birth?

pregnancies

19j. If you breastfed these babies, how many months did you breastfeed these babies altogether?
months

[If none, enter 00]

PERINATAL DEPRESSION/ANXIETY
20. During how many of your pregnancies did you feel sad, miserable, or very anxious? By this, we mean a
period of at least 2 weeks when you were not yourself and which was worse than the normal ups and
downs of life? By “two weeks,” I mean most of the day, nearly every day.

21. After how many of your deliveries, within the first 6 months postpartum, did you feel sad, miserable, or
very anxious? By this, we mean a period of at least 2 weeks, when you were not yourself and which
was worse than the normal ups and downs of life? By “for two weeks,” I mean most of the day,
nearly every day.

For PREGNANCIES LASTING MORE THAN SIX MONTHS
22. During how many of these pregnancies did you get prenatal care?
23. For pregnancies for which you received prenatal care, for how many pregnancies did you receive care:
8a. In the United States
8b. Outside of the United States
8c. Both in and out of the United States
Now, we would like to ask you some more detailed questions about your pregnancies that lasted more
than six months and occurred after SOL Visit 1 on [DATE]
GO to PREGNANCY COMPLICATIONS Form to collect details of each pregnancy of 6+ months.

RME-Repro and Medical Hx_12-10-13.docx

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