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pdfForm Approved
OMB No. 0920-0010
Exp. Date: 01/31/2017
Centers for Birth Defects Research and Prevention
Birth Defects Study To Evaluate Pregnancy exposureS (BD-STEPS)
Computer-Assisted Telephone Interview
Questionnaire Version 7.0
English Version
Public reporting burden of this collection of information is estimated to average 45 minutes, 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 Road NE, MS D-74, Atlanta, Georgia
30333; ATTN: PRA (0920-0010).
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Contents
OPENING STATEMENT ................................................................................................................................................. 1
Section A: ESTABLISHING DATES ................................................................................................................................. 1
Section B: MULTIPLE GESTATION ................................................................................................................................ 2
Section C: PREGNANCY HISTORY ................................................................................................................................. 3
Section D: FAMILY HISTORY......................................................................................................................................... 5
Section E: FERTILITY ..................................................................................................................................................... 7
Maternal Health Introduction ................................................................................................................................... 14
Section F: DIABETES ................................................................................................................................................... 14
Section G: CANCER .................................................................................................................................................... 22
Section H: HEART PROBLEMS .................................................................................................................................... 23
Section I: THYROID DISEASE ...................................................................................................................................... 33
Section J: ASTHMA..................................................................................................................................................... 39
Section K: EPILEPSY.................................................................................................................................................... 51
Section L: MIGRAINE.................................................................................................................................................. 56
Section M: AUTOIMMUNE DISEASE .......................................................................................................................... 62
Section N: TRANSPLANT RECEIPT .............................................................................................................................. 71
Section O: DEPRESSION / ANXIETY ............................................................................................................................ 74
Section P: ATTENTION DEFICIT HYPERACTIVITY DISORDER (ADHD) ......................................................................... 80
Section Q: CHRONIC DISEASE CATCH-ALL QUESTION ............................................................................................... 85
Section R: GENITOURINARY INFECTIONS .................................................................................................................. 88
Section S: FEVERS ...................................................................................................................................................... 94
Section T: MEDICATIONS/HERBALS/VITAMINS ......................................................................................................... 96
Section U: STRESS .................................................................................................................................................... 132
Section V: PHYSICAL ACTIVITY ................................................................................................................................. 134
Section W: OBESITY ................................................................................................................................................. 137
Section X: DENTAL PROCEDURES ............................................................................................................................ 140
Section Y: SMOKING ................................................................................................................................................ 146
Section Z: ALCOHOL ................................................................................................................................................. 147
Section AA: RESIDENCE HISTORY............................................................................................................................. 148
Section BB: MATERNAL OCCUPATION..................................................................................................................... 148
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Section CC: RACE / ACCULTURATION / EDUCATION ............................................................................................... 150
Section DD: INSURANCE STATUS ............................................................................................................................. 155
Section EE: CLOSING ................................................................................................................................................ 156
Section FF: INTERVIEWER REMARKS ....................................................................................................................... 160
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OPENING STATEMENT
In this interview we will be asking you questions about your family, health, and lifestyle. 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 time before and during your pregnancy [TAB: with [NOIB]; affected by
a birth defect]. In order to do this, I need to start by asking you some dates.
A1. [TAB: What was [NOIB]’s date of birth/On what date did the affected pregnancy end]?
a. MM/DD/YYYY CAN USE DK OR RF FOR MM OR DD OR YY
A2. What date did the doctor give you as a due date for [TAB: [NOIB]’s birth; the affected pregnancy]? That
is, when was [TAB: [NOIB]; the baby] expected to be born?
a. MM/DD/YYYY CAN USE DK OR RF FOR MM OR DD OR YY
IF NOIB IS TAB OR STILLBIRTH, SKIP TO A6
A3. Is [NOIB] still living?
a.
b.
c.
d.
YES SKIP TO A6
NO CONTINUE TO A4
DK SKIP TO A6
RF SKIP TO A6
A4. What did s/he die of?
a. SPECIFY:__________
b. DK
c. RF
A5. How old was s/he when s/he died? NOTE: IF THE BABY LIVED LESS THAN 24 HOURS, THE RESPONSE LESS
THAN 1 DAY CAN BE RECORDED AS 1 DAY.
a. AGE:__________
DK
RF
i. UNITS:__________ (Days, Weeks, Months, Years)
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A6. What was your date of birth?
a. MM/DD/YYYY
CAN USE DK OR RF FOR MM OR DD OR YYYY
A7. I would like to ask about [TAB: [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? CAN USE DK OR
RF FOR MM OR DD OR YYYY
a. MM/DD/YYYY CAN USE DK OR RF FOR MM OR DD OR YYYY
b. DK WHO FATHER IS
Section B: MULTIPLE GESTATION
B1. In [TAB: your pregnancy with [NOIB]; the affected pregnancy], how many babies were you carrying?
PROBE: Were you carrying a single baby, twins, or more babies?
a. Number:__________
i. IF 1 (SINGLE BABY) SKIP TO NEXT SECTION
ii. IF ≥2 (TWINS OR HIGHER ORDER MULTIPLE) CONTINUE TO B2; IF TAB: SKIP TO NEXT
SECTION
iii. DK SKIP TO NEXT SECTION
iv. RF SKIP TO NEXT SECTION
B2. [Is the other baby/are the other babies] still living?
a.
b.
c.
d.
e.
Yes, all other babies still living
Some babies still living, others are not
No, no other babies still living
DK
RF
B3. What is/was [if deceased] the sex of the [first/second/third, etc. baby]? [RECORD FOR EACH ADDITIONAL
BABY (NUMBER REPORTED IN B1)]
a.
b.
c.
d.
e.
Girl
Boy
Indeterminate
DK
RF
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B4. Was this baby affected by a birth defect? [RECORD FOR EACH ADDITIONAL BABY]
a.
b.
c.
d.
YES CONTINUE TO B5
NO SKIP TO B6/NEXT SECTION
DK SKIP TO B6/NEXT SECTION
RF SKIP TO B6/NEXT SECTION
B5. What was it? / Anything else? [RECORD FOR EACH ADDITIONAL BABY]
a. SPECIFY:___________________________ (PROMPTS COMING TO CATI IN FUTURE RELEASE.
MEANWHILE USE LIST IN QxQ.)
b. DK
c. RF
B6. FOR SAME SEX TWINS ONLY: The next question is to see how similar your twins’ appearances are. There
are three options. Would you say that your twins: [READ OPTIONS]
a.
b.
c.
d.
e.
Look/ed virtually the same, as physically alike as “two peas in a pod”; or
As similar as typical brothers or sisters at the same age; or
Do not look very much alike at all?
DK
RF
Section C: PREGNANCY HISTORY
Now I’m going to ask you about your previous pregnancy experiences.
C1. How many times have you been pregnant before [TAB: [NOIB]; the pregnancy that ended on [DOIB]],
including pregnancies that may have ended in miscarriages, stillbirths, induced abortions, or other
outcomes?
a. NUMBER:__________
i. IF 0 SKIP TO NEXT SECTION
ii. IF >0 CONTINUE TO C2
b. DK SKIP TO NEXT SECTION
c. RF SKIP TO NEXT SECTION
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C2. When did the last pregnancy before [TAB: [NOIB]; the pregnancy that ended on [DOIB]] end?
a. MM/DD/YYYY CAN USE DK OR RF FOR MM OR DD OR YYYY OR
b. TIME PERIOD AGO:__________
i. YEARS
ii. MONTHS
iii. WEEKS
C3a. Did that pregnancy end with a live birth? IF A MULTIPLE PREGNANCY HAD AT LEAST ONE FETUS BORN
LIVE, SELECT YES
a.
b.
c.
d.
YES SKIP TO NEXT SECTION IFC1a = 1/SKIP TO C5 IF C1a >1
NO CONTINUE TO C3b
DK SKIP TO NEXT SECTION IF C1a = 1/SKIP TO C5 IF C1a >1
RF SKIP TO NEXT SECTION IF C1a = 1/SKIP TO C5 IF C1a >1
C3b. Did that pregnancy end with (a/an) (READ CATEGORIES: stillbirth, induced abortion, miscarriage, or
some other outcome)? IF 2 OR MORE OUTCOMES IN 1 PREGNANCY SELECT OTHER
a.
b.
c.
d.
e.
f.
Stillbirth CONTINUE TO C4
Induced abortion CONTINUE TO C4
Miscarriage CONTINUE TO C4
Some other outcome (SPECIFY) CONTINUE TO C4
DK CONTINUE TO C4
RF CONTINUE TO C4
C4. IF REPORTING ANY OUTCOME BESIDES LIVE BIRTH: How far along were you in your pregnancy when the
pregnancy ended? For example, the week or month?
a. AMOUNT:______________ SKIP TO NEXT SECTION IF C1a=1/CONTINUE TO C5 IF C1a>1
i. UNITS:___________(Days, Weeks, Months, Trimesters)
b. DK SKIP TO NEXT SECTION IF C1a=1/CONTINUE TO C5 IF C1a>1
c. RF SKIP TO NEXT SECTION IF C1a=1/CONTINUE TO C5 IF C1a>1
C5. IF C1a>2: Now, I would like to get some information about your other pregnancies, starting with the first
one. Did your [insert counter(1st, etc)] pregnancy end in a live birth? [REPEAT (C1a NUMBER) – 1 TIMES]
IF REPORTING 2 PREVIOUS PREGNANCIES (C1a = 2): Did your first pregnancy end in a live birth?
a. YES SKIP TO NEXT SECTION/ASK ABOUT NEXT PREGNANCY
b. NO CONTINUE TO C6
c. DK SKIP TO NEXT SECTION/ASK ABOUT NEXT PREGNANCY
d. RF SKIP TO NEXT SECTION/ASK ABOUT NEXT PREGNANCY
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C6. Did that pregnancy end with (a/an) (READ CATEGORIES: stillbirth, induced abortion, miscarriage, or some
other outcome)? IF 2 OR MORE OUTCOMES IN 1 PREGNANCY SELECT OTHER
a. Stillbirth CONTINUE TO C7
b. Induced abortion CONTINUE TO C7
c. Miscarriage CONTINUE TO C7
d. Some other outcome (SPECIFY) CONTINUE TO C7
e. DK CONTINUE TO C7
f. RF CONTINUE TO C7
C7. IF REPORTING ANY OUTCOME BESIDES LIVE BIRTH: How far along were you in your pregnancy when the
pregnancy ended? For example, the week or month?
a. AMOUNT:______________ SKIP TO NEXT SECTION/ASK ABOUT NEXT PREGNANCY
i. UNITS:___________(Days, Weeks, Months, Trimesters)
b. DK SKIP TO NEXT SECTION/ASK ABOUT NEXT PREGNANCY
c. RF SKIP TO NEXT SECTION/ASK ABOUT NEXT PREGNANCY
Section D: FAMILY HISTORY
D1. Did you have a health problem at birth or a birth defect that was diagnosed in childhood?
a.
b.
c.
d.
YES CONTINUE TO D2
NO SKIP TO D3
DK SKIP TO D3
RF SKIP TO D3
D2. What was it? / Anything else?
a. SPECIFY:___________________________
i. (PROMPTS COMING TO CATI IN FUTURE RELEASE. MEANWHILE USE LIST IN QxQ)
b. DK
c. RF
D3. IF FATHER UNKNOWN, SKIP TO D5: Did [TAB: [NOIB]’s; the] biological or natural father have a health
problem at birth or a birth defect that was diagnosed in childhood?
a.
b.
c.
d.
YES CONTINUE TO D4
NO SKIP TO D5/NEXT SECTION
DK SKIP TO D5/NEXT SECTION
RF SKIP TO D5/NEXT SECTION
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D4. What was it? / Anything else?
a. SPECIFY:___________________________
i. (PROMPTS COMING TO CATI IN FUTURE RELEASE. MEANWHILE USE LIST IN QxQ)
b. DK
c. RF
D5. IF PREVIOUS PREGNANCIES REPORTED: Did any of [TAB: [NOIB]’s; the) brothers or sisters have a health
problem at birth or a birth defect that was diagnosed during pregnancy or in childhood? Please do not
include half-siblings or step-siblings. Please do include full siblings who are not still living, including
previous pregnancies that ended in a miscarriage, stillbirth, or induced abortion.
a.
b.
c.
d.
YES CONTINUE TO D6
NO SKIP TO NEXT SECTION
DK SKIP TO NEXT SECTION
RF SKIP TO NEXT SECTION
D6. What was it? / Anything else?
a. SPECIFY:___________________________
DK
RF
i. (PROMPTS COMING TO CATI IN FUTURE RELEASE. MEANWHILE USE LIST IN QxQ
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Section E: FERTILITY
Now I have some questions specific to your pregnancy [TAB: with [NOIB]; that ended on [-DOIB]].
E1. How long were you trying to get pregnant with [TAB: [NOIB]; the pregnancy affected by a birth defect]
before you became pregnant? [READ OPTIONS]
a.
b.
c.
d.
e.
f.
g.
h.
i.
We were not trying SKIP TO E14
Less than 6 months
6 months or more, but less than a year
A year or more, but less than 3 years
3 years or more, but less than 5 years
5 years or more, but less than 7 years
7 years or more
DK
RF
E2a. In the two months before you became pregnant with [TAB: [NOIB]; the pregnancy that ended on [DOIB]]
did you use In-vitro fertilization, also known as IVF, Intracytoplasmic sperm injection, also known as ICSI,
or Artificial insemination to help you become pregnant?
a.
b.
c.
d.
YES CONTINUE TO E2b
NO SKIP TO E9
DK SKIP TO E9
RF SKIP TO E9
E2b. Which procedure or procedures did you use? READ LIST:
a.
b.
c.
d.
e.
In-vitro fertilization, or IVF
Intracytoplasmic sperm injection, or ICSI
Artificial insemination
DK
RF
IF YES TO ONLY ONE PROCEDURE SKIP TO E4
IF YES TO MORE THAN ONE PROCEDURE CONTINUE TO E3
IF NO AND/OR DK AND/OR RF TO ALL SKIP TO E9
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E3. Which was the last procedure you used before getting pregnant with [TAB: [NOIB]; the affected
pregnancy]?
a.
b.
c.
d.
e.
IN-VITRO FERTILIZATION, OR IVF
INTRACYTOPLASMIC SPERM INJECTION, OR ICSI
ARTIFICIAL INSEMINATION
DK
RF
E4. What was the date of that procedure?
a. MM/DD/YYYY
CAN USE DK OR RF FOR MM OR DD OR YYYY
E5. Were donor egg(s), donor sperm, or donor embryo(s) used on [ANSWER]/ (IF DATE UNKNOWN) during
this last procedure?
a.
b.
c.
d.
YES CONTINUE TO E6
NO SKIP TO E7
DK SKIP TO E7
RF SKIP TO E7
E6. Which of these were used? [SELECT ALL THAT APPLY]?
a.
b.
c.
d.
e.
Donor eggs
Donor sperm
Donor embryos
DK
RF
E7. Were frozen egg(s), frozen sperm, or frozen embryo(s) used on [REFERENCE:280]?
a.
b.
c.
d.
YES CONTINUE TO E8
NO SKIP TO E9
DK SKIP TO E9
RF SKIP TO E9
E8. Which of these were used? [SELECT ALL THAT APPLY]
a.
b.
c.
d.
e.
Frozen eggs
Frozen sperm
Frozen embryos
DK
RF
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E9. In the two months before you became pregnant with [TAB: [NOIB]; the pregnancy that ended on [DOIB]]
did you take any medications to help you become pregnant?
a. YES
b. NO IF E2 = YES SKIP TO E11. IF E2 = NO/DK/RF AND IF C1 = 0 SKIP TO E15. IF E2 = NO/DK/RF
AND IF C1 = >0 SKIP TO E14.
c. DK IF E2 = YES SKIP TO E11. IF E2 = NO/DK/RF AND IF C1 = 0 SKIP TO E15. IF E2 = NO/DK/RF
AND IF C1 = >0 SKIP TO E14.
d. RF IF E2 = YES SKIP TO E11. IF E2 = NO/DK/RF AND IF C1 = 0 SKIP TO E15. IF E2 = NO/DK/RF AND
IF C1 = >0 SKIP TO E14.
E9a. Did you take Clomid or clomiphene citrate?
i.
ii.
iii.
iv.
YES ASK E10a
NO
DK
RF
E9b. Did you take Letrozole/Femara?
i.
ii.
iii.
iv.
YES ASK E10b
NO
DK
RF
E9c. Did you take anything else?
i.
ii.
iii.
iv.
YES
NO
DK
RF
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E9d. What did you take? IF CAN’T RECALL, READ LIST:
i.
ii.
iii.
iv.
v.
vi.
vii.
viii.
ix.
x.
xi.
xii.
xiii.
xiv.
xv.
xvi.
xvii.
xviii.
Bromocriptine
Danazol
Danocrine
Depo-Provera
Factrel
Lupron
Lutrepulse
Metrodin
Parlodel
Pergonal
Pregnyl
Profasi HP
Provera
Serophene
Synarel
OTHER, SPECIFY:_____________
DK
RF
E10a. IF E9a=YES: How many Clomid or clomiphene citrate pills per day did you take at your last cycle before
getting pregnant?
i. NUMBER:__________
ii. DK
iii. RF
E10b. IF E9b=YES: How many Letrozole/Femara pills per day did you take at your last cycle before getting
pregnant?
i. NUMBER:__________
ii. DK
iii. RF
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E11. IF REPORT ANY FERTILITY PROCEDURES OR MEDICATIONS: How many menstrual cycles with fertility
treatments (complete or incomplete) did you have before [TAB: you got pregnant with NOIB; the
pregnancy that ended on [DOIB]]?
a.
b.
c.
d.
e.
f.
1 cycle
2-3 cycles
4-6 cycles
≥7 cycles
DK
RF
E12. IF REPORT ANY FERTILITY PROCEDURES OR MEDICATIONS: What was the reason(s) for fertility
treatments? Was it…[READ OPTIONS; INDICATE ALL THAT APPLY]
a. A female issue, such as blocked fallopian tubes or Polycystic Ovary Syndrome CONTINUE TO
E13
b. A male issue, such as low sperm count or low motility SKIP TO E14 IF PREVIOUS PREGNANCY
REPORTED/E15 IF ONLY ONE PREGNANCY REPORTED
c. No male partner SKIP TO E14/E15
d. Unexplained SKIP TO E14/E15
e. DK SKIP TO E14/E15
f. RF SKIP TO E14/E15
E13. IF REPORT FEMALE FACTOR: What was the female issue? Was it…[READ OPTIONS; INDICATE ALL THAT
APPLY]
a.
b.
c.
d.
e.
f.
g.
Blocked fallopian tubes
Polycystic Ovary Syndrome (PCOS)
Endometriosis
Ovulation problems (irregular periods)
OTHER (SPECIFY):_______________
DK
RF
E14. IF PREVIOUS PREGNANCY REPORTED: Have you ever conceived a previous pregnancy using [READ ALL,
INDICATE ALL THAT APPLY]:
E14b.
E14c.
E14d.
E14e.
Ovulation stimulation pills, such as Clomid or Femara
Artificial insemination
In-vitro fertilization, or IVF; or
Intracytoplasmic sperm injection, or ICSI
11
YES
YES
YES
YES
NO
NO
NO
NO
DK
DK
DK
DK
RF
RF
RF
RF
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E15. During the first trimester of your pregnancy with [TAB: [NOIB]/the pregnancy that ended on [DOIB]],
did you take any medications to prevent pregnancy complications or pregnancy loss, such as hormones,
steroids, or injections?
a.
b.
c.
d.
YES CONTINUE TO E16
NO SKIP TO NEXT SECTION
DK SKIP TO NEXT SECTION
RF SKIP TO NEXT SECTION
E16. What did you take? / Did you take anything else? LIST ALL. IF CAN’T RECALL, READ LIST: Was it…?
a.
b.
c.
d.
e.
f.
g.
h.
i.
j.
Depo-Provera
Magnesium Sulfate
Progesterone
Rho(D) immune globulin
Rhogam
Calcium Channel Blockers NOS
Steroid NOS
OTHER, SPECIFY:________
DK SKIP TO NEXT SECTION
RF SKIP TO NEXT SECTION
E17. When in the first trimester did you start using [ANSWER] to prevent complications or pregnancy loss?
a.
b.
c.
d.
MM/DD/YYYY OR
MONTH OF PREGNANCY (P1, P2, P3, T1)
DK
RF
E18. When did you stop using [ANSWER] for the last time during this time period?
a.
b.
c.
d.
MM/DD/YYYY OR
MONTH OF PREGNANCY(P1, P2, P3, T1) IF VALID START AND STOP DATE, SKIP TO E20
DK
RF
E19. How long did you take it? You can say the length of time in days, weeks or months.
a. AMOUNT:__________
i. Days
ii. Weeks
iii. Months
b. DK
c. RF
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E20. How often did you use [ANSWER] in the first three months of your pregnancy? You can say the number
of times per day, per week, per month, or during the entire 3 month period.
a. AMOUNT:__________ Per Day/Per Week/Per Month/Per Time Period/DK/RF
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Maternal Health Introduction
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 and home remedies. If you filled out the medication worksheet we included
in your introductory packet, it will be helpful for you to have it in front of you for these questions. Now I have
some questions about your health.
Section F: DIABETES
F1. Were you ever told by a doctor that you had diabetes (including gestational diabetes), sometimes called
sugar diabetes or diabetes mellitus?
a.
b.
c.
d.
YES CONTINUE TO F2
NO SKIP TO NEXT SECTION
DK SKIP TO NEXT SECTION
RF SKIP TO NEXT SECTION
F2. What type of diabetes did you or do you currently have? Was it [READ LIST]?
a.
b.
c.
d.
e.
Gestational, that is, during pregnancy only
Insulin-dependent diabetes, also called Type 1, or Juvenile
Non-insulin-dependent diabetes, also called Type 2, or Adult onset
DK
RF
F3. When were you first diagnosed with diabetes in relation to your pregnancy with [TAB: [NOIB]; the
affected pregnancy]? [READ LIST]
a.
b.
c.
d.
e.
Before this pregnancy and not during any other pregnancy?
During a previous pregnancy?
During this pregnancy?
DK
RF
IF F2=a, d, or e OR F3=b, c, d, e THEN SKIP TO F7 [ONLY ASK F4 if F2 = b or c AND F3=a
F4. Either before or during your pregnancy, did you speak with a healthcare provider about your treatment
options during pregnancy?
a.
b.
c.
d.
YES GO TO F5
NO SKIP TO F7
DK SKIP TO F7
RF SKIP TO F7
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F5. Did you discuss these options before your pregnancy began?
a.
b.
c.
d.
YES SKIP TO F7
NO GO TO F6
DK SKIP TO F7
RF SKIP TO F7
F6. How far along were you in your pregnancy when you discussed treatment options with your provider?
a. AMOUNT:__________
b. UNITS:
i. Days
ii. Weeks
iii. Months
iv. Trimesters
c. DK
d. RF
F7. How did you manage your diabetes and its complications during the time between the month before
your pregnancy and the end of the third month of your pregnancy? GIVE OPTIONS; INDICATE ALL THAT
APPLY.
a.
b.
c.
d.
e.
f.
g.
Take medications or other remedies IF YES, CONTINUE TO F8 AFTER QUERYING F7b-F7d
Modify your eating habits IF YES, ASK F19
Control your weight or weight gain IF YES, ASK F19
Do anything else IF YES, ASK F20
NONE OF THE ABOVE SKIP TO F22
DK SKIP TO F22
RF SKIP TO F22
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F8. IF 7a: What medications did you take?/Did you take anything else? LIST ALL. IF CAN’T RECALL, READ
FROM DRUG LIST. Did you take…?
a.
b.
c.
d.
e.
f.
g.
h.
i.
j.
k.
l.
m.
n.
o.
p.
q.
r.
s.
t.
u.
v.
w.
x.
y.
z.
aa.
bb.
cc.
dd.
Actos
Amaryl
Byetta
Diabeta
Diabinese
Glucophage
Glucotrol
Glucotrol XL
Glumetza
Glyburide
Glynase PresTab
Humalog
Humulin N
Humulin R
Januvia
Lantus
Levemir
Metformin HCL
Micronase
Novolin N
Novolin R
Novolog
Onglyza
Prandin
Precose
Starlix
Victoza
OTHER (SPECIFY)
DK SKIP TO F19/F20 OR F21
RF SKIP TO F19/F20 OR F21
F9. Did you use [ANSWER] for the entire time from the month before your pregnancy through your third
month of pregnancy, that is from [B1] to [P4(-1)]?
a.
b.
c.
d.
YES SKIP TO F13
NO CONTINUE TO F10
DK CONTINUE TO F10
RF CONTINUE TO F10
16
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F10.When did you start using [REFERENCE:520|1.*.1] for diabetes for the first time during this period?
a.
b.
c.
d.
MM/DD/YYYY or
MONTH OF PREGNANCY (B1, P1, P2, P3)
DK
RF
F11. When did you stop using [REFERENCE:520|1.*.1] for the last time during this time period?
a.
b.
c.
d.
MM/DD/YYYY or
MONTH OF PREGNANCY (B1, P1, P2, P3) IF VALID RESPONSE TO F10 AND F11, SKIP F12
DK
RF
F12. Or, how long did you take it?
a. AMOUNT:__________
i. Days
ii. Weeks
iii. Months
b. DK
c. RF
F13. How often did you use [PASSIN] during the month before your pregnancy through the end of your third
month of pregnancy? You can say the number of times per day, per week, per month, or during the
entire 4 month period.
a. AMOUNT:__________ Per Day/Per Week/Per Month/Per Time Period/DK/RF
F14. Did you take the same dose of [PASSIN] each time you took it throughout [B1] TO [P4(-1)]? That is, for
example, the same number of milligrams of medicine in each dose.
a.
b.
c.
d.
YES CONTINUE TO F15
NO SKIP TO F16a
DK CONTINUE TO F15
RF CONTINUE TO F15
17
BD-STEPS CATI – FULL DRAFT
9/24/14
F15. What dose of [PASSIN] did you take each time you took it?
a. AMOUNT:_______________ SKIP TO F19 (IF F7b OR F7c=YES) OR F20 (IF F7b AND F7c=NO
AND F7d=YES) OR F22 (IF F7b, F7c, AND F7d=NO)
i. UNITS:__________
b. DK or RF SKIP TO F19 (IF F7b OR F7c=YES) OR F20 (IF F7b AND F7c=NO AND F7d=YES) OR F22
(IF F7b, F7c, AND F7d=NO)
FOR EACH DRUG UNIT RESPONSE IN SECTION F THROUGH X, THESE ARE THE OPTIONS:
MICROGRAMS
MILLIGRAM(S)
MILLILITER(S)
TEASPOON(S)
TABLESPOON(S)
INTERNATIONAL UNITS
PILL/CAPSULE/CAPLET(S)
PUFF(S)
DROP(S)
OTHER, SPECIFY
DK, RF
F16a. How many different dosage amounts do you remember taking?
i. AMOUNT:__________
F16b. What dose of [REFERENCE:520|*.1.1] did you take the [CHAPTER] time?
i. AMOUNT:__________
DK SKIP TO F17
RF SKIP TO F17
ii. UNITS:__________
DK
RF
F17. When did you begin taking that dose?
a.
b.
c.
d.
MM/DD/YYYY or
MONTH OF PREGNANCY(B1, P1, P2, P3)
DK
RF
18
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F18.
When did you stop taking that dose?
a. MM/DD/YYYY OR CONTINUE TO F19 (IF F7b OR F7c=YES) OR F20 (IF F7b AND F7c=NO AND
F7d=YES) OR F21 (IF F7b, F7c, AND F7d=NO)
b. MONTH OF PREGNANCY (B1, P1, P2, P3) IF VALID RESPONSE TO F17 AND F18, SKIP F18a.
CONTINUE TO F19 (IF F7b OR F7c=YES) OR F20 (IF F7b AND F7c=NO AND F7d=YES) OR F21 (IF F7b,
F7c, AND F7d=NO)
c. DK CONTINUE TO F19 (IF F7b OR F7c=YES) OR F20 (IF F7b AND F7c=NO AND F7d=YES) OR F21
(IF F7b, F7c, AND F7d=NO)
d. RF CONTINUE TO F19 (IF F7b OR F7c=YES) OR F20 (IF F7b AND F7c=NO AND F7d=YES) OR F21
(IF F7b, F7c, AND F7d=NO)
F18a. OR: How long did you take it?
a. AMOUNT:__________
i. Days
ii. Weeks
iii. Months
DK
RF
F19. ASK IF F7b OR F7c=YES: In order to modify your eating habits or control your weight, did you…? READ
OPTIONS. Did you do anything else?
a.
b.
c.
d.
e.
f.
F20.
Follow a diet specifically for diabetes?
Eat healthier but no specific diabetes diet?
Do physical exercise?
OTHER, SPECIFY____________________________
DK
RF
IF F7d=YES: What else did you do to manage your diabetes and its complications?/Anything else?
a. SPECIFY:_____________________________
b. DK
c. RF
F21a. IF F7a = YES: How often did taking medications or other remedies work in controlling your diabetes?
READ OPTIONS.
a.
b.
c.
d.
e.
f.
Always
Most of the time
Part of the time
Never or rarely
DK
RF
19
BD-STEPS CATI – FULL DRAFT
9/24/14
F21b. IF F7b = YES: How often did modifying your eating habits work in controlling your diabetes? READ
OPTIONS.
a.
b.
c.
d.
e.
f.
Always
Most of the time
Part of the time
Never or rarely
DK
RF
F21c. IF F7c = YES: How often did controlling your weight gain work in controlling your diabetes? READ
OPTIONS.
a.
b.
c.
d.
e.
f.
Always
Most of the time
Part of the time
Never or rarely
DK
RF
F21d. IF F7d = YES: How often did [RE-WORD APPROPRIATELY IF F20 =DO NOT KNOW]
([REFERENCE:640|1.1.1.1.1.1]) work in controlling your diabetes? READ OPTIONS.
a.
b.
c.
d.
e.
f.
Always
Most of the time
Part of the time
Never or rarely
DK
RF
F22. Glycosylated (GLY-CO-SYL-AT-ED) hemoglobin or the “A one C” test measures your average level of
blood sugar for the past 3 months, and usually ranges between 5.0 and 13.9. At the time that you
became pregnant with [TAB: [NOIB]; the pregnancy that ended on [DOIB]], had a doctor or other health
professional ever checked your glycosylated hemoglobin or “A one C”?
a.
b.
c.
d.
YES CONTINUE TO F23
NO SKIP TO NEXT SECTION
DK SKIP TO NEXT SECTION
RF SKIP TO NEXT SECTION
20
BD-STEPS CATI – FULL DRAFT
9/24/14
F23. What was your “A one C” level at the time it was tested closest to when you became pregnant with
[TAB: [NOIB]; the pregnancy that ended on [DOIB]]? OR PROBE: If you can't remember the actual
number, do you know if it was normal or high?
AMOUNT:__________/High/Normal/DK/RF
F24.
When was the “A one C” test conducted?
a. MM/DD/YYYY or
b. RELATIVE TO PREGNANCY:
1 month to 3 months before pregnancy
4 months to 6 months before pregnancy
6 months to 1 year before pregnancy
Greater than 1 year before pregnancy
c. DK
d. RF
21
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Section G: CANCER
G1. Have you ever been told by a doctor or other health professional that you had cancer or a malignancy of
any kind?
a.
b.
c.
d.
YES CONTINUE TO G2
NO SKIP TO NEXT SECTION
DK SKIP TO NEXT SECTION
RF SKIP TO NEXT SECTION
G2. What kind of cancer was it? CAN ENTER MULTIPLE SITES IF APPLICABLE.
a. SPECIFY:__________
b. DK
c. RF
G3. How old were you when you were diagnosed with cancer for the first time?
a. AGE:_______________________
b. DK
c. RF
G4. What is the current status of your cancer? (READ OPTIONS)
a.
b.
c.
d.
Active SKIP TO NEXT SECTION
In remission CONTINUE TO G5
DK SKIP TO NEXT SECTION
RF SKIP TO NEXT SECTION
G5. How long has it been in remission?
a. TIME:__________
i. Years
ii. Months
iii. Weeks
iv. Days
b. DK
c. RF
22
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Section H: HEART PROBLEMS
H1. Do you have a heart problem that has been present since birth?
a.
b.
c.
d.
YES CONTINUE TO H2
NO SKIP TO H15
DK SKIP TO H15
RF SKIP TO H15
H2. What is it?
a. SPECIFY:__________
b. DK
c. RF
H3. Did you take any medications or remedies for [REFERENCE:750] during the month before your pregnancy
through the third month of your (pregnancy with [TAB: [NOIB]; the pregnancy that ended on [DOIB]]?
a.
b.
c.
d.
YES CONTINUE TO H4
NO SKIP TO H15
DK SKIP TO H15
RF SKIP TO H15
H4. What did you take? / Did you take anything else?
a. SPECIFY:__________
b. DK SKIP TO H15
c. RF SKIP TO H15
H5. Did you use [PASSIN] for the entire time from the month before your pregnancy through your third
month of pregnancy, that is from [B1] through [P4(-1)]?
a.
b.
c.
d.
YES SKIP TO H9
NO CONTINUE TO H6
DK CONTINUE TO H6
RF CONTINUE TO H6
H6. When did you start using [PASSIN] for the first time during this period?
a.
b.
c.
d.
MM/DD/YYYY or
MONTH OF PREGNANCY (B1, P1, P2, P3)
DK
RF
23
BD-STEPS CATI – FULL DRAFT
9/24/14
H7. When did you stop using [PASSIN] for the last time during this time period?
a.
b.
c.
d.
MM/DD/YYYY or
MONTH OF PREGNANCY (B1, P1, P2, P3) IF VALID RESPONSE TO H6 AND H7, SKIP H8
DK
RF
H8. OR How long did you take it?
a. AMOUNT:__________
i. Days
ii. Weeks
iii. Months
b. DK
c. RF
H9. How often did you use [PASSIN] during the month before your pregnancy through the end of your third
month of pregnancy? You can say the number of times per day, per week, per month, or during the
entire 4 month period.
a. AMOUNT:__________ Per Day/Per Week/Per Month/Per Time Period/DK/RF
H10. Did you take the same dose of medicine each time you took it throughout [B1] to [P4(-1)]? That is, for
example, the same number of milligrams of medicine in each dose.
a.
b.
c.
d.
YES CONTINUE TO H11
NO SKIP TO H12a
DK CONTINUE TO H11
RF CONTINUE TO H11
H11. What dose of [PASSIN] did you take each time you took it?
a. AMOUNT:__________ SKIP TO H15
DK SKIP TO H15
RF SKIP TO H15
b. UNITS:__________ SKIP TO H15
DK SKIP TO H15
RF SKIP TO H15
H12a. How many different dosage amounts do you remember taking?
i. AMOUNT:__________
24
BD-STEPS CATI – FULL DRAFT
9/24/14
H12b. What dose of [REFERENCE:770|1.1.V] did you take the [CHAPTER] time?
i. AMOUNT:__________
DK SKIP TO H13
RF SKIP TO H13
ii. UNITS:__________
DK
RF
H13. When did you begin taking that dose?
a.
b.
c.
d.
MM/DD/YYYY or
MONTH OF PREGNANCY(B1, P1, P2, P3)
DK
RF
H14. When did you stop taking that dose?
a.
b.
c.
d.
MM/DD/YYYY or
MONTH OF PREGNANCY(B1, P1, P2, P3) IF VALID RESPONSE TO H13 AND H14, SKIP H14a
DK
RF
H14a. OR How long did you take it?
a.
b.
c.
AMOUNT:__________
i. Days
ii. Weeks
iii. Months
DK
RF
H15. Have you ever been diagnosed with cardiac arrhythmias?
a.
b.
c.
d.
YES CONTINUE TO H16
NO SKIP TO H28
DK SKIP TO H28
RF SKIP TO H28
25
BD-STEPS CATI – FULL DRAFT
9/24/14
H16. Did you take any medication for arrhythmias during the month before your pregnancy through the
third month of pregnancy?
a.
b.
c.
d.
YES CONTINUE TO H17
NO SKIP TO H28
DK SKIP TO H28
RF SKIP TO H28
H17. What did you take? / Did you take anything else? IF CAN’T RECALL, READ FROM DRUG LIST:
a.
b.
c.
d.
e.
f.
g.
h.
i.
j.
k.
l.
m.
n.
o.
p.
q.
r.
s.
t.
u.
Amiodarone
Atenolol
Betapace
Cardizem
Cartia XT
Carvedilol
Cordarone
Diltiazem HCL
Labetolol
Lopressor
Metoprolol
Pacerone
Propafenone HCL
Propranolol
Rythmol
Sotalol
Toprol XL
Verapamil
OTHER (SPECIFY)
DK SKIP TO H28
RF SKIP TO H28
H18. Did you use [ANSWER] for the entire time from the month before your pregnancy through the third
month of pregnancy, that is from [B1] to [P4(-1)]?
a.
b.
c.
d.
YES SKIP TO H22
NO CONTINUE TO H19
DK CONTINUE TO H19
RF CONTINUE TO H19
26
BD-STEPS CATI – FULL DRAFT
9/24/14
H19. When did you start using [REFERENCE:900|1.*.1] for arrhythmias for the first time during this period?
a.
b.
c.
d.
MM/DD/YYYY or
MONTH OF PREGNANCY(B1, P1, P2, P3)
DK
RF
H20. When did you stop using [REFERENCE:900|1.*.1] for arrhythmias for the last time during this time
period?
a.
b.
c.
d.
MM/DD/YYYY or
MONTH OF PREGNANCY(B1, P1, P2, P3) IF VALID RESPONSE TO H19 AND H20, SKIP H21
DK
RF
H21. Or, how long did you take it?
a. AMOUNT:__________
i. Days
ii. Weeks
iii. Months
b. DK
c. RF
H22. How often did you use [REFERENCE:900|1.*.1] during the month before your pregnancy through the
end of your third month of pregnancy? You can say the number of times per day, per week, per
month, or during the entire 4 month period.
a. AMOUNT:__________ Per Day/Per Week/Per Month/Per Time Period/DK/RF
H23. Did you take the same dose of medicine each time you took it throughout [B1] to [P4(-1)]? That is, for
example, the same number of milligrams of medicine in each dose.
a.
b.
c.
d.
YES CONTINUE TO H24
NO SKIP TO H25a
DK CONTINUE TO H24
RF CONTINUE TO H24
H24. What dose of [REFERENCE:900|1.*.1] did you take each time you took it?
a. AMOUNT:__________ SKIP TO H28
i. UNITS:__________
b. DK SKIP TO H28
c. RF SKIP TO H28
27
BD-STEPS CATI – FULL DRAFT
9/24/14
H25a. How many different dosage amounts do you remember taking?.
i. AMOUNT:__________
H25b. What dose of [REFERENCE:900|1.1.V] did you take the [CHAPTER] time?
i. AMOUNT:__________
DK SKIP TO H26
RF SKIP TO H26
ii. UNITS:__________
DK
RF
H26. When did you begin taking that dose?
a.
b.
c.
d.
MM/DD/YYYY or
MONTH OF PREGNANCY(B1, P1, P2, P3)
DK
RF
H27. When did you stop taking that dose?
a.
b.
c.
d.
MM/DD/YYYY or
MONTH OF PREGNANCY(B1, P1, P2, P3) IF VALID RESPONSE TO H26 and H27, SKIP H27a
DK
RF
H27a. How long did you take it?
a. AMOUNT:__________
i. Days
ii. Weeks
iii. Months
b. DK
c. RF
H28.
Were you ever in your life told by a doctor that you had high blood pressure?
a.
b.
c.
d.
YES CONTINUE TO H29
NO SKIP TO NEXT SECTION
DK SKIP TO NEXT SECTION
RF SKIP TO NEXT SECTION
28
BD-STEPS CATI – FULL DRAFT
9/24/14
H29. What type of high blood pressure did you or do you have? Was it pregnancy-related – that is during
pregnancy only? This might also be called pregnancy-induced toxemia or pre-eclampsia or eclampsia.
Or is 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.
a.
b.
c.
d.
e.
Pregnancy related
Chronic hypertension
Both
DK
RF
IF H29=a, d, or e THEN SKIP TO H33 (ONLY ASK H30 if H29=b, c)
H30. Either before or during your pregnancy, did you speak with a healthcare provider about your treatment
options during pregnancy?
a.
b.
c.
d.
YES GO TO H31
NO SKIP TO H33
DK SKIP TO H33
RF SKIP TO H33
H31. Did you discuss these options before your pregnancy began?
a.
b.
c.
d.
YES SKIP TO H33
NO GO TO H32
DK SKIP TO H33
RF SKIP TO H33
H32. How far along were you in your pregnancy when you discussed treatment options with your provider?
a. AMOUNT:__________ Days/Weeks/Months/Trimesters/DK/RF
H33. Did you take any medications or remedies for high blood pressure during the month before your
pregnancy through the third month of pregnancy?
a.
b.
c.
d.
YES CONTINUE TO H34
NO SKIP TO NEXT SECTION
DK SKIP TO NEXT SECTION
RF SKIP TO NEXT SECTION
29
BD-STEPS CATI – FULL DRAFT
9/24/14
H34. What did you take? / Did you take anything else? IF CAN’T RECALL, READ FROM DRUG LIST:
a. Accupril
b. Adalat
c. Altace
d. Amlodipine
e. Atenolol
f. Avapro
g. Benazepril HCL
h. Benicar
i. Calan
j. Capoten
k. Cardizem
l. Covera -HS
m. Cozaar
n. Diltiazem HCL
o. Diovan
p. Enalapril Maleate
q. Hydralazine
r. Hydrochlorothiazide
s. Inderal
t. Irbesartan
u. Labetalol
v. Lisinopril
w. Losartan Potassium
x. Lotensin
y. Methyldopa
z. Metoprolol
aa. Microzide
bb. Nifedipine
cc. Normodyne
dd. Norvasc
ee. Olmesartan Medoxomil
ff. Prinivil
gg. Procardia
hh. Propranolol
ii. Quinapril HCL
jj. Ramipril
kk. Tenormin
ll. Tiazac
mm. Trandate
nn. Valsartan
30
BD-STEPS CATI – FULL DRAFT
9/24/14
oo.
pp.
qq.
rr.
ss.
tt.
uu.
Vasotec
Verapamil
Verelan
Zestril
OTHER (SPECIFY):__________
DK SKIP TO NEXT SECTION
RF SKIP TO NEXT SECTION
H35. Did you use [ANSWER] for the entire time from the month before your pregnancy through your third
month of pregnancy, that is from [B1] to [P4(-1)]?
a.
b.
c.
d.
YES SKIP TO H39
NO CONTINUE TO H36
DK CONTINUE TO H36
RF CONTINUE TO H36
H36. When did you start using [REFERENCE:1070|1.*.1] for high blood pressure for the first time during this
period?
a.
b.
c.
d.
MM/DD/YYYY or
MONTH OF PREGNANCY(B1, P1, P2, P3)
DK
RF
H37. When did you stop using [REFERENCE:1070|1.*.1] for the last time during this time period?
a.
b.
c.
d.
MM/DD/YYYY or
MONTH OF PREGNANCY(B1, P1, P2, P3) IF VALID RESPONSE TO H36 and H37, SKIP H38
DK
RF
H38. How long did you take it?
a. AMOUNT:__________
i. Days
ii. Weeks
iii. Months
b. DK
c. RF
H39. How often did you use [ANSWER] during the month before your pregnancy through the end of your
third month of pregnancy? You can say the number of times per day, per week, per month, or during the
entire 4 month period.
a. AMOUNT:__________ Per Day/Per Week/Per Month/Per Time Period/DK/RF
31
BD-STEPS CATI – FULL DRAFT
9/24/14
H40. Did you take the same dose of medicine each time you took it throughout [B1] to [P4(-1)]? That is, for
example, the same number of milligrams of medicine in each dose.
a.
b.
c.
d.
YES CONTINUE TO H41
NO SKIP TO H42a
DK CONTINUE TO H41
RF CONTINUE TO H41
H41. What dose of [REFERENCE:1070|1.*.1] did you take each time you took it?
i. AMOUNT:__________
DK SKIP TO NEXT SECTION
RF SKIP TO NEXT SECTION
ii. UNITS:__________
DK
RF
H42a. How many different dosage amounts do you remember taking?
i. AMOUNT:__________
H42b. What dose of [REFERENCE:1070|1.1.V] did you take the [CHAPTER] time?
i. AMOUNT:__________
DK SKIP TO H43
RF SKIP TO H43
ii. UNITS:__________
DK
RF
H43. When did you begin taking that dose?
a.
b.
c.
d.
MM/DD/YYYY or
MONTH OF PREGNANCY(B1, P1, P2, P3)
DK
RF
H44. When did you stop taking that dose?
a.
b.
c.
d.
MM/DD/YYYY or
MONTH OF PREGNANCY(B1, P1, P2, P3) IF VALID RESPONSE TO H43 and H44, SKIP H44a
DK
RF
32
BD-STEPS CATI – FULL DRAFT
9/24/14
H44a. How long did you take it?
a. AMOUNT:__________
i. Days
ii. Weeks
iii. Months
b. DK
c. RF
Section I: THYROID DISEASE
I1 Have you ever been diagnosed with thyroid disease, not including thyroid cancer, which we have already
talked about?
a.
b.
c.
d.
YES CONTINUE TO I2
NO SKIP TO NEXT SECTION
DK SKIP TO NEXT SECTION
RF SKIP TO NEXT SECTION
I2. What type of thyroid disease were you diagnosed with originally? Was it…[READ ALL]
a.
b.
c.
d.
e.
Hypothyroidism, also called having an “underactive” thyroid?
Hashimoto’s Disease or autoimmune thyroiditis?
Hyperthyroidism, also called having an “overactive” thyroid?
Graves’ Disease?
OTHER, SPECIFY:_______________________________________
NOTE: THYROID CANCER COVERED EARLIER
f. DK
g. RF
I3. When was [PASSIN] first diagnosed relative to [TAB: your pregnancy with [NOIB]; the pregnancy that
ended on [DOIB]]? [READ LIST]
a.
b.
c.
d.
e.
f.
g.
More than 2 years before
In the 2 years before
During the first trimester
After the first trimester but still during pregnancy
After the pregnancy
RF
DK
33
BD-STEPS CATI – FULL DRAFT
9/24/14
I4. [IF REPORTING HYPERTHYROIDISM/OVERACTIVE THYROID/GRAVES’ DISEASE CONTINUE, OTHERWISE,
SKIP TO I9]: Have you had surgery to remove all or part of your thyroid gland?
a.
b.
c.
d.
YES CONTINUE TO I5
NO SKIP I7
DK SKIP I7
RF SKIP I7
I5. Did you have all or part of your thyroid gland removed?
a.
b.
c.
d.
All
Part
DK
RF
I6. When did you have this surgery?
a. MM/DD/YYYY or
b. AGE:__________ or
c. Time period ago:__________
i. Years
ii. Months
iii. Weeks
iv. Days
d. DK
e. RF
I7. Did you have treatment with radioactive iodine?
a.
b.
c.
d.
YES CONTINUE TO I8
NO SKIP TO I8 IF I4 = YES/ I9 IF I4 = NO,DK,RF/I12 IF I3 = c, d, e, f or g
DK SKIP TO I8 IF I4 = YES/ I9 IF I4 = NO,DK,RF/I12 IF I3 = c, d, e, f or g
RF SKIP TO I8 IF I4 = YES/ I9 IF I4 = NO,DK,RF/I12 IF I3 = c, d, e, f or g
I8. When did you have this procedure?
a. MM/DD/YYYY or
b. AGE:__________ or
c. Time period ago:__________
i. Years
ii. Months
iii. Weeks
iv. Days
d. DK
e. RF
34
BD-STEPS CATI – FULL DRAFT
9/24/14
IF I3=c, d, e, f, OR g THEN SKIP TO I12 (ONLY ASK I9 IF I3=a or b)
I9. Either before or during your pregnancy, did you speak with a healthcare provider about your treatment
options during pregnancy?
a.
b.
c.
d.
YES GO TO I10
NO SKIP TO I12
DK SKIP TO I12
RF SKIP TO I12
I10. Did you discuss these options before your pregnancy began?
a.
b.
c.
d.
YES SKIP TO I12
NO GO TO I11
DK SKIP TO I12
RF SKIP TO I12
I11. How far along were you in your pregnancy when you discussed treatment options with your provider?
a. AMOUNT:__________
b. UNITS:
i. Days
ii. Weeks
iii. Months
iv. Trimesters
c. DK
d. RF
I12. Did you take any medications or remedies for [REFERENCE:1190] during the month before your
pregnancy through the third month of pregnancy, that is from [B1] to [P4(-1)]?
a.
b.
c.
d.
YES CONTINUE TO I13
NO SKIP TO NEXT SECTION
DK SKIP TO NEXT SECTION
RF SKIP TO NEXT SECTION
35
BD-STEPS CATI – FULL DRAFT
9/24/14
I13. What did you take? / Did you take anything else?
IF CAN’T RECALL, READ FROM LIST:
a.
b.
c.
d.
e.
f.
g.
h.
i.
j.
k.
l.
m.
n.
o.
p.
q.
r.
s.
t.
Armour Thyroid
Carbimazole
Cytomel
Levothroid
Levothyroxine Sodium
Levoxyl
Liothyronine
Liotrix
Methimazole
Nature-throid
Propylthiouracil (PTU)
Synthroid
Thiamazole
Thyrolar
Tirosint
Unithroid
Westhroid
OTHER (SPECIFY):__________
DK SKIP TO NEXT SECTION
RF SKIP TO NEXT SECTION
I14. Did you use [ANSWER] for the entire time from the month before your pregnancy through the third
month of your pregnancy?
a.
b.
c.
d.
YES SKIP TO I18
NO CONTINUE TO I15
DK CONTINUE TO I15
RF CONTINUE TO I15
I15. When did you start using [REFERENCE:1300|1.*.1] for [REFERENCE:1190] for the first time during this
period?
a.
b.
c.
d.
MM/DD/YYYY or
MONTH OF PREGNANCY(B1, P1, P2, P3)
DK
RF
36
BD-STEPS CATI – FULL DRAFT
9/24/14
I16. When did you stop using [REFERENCE:1300|1.*.1] for [REFERENCE:1190] for the last time during this time
period?
a.
b.
c.
d.
MM/DD/YYYY or
MONTH OF PREGNANCY(B1, P1, P2, P3) IF VALID RESPONSE TO I15 AND I16, SKIP I17
DK
RF
I17. How long did you take it?
a. AMOUNT:__________
i. Days
ii. Weeks
iii. Months
b. DK
c. RF
I18. How often did you use [REFERENCE:1300|1.*.1] during the month before your pregnancy through the
end of your third month of pregnancy? You can say the number of times per day, per week, per month,
or during the entire 4 month period.
a. AMOUNT:__________ Per Day/Per Week/Per Month/Per Time Period/DK/RF
I19. Did you take the same dose of medicine each time you took it throughout [B1] to [P4(-1)]? That is, for
example, the same number of milligrams of medicine in each dose.
a.
b.
c.
d.
YES CONTINUE TO I20
NO SKIP TO I21a
DK CONTINUE TO I20
RF CONTINUE TO I20
I20. What dose of [REFERENCE:1300|1.*.1] did you take each time you took it?
a. AMOUNT:__________ DK
RF SKIP TO NEXT SECTION
i. UNITS:__________
I21a. How many different dosage amounts do you remember taking?
i. AMOUNT:__________
37
BD-STEPS CATI – FULL DRAFT
9/24/14
I21b. What dose of [REFERENCE:1300|1.1.V ] did you take the [CHAPTER] time?
i. AMOUNT:__________
DK SKIP TO I22
RF SKIP TO I22
ii. UNITS:__________
DK
RF
I22. When did you begin taking that dose?
a.
b.
c.
d.
MM/DD/YYYY or
MONTH OF PREGNANCY(B1, P1, P2, P3)
DK
RF
I23. When did you stop taking that dose?
a.
b.
c.
d.
MM/DD/YYYY or
MONTH OF PREGNANCY(B1, P1, P2, P3) IF VALID RESPONSE TO I22 and I23, SKIP I23a
DK
RF
I23a. How long did you take it?
a. AMOUNT:__________
i. Days
ii. Weeks
iii. Months
b. DK
c. RF
38
BD-STEPS CATI – FULL DRAFT
9/24/14
Section J: ASTHMA
J1. Have you ever been diagnosed with asthma or reactive airway disease?
a.
b.
c.
d.
YES CONTINUE TO J2
NO SKIP TO NEXT SECTION
DK SKIP TO NEXT SECTION
RF SKIP TO NEXT SECTION
J2. When was your asthma or reactive airway disease first diagnosed, relative to [TAB: your pregnancy with
[NOIB]; the pregnancy that ended on [DOIB]]? [READ LIST]
a.
b.
c.
d.
e.
f.
g.
More than 2 years before
In the 2 years before
During the first trimester
After the first trimester but still during pregnancy
After the pregnancy
RF
DK
J3. Did you have any asthma symptoms in the month before your pregnancy through your third month of
pregnancy, that is from [B1] to [P4(-1)]? These symptoms include shortness of breath, chest tightness or
pain, coughing or wheezing, or low peak expiratory flow (PEF) readings.
a.
b.
c.
d.
YES CONTINUE TO J4
NO SKIP TO J6
DK SKIP TO J6
RF SKIP TO J6
J4. During that 4 month period did you miss any work, school, or normal daily activities because of your
asthma?
a.
b.
c.
d.
YES
NO
DK
RF
39
BD-STEPS CATI – FULL DRAFT
9/24/14
J5. During that 4 month period how often did you wake up at night because of your asthma? [READ
OPTIONS]
a.
b.
c.
d.
e.
f.
Not at all
Less than once per month
Once or twice per month
More than twice per month
DK
RF
IF J2=c, d, e, f, g THEN SKIP TO J9 (ONLY ASK J6 IF J2=a, b).
J6. Either before or during your pregnancy, did you speak with a healthcare provider about your treatment
options during pregnancy?
a.
b.
c.
d.
YES GO TO J7
NO SKIP TO J9
DK SKIP TO J9
RF SKIP TO J9
J7. Did you discuss these options before your pregnancy began?
a.
b.
c.
d.
YES SKIP TO J9
NO GO TO J8
DK SKIP TO J9
RF SKIP TO J9
J8. How far along were you in your pregnancy when you discussed treatment options with your provider?
a. AMOUNT:__________
b. UNITS:
i. Days
ii. Weeks
iii. Months
iv. Trimesters
DK
RF
Now I am going to ask about maintenance medications and remedies for long-term control of your asthma and
then fast-acting, or “rescue”, medications for treatment of an asthma attack. First…
J9. Did you take any maintenance medications or remedies for long-term control of your asthma during the
month before your pregnancy through the third month of pregnancy?
a.
b.
c.
d.
YES CONTINUE TO J10a
NO SKIP TO J45
DK SKIP TO J45
RF SKIP TO J45
40
BD-STEPS CATI – FULL DRAFT
9/24/14
J10a. Did you use any nasal sprays?
a.
b.
c.
d.
YES CONTINUE TO J10b
NO SKIP TO J22a
DK SKIP TO J22a
RF SKIP TO J22a
J10b. What did you take? / Did you take anything else? IF CAN’T RECALL, READ FROM DRUG LIST:
NASAL SPRAYS
a. Flonase
b. Flunisolide
c. Fluticasone Nasal Spray
d. Nasonex Nasal Spray
e. Omnaris Nasal Spray
f. Qnasl Nasal Aerosol
g. Rhinocort
h. OTHER (SPECIFY):__________
i. DK SKIP TO J22a
j. RF SKIP TO J22a
J11. [QUESTION REMOVED]
J12. Did you use [REFERENCE:1500|1.*.1] for the entire time from the month before your pregnancy through
your third month of pregnancy?
a.
b.
c.
d.
YES SKIP TO J16
NO CONTINUE TO J13
DK CONTINUE TO J13
RF CONTINUE TO J13
J13. When did you start using [REFERENCE:1500|1.*.1] for asthma or reactive airway disease for the first
time during this period?
a.
b.
c.
d.
MM/DD/YYYY or
MONTH OF PREGNANCY(B1, P1, P2, P3)
DK
RF
J14. When did you stop using [REFERENCE:1500|1.*.1] for the last time during this time period?
a.
b.
c.
d.
MM/DD/YYYY or
MONTH OF PREGNANCY(B1, P1, P2, P3) IF VALID RESPONSE TO J13 ANd J14, SKIP J15
DK
RF
41
BD-STEPS CATI – FULL DRAFT
9/24/14
J15. How long did you take it?
a. AMOUNT:__________
i. Days
ii. Weeks
iii. Months
b. DK
c. RF
J16. How often did you use [REFERENCE:1500|1.*.1] during the month before your pregnancy through the
end of your third month of pregnancy? You can say the number of times per day, per week, per month,
or during the entire 4 month period.
a. AMOUNT:__________ Per Day/Per Week/Per Month/Per Time Period/DK/RF
J17 Did you take the same dose of medicine each time you took it throughout [B1] to [P4(-1)]? That is, for
example, the same number of milligrams of medicine in each dose.
a.
b.
c.
d.
YES J18
NO SKIP TO J19a
DK CONTINUE TO J18
RF CONTINUE TO J18
J18. What dose of [REFERENCE:1500|1.*.1] did you take each time you took it?
a. AMOUNT:__________ SKIP TO J22a
i. UNITS:__________
b. DK SKIP TO J22a
c. RF SKIP TO J22a
J19a. How many different dosage amounts do you remember taking?.
i. AMOUNT:__________
J19b. What dose of [REFERENCE:1500|1.1.V] did you take the [CHAPTER] time?
i. AMOUNT:__________
DK SKIP TO J20
RF SKIP TO J20
ii. UNITS:__________
DK
RF
42
BD-STEPS CATI – FULL DRAFT
9/24/14
J20. When did you begin taking that dose?
a.
b.
c.
d.
MM/DD/YYYY or
MONTH OF PREGNANCY(B1, P1, P2, P3)
DK
RF
J21. When did you stop taking that dose?
a.
b.
c.
d.
MM/DD/YYYY or
MONTH OF PREGNANCY(B1, P1, P2, P3) IF VALID RESPONSE TO J20 and J21, SKIP J21a
DK
RF
J21a. How long did you take it?
a. AMOUNT:__________ DK
i. Days
ii. Weeks
iii. Months
RF
J22a. Did you use any oral inhalants, that is medicine you sprayed in your mouth?
a.
b.
c.
d.
YES CONTINUE TO J22b
NO SKIP TO J34a
DK SKIP TO J34a
RF SKIP TO J34a
43
BD-STEPS CATI – FULL DRAFT
9/24/14
J22b. What did you take? / Did you take anything else? IF CAN’T RECALL, READ FROM DRUG LIST:
ORAL INHALANTS
a. Advair
b. Aerobid
c. Aerospan Hfa
d. Alvesco Inhaler
e. Asmanex Twisthaler
f. Budesonide Inhalation Suspension
g. Dulera
h. Flovent
i. Foradil
j. Formoterol Fumarate
k. Perforomist
l. Pulmicort
m. Qvar HFA Inhaler
n. Salmeterol Xinafoate
o. Serevent
p. Symbicort
q. OTHER (SPECIFY):__________
k. DK SKIP TO J34a
l. RF SKIP TO J34a
J23. Did you use [REFERENCE:1500|1.*.1] for the entire time from the month before your pregnancy through
your third month of pregnancy?
a.
b.
c.
d.
YES SKIP TO J27
NO CONTINUE TO J24
DK CONTINUE TO J24
RF CONTINUE TO J24
J24. When did you start using [REFERENCE:1500|1.*.1] for asthma or reactive airway disease for the first time
during this period?
a.
b.
c.
d.
MM/DD/YYYY or
MONTH OF PREGNANCY(B1, P1, P2, P3)
DK
RF
44
BD-STEPS CATI – FULL DRAFT
9/24/14
J25. When did you stop using [REFERENCE:1500|1.*.1] for the last time during this time period?
a.
b.
c.
d.
MM/DD/YYYY or
MONTH OF PREGNANCY(B1, P1, P2, P3) IF VALID RESPONSE TO J24 and J25, SKIP J26
DK
RF
J26. How long did you take it?
a. AMOUNT:__________
i. Days
ii. Weeks
iii. Months
b. DK
c. RF
J27. How often did you use [REFERENCE:1500|1.*.1] during the month before your pregnancy through the
end of your third month of pregnancy? You can say the number of times per day, per week, per month,
or during the entire 4 month period.
a. AMOUNT:__________ Per Day/Per Week/Per Month/Per Time Period/DK/RF
J28 Did you take the same dose of medicine each time you took it throughout [B1] to [P4(-1)]? That is, for
example, the same number of milligrams of medicine in each dose.
a.
b.
c.
d.
YES J29
NO SKIP TO J30a
DK CONTINUE TO J29
RF CONTINUE TO J29
J29. What dose of [REFERENCE:1500|1.*.1] did you take each time you took it?
a. AMOUNT:___________ SKIP TO J34a
i. UNITS:__________
b. DK SKIP TO J34a
c. RF SKIP TO J34a
J30a. How many different dosage amounts do you remember taking?.
i. AMOUNT:__________
45
BD-STEPS CATI – FULL DRAFT
9/24/14
J30b. What dose of [REFERENCE:1500|1.1.V] did you take the [CHAPTER] time?
i. AMOUNT:__________
DK SKIP TO J31
RF SKIP TO J31
ii. UNITS:__________
DK
RF
J31. When did you begin taking that dose?
a.
b.
c.
d.
MM/DD/YYYY or
MONTH OF PREGNANCY(B1, P1, P2, P3)
DK
RF
J32. When did you stop taking that dose?
a.
b.
c.
d.
MM/DD/YYYY or
MONTH OF PREGNANCY(B1, P1, P2, P3) IF VALID RESPONSE TO J31 and J32, SKIP J32a
DK
RF
J32a. How long did you take it?
a. AMOUNT:__________ DK
i. Days
ii. Weeks
iii. Months
RF
J33 [QUESTION NUMBER NOT USED]
J34a. Did you use any pills you took by mouth?
a.
b.
c.
d.
YES CONTINUE TO J34b
NO SKIP TO J45
DK SKIP TO J45
RF SKIP TO J45
46
BD-STEPS CATI – FULL DRAFT
9/24/14
J34b. What did you take? / Did you take anything else? IF CAN’T RECALL, READ FROM DRUG LIST:
ORAL TABLETS/CAPS
a. Accolate
b. Montelukast Sodium
c. Singulair
d. Zafirlukast
e. Zileuton
f. Zyflo
g. OTHER (SPECIFY):__________
h. DK SKIP TO J45
i. RF SKIP TO J45
ASK J35-J44, AS APPROPRIATE FOR EACH DRUG USED IN J34b:
J35. Did you use [REFERENCE:1500|1.*.1] for the entire time from the month before your pregnancy through
your third month of pregnancy?
a.
b.
c.
d.
YES SKIP TO J39
NO CONTINUE TO J36
DK CONTINUE TO J36
RF CONTINUE TO J36
J36. When did you start using [REFERENCE:1500|1.*.1] for asthma or reactive airway disease for the first time
during this period?
a.
b.
c.
d.
MM/DD/YYYY or
MONTH OF PREGNANCY(B1, P1, P2, P3)
DK
RF
J37. When did you stop using [REFERENCE:1500|1.*.1] for the last time during this time period?
a.
b.
c.
d.
MM/DD/YYYY or
MONTH OF PREGNANCY(B1, P1, P2, P3) IF VALID RESPONSE TO J36 and J37, SKIP J38
DK
RF
J38. How long did you take it?
a. AMOUNT:__________
i. Days/Weeks/Months
b. DK
c. RF
47
BD-STEPS CATI – FULL DRAFT
9/24/14
J39. How often did you use [REFERENCE:1500|1.*.1] during the month before your pregnancy through the
end of your third month of pregnancy? You can say the number of times per day, per week, per month,
or during the entire 4 month period.
a. AMOUNT:__________ Per Day/Per Week/Per Month/Per Time Period/DK/RF
J40. Did you take the same dose of medicine each time you took it throughout [B1] to [P4(-1)]? That is, for
example, the same number of milligrams of medicine in each dose.
a.
b.
c.
d.
YES J41
NO SKIP TO J42a
DK CONTINUE TO J41
RF CONTINUE TO J41
J41. What dose of [REFERENCE:1500|1.*.1] did you take each time you took it?
a. AMOUNT:_____ SKIP TO J45
i. UNITS:__________
b. DK SKIP TO J45
c. RF SKIP TO J45
J42a. How many different dosage amounts do you remember taking?
i. AMOUNT:__________
J42b. What dose of [REFERENCE:1500|1.1.V] did you take the [CHAPTER] time?
i. AMOUNT:__________
DK SKIP TO J43
RF SKIP TO J43
ii. UNITS:__________
DK
RF
J43. When did you begin taking that dose?
a.
b.
c.
d.
MM/DD/YYYY or
MONTH OF PREGNANCY(B1, P1, P2, P3)
DK
RF
J44. When did you stop taking that dose?
a.
b.
c.
d.
MM/DD/YYYY or
MONTH OF PREGNANCY(B1, P1, P2, P3) IF VALID RESPONSE TO J43 and J44, SKIP J44a
DK
RF
48
BD-STEPS CATI – FULL DRAFT
9/24/14
J44a. How long did you take it?
a. AMOUNT:__________ DK
RF
i. Days
ii. Weeks
iii. Months
J45. Did you take any fast-acting, or “rescue” medications or remedies for treatment of an asthma attack
during the month before your pregnancy through the third month of pregnancy?
a.
b.
c.
d.
YES CONTINUE TO J46
NO SKIP TO NEXT SECTION
DK SKIP TO NEXT SECTION
RF SKIP TO NEXT SECTION
J46. What did you take? / Did you take anything else? IF CAN’T RECALL, READ FROM DRUG LIST: AFTER
READING LIST, ASK "Other steroids, such as prednisone or methylprednisone ". RECORD RESPONSE IN
"OTHER" BOX.
a.
b.
c.
d.
e.
f.
g.
h.
i.
j.
k.
l.
m.
Albuterol SKIP TO J48
Asthmanefrin SKIP TO J48
Atrovent HFA SKIP TO J48
Ipratropium Bromide SKIP TO J48
Levalbuterol Tartrate SKIP TO J48
Maxair SKIP TO J48
Pirbuterol Acetate SKIP TO J48
ProAir HFA Inhaler SKIP TO J48
Ventolin HFA SKIP TO J48
Xopenex HFA SKIP TO J48
OTHER (SPECIFY):__________ CONTINUE TO J47
DK SKIP TO K1
RF SKIP TO K1
J47. Did you get [ANSWER] from a pill that you swallowed or from a shot?
a.
b.
c.
d.
e.
Pill
Shot (injection)
Inhaler
DK
RF
49
BD-STEPS CATI – FULL DRAFT
9/24/14
J48. How often did you use [REFERENCE:1630|1.*.1] during the month before your pregnancy through the
third month of your pregnancy? You can say the number of times per day, per week, per month, or
during the entire 4 month period.
a. AMOUNT:__________ Per Day/Per Week/Per Month/Per Time Period/DK/RF
J49. Did you use [REFERENCE:1630|1.*.1] [ANSWER]throughout the entire time from a month before your
pregnancy through the third month of your pregnancy? CHOOSE "NA" IF J48 TIME PERIOD IS "PER
PERIOD"
a.
b.
c.
d.
e.
YES SKIP TO NEXT SECTION
NO CONTINUE TO J50a
DK CONTINUE TO J50a
RF CONTINUE TO J50a
NA SKIP TO NEXT SECTION WITHOUT READING THIS QUESTION
J50a.How often did you use [REFERENCE:1630|1.*.1] during the month before your pregnancy, which was
[B1] to [END DATE OF B1]?
i. AMOUNT:__________ Per Day/Per Week/Per Month/Per Time Period/Per Year/DK/RF
ii. DID NOT TAKE
J50b. How often did you use [REFERENCE:1630|1.1.1.1.*.1] during the first month of your pregnancy, which
was [START DATE OF P1] to [END DATE OF P1]?
i. AMOUNT:__________ Per Day/Per Week/Per Month/ Per Time Period/Per Year/DK/RF
ii. DID NOT TAKE
J50c. How often did you use [REFERENCE:1630|1.*.1] during the second month of your pregnancy, which was
[P2] to [P3(-1)]?
i. AMOUNT:__________ Per Day/Per Week/Per Month/ Per Time Period/Per Year/DK/RF
ii. DID NOT TAKE
J50d. How often did you use [REFERENCE:1630|1.*.1] during the third month of your pregnancy, which was
[P3] to [P4(-1)]?
i. AMOUNT:__________ Per Day/Per Week/Per Month/ Per Time Period/Per Year/DK/RF
ii. DID NOT TAKE
50
BD-STEPS CATI – FULL DRAFT
9/24/14
Section K: EPILEPSY
K1. Were you ever told by a doctor that you had epilepsy?
a.
b.
c.
d.
YES CONTINUE TO K2
NO SKIP TO NEXT SECTION
DK SKIP TO NEXT SECTION
RF SKIP TO NEXT SECTION
K2. What type of epilepsy do you have? IF CAN’T RECALL, READ FROM LIST:
a.
b.
c.
d.
e.
f.
g.
h.
Temporal Lobe Epilepsy
Frontal Lobe Epilepsy
Reflex Epilepsy
Childhood Absence Epilepsy
Juvenile Absence Epilepsy
OTHER, SPECIFY:____________
DK
RF
K3. When were you first diagnosed with epilepsy in relation to [TAB: your pregnancy with [NOIB]; the
pregnancy that ended on [DOIB]]? [READ LIST]
a.
b.
c.
d.
e.
f.
g.
More than 2 years before
In the 2 years before
During the first trimester
After the first trimester but still during pregnancy
After the pregnancy
RF
DK
IF K3=c, d, e, f, g THEN SKIP TO K7 (ONLY ASK K4 if K3=a, b)
K4. Either before or during your pregnancy, did you speak with a healthcare provider about your treatment
options during pregnancy?
a.
b.
c.
d.
YES GO TO K5
NO SKIP TO K7
DK SKIP TO K7
RF SKIP TO K7
51
BD-STEPS CATI – FULL DRAFT
9/24/14
K5. Did you discuss these options before your pregnancy began?
a.
b.
c.
d.
YES SKIP TO K7
NO GO TO K6
DK SKIP TO K7
RF SKIP TO K7
K6. How far along were you in your pregnancy when you discussed treatment options with your provider?
a. AMOUNT:__________ DK
i. Days
ii. Weeks
iii. Months
iv. Trimesters
RF
K7. Did you take any medications or remedies for epilepsy during the month before your pregnancy through
the third month of pregnancy?
a.
b.
c.
d.
YES CONTINUE TO K8
NO SKIP TO K19
DK SKIP TO K19
RF SKIP TO K19
52
BD-STEPS CATI – FULL DRAFT
9/24/14
K8. What did you take? / Did you take anything else? IF CAN’T RECALL, READ FROM DRUG LIST:
a.
b.
c.
d.
e.
f.
g.
h.
i.
j.
k.
l.
m.
n.
o.
p.
q.
r.
s.
t.
Carbamazepine
Carbatrol
Clonazepam
Depakene Capsules
Depakote
Dilantin
Felbatol
Keppra
Klonopin
Lamictal
Phenobarbital
Phenytoin
Stavzor
Tegretol
Topamax
Topiramate
Trileptal
Valproic Acid
OTHER (SPECIFY)
DK or RF SKIP TO K19
K9. Did you use [ANSWER] for the entire time from the month before your pregnancy through your third
month of pregnancy, that is from [B1] to [P4(-1)]?
a.
b.
c.
d.
YES SKIP TO K13
NO CONTINUE TO K10
DK CONTINUE TO K10
RF CONTINUE TO K10
K10. When did you start using [REFERENCE:1780|1.*.1] for epilepsy for the first time during this period?
a.
b.
c.
d.
MM/DD/YYYY or
MONTH OF PREGNANCY(B1, P1, P2, P3)
DK
RF
K11. When did you stop using [REFERENCE:1780|1.*.1] for the last time during this time period?
a.
b.
c.
d.
MM/DD/YYYY or
MONTH OF PREGNANCY(B1, P1, P2, P3) IF VALID RESPONSE TO K10 and K11, SKIP K12
DK
RF
53
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K12. How long did you take it?
a. AMOUNT:________________
i. Days
ii. Weeks
iii. Months
b. DK
c. RF
K13. How often did you use [REFERENCE:1780|1.*.1] during the month before your pregnancy through the
end of your third month of pregnancy? You can say the number of times per day, per week, per month,
or during the entire 4 month period.
a. AMOUNT:__________ Per Day/Per Week/Per Month/Per Time Period/DK/RF
K14. Did you take the same dose of medicine each time you took it throughout [B1] to [P4(-1)]? That is, for
example, the same number of milligrams of medicine in each dose.
a.
b.
c.
d.
YES CONTINUE TO K15
NO SKIP TO K16a
DK CONTINUE TO K15
RF CONTINUE TO K15
K15. What dose of [REFERENCE:1780|1.*.1] did you take each time you took it?
a. AMOUNT:__________ SKIP TO K19
i. UNITS:____________
b. DK SKIP TO K19
c. RF SKIP TO K19
K16a. How many different dosage amounts do you remember taking?
i. AMOUNT:__________
K16b. What dose of [REFERENCE:1780|1.1.V] did you take [CHAPTER] time?
i. AMOUNT:__________
DK SKIP TO K17
RF SKIP TO K17
ii. UNITS:__________
DK
RF
54
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K17. When did you begin taking that dose?
a.
b.
c.
d.
MM/DD/YYYY or
MONTH OF PREGNANCY(B1, P1, P2, P3)
DK
RF
K18. When did you stop taking that dose?
a.
b.
c.
d.
MM/DD/YYYY or
MONTH OF PREGNANCY(B1, P1, P2, P3) IF VALID RESPONSE TO K17 and K18, SKIP K18a
DK
RF
K18a. How long did you take it?
a. AMOUNT:________________
i. Days
ii. Weeks
iii. Months
b. DK
c. RF
K19. Did you have any seizures in the month before your pregnancy through the third month of pregnancy?
a.
b.
c.
d.
YES CONTINUE TO K20
NO SKIP TO NEXT SECTION
DK SKIP TO NEXT SECTION
RF SKIP TO NEXT SECTION
K20. How many seizures did you have altogether during that time?
a. AMOUNT:__________
b. DK
c. RF
55
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Section L: MIGRAINE
L1. Have you ever had a migraine headache, also sometimes called a sick headache?
a.
b.
c.
d.
YES CONTINUE TO L2
NO SKIP TO NEXT SECTION
DK SKIP TO NEXT SECTION
RF SKIP TO NEXT SECTION
L2. How old were you when you had the first migraine headache?
a. AGE:___________
b. DK
c. RF
L3. Did you have any migraine headaches in the month before your pregnancy through the third month of
pregnancy, that is from [B1] to [P4(-1)]?
a.
b.
c.
d.
YES CONTINUE TO L4
NO SKIP TO L5
DK SKIP TO L5
RF SKIP TO L5
L4. How many migraines did you have altogether during that time?
a. Total number:__________ DK RF
b. Frequency – AMOUNT:__________
i. Per day
ii. Per week
iii. Per month
OR
Now I am going to ask about maintenance medications and remedies you may use for your migraines. Please
include medications that you may use to keep from having or to prevent migraines AND medications that you
may use to treat migraine pain when it happens. Please include over-the-counter medications and
prescription medications.
L5. Did you take any medications or remedies for migraines during the month before your pregnancy
through the third month of pregnancy?
a.
b.
c.
d.
YES CONTINUE TO L6
NO SKIP TO NEXT SECTION
DK SKIP TO NEXT SECTION
RF SKIP TO NEXT SECTION
56
BD-STEPS CATI – FULL DRAFT
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L6. What did you take? / Did you take anything else? IF CAN’T RECALL: Was this a medication you used to
prevent a migraine from starting or to treat pain from a migraine that already started? IF IT WAS PAIN
MEDICATION: Was this over-the-counter or prescription? THEN READ FROM THE APPROPRIATE DRUG
LIST:
PREVENTION MEDICATIONS
a.
b.
c.
d.
e.
f.
g.
h.
i.
j.
k.
l.
m.
n.
o.
p.
q.
r.
s.
t.
u.
v.
w.
x.
y.
z.
aa.
bb.
cc.
dd.
ee.
ff.
gg.
hh.
ii.
jj.
Advil
Aleve
Amitriptyline
Aspirin
Atenolol
Botox
Calan
Cyproheptadine HCL
Depakote
Diltiazem
Divalproex Sodium
Doxepin
Effexor
Excedrin Extra Strength Caplets/Tablets/Geltabs
Gabapentin
Ibuprofen
Inderal
Innopran XL
Lamictal
Lamotrigine
Lisinopril
Metoprolol
Motrin
Motrin Ib
Nadolol
Naproxen Sodium
Neurontin
Nifedipine
Nimodipine
Nortriptyline
Pamelor
Propranolol
Protriptyline HCL
Timolol
Topamax
Topiramate
57
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9/24/14
kk. Valproate Sodium
ll. Valproic Acid
mm. Venlafaxine
nn. Verapamil
oo. Verelan
pp. Vivactil
qq. Zestril
OVER-THE-COUNTER PAIN MEDICATIONS
rr. Acetaminophen
ss. Advil
tt. Aleve
uu. Aspirin
vv. Excedrin Migraine
ww. Ibuprofen
xx. Motrin
yy. Naproxen Sodium
zz. Tylenol
PRESCRIPTION PAIN MEDICATIONS
aaa.
Acetaminophen with Codeine
bbb. Almotriptan Maleate
ccc.
Amerge
ddd. Axert
eee.
Cafergot
fff.
Dihydroergotamine
ggg.
Eletriptan Hydrobromide
hhh. Ergotamine
iii.
Fioricet
jjj.
Frova
kkk.
Frovatriptan Succinate
lll.
Imitrex
mmm. Indomethacin
nnn. Maxalt
ooo. Migergot Suppositories
ppp. Migranal
qqq. Naproxen Sodium / Sumatriptan Succinate
rrr.
Naratriptan
sss.
Relpax
ttt.
Rizatriptan
uuu. Sumatriptan Succinate
vvv.
Treximet
www. Zolmitriptan
xxx.
Zomig
yyy.
OTHER (SPECIFY):__________
58
BD-STEPS CATI – FULL DRAFT
9/24/14
zzz.
aaaa.
DK SKIP TO NEXT SECTION
RF SKIP TO NEXT SECTION
L7. Did you use [ANSWER] for the entire time from the month before your pregnancy through your third
month of pregnancy?
a.
b.
c.
d.
YES SKIP TO L11
NO CONTINUE TO L8
DK CONTINUE TO L8
RF CONTINUE TO L8
L8. When did you start using [REFERENCE:1960|1.*.1] for migraines for the first time during this period?
a.
b.
c.
d.
MM/DD/YYYY or
MONTH OF PREGNANCY (B1, P1, P2, P3)
DK
RF
L9. When did you stop using [REFERENCE:1960|1.*.1] for the last time during this time period?
a.
b.
c.
d.
MM/DD/YYYY or
MONTH OF PREGNANCY (B1, P1, P2, P3) IF VALID RESPONSE TO L8 and L9, SKIP L10
DK
RF
L10. How long did you take it?
a. AMOUNT:________________
i. Days
ii. Weeks
iii. Months
b. DK
c. RF
L11. How often did you use [REFERENCE:1960|1.*.1] during the month before your pregnancy through the
end of your third month of pregnancy? You can say the number of times per day, per week, per month,
or during the entire 4 month period.
a. AMOUNT:__________ Per Day/Per Week/Per Month/Per Time Period/DK/RF
59
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L12. Did you take the same dose of medicine each time you took it throughout [B1] to [P4(-1)]? That is, for
example, the same number of milligrams of medicine in each dose.
a.
b.
c.
d.
YES CONTINUE TO L13
NO SKIP TO L14a
DK CONTINUE TO L13
RF CONTINUE TO L13
L13. What dose of [REFERENCE:1960|1.*.1] did you take each time you took it?
a. AMOUNT:__________ SKIP TO NEXT SECTION
i. UNITS:__________
b. DK SKIP TO NEXT SECTION
c. RF SKIP TO NEXT SECTION
L14a. How many different dosage amounts do you remember taking?
i. AMOUNT:__________
L14b. What dose of [REFERENCE:1960|1.1.V] did you take the [CHAPTER] time?
i. AMOUNT:__________
DK SKIP TO L15
RF SKIP TO L15
ii. UNITS:__________
DK
RF
L15. When did you begin taking that dose?
a.
b.
c.
d.
MM/DD/YYYY or
MONTH OF PREGNANCY(B1, P1, P2, P3)
DK
RF
L16. When did you stop taking that dose?
a.
b.
c.
d.
MM/DD/YYYY or
MONTH OF PREGNANCY(B1, P1, P2, P3) IF VALID RESPONSE TO L15 and L16, SKIP L16a
DK
RF
60
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L16a. How long did you take it?
a. AMOUNT:__________
i. Days
ii. Weeks
iii. Months
b. DK
c. RF
61
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9/24/14
Section M: AUTOIMMUNE DISEASE
M1.Have you ever been diagnosed with any of the following [ASK EACH AND INDICATE ALL THAT APPLY]?
a.
b.
c.
d.
e.
f.
g.
h.
Lupus
Rheumatoid arthritis
Multiple sclerosis
Celiac disease
Crohn’s disease
Ulcerative colitis; please note that we are not asking about general colitis here
Psoriasis
Other autoimmune disease (not including diabetes or thyroid disorders, which we have already
discussed) IF CAN’T RECALL, READ FROM LIST:
i. Immune/idiopathic thrombocytopenic purpura
ii. Interstitial cystitis
iii. Antiphospholipid antibody syndrome/lupus anticoagulant syndrome/APLS
iv. Addison’s disease
v. Pernicious anemia
vi. Myasthenia gravis
vii. Autoimmune hemolytic anemia
viii. Berger’s disease/IgA nephropathy
ix. Alopecia, universalis or areata
x. Vitiligo
xi. Juvenile arthritis
xii. Guillain Barre syndrome
xiii. Scleroderma, morphea
xiv. Sjögren's syndrome/Sicca syndrome
xv. Ankylosing spondylitis
xvi. Rheumatic fever
xvii. OTHER (SPECIFY):__________
xviii. NONE SKIP TO NEXT SECTION
xix. DK SKIP TO NEXT SECTION
xx. RF SKIP TO NEXT SECTION
IF YES TO ANY, CONTINUE TO M2
62
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9/24/14
M2. When were you first diagnosed with [ANSWER] relative to [TAB: your pregnancy with [NOIB]; the
pregnancy that ended on [DOIB]]? READ OPTIONS (ASK FOLLOWING QUESTIONS FOR EACH CONDITION
IF MORE THAN ONE CONDITION REPORTED)
a.
b.
c.
d.
e.
f.
g.
More than 2 years before
In the 2 years before
During the first trimester y]
After the first trimester but still during pregnancy
After the pregnancy
RF
DK
IF M2=c, d, e, f, g THEN SKIP TO M6 (ONLY ASK M3 IF M2=a or b)
M3. Either before or during your pregnancy, did you speak with a healthcare provider about your treatment
options during pregnancy?
a.
b.
c.
d.
YES GO TO M4
NO SKIP TO M6
DK SKIP TO M6
RF SKIP TO M6
M4.Did you discuss these options before your pregnancy began?
a.
b.
c.
d.
YES SKIP TO M6
NO GO TO M5
DK SKIP TO M6
RF SKIP TO M6
M5.How far along were you in your pregnancy when you discussed treatment options with your provider?
a. AMOUNT:__________
UNITS:
i. Days
ii. Weeks
iii. Months
iv. Trimesters
DK
RF
M6.
Did you take any medications or remedies for [PASSIN] in the month before your pregnancy through the
third month of pregnancy, that is from [B1] TO [P4(-1)]?
a.
b.
c.
d.
YES CONTINUE TO M7
NO SKIP TO NEXT SECTION
DK SKIP TO NEXT SECTION
RF SKIP TO NEXT SECTION
63
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9/24/14
M7. What did you take? / Did you take anything else? SPECIFY: ______________
IF CAN’T RECALL, READ FROM DRUG PROMPT LISTS FOR THESE 4 CONDITIONS, BUT DRUGS ASKED FOR
EACH CONDITION.
M7a. Lupus:
a.
b.
c.
d.
e.
f.
g.
h.
i.
j.
k.
l.
m.
n.
o.
p.
q.
r.
s.
t.
u.
Advil
Aleve
Arava
Azasan
Azathioprine
Belimumab
Benlysta
Cellcept
Cyclophosphamide
Cytoxan
Hydroxychloroquine Sulfate
Leflunomide
Methotrexate
Motrin
Mycophenolate Mofetil
Plaquenil
Prednisone
Trexall
OTHER, SPECIFY:______________
DK SKIP TO NEXT CONDITION/NEXT SECTION
RF SKIP TO NEXT CONDITION/NEXT SECTION
64
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9/24/14
M7b. Rheumatoid arthritis:
a. Abatacept
b. Actemra
c. Adalimumab
d. Advil
e. Aleve
f. Anakinra
g. Arava
h. Azasan
i. Azathioprine
j. Azulfidine
k. Certolizumab Pegol
l. Cimzia
m. Cyclophosphamide
n. Cyclosporine
o. Cytoxan
p. Dynacin
q. Enbrel
r. Etanercept
s. Gengraf
t. Golimumab
u. Humira
v. Hydroxychloroquine Sulfate
w. Ibuprofen
x. Imuran
y. Infliximab
z. Kineret
aa. Leflunomide
bb. Methotrexate
cc. Minocin
dd. Minocycline
ee. Motrin
ff. Naproxen Sodium
gg. Neoral
hh. Orencia
ii. Plaquenil
jj. Prednisone
kk. Remicade
ll. Rituxan
mm. Rituximab
nn. Sandimmune
oo. Simponi
65
BD-STEPS CATI – FULL DRAFT
9/24/14
pp.
qq.
rr.
ss.
tt.
uu.
Sulfasalazine
Tocilizumab
Trexall
OTHER, SPECIFY:______________
DK SKIP TO NEXT CONDITION/NEXT SECTION
RF SKIP TO NEXT CONDITION/NEXT SECTION
M7c. Multiple sclerosis:
a.
b.
c.
d.
e.
f.
g.
h.
i.
j.
k.
l.
m.
n.
o.
p.
q.
r.
s.
t.
u.
v.
w.
x.
y.
z.
aa.
bb.
cc.
dd.
Amantadine
Ampyra
Amrix
Aubagio
Avonex
Baclofen
Betaseron
Copaxone
Cyclobenzaprine
Dalfampridine
Extavia
Fingolimod
Flexeril
Gilenya
Glatiramer Acetate
Lioresal
Methylprednisolone
Mitoxantrone HCL
Natalizumab
Prednisone
Rebif
Solu-Medrol
Tecfidera
Teriflunomide
Tizanidine HCL
Tysabri
Zanaflex
OTHER, SPECIFY:______________
DK SKIP TO NEXT CONDITION/NEXT SECTION
RF SKIP TO NEXT CONDITION/NEXT SECTION
66
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9/24/14
M7d. Crohn’s disease and ulcerative colitis:
a.
b.
c.
d.
e.
f.
g.
h.
i.
j.
k.
l.
m.
n.
o.
p.
q.
r.
s.
t.
u.
v.
w.
x.
y.
z.
aa.
bb.
cc.
dd.
ee.
ff.
gg.
hh.
ii.
jj.
Adalimumab
Apriso
Asacol
Azasan
Azathioprine
Azulfidine
Balsalazide Disodium
Certolizumab Pegol
Cimzia
Cipro
Ciprofloxacin HCL
Colazal
Cyclosporine
Dipentum
Flagyl
Gengraf
Humira
Imuran
Infliximab
Lialda
Mercaptopurine
Mesalamine
Methotrexate
Metronidazole
Natalizumab
Neoral
Olsalazine Sodium
Purinethol
Remicade
Rheumatrex
Sandimmune
Sulfasalazine
Tysabri
OTHER (SPECIFY):__________
DK SKIP TO NEXT CONDITION/NEXT SECTION
RF SKIP TO NEXT CONDITION/NEXT SECTION
67
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9/24/14
M7e. Psoriasis:
a.
b.
c.
d.
e.
f.
g.
h.
i.
j.
k.
l.
m.
n.
Anthralin
Calcipotriene
Coal Tar
Dovonex
Elidel
Protopic Ointment
Retin-A
Salicylic Acid
Tazorac
Tazarotene
Tretinoin
OTHER (SPECIFY):__________
DK SKIP TO NEXT CONDITION/NEXT SECTION
RF SKIP TO NEXT CONDITION/NEXT SECTION
M8. Did you use [ANSWER] for the entire time from the month before your pregnancy through the third
month of pregnancy?
a.
b.
c.
d.
YES SKIP TO M12
NO CONTINUE TO M9
DK CONTINUE TO M9
RF CONTINUE TO M9
M9. When did you start using [REFERENCE:2280|1.*.1] for [REFERENCE:2220|1.*.1] for the first time during
this period?
a.
b.
c.
d.
MM/DD/YYYY or
MONTH OF PREGNANCY(B1, P1, P2, P3)
DK
RF
M10. When did you stop using [REFERENCE:2280|1.*.1] for the last time during this time period?
a.
b.
c.
d.
MM/DD/YYYY or
MONTH OF PREGNANCY(B1, P1, P2, P3) IF VALID START AND STOP DATE, SKIP M11
DK
RF
68
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9/24/14
M11. How long did you take it?
a. AMOUNT:__________
i. Days
ii. Weeks
iii. Months
b. DK
c. RF
M12. How often did you use [REFERENCE:2280|1.*.1] during the month before your pregnancy through the
end of your third month of pregnancy? You can say the number of times per day, per week, per month,
or during the entire 4 month period.
a. AMOUNT:__________ Per Day/Per Week/Per Month/Per Time Period/DK/RF
M13. Did you take the same dose of medicine each time you took it throughout [B1] to [P4(-1)]? That is, for
example, the same number of milligrams of medicine in each dose.
a.
b.
c.
d.
YES CONTINUE TO M14
NO SKIP TO M15a
DK CONTINUE TO M14
RF SKIP TO M14
M14. What dose of [REFERENCE:2280|1.*.1] did you take each time you took it?
a. AMOUNT:__________ SKIP TO NEXT SECTION
i. UNITS:__________
b. DK SKIP TO NEXT SECTION
c. RF SKIP TO NEXT SECTION
M15a. How many different dosage amounts do you remember taking?
i. AMOUNT:__________
M15b. What dose of [REFERENCE:2280|1.V.C] did you take the [CHAPTER] time?
i. AMOUNT:__________
DK SKIP TO M16
RF SKIP TO M16
ii. UNITS:__________
DK
RF
69
BD-STEPS CATI – FULL DRAFT
9/24/14
M16. When did you begin taking that dose?
a.
b.
c.
d.
MM/DD/YYYY or
MONTH OF PREGNANCY(B1, P1, P2, P3)
DK
RF
M17. When did you stop taking that dose?
a.
b.
c.
d.
MM/DD/YYYY or
MONTH OF PREGNANCY(B1, P1, P2, P3) IF VALID START AND STOP DATE, SKIP M17a
DK
RF
M17a. How long did you take it?
a. AMOUNT:__________
i. Days
ii. Weeks
iii. Months
b. DK
c. RF
70
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9/24/14
Section N: TRANSPLANT RECEIPT
N1. Have you ever received an organ or tissue transplant?
a.
b.
c.
d.
YES CONTINUE TO N2
NO SKIP TO NEXT SECTION
DK SKIP TO NEXT SECTION
RF SKIP TO NEXT SECTION
N2. What organ or tissue was transplanted?
a. SPECIFY:_________________________ DK
RF
N3. What was the date of the transplant?
a. MM/DD/YYYY
b. DK
c. RF
N4. Did you take any medications related to your transplant during the month before your pregnancy
through your third month of pregnancy, that is from [B1] to [P4(-1)]?
a.
b.
c.
d.
YES CONTINUE TO N5
NO SKIP TO NEXT SECTION
DK SKIP TO NEXT SECTION
RF SKIP TO NEXT SECTION
N5. What did you take? / Did you take anything else? IF CAN’T RECALL, READ FROM DRUG LIST
a.
b.
c.
d.
e.
f.
g.
h.
i.
j.
k.
l.
m.
n.
o.
Atgam
Azathioprine
Cellcept
Cyclosporine
Mycophenolate Mofetil
Myfortic
Orthoclone OKT3
Prednisone
Prograf
Sirolimus
Tacrolimus
Thymoglobulin
OTHER (SPECIFY):__________
DK SKIP TO NEXT CONDITION/NEXT SECTION
RF SKIP TO NEXT CONDITION/NEXT SECTION
71
BD-STEPS CATI – FULL DRAFT
9/24/14
N6. Did you use [ANSWER] for the entire time from the month before your pregnancy through your third
month of pregnancy?
a.
b.
c.
d.
YES SKIP TO N10
NO CONTINUE TO N7
DK CONTINUE TO N7
RF CONTINUE TO N7
N7. When did you start using [REFERENCE:2430|1.*.1] for your transplant for the first time during this
period?
a.
b.
c.
d.
MM/DD/YYYY or
MONTH OF PREGNANCY(B1, P1, P2, P3)
DK
RF
N8. When did you stop using [REFERENCE:2430|1.*.1] for the last time during this time period?
a.
b.
c.
d.
MM/DD/YYYY or
MONTH OF PREGNANCY(B1, P1, P2, P3) IF VALID START AND STOP DATE, SKIP N9
DK
RF
N9. How long did you take it?
a. AMOUNT:__________
i. Days
ii. Weeks
iii. Months
DK
RF
N10. How often did you use [REFERENCE:2430|1.*.1] during the month before your pregnancy through the
end of your third month of pregnancy? You can say the number of times per day, per week, per month,
or during the entire 4 month period.
a. AMOUNT:__________ Per Day/Per Week/Per Month/Per Time Period/DK/RF
N11. Did you take the same dose of medicine each time you took it throughout [B1] to [P4(-1)]? That is, for
example, the same number of milligrams of medicine in each dose.
a.
b.
c.
d.
YES CONTINUE TO N12
NO SKIP TO N13a
DK CONTINUE TO N12
RF CONTINUE TO N12
72
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9/24/14
N12. What dose of [REFERENCE:2430|1.*.1] did you take each time you took it?
a. AMOUNT:__________ SKIP TO NEXT SECTION
i. UNITS:__________
b. DK SKIP TO NEXT SECTION
c. RF SKIP TO NEXT SECTION
N13a. How many different dosage amounts do you remember taking?.
a. AMOUNT:__________
N13b. What dose of [REFERENCE:2430|1.1.V] did you take the [CHAPTER] time?
i. AMOUNT:__________
DK SKIP TO N14
RF SKIP TO N14
ii. UNITS:__________
DK
RF
N14. When did you begin taking that dose?
a.
b.
c.
d.
MM/DD/YYYY or
MONTH OF PREGNANCY(B1, P1, P2, P3)
DK
RF
N15. When did you stop taking that dose?
a.
b.
c.
d.
MM/DD/YYYY or
MONTH OF PREGNANCY(B1, P1, P2, P3) IF VALID START AND STOP DATE, SKIP N15a
DK
RF
N15a. How long did you take it?
a. AMOUNT:__________
i. Days
ii. Weeks
iii. Months
b. DK
c. RF
73
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Section O: DEPRESSION / ANXIETY
O1. Has a doctor or other healthcare provider EVER told you that you had an anxiety disorder, including acute
stress disorder, anxiety, generalized anxiety disorder, obsessive-compulsive disorder, panic disorder,
phobia, posttraumatic stress disorder, or social anxiety disorder?
a.
b.
c.
d.
YES CONTINUE TO O2
NO SKIP TO O4
DK SKIP TO O4
RF SKIP TO O4
O2. What condition were you told you had / Anything else?
a. SPECIFY:___________ DK
RF
O3. When were you first diagnosed relative to [TAB: your pregnancy with [NOIB]; the pregnancy that ended
on [DOIB]]? [READ LIST]
a.
b.
c.
d.
e.
f.
g.
More than 2 years before
In the 2 years before
During the first trimester
After the first trimester but still during pregnancy
After the pregnancy
DK
RF
O4. Has a doctor or other healthcare provider EVER told you that you had depression?
a. YES CONTINUE TO O5
b. If NO/DK/RF, and YES to O1 CONTINUE TO O6
c. If NO/DK/RF, and NO/DK/RF to O1 SKIP TO NEXT SECTION
O5. When were you first diagnosed with depression relative to [TAB: your pregnancy with [NOIB]; the
pregnancy that ended on [DOIB]]? [READ LIST]
a.
b.
c.
d.
e.
f.
g.
More than 2 years before
In the 2 years before
During the first trimester
After the first trimester but still during pregnancy
After the pregnancy
DK
RF
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O6. Did you experience any symptoms in the month before your pregnancy through the end of the third
month of pregnancy, that is from [B1] to [P4(-1)]?
a.
b.
c.
d.
YES CONTINUE TO O7
NO SKIP TO INSTRUCTIONS BEFORE O8
DK SKIP TO INSTRUCTIONS BEFORE O8
RF SKIP TO INSTRUCTIONS BEFORE O8
O7. What were the symptoms you experienced?
a. SPECIFY:__________ DK
RF
IF O1=a AND O4=a AND O3=c, d, e, f, g AND O5=c, d, e, f, g THEN SKIP TO O11 (REPORTED ANXIETY AND
DEPRESSION, BUT BOTH WERE DIAGNOSED DURING OR AFTER PREGNANCY)
IF O1=b, c, d AND O4=a AND O5=c, d, e, f, g THEN SKIP TO O11 (REPORTED ONLY DEPRESSION
DIAGNOSED DURING OR AFTER PREGNANCY)
IF O1 = a AND O4=b AND O3= c, d, e, f, g THEN SKIP TO O11 (REPORTED ONLY ANXIETY DIAGNOSED
DURING OR AFTER PREGNANCY)
O8. IF O1 AND/OR 04 = YES, ASK 08 THROUGH REST OF SECTION JUST ONCE: Either before or during your
pregnancy, did you speak with a healthcare provider about your treatment options during pregnancy?
a.
b.
c.
d.
YES GO TO O9
NO SKIP TO O11
DK SKIP TO O11
RF SKIP TO O11
O9. Did you discuss these options before your pregnancy began?
a.
b.
c.
d.
YES SKIP TO O11
NO GO TO O10
DK SKIP TO O11
RF SKIP TO O11
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O10. How far along were you in your pregnancy when you discussed treatment options with your provider?
a. AMOUNT:__________ DK
UNITS:
i. Days
ii. Weeks
iii. Months
iv. Trimesters
RF
O11. How did you treat your condition(s) in the month before your pregnancy through the end of the third
month of pregnancy? (INDICATE ALL THAT APPLY. READ CHOICES. AFTER READING CHOICES, ASK: "Or
something else?")
a.
b.
c.
d.
e.
f.
Under care of therapist/psychologist IF THIS ONLY SKIP TO NEXT SECTION
With medication IF YES, CONTINUE WITH O12
You didn’t receive any treatment IF THIS ONLY SKIP TO NEXT SECTION
Or something else? (SPECIFY):__________IF THIS ONLY SKIP TO NEXT SECTION
DK CONTINUE WITH O12
RF IF THIS ONLY SKIP TO NEXT SECTION
O12. Did you use medication to treat your condition(s) in the month before your pregnancy through the third
month of pregnancy?
a.
b.
c.
d.
YES CONTINUE TO O13
NO SKIP TO NEXT SECTION
DK SKIP TO NEXT SECTION
RF SKIP TO NEXT SECTION
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O13. What did you take? / Did you take anything else? IF CAN’T RECALL, READ FROM DRUG LIST
a.
b.
c.
d.
e.
f.
g.
h.
i.
j.
k.
l.
m.
n.
o.
p.
q.
r.
s.
t.
u.
v.
w.
x.
y.
z.
aa.
bb.
cc.
dd.
ee.
ff.
gg.
hh.
ii.
jj.
kk.
ll.
Abilify
Alprazolam
Anafranil
Aripiprazole
Ativan
Bupropion
Buspar
Buspirone HCL
Celexa
Citalopram Hydrobromide
Clomipramine
Clonazepam
Cymbalta
Diazepam
Duloxetine HCL
Effexor
Escitalopram Oxolate
Fluoxetine HCL
Imipramine
Inderal
Klonopin
Lexapro
Lorazepam
Paroxetine HCL
Paxil
Propranolol
Prozac
Sertraline HCL
St. John’s Wort
Tofranil
Valium
Venlafaxine
Wellbutrin
Xanax
Zoloft
OTHER (SPECIFY):__________
DK SKIP TO NEXT SECTION
RF SKIP TO NEXT SECTION
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O14. Did you use [ANSWER] for the entire time from the month before your pregnancy through your third
month of pregnancy?
a.
b.
c.
d.
YES SKIP TO O18
NO CONTINUE TO O15
DK CONTINUE TO O15
RF CONTINUE TO O15
O15. When did you start using [REFERENCE:2660|1.*.1] for [REFERENCE:2550] for the first time during this
period?
a.
b.
c.
d.
MM/DD/YYYY or
MONTH OF PREGNANCY(B1, P1, P2, P3)
DK
RF
O16. When did you stop using [REFERENCE:2660|1.*.1] for the last time during this time period?
a.
b.
c.
d.
MM/DD/YYYY or
MONTH OF PREGNANCY(B1, P1, P2, P3) IF VALID START AND STOP DATE, SKIP O17
DK
RF
O17. How long did you take it?
a. AMOUNT:__________
i. Days
ii. Weeks
iii. Months
b. DK
c. RF
O18. How often did you use [REFERENCE:2660|1.*.1] during the month before your pregnancy through the
end of your third month of pregnancy? You can say the number of times per day, per week, per month,
or during the entire 4 month period.
a. AMOUNT:__________ Per Day/Per Week/Per Month/Per Time Period/DK/RF
O19. Did you take the same dose of medicine each time you took it throughout [B1] to [P4(-1)]? That is, for
example, the same number of milligrams of medicine in each dose.
a.
b.
c.
d.
YES CONTINUE TO O20
NO SKIP TO O21a
DK CONTINUE TO O20
RF CONTINUE TO O20
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O20. What dose of [REFERENCE:2660|1.*.1] did you take each time you took it?
a. AMOUNT:__________ SKIP TO NEXT SECTION
i. UNITS:__________
b. DK SKIP TO NEXT SECTION
c. RF SKIP TO NEXT SECTION
O21a. How many different dosage amounts do you remember taking?
i. AMOUNT:__________
O21b. What dose of [REFERENCE:2660|1.1.V] did you take[CHAPTER] time?
i. AMOUNT:__________
DK SKIP TO O22
RF SKIP TO O22
ii. UNITS:__________
DK
RF
O22. When did you begin taking that dose?
a.
b.
c.
d.
MM/DD/YYYY or
MONTH OF PREGNANCY(B1, P1, P2, P3)
DK
RF
O23. When did you stop taking that dose?
a. MM/DD/YYYY or
b. MONTH OF PREGNANCY(B1, P1, P2, P3) IF VALID START AND STOP DATE in O22 and O23, SKIP
O23a
c. DK
d. RF
O23a. How long did you take it?
a. AMOUNT:__________
i. Days
ii. Weeks
iii. Months
b. DK
c. RF
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Section P: ATTENTION DEFICIT HYPERACTIVITY DISORDER (ADHD)
P1. Have you EVER been told by a doctor or other health professional that you had AttentionDeficit/Hyperactivity Disorder (ADHD) or Attention-Deficit Disorder (ADD)?
a.
b.
c.
d.
YES CONTINUE TO P2
NO SKIP TO NEXT SECTION
DK SKIP TO NEXT SECTION
RF SKIP TO NEXT SECTION
P2. With which condition were you diagnosed?
a.
b.
c.
d.
e.
Attention Deficit Hyperactivity Disorder
Attention Deficit Disorder
OTHER (SPECIFY):__________
DK
RF
P3. When were you diagnosed with [REFERENCE:2780|1.*.1]? [READ LIST]
a.
b.
c.
d.
e.
f.
g.
More than 2 years before
In the 2 years before
During the first trimester
After the first trimester but still during pregnancy
After the pregnancy ended
DK
RF
IF P3=c, d, e, f, g THEN SKIP TO P7 (ONLY ASK P4 if P3=a, b)
P4. Either before or during your pregnancy, did you speak with a healthcare provider about your treatment
options during pregnancy?
a.
b.
c.
d.
YES GO TO P5
NO SKIP TO P7
DK SKIP TO P7
RF SKIP TO P7
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P5. Did you discuss these options before your pregnancy began?
a.
b.
c.
d.
YES SKIP TO P7
NO GO TO P6
DK SKIP TO P7
RF SKIP TO P7
P6. How far along were you in your pregnancy when you discussed treatment options with your provider?
a. AMOUNT:__________
UNITS:
i. Days
ii. Weeks
iii. Months
iv. Trimesters
b. DK
c. RF
P7. Did you take any medications to treat your [REFERENCE:2780|1.*.1] during the month before your
pregnancy through the third month of pregnancy, that is from [B1] to [P4(-1)]?
a.
b.
c.
d.
YES CONTINUE TO P8
NO SKIP TO NEXT SECTION
DK SKIP TO NEXT SECTION
RF SKIP TO NEXT SECTION
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P8. What did you take? / Did you take anything else? IF CAN’T RECALL, READ FROM DRUG LIST
a.
b.
c.
d.
e.
f.
g.
h.
i.
j.
k.
l.
m.
n.
o.
p.
q.
r.
s.
t.
u.
v.
w.
x.
y.
z.
aa.
bb.
cc.
dd.
ee.
ff.
gg.
Adderall
Adderall XR
Amphetamine Mixed Salts
Atomoxetine HCL
Celexa
Citalopram Hydrobromide
Clonidine HCL
Concerta
Daytrana Patch
Dexedrine
Dexmethylphenidate HCL
Dextroamphetamine
Dextrostat
Focalin
Focalin XR
Guanfacine
Intuniv
Kapvay
Lisdexamfetamine Dimesylate
Metadate Cd
Methylin
Methylphenidate HCL
Prozac
Ritalin
Ritalin La
Ritalin Sr
Sertraline HCL
Strattera
Vyvanse
Zoloft
OTHER, SPECIFY: ____________
DK SKIP TO NEXT SECTION
RF SKIP TO NEXT SECTION
P9. Did you use [REFERENCE:2780|1.*.1] for the entire time from the month before your pregnancy through
your third month of pregnancy?
a.
b.
c.
d.
YES SKIP TO P13
NO CONTINUE TO P10
DK CONTINUE TO P10
RF CONTINUE TO P10
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P10. When did you start using [REFERENCE:2840|1.*.1] for [REFERENCE:2780|1.*.1] for the first time during
this period?
a.
b.
c.
d.
MM/DD/YYYY or
MONTH OF PREGNANCY(B1, P1, P2, P3)
DK
RF
P11. When did you stop using [REFERENCE:2840|1.*.1] for the last time during this time period?
a.
b.
c.
d.
MM/DD/YYYY or
MONTH OF PREGNANCY(B1, P1, P2, P3) IF VALID START AND STOP DATE, SKIP P12
DK
RF
P12. How long did you take it?
a. AMOUNT:__________
i. Days
ii. Weeks
iii. Months
b. DK
c. RF
P13. How often did you use [REFERENCE:2840|1.*.1] during the month before your pregnancy through the
end of your third month of pregnancy? You can say the number of times per day, per week, per month,
or during the entire 4 month period.
a. AMOUNT:__________ Per Day/Per Week/Per Month/Per Time Period/DK/RF
P14. Did you take the same dose of medicine each time you took it throughout [B1] to [P4(-1)]? That is, for
example, the same number of milligrams of medicine in each dose.
a.
b.
c.
d.
YES CONTINUE TO P15
NO SKIP TO P16a
DK CONTINUE TO P15
RF CONTINUE TO P15
P15. What dose of [REFERENCE:2840|1.*.1] did you take each time you took it?
a. AMOUNT:__________ SKIP TO NEXT SECTION
i. UNITS:__________
b. DK SKIP TO NEXT SECTION
c. RF SKIP TO NEXT SECTION
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P16a. How many different dosage amounts do you remember taking?
i. AMOUNT:__________
P16b. What dose of [REFERENCE:2840|1.1.V] did you take the [CHAPTER] time?
i. AMOUNT:__________
DK SKIP TO P17
RF SKIP TO P17
ii. UNITS:__________
DK
RF
P17. When did you begin taking that dose?
a.
b.
c.
d.
MM/DD/YYYY or
MONTH OF PREGNANCY(B1, P1, P2, P3)
DK
RF
P18. When did you stop taking that dose?
a.
b.
c.
d.
MM/DD/YYYY or
MONTH OF PREGNANCY(B1, P1, P2, P3) IF VALID START AND STOP DATE, SKIP P18a
DK
RF
P18a. How long did you take it?
a. AMOUNT:__________
i. Days
ii. Weeks
iii. Months
b. DK
c. RF
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Section Q: CHRONIC DISEASE CATCH-ALL QUESTION
Q1. Have you ever been diagnosed with any other chronic diseases or long-term illnesses that we haven’t
talked about such as fibromyalgia, hepatitis, blood clotting disorders, irritable bowel syndrome, sleep
apnea or other sleep disorders, bipolar disorder, schizophrenia or other mental health conditions?
PROBE: This does not include short-term illnesses such as colds.
a.
b.
c.
d.
YES CONTINUE TO Q2
NO SKIP TO NEXT SECTION
DK SKIP TO NEXT SECTION
RF SKIP TO NEXT SECTION
Q2. What did you have? / Did you have anything else? READ LIST IF NECESSARY.
a.
b.
c.
d.
e.
f.
g.
h.
i.
j.
Fibromyalgia
Hepatitis
Blood clotting disorders
Irritable bowel syndrome
Sleep apnea or other sleep disorders
Bipolar disorder
Schizophrenia
UNSPECIFIED CHRONIC DISEASE OR LONG-TERM ILLNESS
SPECIFY:__________________ CONTINUE TO Q3
RF SKIP TO NEXT SECTION
Q3. How old were you when the [REFERENCE:2960|1.*.1] was diagnosed?
a. AGE:_____________________
i. Years
ii. Months
b. DK
c. RF
Q4. Did you take any medications or remedies for [REFERENCE:2960|1.*.1] during the month before your
pregnancy through the third month of pregnancy, that is from [B1] to [P4(-1)]?
a.
b.
c.
d.
YES CONTINUE TO Q5
NO SKIP TO NEXT SECTION
DK SKIP TO NEXT SECTION
RF SKIP TO NEXT SECTION
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Q5. What did you take? / Did you take anything else?
a. SPECIFY:____________________________
b. DK SKIP TO NEXT SECTION
c. RF SKIP TO NEXT SECTION
Q6. Did you use [ANSWER] for the entire time from the month before your pregnancy through your third
month of pregnancy?
a.
b.
c.
d.
YES SKIP TO Q10
NO CONTINUE TO Q7
DK CONTINUE TO Q7
RF CONTINUE TO Q7
Q7. When did you start using [REFERENCE:2990|1.*.1] for [REFERENCE:2960|1.*.1] for the first time during
this period?
a.
b.
c.
d.
MM/DD/YYYY or
MONTH OF PREGNANCY(B1, P1, P2, P3)
DK
RF
Q8. When did you stop using [REFERENCE:2990|1.*.1] for the last time during this time period?
a.
b.
c.
d.
MM/DD/YYYY or
MONTH OF PREGNANCY(B1, P1, P2, P3) IF VALID RESPONSE TO Q7 and Q8, SKIP Q9
DK
RF
Q9. How long did you take it?
a. AMOUNT:__________
i. Days
ii. Weeks
iii. Months
b. DK
c. RF
Q10. How often did you use [REFERENCE:2990|1.*.1] during the month before your pregnancy through the
end of your third month of pregnancy? You can say the number of times per day, per week, per month,
or during the entire 4 month period.
a. AMOUNT:__________ Per Day/Per Week/Per Month/Per Time Period/DK/RF
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Q11. Did you take the same dose of medicine each time you took it throughout [B1] to [P4(-1)]? That is, for
example, the same number of milligrams of medicine in each dose.
a.
b.
c.
d.
YES CONTINUE TO Q12
NO SKIP TO Q13a
DK CONTINUE TO Q12
RF CONTINUE TO Q12
Q12. What dose of [REFERENCE:2990|1.*.1] did you take each time you took it?
a. AMOUNT:__________ SKIP TO NEXT SECTION
i. UNITS:__________
b. DK SKIP TO NEXT SECTION
c. RF SKIP TO NEXT SECTION
Q13a. How many different dosage amounts do you remember taking?
i. AMOUNT:__________
Q13b. What dose of [REFERENCE:2990|1.1.V] did you take the [CHAPTER] time?
i. AMOUNT:__________
DK or RF SKIP TO Q14
ii. UNITS:__________
DK
RF
Q14. When did you begin taking that dose?
a.
b.
c.
d.
MM/DD/YYYY or
MONTH OF PREGNANCY(B1, P1, P2, P3)
DK
RF
Q15. When did you stop taking that dose?
a.
b.
c.
d.
MM/DD/YYYY
MONTH OF PREGNANCY(B1, P1, P2, P3) IF VALID RESPONSE TO Q14 and Q15, SKIP Q15a
DK
RF
Q15a. How long did you take it?
a. AMOUNT:__________ DK
i. Days
ii. Weeks
iii. Months
RF
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Section R: GENITOURINARY INFECTIONS
R1. From the month before you became pregnant to the end of the third month of pregnancy, that is from
[B1] to [P4(-1)], did you have: a kidney, bladder, or urinary tract infection?
a.
b.
c.
d.
YES CONTINUE TO R2
NO SKIP TO R15
DK SKIP TO R15
RF SKIP TO R15
R2. Was the infection diagnosed by a doctor? ASK FOR EACH INFECTION REPORTED
a.
b.
c.
d.
YES
NO
DK
RF
R3. Did you take any medications or remedies for your infection?
a.
b.
c.
d.
YES CONTINUE TO R4
NO SKIP TO R15
DK SKIP TO R15
RF SKIP TO R15
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ASK THIS SERIES FOR EACH MEDICINE USED:
ROW
#
1
R4.
R18.
R32.
QUESTION
What did you take? / Did you take anything
else?
R4, R18 (UTI OR PID MEDS): PROBE: IF CAN’T
RECALL, READ FROM DRUG LIST:
RESPONSE
MEDICATION:______________________
DK
RF
R4: IF NO/DK/RF – SKIP TO R15
R18: IF NO/DK/RF – SKIP TO R29
Amoxicillin
Amoxil
Augmentin
Azithromycin
Bactrim
Biaxin
Ceftriaxone sodium
Cipro
Doxycycline
EES
Erythrocin
Erythromycin
Furadantin
Levaquin
Macrobid
Macrodantin
Nitrofurantoin
Nitrofurantoin Macrocrystals
Penicillin NOS
Rebetol
Septra
Sulfamethoxazole/trimethoprim
Trimox
Vibramycin
Virazole
Zithromax
Antibiotic NOS
R32: IF NO/DK/RF – SKIP TO R43
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R32 (STD MEDS): PROBE: IF CAN’T RECALL,
READ FROM DRUG LIST
Acyclovir
Aldara
Condylox
Famciclovir
Famvir
Imiquimod
Podofilox
Podophyllin
Trichloroacetic acid (TCA)
Valacyclovir
Valtrex
Zovirax
Zyclara
2
R5.
R19.
R33.
Did you use [REFERENCE:3100|1.*.1] for the
entire time from the month before your
pregnancy through your third month of
pregnancy?
3
R6.
R20.
R34.
When did you start using
[REFERENCE:3100|1.*.1] for [the
infection/CONDITION] for the first time during
this period?
MM/DD/YYYY __ /__ /____ or
MONTH OF PREGNANCY(B1, P1, P2, P3)
DK
RF
4
R7.
R21.
R35.
When did you stop using
[REFERENCE:3100|1.*.1] for the last time
during this time period?
MM/DD/YYYY __ /__ /____ or
MONTH OF PREGNANCY(B1, P1, P2, P3)
IF VALID START AND STOP DATE, SKIP
ROW 5
DK
RF
5
R8.
R22.
R36.
How long did you take it?
AMOUNT:__________
Days
Weeks
DK
RF
R9.
R23.
R37.
How often did you use [REFERENCE:3100|1.*.1]
during the month before your pregnancy
through the end of your third month of
pregnancy? You can say the number of times
per day, per week, per month, or during the
entire 4 month period.
6
90
YES: SKIP TO ROW 6
NO, DK, RF: CONTINUE TO ROW 3
Months
AMOUNT:__________
Per day/Per week/Per month/Per time
period
DK
RF
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7
R10.
R24.
R38.
Did you take the same dose of medicine each
time you took it throughout [B1] to [P4(-1)]?
That is, for example, the same number of
milligrams of medicine in each dose.
YES, DK, RF CONTINUE TO ROW 8
NO SKIP TO ROW 9
8
R11.
R25.
R39.
What dose of [REFERENCE:3100|1.*.1] did you
take each time you took it?
AMOUNT:______ DK, RF SKIP UNITS
UNITS:_________ DK
RF
R11 - SKIP TO R15
R25 – SKIP TO R29
R39 – SKIP TO R43
9
R12a.
R26a.
R40a.
How many different dosage amounts do you
remember taking?
10
R12b. What dose of [REFERENCE:3100|1.1.V] did you
R26b. take the [CHAPTER] time?
R40b.
AMOUNT:______ DK, RF SKIP UNITS
11
R13.
R27.
R41a.
MM/DD/YYYY __ /__ /____ or
MONTH OF PREGNANCY(B1, P1, P2, P3)
DK
RF
12
R14. When did you stop taking that dose?
R28.
R41b.
MM/DD/YYYY __ /__ /____ or
MONTH OF PREGNANCY(B1, P1, P2, P3)
IF VALID START AND STOP DATE, SKIP
ROW 13
DK
RF
13
R14a
R28a
R42.
AMOUNT:__________
Days
Weeks
DK
RF
When did you begin taking that dose?
Or How long did you take it?
AMOUNT:__________
UNITS:_________ DK
RF
Months
AFTER R14, CONTINUE WITH R15 BELOW. AFTER R28a, CONTINUE WITH R29 BELOW.
AFTER R42, CONTINUE WITH R43 BELOW.
FOR R15-R28, FOR R29 –R42 AND FOR R43-R47, USE SAME RESPONSES AND SKIP PATTERNS AS FOR
SIMILAR QUESTIONS IN R1-R14 ABOVE.
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R15. From the month before you became pregnant to the end of the third month of pregnancy, that is from
[B1] to [P4(-1)], did you have pelvic inflammatory disease or PID?
a.
b.
c.
d.
YES CONTINUE TO R16
NO SKIP TO R29
DK SKIP TO R29
RF SKIP TO R29
R16. Was the pelvic inflammatory disease or PID diagnosed by a doctor?
a.
b.
c.
d.
YES
NO
DK
RF
R17. Did you take any medications or remedies for your pelvic inflammatory disease or PID?
a.
b.
c.
d.
YES CONTINUE TO R18 IN TABLE ABOVE
NO SKIP TO R29
DK SKIP TO R29
RF SKIP TO R29
AFTER R18 – R28 IN TABLE ABOVE, CONTINUE:
R29. From the month before you became pregnant to the end of the third month of pregnancy, that is from
[B1] to [P4(-1)], did you have any a sexually transmitted disease, such as chlamydia, HPV, herpes,
syphilis, genital warts, or gonorrhea?
a.
b.
c.
d.
YES CONTINUE TO R29a
NO SKIP TO R43
DK SKIP TO R43
RF SKIP TO R43
R29a. What was it? _____________________
a. DK SKIP TO R43
b. RF SKIP TO R43
R30. Was the [REFERENCE:3176|1.*.1] diagnosed by a doctor?
a.
b.
c.
d.
YES
NO
DK
RF
92
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9/24/14
R31. Did you take any medications or remedies for your [REFERENCE:3176|1.*.1]? This includes medicines
applied by you or a provider.
a. YES CONTINUE TO R32 IN TABLE ABOVE
b. NO SKIP TO R43
c. DK or RF SKIP TO R43
AFTER R32 – R42 IN TABLE ABOVE, CONTINUE:
R43. From the month before you became pregnant to the end of the third month of pregnancy, that is from
[B1] to [P4(-1)], did you have a yeast infection?
a. YES CONTINUE TO R44
b. NO SKIP TO NEXT SECTION
c. DK or RF SKIP TO NEXT SECTION
R44. Was the yeast infection diagnosed by a doctor?
a.
b.
c.
d.
YES
NO
DK
RF
R45. Did you take any medications or remedies for your yeast infection?
a.
b.
c.
d.
YES CONTINUE TO R46
NO SKIP TO NEXT SECTION
DK SKIP TO NEXT SECTION
RF SKIP TO NEXT SECTION
R46. Did you take a medicine that a doctor prescribed for you or did you buy it “over-the-counter”, without a
prescription?
a.
b.
c.
d.
Prescription
Over-the-counter
DK
RF
R47. Did you use a medicine that you inserted or applied on the outside or a pill that you swallowed?
a.
b.
c.
d.
e.
External or inserted product SKIP TO NEXT SECTION
Pill SKIP TO NEXT SECTION
OTHER (SPECIFY):__________ SKIP TO NEXT SECTION
DK SKIP TO NEXT SECTION
RF SKIP TO NEXT SECTION
93
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Section S: FEVERS
S1. From one month before you became pregnant to the end of the third month of your pregnancy, that is
from [B1] to [P4(-1)], did you have any fevers, including those due to respiratory illness, bronchitis,
pneumonia, a kidney, bladder, or urinary tract infection, pelvic inflammatory disease, or other infections
or illness?
a.
b.
c.
d.
YES CONTINUE TO S2
NO SKIP TO NEXT SECTION
DK SKIP TO NEXT SECTION
RF SKIP TO NEXT SECTION
S2. How many fevers do you remember having? IF DK NUMBER, SELECT 1 AND ASK MOM FOR DETAILS
ABOUT 1 FEVER SHE REMEMBERS.
a. NUMBER:__________
S3. What was the cause of the [PASSIN]fever?
a. CAUSE:__________
b. DK
c. RF
S4. When you had [REFERENCE:3280|1.*.1], during which of those months did you have a fever?
a.
b.
c.
d.
e.
f.
B1
P1
P2
P3
DK
RF
S5. What was the highest temperature recorded during your fever?
a. VALUE:__________
i. UNITS: F or C
DK
RF SKIP UNITS
S6. Did you take any medications or remedies for the fever?
a.
b.
c.
d.
YES CONTINUE TO S7
NO SKIP TO NEXT SECTION
DK SKIP TO NEXT SECTION
RF SKIP TO NEXT SECTION
94
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S7. What did you take? Did you take anything else? CODE ALL THAT APPLY. IF CAN’T RECALL, READ FROM
DRUG LIST: Did you take…?
a.
b.
c.
d.
e.
f.
g.
h.
i.
j.
k.
Acetaminophen
Advil
Aleve
Ibuprofen
Motrin
Naproxen sodium
Nuprin
Tylenol
OTHER (SPECIFY):__________
DK SKIP TO NEXT SECTION
RF SKIP TO NEXT SECTION
S8. When did you start using [REFERENCE:3320|1.*.1] for this [REFERENCE:3280|1.*.1] for the first time
during this period?
a.
b.
c.
d.
MM/DD/YYYY or
MONTH OF PREGNANCY(B1, P1, P2, P3)
DK
RF
S9. When did you stop using [REFERENCE:3320|1.*.1] for the last time during this time period?
a.
b.
c.
d.
MM/DD/YYYY or
MONTH OF PREGNANCY(B1, P1, P2, P3) IF VALID RESPONSE TO S8 and S9, SKIP S10
DK
RF
S10. How long did you take it?
a. AMOUNT:__________
i. Days
ii. Weeks
iii. Months
b. DK
c. RF
S11. How often did you use [[REFERENCE:3320|1.*.1]] during the month before your pregnancy through the
end of your third month of pregnancy? You can say the number of times per day, per week, per month,
or during the entire 4 month period.
a. AMOUNT:__________ Per Day/Per Week/Per Month/Per Time Period/DK/RF
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Section T: MEDICATIONS/HERBALS/VITAMINS
We are interested in medicines that you may have taken from 1 month before you became pregnant, which
would be [B1], to the end of the third month of pregnancy, which would be [P4(-1)]. These would include
prescription and nonprescription medicines. Please include medicines prescribed to you by a healthcare
provider and medicines you used that may have been prescribed to someone else. Some of these medicines
we may have already discussed, but please report on them again in response to these questions. Sometimes
the same medication can be used for different reasons, which is why some questions may seem repetitive.
To begin, I’m going to ask you about whether you have used certain types of medicines, and then I’ll ask
about your use of specific medicines. If you filled out the medication worksheet we included in your
introductory packet, it will be helpful for you to have it in front of you for these questions. To keep you from
having to repeat information we’ve already discussed, I may ask you for your help in remembering whether
you’ve reported using a medication to me already and for what medical condition you reported taking it for.
Unfortunately we are not able to see your responses from earlier in the interview.
Medication Categories
QUESTION
During [B1] to [P4(-1)] did you take…./did
you get any vaccines (T154)?
T1.
T18.
T35.
T52.
T69.
T86.
T103.
T120.
T137.
T154.
T171.
RESPONSES
IF YES, ASK
FOLLOW-UP
QUESTIONS
IF NO, ASK
NEXT
CATEGORY
IF DK, ASK
NEXT
CATEGORY
IF RF, ASK
NEXT
CATEGORY
Birth control pills (FOLLOW-UPS BEGIN WITH
T3 ON PAGE 108.)
Antibiotics
Over-the-counter pain relievers
Prescription pain relievers
Medicines to help lower your cholesterol
(“statins”)
Medicines to help you quit smoking
Medicines to help with allergies or cold
symptoms (e.g. runny nose, cough)
Medicine to treat an infection with a virus,
like the flu (“antiviral”)
Medicine to help you sleep (“sleep aid”)
Vaccines
(WILL ONLY CAPTURE NAME &
DATE OF VACCINES)
Y
N
DK
RF
Y
Y
Y
Y
N
N
N
N
DK
DK
DK
DK
RF
RF
RF
RF
Y
Y
N
N
DK
DK
RF
RF
Y
N
DK
RF
Y
Y
N
N
DK
DK
RF
RF
Medicines to treat nausea or vomiting
Y
N
DK
RF
96
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9/24/14
T3.
What was the name of the medication? / Did
you take any other medicine in this category?
NAME:_____________________
DK SKIP TO NEXT CATEGORY
PROBE: READ LIST IF NECESSARY
RF SKIP TO NEXT CATEGORY
BIRTH CONTROL PILLS PROMPTS:
Apri
Aviane (21,28)
Beyaz
Brevicon (21,28)
Camila
Cryselle 28
Cyclessa
Desogen
Jolivette
Kariva
Levora
Lo Loestrin Fe
Lo/Ovral 21
LoSeasonique
Low-Ogestrel (21,28)
Micronor
Mircette
Nor-QD
Nora-BE
Nordette (21,28)
Ogestrel 0.5/50
Ortho Tri-Cyclen
Ortho Tri-Cyclen Lo
Ortho-Cept
Ortho-Cyclen
Ortho-Novum 1/35
Ortho-Novum 7/7/7
Ovcon 35
Ovcon 50
Portia
Seasonale
Seasonique
Sprintec
TriNessa
Tri-Norinyl
Tri-Sprintec
Trivora
Yasmin
Yaz
OTHER, SPECIFY:
SELECT EACH YES:
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
97
BD-STEPS CATI – FULL DRAFT
9/24/14
FOR EACH REPORTED DRUG ABOVE, CONTINUE WITH T4/ROW 1 THROUGH T6/ROW 3 AND SKIP TO
T8/ROW 5.
T20.
What was the name of the medication? / Did
you take any other medicine in this category?
NAME:_____________________
DK SKIP TO NEXT CATEGORY
PROBE: READ LIST IF NECESSARY
RF SKIP TO NEXT CATEGORY
ANTIBIOTICS PROMPTS:
Amoxicillin
Amoxil
Augmentin
Biaxin
Cipro
Ciprofloxacin
Cleocin
Doxycycline
Erythromycin
Flagyl
Macrodantin
Nitrofurantoin
Penicillin
Sulfamethoxazole-Trimethoprim
Vancocin
Vibramycin
Zithromax
Z-Pak
OTHER, SPECIFY:
SELECT EACH YES:
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
FOR EACH REPORTED DRUG ABOVE, CONTINUE WITH T4/ROW 1-T24/ROW 4.
98
BD-STEPS CATI – FULL DRAFT
9/24/14
T37.
What was the name of the medication? / Did
you take any other medicine in this category?
NAME:_____________________
DK SKIP TO NEXT CATEGORY
PROBE: READ LIST IF NECESSARY
RF SKIP TO NEXT CATEGORY
OVER-THE-COUNTER PAIN RELIEVERS
PROMPTS:
Acetaminophen
Advil
Aleve
Aspirin
Excedrin Extra Strength
Caplets/Tablets/Geltabs
Ibuprofen
Motrin
Naproxen Sodium
Tylenol
OTHER, SPECIFY:
SELECT EACH YES:
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
FOR EACH REPORTED DRUG ABOVE, CONTINUE WITH T4/ROW 1-T24/ROW 4.
T54.
What was the name of the medication? / Did
you take any other medicine in this category?
NAME:_____________________
DK SKIP TO NEXT CATEGORY
PROBE: READ LIST IF NECESSARY
RF SKIP TO NEXT CATEGORY
PRESCRIPTION PAIN RELIEVERS
Celebrex
Hydrocodone Bitartrate/ APAP
Lorcet
Lortab
Neurontin
Oxycodone/Acetaminophen-NOS
Oxycontin
Percocet-NOS
Roxicet-NOS
Tramadol
Tramadol HCL/ Acetaminophen
Tylenol #1,#2,#3,#4
Ultram
Vicodin –NOS
OTHER, SPECIFY:
SELECT EACH YES:
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
99
BD-STEPS CATI – FULL DRAFT
9/24/14
FOR EACH REPORTED DRUG ABOVE, CONTINUE WITH T4/ROW 1-T24/ROW 4.
T71.
What was the name of the medication? / Did
you take any other medicine in this category?
NAME:_____________________
DK SKIP TO NEXT CATEGORY
PROBE: READ LIST IF NECESSARY
RF SKIP TO NEXT CATEGORY
MEDICINES TO HELP LOWER YOUR
CHOLESTEROL (“STATINS”)
Altoprev
Atorvastatin
Crestor
Fluvastatin
Lescol
Lipitor
Livalo
Lovastatin
Mevacor
Pitavastatin
Pravachol
Pravastatin Sodium
Rosuvastatin Calcium
Simvastatin
Zocor
OTHER, SPECIFY:
SELECT EACH YES:
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
FOR EACH REPORTED DRUG ABOVE, CONTINUE WITH T4/ROW 1 THROUGH T6/ROW 3 AND SKIP TO
T8/ROW 5.
100
BD-STEPS CATI – FULL DRAFT
9/24/14
T88.
What was the name of the medication? / Did
you take any other medicine in this category?
NAME:_____________________
DK SKIP TO NEXT CATEGORY
PROBE: READ LIST IF NECESSARY
RF SKIP TO NEXT CATEGORY
MEDICINES TO HELP YOU QUIT SMOKING
Budeprion SR
Bupropion HCL
Chantix
Clonidine
Nicoderm CQ
Nicorette Gum
Nicotine Gum NOS
Nicotine Inhaler NOS
Nicotrol Inhaler
Nortriptyline
Pamelor
Varenicline Tartrate
Wellbutrin
Wellbutrin XL
Zyban
OTHER, SPECIFY:
SELECT EACH YES:
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
FOR EACH REPORTED DRUG ABOVE, CONTINUE WITH T4/ROW 1 THROUGH T6/ROW 3 AND SKIP TO
T8/ROW 5.
101
BD-STEPS CATI – FULL DRAFT
9/24/14
T105.
What was the name of the medication? / Did
you take any other medicine in this category?
NAME:_____________________
DK SKIP TO NEXT CATEGORY
PROBE: READ LIST IF NECESSARY
MEDICINES TO HELP WITH ALLERGIES OR
COLD SYMPTOMS (E.G. RUNNY NOSE,
COUGH)
Afrin 12 Hour Nasal Spray
Allegra
Allegra D
Benadryl
Clarinex
Clarinex D
Claritin
Claritin D
Delsym 12 Hour Cough Relief
Mucinex
Mucinex Dm
Phenylephrine
Pseudoephedrine
Sudafed PE Nasal Decongestant
Sudafed Nasal Decongestant
Zyrtec
Zyrtec D
OTHER, SPECIFY:
RF SKIP TO NEXT CATEGORY
SELECT EACH YES:
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
FOR EACH REPORTED DRUG ABOVE, CONTINUE WITH T4/ROW 1-T24/ROW 4.
T122.
What was the name of the medication? / Did
you take any other medicine in this category?
NAME:_____________________
DK SKIP TO NEXT CATEGORY
RF SKIP TO NEXT CATEGORY
MEDICINE TO TREAT AN INFECTION WITH A
VIRUS, LIKE THE FLU (“ANTIVIRAL”)
Acyclovir
Amantadine
Combivir
Oseltamivir Phosphate
Relenza
Tamiflu
Zanamivir
OTHER, SPECIFY:
SELECT EACH YES:
Y
Y
Y
Y
Y
Y
Y
Y
FOR EACH REPORTED DRUG ABOVE, CONTINUE WITH T4/ROW 1-T24/ROW 4.
102
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9/24/14
T139.
What was the name of the medication? / Did
you take any other medicine in this category?
NAME:_____________________
DK SKIP TO NEXT CATEGORY
PROBE: READ LIST IF NECESSARY
RF SKIP TO NEXT CATEGORY
MEDICINE TO HELP YOU SLEEP (“SLEEP AID”)
Ambien
Benadryl
Compoz (New Form 1984)
Diphenhydramine
Doxylamine
Eszopiclone
Kava-Kava, Herb
L-Tryptophan
Lunesta
Melatonin
Nytol (New Form 1984)
Prosom
Ramelteon
Restoril
Rozerem
Sleepinal
Sominex (New Form 1988)
Sonata
Tryptophan
Valerian Extract
Zaleplon
Zolpidem Tartrate
Zzzquil Liquicaps Sleep-Aid
Zzzquil Liquid Sleep-Aid
OTHER, SPECIFY:
SELECT EACH YES:
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
FOR EACH REPORTED DRUG ABOVE, CONTINUE WITH T4/ROW 1 THROUGH T6/ROW 3 AND SKIP TO
T8/ROW 5.
103
BD-STEPS CATI – FULL DRAFT
9/24/14
T156.
Which vaccines did you get?
NAME:_____________________
PROBE: READ LIST IF NECESSARY
DK SKIP TO NEXT CATEGORY
RF SKIP TO NEXT CATEGORY
VACCINES
Chickenpox Vaccine
Flu Vaccine NOS
Hepatitis A Vaccine
Hepatitis B Vaccine
HPV Vaccine NOS (Human Papillomavirus)
Measles, Mumps, Rubella Vaccine
NOS-Meningococcal Vaccine
Pneumococcal Vaccine, polyvalent
Shingles Vaccine NOS
OTHER, SPECIFY_______________________
T157.
When did you get the [NAME OF VACCINE]?
SKIP TO CONTINUE TO T171, NEXT CATEGORY.
104
SELECT EACH YES:
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
a. MM/DD/YYYY or
b. MONTH OF PREGNANCY(B1, P1, P2,
P3)
c. DK
d. RF
BD-STEPS CATI – FULL DRAFT
9/24/14
T173.
What was the name of the medication? / Did
you take any other medicine in this category?
NAME:_____________________
DK SKIP TO SPECIFIC MEDICINES
PROBE: READ LIST IF NECESSARY
RF SKIP TO SPECIFIC MEDICINES
MEDICINES TO TREAT NAUSEA OR VOMITING
SELECT EACH YES:
Benadryl
Bonine
Diphenhydramine
Doxylamine
Ginger
Metoclopramide
Ondansetron
Phenergan
Preggy Pops
Promethazine
Reglan
Tigan
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Unisom
Y
Vitamin B6
Y
Zofran
OTHER, SPECIFY
Y
Y
FOR EACH REPORTED DRUG ABOVE, CONTINUE WITH T4/ROW 1-T24/ROW 4.
105
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9/24/14
ASK THIS SERIES FOR EACH MEDICINE USED IN T1 THROUGH T137 AND T171. NOT ASKED OF VACCINES.
Row
1
Quex #
Question Text
T4
Did you already tell me about taking this
T21
medication earlier in the interview?
T38
T55
T72
T89
T106
T123
T140
T174
a.
b.
c.
d.
Responses
YES CONTINUE TO T5/ROW2
NO CONTINUE TO T24/ROW 4 or
SKIP TO T8/ROW 5
DK CONTINUE TO T24/ROW 4 or
SKIP TO T8/ROW 5
RF CONTINUE TO T24/ROW 4 or SKIP
TO T8/ROW 5
2
T5
T22
T39
T56
T73
T90
T107
T124
T141
T175
Could you please remind me of the medical
condition you took this for?
a. CONDITION______________________
b. DK
c. RF
3
T6
T23
T40
T57
T74
T91
T108
T125
T176
Did you take this medication for any other
reasons that we have not already talked
about?
a.. YES CONTINUE TO T24/ROW 4 OR
SKIP TO T8/ROW 5
b.. NO/DK/RF CONTINUE TO NEXT
MEDICATION CATEGORY OR SKIP TO
SPECIFIC MEDICATIONS INTRO
106
BD-STEPS CATI – FULL DRAFT
9/24/14
FOR ALL MEDICATION CATEGORIES, EXCEPT BIRTH CONTROL PILLS, STATINS, SMOKING CESSATION
MEDICATIONS, SLEEP AIDS, AND VACCINES ASK T24/ROW 4; FOR THE AFOREMENTIONED CATEGORIES,
SKIP TO T8/ROW 5.
4
T24
T41
T58
T109
T126
T177
Why did you take [REFERENCE:3390|1.*.1]?
a. REASON:__________
b. DK
c. RF
5
T8
T25
T42
T59
T76
T93
T110
T127
T144
T178
Did you use [REFERENCE:3390|1.*.1] for the
entire time from the month before your
pregnancy through your third month of
pregnancy?
a.
b.
c.
d.
6
T9
T26
T43
T60
T77
T94
T111
T128
T145
T179
When did you start using
[REFERENCE:3390|1.*.1] during the month
before your pregnancy through the third
month of pregnancy?
a. MM/DD/YYYY or
b. MONTH OF PREGNANCY(B1, P1, P2,
P3)
c. DK
d. RF
7
T10
T27
T44
T61
T78
T95
T112
T129
T146
T180
When did you stop using
[REFERENCE:3390|1.*.1] for the last time
during this time period?
a. MM/DD/YYYY or
b. MONTH OF PREGNANCY(B1, P1, P2,
P3) IF VALID STOP AND START DATE,
SKIP T11/ROW 8
c. DK
d. RF
107
YES SKIP TO T12/ROW 9
NO CONTINUE TO T9/ROW 6
DK CONTINUE TO T9/ROW 6
RF CONTINUE TO T9/ROW 6
BD-STEPS CATI – FULL DRAFT
9/24/14
8
T11
T28
T45
T62
T79
T96
T113
T130
T147
T181
How long did you take
[REFERENCE:3390|1.*.1]?
AMOUNT_______
Days
Weeks
DK
RF
9
T12
T29
T46
T63
T80
T97
T114
T131
T148
T182
How often did you use
[REFERENCE:3390|1.*.1] during the month
before your pregnancy through the end of
your third month of pregnancy? You can say
the number of times per day, per week, per
month, or during the entire 4 month period.
AMOUNT:__________
Per day/Per week/Per month/Per time
period
DK
RF
10
T13
T30
T47
T64
T81
T98
T115
T132
T149
T183
Did you take the same dose of medicine, each
time that you took it, for the whole time that
you took it during the month before your
pregnancy through the end of your third
month of pregnancy? That is, for example, the
same number of milligrams of medicine in
each dose
11
T14
T31
T48
T65
T82
T99
T116
T133
T150
T184
What dose of [REFERENCE:3390|1.*.1] did you
take each time you took it?
a.
b.
c.
d.
Months
YES CONTINUE TO T14a/ROW 11
NO SKIP TO T15a/ROW 12
DK CONTINUE TO T14/ROW 11
RF CONTINUE TO T14/ROW 11
AMOUNT:______ DK, RF SKIP UNITS
UNITS:_________ DK
RF
SKIP TO T18/NEXT CATEGORY
108
BD-STEPS CATI – FULL DRAFT
9/24/14
12
T15a
T32a
T49a
T66a
T83a
T100a
T117a
T134a
T151a
T185a
How many different dosage amounts do you
remember taking?
AMOUNT_______
13
T15b
T32b
T49b
T66b
T83b
T100b
T117b
T134b
T151b
T185b
What dose of [REFERENCE:3390|1.1.V] did you
take the [CHAPTER] time?
AMOUNT:______ DK, RF SKIP UNITS
14
T16
T33
T50
T67
T84
T101
T118
T135
T152
T186
When did you begin taking that dose?
a. MM/DD/YYYY or
b. MONTH OF PREGNANCY(B1, P1, P2,
P3)
c. DK
d. RF
15
T17
T34
T51
T68
T85
T102
T119
T136
T153
T187
When did you stop taking that dose?
a. MM/DD/YYYY or
b. MONTH OF PREGNANCY(B1, P1, P2,
P3) IF VALID STOP AND START DATE,
SKIP T17a/ROW 16
c. DK
d. RF
109
UNITS:_________ DK
RF
BD-STEPS CATI – FULL DRAFT
9/24/14
16
T17a
T34a
T51a
T68a
T85a
T102a
T119a
T136a
T153a
T187a
How long did you take it?
AMOUNT_______
Days
Weeks
DK
RF
Months
AFTER T17, CONTINUE TO T18 AT BEGINNING OF TABLE, OR NEXT CATEGORY.
CYCLE BACK UP TO NEXT MEDICATION CATEGORY ON THE LIST AND CONTINUE WITH QUESTIONS UNTIL
YOU HAVE ASKED ABOUT EACH MEDICATION CATEGORY THROUGH THOSE FOR NAUSEA AND VOMITING.
110
BD-STEPS CATI – FULL DRAFT
9/24/14
SPECIFIC MEDICATIONS:
Now I’m going to ask you about your use of specific medications. As I read the list, please tell me Yes or No
for each medicine. We may have already discussed some of these medicines, but please report on them
again in response to these questions
During [B1] to [P4(-1)] did you take:
T188.
T203.
T218.
T233.
T248.
T263.
T278.
T293.
T308.
T323.
T338.
T353.
T368.
T383.
T398.
T413.
T428.
T443.
T458.
T473.
T488.
T503.
T518.
T533.
T548.
T563.
T578.
T593.
Prozac
Wellbutrin
Paxil
Zoloft
Effexor
Celexa
Lexapro
Cymbalta
Abilify
Seroquel
Zyprexa
Depakene, Depakote, or Valproic acid
Dilantin or Phenytoin
Felbatol
Klonopin or Clonazepam
Lamictal
Phenobarbital
Topiramate or Topamax
Furadantin
Macrodantin
Qsymia
Thalidomide
Accutane or Isotretinoin
CellCept
Myfortic
Cytotec
Misoprostol
Methotrexate
111
IF YES,
ASK NEXT
QUESTION
IN ROW
17
IF NO,
ASK NEXT
DRUG
IF DK, ASK
NEXT
DRUG
IF RF, ASK
NEXT
DRUG
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
N
N
N
N
N
N
N
N
N
N
N
N
N
N
N
N
N
N
N
N
N
N
N
N
N
N
N
N
DK
DK
DK
DK
DK
DK
DK
DK
DK
DK
DK
DK
DK
DK
DK
DK
DK
DK
DK
DK
DK
DK
DK
DK
DK
DK
DK
DK
RF
RF
RF
RF
RF
RF
RF
RF
RF
RF
RF
RF
RF
RF
RF
RF
RF
RF
RF
RF
RF
RF
RF
RF
RF
RF
RF
RF
SKIP TO
T608
SKIP TO
T608
SKIP TO
T608
BD-STEPS CATI – FULL DRAFT
9/24/14
ASK THIS SERIES FOR EACH MEDICATION TAKEN IN T188-T593:
ROW Quex #
17
T189
T204
T219
T234
T249
T264
T279
T309
T324
T339
T354
T369
T384
T399
T414
T429
T444
T459
T474
T489
T504
T519
T534
T549
T564
T579
T594
Question Text
Did you already tell me about taking this
medication earlier in the interview?
112
a.
b.
c.
d.
Responses
YES CONTINUE TO T190/ROW 18
NO SKIP TO T192/ROW 20
DK SKIP TO T192/ROW 20
RF SKIP TO T192/ROW 20
BD-STEPS CATI – FULL DRAFT
9/24/14
18
T190
T205
T220
T235
T250
T265
T280
T295
T310
T325
T340
T355
T370
T385
T400
T415
T430
T445
T460
T475
T490
T505
T520
T535
T550
T565
T580
T595
Could you please remind me of the medical
condition you took this for?
113
a. CONDITION_____________
b. DK
c. RF
BD-STEPS CATI – FULL DRAFT
9/24/14
19
T191
T206
T221
T236
T251
T266
T281
T296
T311
T326
T341
T356
T371
T386
T401
T416
T431
T446
T461
T476
T491
T506
T521
T536
T551
T566
T581
T596
Did you take this medication for any other
reasons that we have not already talked
about?
114
a.
b.
C.
D.
YES CONTINUE TO T192/ROW 20
NO SKIP TO T203/NEXT MEDICINE
DK SKIP TO T203/NEXT MEDICINE
RF SKIP TO T203/NEXT MEDICINE
BD-STEPS CATI – FULL DRAFT
9/24/14
20
T192
T207
T222
T237
T252
T267
T282
T297
T312
T327
T342
T357
T372
T387
T402
T417
T432
T447
T462
T477
T492
T507
T522
T537
T552
T567
T582
T597
Why did you take [Prozac/MEDICINE]?
115
a. REASON:__________
b. DK
c. RF
BD-STEPS CATI – FULL DRAFT
9/24/14
21
T193
T208
T223
T238
T253
T268
T283
T298
T313
T328
T343
T358
T373
T388
T403
T418
T433
T448
T463
T478
T493
T508
T523
T538
T553
T568
T583
T598
Did you use [Prozac/MEDICINE] for the entire
time from the month before your pregnancy
through your third month of pregnancy?
116
a.
b.
c.
d.
YES SKIP TO T197/ROW 25
NO CONTINUE TO T194/ROW 22
DK CONTINUE TO T194/ROW 22
RF CONTINUE TO T194/ROW 22
BD-STEPS CATI – FULL DRAFT
9/24/14
22
T194
T209
T224
T239
T254
T269
T284
T299
T314
T329
T344
T359
T374
T389
T404
T419
T434
T449
T464
T479
T494
T509
T524
T539
T554
T569
T584
T599
When did you start using [Prozac/MEDICINE]
during the month before your pregnancy
through the third month of pregnancy?
117
a. MM/DD/YYYY or
b. MONTH OF PREGNANCY(B1, P1, P2,
P3)
c. DK
d. RF
BD-STEPS CATI – FULL DRAFT
9/24/14
23
T195
T210
T225
T240
T255
T270
T285
T300
T315
T330
T345
T360
T375
T390
T405
T420
T435
T450
T465
T480
T495
T510
T525
T540
T555
T570
T585
T600
When did you stop using [Prozac/MEDICINE]
for the last time during this time period?
118
a. MM/DD/YYYY or
b. MONTH OF PREGNANCY(B1, P1, P2,
P3) IF VALID STOP AND START DATE,
SKIP T196/ROW 24
c. DK
d. RF
BD-STEPS CATI – FULL DRAFT
9/24/14
24
T196
T211
T226
T241
T256
T271
T286
T301
T316
T331
T346
T361
T376
T391
T406
T421
T436
T451
T466
T481
T496
T511
T526
T541
T556
T571
T586
T601
How long did you take
[REFERENCE:3390|1.*.1]?
AMOUNT_______
Days
Weeks
DK
RF
119
Months
BD-STEPS CATI – FULL DRAFT
9/24/14
25
T197
T212
T227
T242
T257
T272
T287
T302
T317
T332
T347
T362
T377
T392
T407
T422
T437
T452
T467
T482
T497
T512
T527
T542
T557
T572
T587
T602
How often did you use [Prozac/MEDICINE]
during the month before your pregnancy
through the end of your third month of
pregnancy? You can say the number of times
per day, per week, per month, or during the
entire 4 month period.
120
AMOUNT:__________
Per day/Per week/Per month/Per time
period
DK
RF
BD-STEPS CATI – FULL DRAFT
9/24/14
26
T198
T213
T228
T243
T258
T273
T288
T303
T318
T333
T348
T363
T378
T393
T408
T423
T438
T453
T468
T483
T498
T513
T528
T543
T558
T573
T588
T603
Did you take the same dose of medicine,
each time you took it, for the whole time
that you took it during the month before
your pregnancy through the end of your
third month of pregnancy? That is, for
example, the same number of milligrams of
medicine in each dose.
121
a.
b.
c.
d.
YES CONTINUE TO T199/ROW 27
NO SKIP TO T200/ROW 28
DK CONTINUE TO T199/ROW 27
RF CONTINUE TO T199/ROW 27
BD-STEPS CATI – FULL DRAFT
9/24/14
27
T199
T214
T229
T244
T259
T274
T289
T304
T319
T334
T349
T364
T379
T394
T409
T424
T439
T454
T469
T484
T499
T514
T529
T544
T559
T574
T589
T604.
What dose of [Prozac/MEDICINE] did you
take each time you took it?
122
AMOUNT:______ DK, RF SKIP UNITS
UNITS:_________ DK
RF
BD-STEPS CATI – FULL DRAFT
9/24/14
28
T200a
T215a
T230a
T245a
T260a
T275a
T290a
T305a
T320a
T335a
T350a
T365a
T380a
T395a
T410a
T425a
T440a
T455a
T470a
T485a
T500a
T515a
T530a
T545a
T560a
T575a
T590a
T605a
How many different dosage amounts do you
remember taking?
123
AMOUNT_______
BD-STEPS CATI – FULL DRAFT
9/24/14
29
T200b
T215b
T230b
T245b
T260b
T275b
T290b
T305b
T320b
T335b
T350b
T365b
T380b
T395b
T410b
T425b
T440b
T455b
T470b
T485b
T500b
T515b
T530b
T545b
T560b
T575b
T590b
T605b
What dose of [Prozac/MEDICINE] did you
take the [CHAPTER] time?
124
AMOUNT:______ DK, RF SKIP UNITS
UNITS:_________ DK
RF
BD-STEPS CATI – FULL DRAFT
9/24/14
30
T201
T216
T231
T246
T261
T276
T291
T306
T321
T336
T351
T366
T381
T396
T411
T426
T441
T456
T471
T486
T501
T516
T531
T546
T561
T576
T591
T606
When did you begin taking that dose?
125
a. MM/DD/YYYY or
b. MONTH OF PREGNANCY(B1, P1, P2,
P3)
c. DK
d. RF
BD-STEPS CATI – FULL DRAFT
9/24/14
31
T202
T217
T232
T247
T262
T277
T292
T307
T322
T337
T352
T367
T382
T397
T412
T427
T442
T457
T472
T487
T502
T517
T532
T547
T562
T577
T592
T607
When did you stop taking that dose?
a. MM/DD/YYYY or
b. MONTH OF PREGNANCY(B1, P1, P2,
P3) IF VALID STOP AND START DATE,
SKIP T202a/ROW 32
c. DK
d. RF
126
BD-STEPS CATI – FULL DRAFT
9/24/14
32
T202a
T217a
T232a
T247a
T262a
T277a
T292a
T307a
T322a
T337a
T352a
T367a
T382a
T397a
T412a
T427a
T442a
T457a
T472a
T487a
T502a
T517a
T532a
T547a
T562a
T577a
T592a
T607a
How long did you take
[REFERENCE:3390|1.*.1]?
AMOUNT_______
Days
Weeks
DK
RF
Months
CYCLE BACK UP TO NEXT SPECIFIC MEDICATION ON THE LIST AND CONTINUE WITH QUESTIONS UNTIL YOU
HAVE ASKED ABOUT EACH SPECIFIC MEDICATION THROUGH METHOTREXATE.
127
BD-STEPS CATI – FULL DRAFT
9/24/14
HERBALS:
T608.
From the month before you became pregnant
to the end of your third month of pregnancy,
did you use any herbs or folk medicines to
treat any medical conditions, to keep you
healthy, or to lose weight? Please do not
include herbal teas.
T609.
Between [START DATE OF B1] to [P4(-1)END
DATE OF P3] what herbs or folk medicines did
you take? / Anything else?
a.
b.
c.
d.
YES CONTINUE TO T609
NO SKIP TO T615
DK SKIP TO T615
RF SKIP TO T615
HERBALS_____________
DK SKIP TO T615
RF SKIP TO T615
ASK THIS SERIES FOR EACH HERBAL PRODUCT USED:
YES SKIP TO T614
NO CONTINUE TO T611
DK CONTINUE TO T611
RF CONTINUE TO T611
T610.
Did you use [ANSWER] for the entire time
from the month before your pregnancy
through your third month of pregnancy?
a.
b.
c.
d.
T611.
When did you start using
[REFERENCE:9450|1.*.1] during the month
before your pregnancy through the third
month of pregnancy?
a. MM/DD/YYYY or
b. MONTH OF PREGNANCY(B1, P1, P2,
P3)
c. DK
d. RF
T612.
When did you stop using
[REFERENCE:9450|1.*.1] for the last time
during this time period?
a. MM/DD/YYYY or
b. MONTH OF PREGNANCY(B1, P1, P2,
P3) IF VALID STOP AND START DATE,
SKIP T613
c. DK
d. RF
T613.
How long did you take
[REFERENCE:9450|1.*.1]?
AMOUNT_______
Days
Weeks
DK
RF
How often did you use
[REFERENCE:9450|1.*.1] during the month
before your pregnancy through the end of
your third month of pregnancy? You can say
the number of times per day, per week, per
month, or during the entire 4 month period.
AMOUNT:__________
Per day/Per week/Per month/Per time
period
DK
RF
T614.
128
Months
BD-STEPS CATI – FULL DRAFT
9/24/14
VITAMINS:
Now I’m going to ask you about your vitamin use before and during your pregnancy.
T615.
From the month before you became pregnant
through the end of your 3rd month of
pregnancy, which would be [B1] to [P4(-1)],
did you take any multivitamins, prenatal
vitamins, or folic acid supplements?
a.
b.
c.
d.
YES CONTINUE TO T616
NO SKIP TO T620
DK SKIP TO T620
RF SKIP TO T620
T616.
Did you begin using it before your pregnancy
began?
a.
b.
c.
d.
YES CONTINUE TO T617
NO SKIP TO T618
DK SKIP TO T618
RF SKIP TO T618
T617.
Did you continue to use it after your
pregnancy began?
a.
b.
c.
d.
YES SKIP TO T620
NO SKIP TO T620
DK SKIP TO T620
RF SKIP TO T620
T618.
Did you begin using it in the first month of
pregnancy?
a.
b.
c.
d.
YES SKIP TO T620
NO CONTINUE TO T619
DK SKIP TO T620
RF SKIP TO T620
T619.
Did you begin using it after the first month of
pregnancy?
a.
b.
c.
d.
YES
NO
DK
RF
129
BD-STEPS CATI – FULL DRAFT
9/24/14
Catch-All Medication Question
YES CONTINUE TO T621
NO SKIP TO NEXT SECTION
DK SKIP TO NEXT SECTION
RF SKIP TO NEXT SECTION
T620.
During this time period, did you take any
medications, remedies, or treatments that we
haven’t already talked about?
a.
b.
c.
d.
T621.
What medicine did you take? /Any others?
SPECIFY______________
DK SKIP TO NEXT SECTION
RF SKIP TO NEXT SECTION
T622.
Why did you take [ANSWER]?
a. REASON:__________
b. DK
c. RF
T623.
Did you use [REFERENCE:9570|1.*.1] for the
entire time from the month before your
pregnancy through your third month of
pregnancy?
a.
b.
c.
d.
T624.
When did you start using
[REFERENCE:9570|1.*.1] during the month
before your pregnancy through the third
month of pregnancy?
a. MM/DD/YYYY or
b. MONTH OF PREGNANCY(B1, P1, P2,
P3)
c. DK
d. RF
T625.
When did you stop using
a. MM/DD/YYYY or
[REFERENCE:9570|1.*.1 MEDICINE] for the last b. MONTH OF PREGNANCY(B1, P1, P2,
time during this time period?
P3) IF VALID STOP AND START DATE,
SKIP T626
c. DK
d. RF
130
YES SKIP TO T627
NO CONTINUE TO T624
DK CONTINUE TO T624
RF CONTINUE TO T624
BD-STEPS CATI – FULL DRAFT
9/24/14
T626.
How long did you take
[REFERENCE:9570|1.*.1]?
AMOUNT_______
Days
Weeks
DK
RF
T627.
How often did you use
[REFERENCE:9570|1.*.1] during the month
before your pregnancy through the end of
your third month of pregnancy? You can say
the number of times per day, per week, per
month, or during the entire 4 month period.
AMOUNT:__________
Per day/Per week/Per month/Per time
period
DK
RF
T628.
Did you take the same dose of
[REFERENCE:9570|1.*.1] each time you took it
throughout [B1] to [P4(-1)]?
a.
b.
c.
d.
T629.
What dose of [REFERENCE:9570|1.*.1] did you
take each time you took it?
AMOUNT:______ DK, RF SKIP UNITS
Months
YES CONTINUE TO T629
NO SKIP TO T630a
DK CONTINUE TO T629
RF CONTINUE TO T629
UNITS:_________ DK
RF
SKIP TO NEXT SECTION
T630a.
How many different dosage amounts do you
remember taking?
AMOUNT_______
T630b. What dose of [REFERENCE:9450|1.1.V] did you
take the [CHAPTER] time ?
AMOUNT:______ DK, RF SKIP UNITS
T631.
When did you begin taking that dose?
a. MM/DD/YYYY or
b. MONTH OF PREGNANCY(B1, P1, P2,
P3)
c. DK
d. RF
T632.
When did you stop taking that dose?
a. MM/DD/YYYY or
b. MONTH OF PREGNANCY(B1, P1, P2,
P3) IF VALID STOP AND START DATE,
SKIP T632b
c. DK
d. RF
T632b. How long did you take
[REFERENCE:9570|1.*.1]?
UNITS:_________ DK
AMOUNT_______
Days
Weeks
DK
RF
131
RF
Months
BD-STEPS CATI – FULL DRAFT
9/24/14
Section U: STRESS
The next series of questions will be about events that may have occurred in your life from the 3 months before
you became pregnant through your 3rd month of pregnancy, which would be [START DATE OF B3] through [P4(1)]. These questions will be a little bit different from some of the other questions we have asked because we are
asking now about the three months before you became pregnant, as well as the first three months of your
pregnancy. 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.
U1. From 3 months before you became pregnant through your 3rd month of pregnancy, did you experience
any serious relationship difficulties with your husband or partner or become separated or divorced?
a.
b.
c.
d.
YES
NO
DK
RF
U2. During this same time period, did you or your husband or partner have any serious legal or financial
problems?
a.
b.
c.
d.
YES
NO
DK
RF
U3. 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. [MOTHER MUST USE HER OWN JUDGEMENT ON WHAT
SHE THINKS IS MEANT BY “SOMEONE CLOSE TO YOU”.]
a.
b.
c.
d.
YES
NO
DK
RF
U4. 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”.]
a.
b.
c.
d.
YES
NO
DK
RF
132
BD-STEPS CATI – FULL DRAFT
9/24/14
U5. 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”.]
a.
b.
c.
d.
YES
NO
DK
RF
U6. 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?
a.
b.
c.
d.
YES
NO
DK
RF
U7. 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?
a.
b.
c.
d.
YES
NO
DK
RF
U8. 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?
a.
b.
c.
d.
YES
NO
DK
RF
U9. During this same time period, how often did you feel nervous and stressed? Would you say…READ
CHOICES
a.
b.
c.
d.
e.
f.
g.
Never
Almost never
Sometimes
Somewhat often
Very often
DK
RF
133
BD-STEPS CATI – FULL DRAFT
9/24/14
Section V: 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 you did for at least
10 minutes at a time.
V1. 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 that you did for at least 10
minutes at a time. (P1)
a. Days Per Week: ______
IF 0 SKIP TO INTRODUCTION TO V3
IF 1 – 7 CONTINUE TO V2
b. DK SKIP TO INTRODUCTION TO V3
c. RF SKIP TO INTRODUCTION TO V3
V2. How much time did you usually spend doing vigorous physical activities on one of those days? PROBE:
Think only about those physical activities that you do for at least 10 minutes at a time. (P2)
a. Hours Per Day:__________ SKIP TO INTRODUCTION TO V3
b. Minutes Per Day:__________ SKIP TO INTRODUCTION TO V3 [REMINDER: IF THEY ANSWER
LESS THAN 10 MINUTES, REMIND THEM THAT WE ARE ONLY INTERESTED IN ACTIVITIES DONE AT
LEAST 10 MINUTES AT A TIME.]
c. DK CONTINUE TO V2b
d. RF CONTINUE TO V2b
V2b. In the three months before you became pregnant, how much time in total would you spend in a typical
week doing vigorous physical activities? PROBE: Think only about those physical activities that you do
for at least 10 minutes at a time.
a.
b.
c.
d.
Hours:__________
Minutes:__________
DK
RF
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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 only about those physical activities that you
did for at least 10 minutes at a time.
V3. 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 that you do for at least
10 minutes at a time. PROBE: Child care includes dressing, bathing, grooming, feeding, or occasional
lifting. (P3)
a. Days Per Week:__________
i. IF 0 SKIP TO INTRODUCTION TO V5
ii. IF 1 – 7 CONTINUE TO V4
b. DK SKIP TO INTRODUCTION TO V5
c. RF SKIP TO INTRODUCTION TO V5
V4. How much time did you usually spend doing moderate physical activities on one of those days? PROBE:
Think only about those physical activities that you do for at least 10 minutes at a time. (P4)
a. Hours Per Day:__________ SKIP TO INTRODUCTION TO V5
b. Minutes Per Day:__________ SKIP TO INTRODUCTION TO V5 [REMINDER: IF THEY ANSWER
LESS THAN 10 MINUTES, REMIND THEM THAT WE ARE ONLY INTERESTED IN ACTIVITIES DONE AT
LEAST 10 MINUTES AT A TIME.]
c. DK CONTINUE TO V4b
d. RF CONTINUE TO V4b
V4b. 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? PROBE: Think only about those physical activities that
you do for at least 10 minutes at a time.
a.
b.
c.
d.
HOURS:__________
MINUTES:__________
DK
RF
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.
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V5. 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. (P5)
a. Days Per Week:____________
i. IF 0 SKIP TO INTRODUCTION TO V7
ii. IF 1 – 7 CONTINUE TO V6
b. DK or RF SKIP TO INTRODUCTION TO V7
V6. How much time did you usually spend walking on one of those days? (P6)
a. Hours Per Day:__________ SKIP TO INTRODUCTION TO V7
b. Minutes Per Day:__________ SKIP TO INTRODUCTION TO V7 [REMINDER: IF THEY ANSWER
LESS THAN 10 MINUTES, REMIND THEM WE ARE ONLY INTERESTED IN ACTIVITIES DONE AT LEAST
10 MINUTES AT A TIME.]
c. DK or RF CONTINUE TO V6b
V6b. In the three months before you became pregnant, what is the total amount of time you spent walking in
a typical week?
a.
b.
c.
d.
Hours:__________
Minutes:__________.
DK
RF
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
sitting at a desk, visiting friends, reading or sitting or lying down to watch television.
V7. 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. (P7)
a.
b.
c.
d.
Hours Per Day:__________ SKIP TO NEXT SECTION
Minutes Per Day:__________ SKIP TO NEXT SECTION
DK CONTINUE TO V7b
RF CONTINUE TO V7b
V7b. What is the total amount of time you spent sitting on a typical Wednesday? PROBE: Include time spent
lying down (awake) as well as sitting.
a.
b.
c.
d.
Hours:__________
Minutes:__________.
DK
RF
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Section W: OBESITY
Now I have some questions about weight changes before [TAB: your pregnancy with [NOIB]; your pregnancy).
W1. What is your height without shoes?
a.
b.
c.
d.
e.
Feet:__________
Inches:__________ OR
Centimeters:__________
DK
RF
W2. How much did you weigh before [TAB: your pregnancy with [NOIB]; your pregnancy)?
a. WEIGHT:__________
i. Pounds
ii. Kilograms
b. DK
c. RF
W3. Not including pregnancy, when you gain weight, where on your body do you mostly add the weight?
READ OPTIONS A-D:
a.
b.
c.
d.
e.
f.
Waist and/or upper body?
Hips, bottom and/or upper thighs?
Evenly over your body?
Don’t gain weight?
DK
RF
W4. Which describes the underlying shape of your body, regardless of weight gain or loss?
READ OPTIONS A-C:
a.
b.
c.
d.
e.
You carry most of your weight around your waist and/or upper body (apple shaped)?
You carry most of your weight around your hips, bottom, or upper thighs (pear shaped)?
You carry most of your weight evenly over your body?
DK
RF
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W5. What is the most you have ever weighed outside of pregnancy?
a. WEIGHT:__________
i. POUNDS
ii. KILOGRAMS
b. DK
c. RF
W6. What was your age when you were that weight?
a. AGE:__________
b. DK
c. RF
W7. What is the least you have weighed outside of pregnancy in the last 5 years?
a. WEIGHT:__________
i. POUNDS
ii. KILOGRAMS
b. DK
c. RF
W8. What was your age when you were that weight?
a. AGE:__________
b. DK
c. RF
W9. In the year before [TAB: your pregnancy with [NOIB]; your pregnancy], did your weight change by more
than 20 pounds/9 kilograms?
a.
b.
c.
d.
YES CONTINUE TO W10
NO SKIP TO W12
DK SKIP TO W12
RF SKIP TO W12
W10. How much did your weight change? NOTE: REFERENCE WEIGHT = THEIR WEIGHT AT THE START OF
THEIR PREGNANCY
a. AMOUNT:__________
i. POUNDS
ii. KILOGRAMS
b. DK
c. RF
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W11. Was this change related to a pregnancy?
a.
b.
c.
d.
YES
NO
DK
RF
W12. Have you ever had surgery to help you lose weight? This does not include cosmetic procedures such as
liposuction.
a.
b.
c.
d.
YES CONTINUE TO W13
NO SKIP TO W14
DK SKIP TO W14
RF SKIP TO W14
W13. What procedure did you have?
a.
b.
c.
d.
e.
Gastric bypass
Belly band / lap band / gastric banding
Gastric sleeve / sleeve gastrectomy
DK
RF
W14. In the month before your pregnancy through the end of your third month of pregnancy, that is [B1] to
[P4(-1)], did you follow any of the following types of diet? [READ LIST. INDICATE ALL THAT APPLY]
a.
b.
c.
d.
e.
f.
g.
h.
i.
j.
Vegetarian
Vegan
Low carbohydrate / low “carb”
Low fat
Gluten free
Dairy free
OTHER (SPECIFY):__________
NONE OF THE ABOVE
DK
RF
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Section X: DENTAL PROCEDURES
The next set of questions is about dental visits you may have had right before and early in your pregnancy.
X1. During the month before your pregnancy through the third month of your pregnancy, that is from [B1] to
[P4(-1)] did you go to the dentist or other dental specialist, such as a periodontist or oral surgeon?
a.
b.
c.
d.
YES CONTINUE TO X2
NO SKIP TO NEXT SECTION
DK SKIP TO NEXT SECTION
RF SKIP TO NEXT SECTION
X2. How many times did you go to the dentist during that time period?
a. NUMBER:__________
b. DK
c. RF
X3. What dental procedures did you receive at that visit/those visits? IF DON’T KNOW GIVE OPTIONS. CAN
REPORT MULTIPLE PROCEDURES.
a.
b.
c.
d.
e.
f.
g.
h.
i.
j.
k.
Teeth cleaning and/or routine checkup
Cavity filled or dental filling placed CONTINUE WITH X4 – X19, BUT SKIP X20 AND GO TO X21
Root canal
Teeth whitening
Teeth removal (e.g. wisdom teeth)
Place dental crown
Dental bridge
Oral surgery
OTHER (SPECIFY):__________
DK
RF
X4. Did you have any x-rays taken during the visit/visits?
a.
b.
c.
d.
YES CONTINUE TO X5
NO SKIP TO X6
DK SKIP TO X6
RF SKIP TO X6
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X5. Did they provide a protective cover for your body during the x-rays?
a.
b.
c.
d.
e.
Yes for all X-rays
Yes for some, but not all X-rays
No for all X-rays
DK
RF
X6. Did you receive a shot to numb your mouth during the visit/at least one of the visits (an injectable
anesthetic)?
a.
b.
c.
d.
YES
NO
DK
RF
X7. Did you receive “laughing gas”, also called nitrous oxide, during the visit/ at least one of the visits?
a. YES
b. NO
c. DK
d. RF
X8. Were you prescribed any medications for your dental visit/visits or at the visit/visits?
a.
b.
c.
d.
YES CONTINUE TO X9
NO SKIP TO X14
DK SKIP TO X14
RF SKIP TO X14
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X9. What medicine were you prescribed / Anything else? IF CAN’T RECALL, READ FROM LIST. MULTIPLE
MEDICATIONS CAN BE REPORTED.
a.
b.
c.
d.
e.
f.
g.
h.
i.
j.
k.
l.
m.
n.
o.
p.
q.
r.
s.
t.
u.
v.
w.
x.
y.
z.
aa.
bb.
Acetaminophen w/Codeine
Amoxicillin
Amoxil
Chlorhexidine Gluconate
Clindamycin
Diazepam
Doxycycline
Erythromycin
FluoridePhosphate,Acidulated
Hydrocodone/Ibuprofen
Hydrocodone Bitartrate/ APAP
Hydrocodone NOS product unknown
Kenalog in Orabase
Magic mouthwash - NOS
Orabase
Orafate Paste
Oxycodone with Acetaminophen
Penicillin NOS
Percocet
Periostat
Tylenol #1,#2,#3,#4
Valium
Vicodin -NOS
Vicoprofen
NOS- Pain Medication W/Codeine Unknown
OTHER (SPECIFY):__________
DK SKIP TO X14
RF SKIP TO X14
X10. ASK SERIES FOR EACH DRUG: When did you start taking [ANSWER]?
a.
b.
c.
d.
e.
MM/DD/YYYY or
MONTH OF PREGNANCY(B1, P1, P2, P3)
DIDN’T TAKE IT (ONLY RECEIVED PRESCRIPTION; DIDN’T FILL IT)
DK
RF
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X11. When did you stop using [ANSWER] for the last time during this time period?
a.
b.
c.
d.
MM/DD/YYYY or
MONTH OF PREGNANCY(B1, P1, P2, P3) IF VALID RESPONSE TO X10 and X11, SKIP X12
DK
RF
X12. How long did you take it?
a. AMOUNT:__________
i. Days
ii. Weeks
iii. Months
DK
RF
X13. How often did you use [ANSWER] during the month before your pregnancy through the end of your
third month of pregnancy? You can say the number of times per day, per week, per month, or during the
entire 4 month period.
a. AMOUNT:__________ Per Day/Per Week/Per Month/Per Time Period/DK/RF
X14. Did you take any over-the-counter medicines just before your dental visit/visits or just after your
visit/visits?
a.
b.
c.
d.
YES CONTINUE TO X15
NO SKIP TO X20
DK SKIP TO X20
RF SKIP TO X20
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X15. What did you take? / Anything else? IF CAN’T RECALL, READ FROM LIST. MULTIPLE MEDICATIONS CAN
BE REPORTED
a.
b.
c.
d.
e.
f.
g.
h.
i.
j.
k.
l.
m.
n.
o.
Acetaminophen
Advil
Anbesol liquid /gel (new form 1998)
Aspirin
Bayer aspirin
Chloraseptic liquid/spray (new form 1990)
Ibuprofen
Motrin
Nuprin
Ora-jel
Tylenol
Xylocaine
OTHER (SPECIFY):__________
DK SKIP TO X20/X21
RF SKIP TO X20/X21
X16. ; ASK SERIES FOR EACH DRUG: When did you start taking [ANSWER] for your dental visit?
a.
b.
c.
d.
MM/DD/YYYY or
MONTH OF PREGNANCY(B1, P1, P2, P3)
DK
RF
X17. When did you stop using [ANSWER] for the last time during this time period?
a.
b.
c.
d.
MM/DD/YYYY or
MONTH OF PREGNANCY(B1, P1, P2, P3) IF VALID RESPONSE TO X16 and X17, SKIP X18
DK
RF
X18. How long did you take it?
a. AMOUNT:__________
i. Per day
ii. Per week
iii. Per month
iv. Per time period
b. DK
c. RF
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X19. How often did you use [ANSWER] during the month before your pregnancy through the end of your
third month of pregnancy? You can say the number of times per day, per week, per month, or during the
entire 4 month period.
a. AMOUNT:__________ Per Day/Per Week/Per Month/Per Time Period/DK/RF
IF THEY REPORTED HAVING A CAVITY FILLED IN X3 SKIP X20 AND CONTINUE TO X21.
X20. IF THEY DID NOT REPORT HAVING A CAVITY FILLED IN X3: Did you have any cavities filled or dental
fillings placed during the visit/visits? [IF THEY DID NOT REPORT HAVING A CAVITY FILLED IN X3]
a.
b.
c.
d.
YES CONTINUE TO X21
NO SKIP TO NEXT SECTION
DK SKIP TO NEXT SECTION
RF SKIP TO NEXT SECTION
X21a. During how many of the visits did you have a dental filling placed?
a. NUMBER:__________ DK
RF
X21b. How many dental fillings do you remember having placed during your [1st, 2nd, etc] visit? IF THEY
REPORT MULTIPLE VISITS CONFIRM THAT THEY HAVE SUMMED ACROSS VISITS.
a. NUMBER:__________
X22.
What was/were the date(s) of the [1st, 2nd, etc] visit when the filling(s) was/were placed? ASK FOR
EACH VISIT IF MULTIPLE VISITS
a.
b.
c.
d.
X23.
MM/DD/YYYY or
MONTH OF PREGNANCY(B1, P1, P2, P3)
DK
RF
Was the filling/Were the fillings silver in color, also called an amalgam filling, or tooth-colored, also
called a composite resin filling? ASK FOR EACH DATE REPORTED. ALLOW MULTIPLE RESPONSES IF
MORE THAN ONE FILLING WAS PLACED DURING A SINGLE VISIT.
a.
b.
c.
d.
Amalgam / silver-colored
Composite resin / tooth-colored
DK
RF
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Section Y: SMOKING
The next questions are about cigarette use.
Y1. At any time from 1 month before you became pregnant to the end of your third month of pregnancy,
that is from [B1] to [P4(-1)] did you smoke cigarettes? PROBE: Even if you did not smoke the whole time,
we are interested in whether you smoked any cigarettes at all during this time period.
a.
b.
c.
d.
YES CONTINUE TO Y2
NO SKIP TO NEXT SECTIONY3
DK SKIP TO Y3
RF SKIP TO Y3
Y2. During which months did you smoke? INDICATE ALL THAT APPLY
a.
b.
c.
d.
e.
f.
B1
P1
P2
P3
DK
RF
Y3. At any time from 1 month before you became pregnant to the end of your third month of pregnancy did
you use electronic cigarettes, also referred to as e-cigarettes?
a.
b.
c.
d.
YES CONTINUE TO Y4
NO SKIP TO NEXT SECTION
DK SKIP TO NEXT SECTION
RF SKIP TO NEXT SECTION
Y4. How often did you use electronic cigarettes during the month before through the third month of
pregnancy?
a.
b.
c.
d.
e.
Every Day
Some Days
Rarely
DK
RF
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Section Z: ALCOHOL
Now I’m going to ask you some questions about drinking alcoholic beverages.
Z1. From one month before you became pregnant to the end of your third month of pregnancy, did you drink
any wine, beer, mixed drinks or shots of liquor?
a.
b.
c.
d.
YES CONTINUE TO Z2
NO SKIP TO NEXT SECTION
DK SKIP TO NEXT SECTION
RF SKIP TO NEXT SECTION
Z2. During which months did you drink any alcoholic beverages?
a.
b.
c.
d.
e.
f.
B1
P1
P2
P3
DK
RF
Z3. What was the greatest number of drinks you had on one occasion from the beginning of your pregnancy
through the end of your third month of pregnancy? We define one drink as one beer, one glass of wine,
one mixed drink, or one shot of liquor.
a. NUMBER:__________
b. DK
c. RF
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Section AA: RESIDENCE HISTORY
We would like to know the address at which you lived when [TAB: you became pregnant with [NOIB]; the
affected pregnancy began] so that we can study possible environmental exposures.
AA1. What is your current address? PROBE: REMEMBER TO ASK ABOUT AN APARTMENT NUMBER IF NONE
GIVEN
a. ADDRESS:__________
b. DK
c. RF
AA2. Do you currently live at the same address that you did at the time [TAB: you became pregnant with
([NOIB]/the pregnancy began]?
a.
b.
c.
d.
YES SKIP TO NEXT SECTION
NO CONTINUE TO QUESTION AA3
DK SKIP TO NEXT SECTION
RF SKIP TO NEXT SECTION
AA3. What was your address at the time [TAB: your pregnancy with [NOIB]; the affected pregnancy] began?
This would be on or around [START DATE OF P1].
a. ADDRESS:__________ SKIP TO NEXT SECTION
b. DK SKIP TO NEXT SECTION
c. RF SKIP TO NEXT SECTION
Section BB: MATERNAL OCCUPATION
The next set of questions asks about your work experiences – paid, volunteer, or military service. This includes
part-time and full-time jobs that lasted one month or more, including jobs you worked at home, jobs on a farm,
or jobs outside your home.
BB1. From 1 month before you became pregnant to the end of your third month of pregnancy, that is from
[B1] to [P4(-1)] did you have a job?
a.
b.
c.
d.
YES SKIP TO BB4
NO CONTINUE TO BB2
DK CONTINUE TO BB2
RF CONTINUE TO BB2
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BB2. Were you [READ CHOICES] or did you do something else?
a.
b.
c.
d.
e.
f.
A homemaker/parent SKIP TO NEXT SECTION
A student GO TO BB3
Disabled SKIP TO NEXT SECTION
Unemployed / in between jobs SKIP TO NEXT SECTION
OTHER (SPECIFY):__________ SKIP TO NEXT SECTION
DK or RF SKIP TO NEXT SECTION
BB3. IF STUDENT: From 1 month before you became pregnant to the end of your third month of pregnancy,
that is from [B1] to [P4(-1)] did you also have a paid or volunteer job while in school, including on-thejob training, such as an apprenticeship, internship, practicum or clinical experience?
a.
b.
c.
d.
YES CONTINUE TO BB4
NO SKIP TO NEXT SECTION
DK SKIP TO NEXT SECTION
RF SKIP TO NEXT SECTION
BB4. Did you hold a job during that time [READ CHOICES]:
a. In the healthcare field?
b. On a farm, ranch, orchard, or in a greenhouse?
c. As a janitor, housekeeper, maid, or other cleaning staff?
d. As a hairdresser, cosmetologist, or nail technician?
e. As a teacher or teaching assistant?
f. In a restaurant, café, or coffee shop?
g. In an office building, performing primarily office, administrative, or computer work
h. As a scientist?
i. As an electronic equipment operator?
j. NONE OF THE ABOVE
k. DK
l. RF
IF ANY YES, QUEUE REQUEST AT END OF INTERVIEW FOR ON-LINE FOLLOW-UP QUESTIONS
BB5. Now think about all the jobs, paid or volunteer, you held from [B1] to [P4(-1)]. What kind of a company
did you work for? Please be as specific as possible. (What did your company make or do?) LIST ALL
EMPLOYERS, INCLUDING “SELF EMPLOYED”
a. SPECIFY:__________________________________
b. DK
IF MOTHER RESPONDS DK, ENTER UNKNOWN IN RESPONSE BOX.
c. RF
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BB6. At the company that did [BB5 RESPONSE]what was your job title there? [ASK FOR EACH EMPLOYER]
a. SPECIFY:__________________________________
b. DK
c. RF
BB7. At the company that did [BB5 RESPONSE] describe what you did and how you did it. What were your
main activities or duties? Anything else? [ASK FOR EACH EMPLOYER]
a. SPECIFY:___________________________________
b. DK
c. RF
Section CC: RACE / ACCULTURATION / EDUCATION
Now I will be asking about your ethnic background.
CC1. Were you born in the U.S.?
a.
b.
c.
d.
YES SKIP TO CC4
NO CONTINUE TO CC2
DK SKIP TO CC4
RF SKIP TO CC4
CC2. Where were you born?
a. SPECIFY:__________
b. DK
c. RF
CC3. How many years have you lived in the US?
a. YEARS:__________
b. DK
c. RF
CC4. What language do you usually speak at home?
a. SPECIFY:__________
b. DK
c. RF
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CC5. Are you Hispanic or Latina?
a.
b.
c.
d.
YES CONTINUE TO CC6
NO SKIP TO CC7
DK SKIP TO CC7
RF SKIP TO CC7
CC6. Which Hispanic or Spanish group do you consider yourself a member of? PROBE: Mexican, Puerto
Rican, Salvadoran, Honduran, Colombian, Peruvian, Guatemalan, Spanish, Central American, South
American, etc.?
a. SPECIFY:__________
b. DK
c. RF
CC7. How would you describe your race? 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.
a.
b.
c.
d.
e.
f.
g.
American Indian or Alaska Native ASK CC9
Asian CONTINUE TO CC8
Black or African American SKIP TO CC10, unless (CC7a), (CC7b), or (CC7d) also selected
Native Hawaiian or Other Pacific Islander CONTINUE TO CC8
White SKIP TO CC10, unless (CC7a), (CC7b), or (CC7d) also selected
DK SKIP TO CC10
RF SKIP TO CC10
CC8. IF CC7 = b OR d: What country? PROBE: Referring to Asian, Native Hawaiian or other Pacific Island
countries
a. COUNTRY:__________
b. DK
c. RF
CC9. IF CC7 = a: What tribe do you consider yourself a member of?
a. TRIBE:__________
b. DK
c. RF
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CC10. What was the highest grade or year of school or college that you had completed [TAB: at the time
[NOIB] was born; by [DOIB]]? IF RESPONDENT HESITATES, BEGIN READING CATEGORIES.
a.
b.
c.
d.
e.
f.
g.
h.
i.
j.
k.
l.
No formal schooling
1-6 years
7-8 years
9-11 years
12 years, completed high school or equivalent
1-3 years college
Completed technical college
4 years college or Bachelor’s degree
Master’s degree
Advanced degree (MD, PhD, JD)
DK
RF
IF THE FATHER IS UNKNOWN, SKIP TO NEXT SECTION
The next few questions are about [TAB: [NOIB]’s; the] biological or natural father.
CC11. Was he born in the U.S.?
a.
b.
c.
d.
YES SKIP TO CC14
NO CONTINUE TO CC12
DK SKIP TO CC14
RF SKIP TO CC14
CC12. Where was he born?
a. SPECIFY:__________
b. DK
c. RF
CC13. How many years has he lived in the U.S.?
a. YEARS:__________
b. DK
c. RF
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CC14. Is the father Hispanic or Latino?
a.
b.
c.
d.
Yes ASK CC15
NO SKIP TO CC16
DK SKIP TO CC16
RF SKIP TO CC16
CC15. Which Hispanic or Spanish group does he consider himself a member of? PROBE: Mexican, Puerto
Rican, Salvadoran, Honduran, Colombian, Peruvian, Guatemalan, Spanish, Central American, South
American, etc.?
a. SPECIFY:__________
b. DK
c. RF
CC16. How would you describe his race? 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.
a. American Indian or Alaska Native ASK CC18
b. Asian ASK CC17
c. Black or African American SKIP TO CC19, UNLESS (CC16a), (CC16b), OR (CC16d) ALSO
SELECTED
d. Native Hawaiian or Other Pacific Islander ASK CC17
e. White SKIP TO CC19, UNLESS (CC16a), (CC16b), OR (CC16d) ALSO SELECTED
f. DK SKIP TO CC 19
g. RF SKIP TO CC19
CC17. IF CC16 = b or d: What country? PROBE: Referring to Asian, Native Hawaiian or other Pacific Island
countries.
a. COUNTRY:__________
b. DK
c. RF
CC18. IF CC16 = a: What tribe does he consider himself a member of?
a. TRIBE:__________
b. DK
c. RF
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CC19. What was the highest grade or year of school or college that he had completed [TAB: at the time
[NOIB] was born; by [DOIB]]? IF RESPONDENT HESITATES, BEGIN READING CATEGORIES.
a.
b.
c.
d.
e.
f.
g.
h.
i.
j.
k.
l.
No formal schooling
1-6 years
7-8 years
9-11 years
12 years, completed high school or equivalent
1-3 years college
Completed technical college
4 years college or Bachelor’s degree
Master’s degree
Advanced degree (MD, PhD, JD)
DK
RF
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Section DD: INSURANCE STATUS
The next questions are about health insurance. Include health insurance obtained through your job or that you
bought directly, as well as government programs like Medicare and Medicaid that provide medical care or help
pay medical bills. Please do not include private plans that only provide extra cash while hospitalized (e.g. Aflack).
DD1. In the month before your pregnancy began, were you covered by health insurance or some other kind
of health care plan?
a.
b.
c.
d.
YES CONTINUE TO DD2
NO SKIP TO DD3
DK SKIP TO DD3
RF SKIP TO DD3
DD2. What was the name of your insurance? / Any other insurance? PROVIDE EXAMPLE IF NEEDED: Blue
Cross/Blue Shield, Wellpoint, UnitedHealth, Wellmark, Medicaid, Medicare, Tricare
a. NAME:__________
b. DK
c. RF
DD3. During your pregnancy, were you covered by health insurance or some other kind of health care plan?
a.
b.
c.
d.
e.
YES, for the entire pregnancy CONTINUE TO DD4
YES, for part of the pregnancy CONTINUE TO DD4
NO SKIP TO NEXT SECTION
DK SKIP TO NEXT SECTION
RF SKIP TO NEXT SECTION
DD4. What was the name of your insurance? / Any other insurance? PROVIDE EXAMPLES IF NEEDED: Blue
Cross/Blue Shield, Wellpoint, UnitedHealth, Wellmark, Medicaid, Medicare, Tricare.
a. NAME:__________
b. DK
c. RF
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Section EE: CLOSING
EE1. IF THE MOTHER REPORTED ONE OF THE OCCUPATIONAL CATEGORIES OF INTEREST: We would like to
get some additional information about your activities at the job you had during the month before your
pregnancy through your third month of pregnancy. Would you be willing to let us send you an email
with a link to an on-line survey with these additional questions once they become available?
a. YES CONTINUE TO EE2
b. NO SKIP TO EE3b
c. DK SKIP TO EE3b
EE2. What is your email address, so that we can send you a link to the questionnaire?
NOTE TO INTERVIEWERS: READ BACK THE EMAIL ADDRESS AND CONFIRM THAT IT HAS BEEN
RECORDED CORRECTLY
a. EMAIL ADDRESS:______________________________
b. DK
EE3a. We may have other on-line surveys in the future on other topics. Would you be willing to let us send
you an email telling you about them to see if you are interested in participating?
a. YES SKIP TO EE6
b. NO SKIP TO EE6
c. DK SKIP TO EE6
EE3b. IF EE1 = NO OR DK: We may have other on-line surveys in the future on other topics. Would you be
willing to let us send you an email telling you about them to see if you are interested in participating?
a. YES SKIP TO EE5
b. NO SKIP TO EE6
c. DK SKIP TO EE6
EE4.
IF MOTHER WAS NOT ASKED ABOUT EMAIL ADDRESS IN EE1-EE3 (DID NOT SELECT AN OCCUPATION
OF INTEREST): We may have on-line surveys in the future to get additional information on certain
topics. Would you be willing to let us send you an email telling you about them to see if you are
interested in participating?
a. YES CONTINUE TO EE5
b. NO SKIP TO EE6
c. DK SKIP TO EE6
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EE5.
What is your email address?
NOTE TO INTERVIEWERS: READ BACK THE EMAIL ADDRESS AND CONFIRM THAT IT HAS BEEN RECORDED
CORRECTLY
a. EMAIL ADDRESS:_____________________________
b. DK
EE6. In case we need to get in touch with you in the future, would you be willing to give us the name,
address and phone number 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.
a. YES CONTINUE TO EE7
b. NO SKIP TO EE8a IF IT IS A CENTER COLLECTING BLOOD SPOT CONSENTS; SKIP TO EE8b IF IT IS
A CENTER NOT COLLECTING BLOOD SPOT CONSENTS
c. DK SKIP TO EE8a IF IT IS A CENTER COLLECTING BLOOD SPOT CONSENTS; SKIP TO EE8b IF IT IS
A CENTER NOT COLLECTING BLOOD SPOT CONSENTS
EE7. Contact information
PREFIX: Ms, Mrs, Mr, Dr
FIRST NAME:_______________________
LAST NAME:________________________
STREET/APARTMENT:________________
CITY/STATE/ZIP:_____________________
HOME PHONE:______________________
WORK PHONE:______________________
RELATIONSHIP:______________________
DK
RF
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FOR EE8, INTERVIEWERS WILL NEED TO USE ID AND INFANT STATUS TO DETERMINE WHICH SCRIPT TO USE:
EE8a. FOR CENTERS THAT ARE COLLECTING BLOODSPOTS (STATE IDs 20, 23, 25, 28) AND A LIVEBORN
INFANT: That completes the interview, but as you read in the advance letter, you may be asked to
participate in other parts of the study. The interview will help us understand the environmental causes
of birth defects. Another part of the study will help us to understand the role genetic and other biologic
factors have in causing birth defects. We will mail you a consent form to allow us to request leftover
newborn bloodspots that were already collected shortly after your baby’s birth by your state’s
newborn screening program. We will enclose a $10 gift card with the consent form as a token of
appreciation for your continued interest in our study.
IF ADDRESS PROVIDED IN RESIDENCE HISTORY AA3: To confirm, I have your address as [PULL ADDRESS
FROM AA3]? Is that the address where you receive mail?
a. YES SKIP TO EE10a IF IT IS A CENTER COLLECTING BLOOD SPOT CONSENTS; SKIP TO EE10b IF IT
IS A CENTER NOT COLLECTING BLOOD SPOT CONSENTS
b. NO CONTINUE TO EE9
c. DK CONTINUE TO EE9
d. RF SKIP TO EE10a IF IT IS A CENTER COLLECTING BLOOD SPOT CONSENTS; SKIP TO QUESTION
EE10b IF IT IS A CENTER NOT COLLECTING BLOOD SPOT CONSENTS
EE8b. FOR CENTERS THAT ARE NOT COLLECTING BLOODSPOTS (STATE IDs 21, 22, 27) OR FOR A NONLIVEBORN INFANT: That completes the interview, but as you read in the advance letter, you may be
asked to participate in other parts of the study. So that we may contact you in the future we would like
to confirm your address.
IF ADDRESS PROVIDED IN RESIDENCE HISTORY AA3): To confirm, I have your address as [PULL ADDRESS
FROM AA3]. Is that the address where you receive mail?
a. YES SKIP TO EE10a IF IT IS A CENTER COLLECTING BLOOD SPOT CONSENTS; SKIP TO EE10B IF IT
IS A CENTER NOT COLLECTING BLOOD SPOT CONSENTS
b. NO CONTINUE TO EE9
c. DK CONTINUE TO EE9
d. RF SKIP TO EE10a IF IT IS A CENTER COLLECTING BLOOD SPOT CONSENTS; SKIP TO EE10B IF IT
IS A CENTER NOT COLLECTING BLOOD SPOT CONSENTS
EE9.
ASK ONLY IF ADDRESS NOT PROVIDED IN RESIDENCE HISTORY AA3 OR ADDRESS ON FILE IS
INCORRECT: What is your current mailing address? REMEMBER TO ASK ABOUT APT NUMBER IF NONE
IS GIVEN.
STREET/APT:_________________________
DK
RF
CITY:___________________________
STATE:______________ ZIP:____________________________
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FOR EE10, INTERVIEWERS WILL NEED TO USE ID AND INFANT STATUS TO DETERMINE WHICH SCRIPT TO USE:
EE10a. FOR CENTERS THAT ARE COLLECTING BLOODSPOTS (STATE IDs 20, 23, 25, 28) AND A LIVEBORN
INFANT: In the introductory letter we sent you, there was a $20 gift card included as a token of
appreciation for your interest. As I just mentioned, you will be sent an additional $10 gift card with the
consent form to access your child’s newborn blood spots. We cannot promise you will get a gift card
from your chosen store, but could you tell me which one of the following stores you would prefer?
[READ LIST]
i.
ii.
iii.
iv.
v.
vi.
Amazon
Target
Wal-Mart
CVS
DK
RF
EE10b. FOR CENTERS THAT ARE NOT COLLECTING BLOODSPOTS (STATE IDs 21, 22, 27) OR A NON-LIVEBORN
INFANT: In the introductory letter we sent you, there was a $20 gift card included as a token of
appreciation for your interest. As I just mentioned, we may ask you to participate in other parts of the
study. We cannot promise you will get a gift card from your chosen store, but could you tell me which
one of the following stores you would prefer? [READ LIST]
i.
ii.
iii.
iv.
v.
vi.
Amazon
Target
Wal-Mart
CVS
DK
RF
EE11. We publish an electronic newsletter yearly to update participants on the progress of the study. You can
access this newsletter at www.BDSTEPS.org. We can print the most recent one for you. Would you like
us to send you a printed copy of the newsletter?
a. YES
b. NO
FINAL REMARK
EE12. 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.
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Section FF: INTERVIEWER REMARKS
FF1. The overall quality of this interview was:
a.
b.
c.
d.
HIGH QUALITY
GENERALLY RELIABLE
QUESTIONABLE
UNSATISFACTORY
FF2. Did the father contribute to the mother’s answers? SKIP IF FATHER UNKNOWN
a. YES
b. NO
c. DK
FF3. Did some other person contribute to the mother’s answers?
a. YES CONTINUE TO FF4
b. NO SKIP TO FF5
c. DK SKIP TO FF5
FF4. Who was it?
a. SPECIFY:__________
b. DK
FF5. IF FF1 = C OR D: The main reason for questionable or unsatisfactory quality of information was because
the respondent: INDICATE ALL THAT APPLY
a.
b.
c.
d.
e.
f.
g.
h.
i.
j.
k.
l.
m.
n.
DID NOT KNOW ENOUGH INFORMATION REGARDING THE TOPIC
DID NOT WANT TO BE MORE SPECIFIC
SOUNDED BORED OR UNINTERESTED
SOUNDED UPSET, DEPRESSED, OR ANGRY
HAD POOR HEARING OR SPEECH
SOUNDED CONFUSED OR DISTRACTED BY FREQUENT INTERRUPTIONS
SOUNDED INHIBITED BY OTHERS AROUND HER
SOUNDED EMBARRASSED BY THE SUBJECT MATTER
SOUNDED EMOTIONALLY UNSTABLE
SOUNDED PHYSICALLY ILL
NOT COMFORTABLE WITH LANGUAGE OF THE QUESTIONNAIRE
DOESN’T HAVE THE TIME
FELT INTERVIEW TOO LONG
OTHER (SPECIFY):__________
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FF6. Was the majority of the interview done in English or Spanish?
a. ENGLISH
b. SPANISH
c. BOTH EQUALLY
ZZ1
INTERVIEW IS COMPLETE. PLEASE CLICK THE FINISH BUTTON
161
| File Type | application/pdf |
| Author | Sarah C Tinker |
| File Modified | 2015-04-24 |
| File Created | 2015-04-24 |