Form 0920-15BEB Attachment 2_BABI_ScreenerQuestionnaire_ENG_V1.0

1/24/2021 BABI SCREENER QUESTIONNAIRE Form Approved

OMB No. 0920-xxxx

Exp. Date xx/xx/xxxx

Name: ________________________ How did you hear about the study: ______________________

Today’s Date: ___________________ Location of recruitment (clinic, floors, etc.): _____________________

Are you currently pregnant? Yes ______ No ______

If yes, how far along are you in your pregnancy? ________ weeks gestation When is your due date? ___/___/___

If not currently pregnant, have you delivered a baby within the past 10 weeks? Yes _____ No ____ (If more than 10 weeks ago then  DNQ)

If delivered in the past 10 weeks, what date did you deliver your child? ___/____/__ ___

Where did you deliver? ______________________

Have you been diagnosed with GDM within the past 6 months? Yes No (If NO DNQ)

How were you diagnosed with gestational diabetes? ­­­­­­­­­­­­­­­­­­­­­___________________________­­­­­_____________________________

Prompts: Did you have an abnormal value on a one hour screening test (drink glucola blood test one hour later)? Yes___ No___

Did you have a three hour test? Yes___ No___ Did you have two or more abnormal values on the three hour OGTT (baseline blood test, drink glucola, blood tests at 1,2,3 hours?) Yes___ No___

Were you put on a special diet? Yes___ No____ Were you put on insulin? Yes___ No____

Have you previously been diagnosed with type 1 or type 2 diabetes? Yes No (If YES DNQ)

Were/are you pregnant with more than two children (more than twins?)Yes _____ No _____ (If YESDNQ)

How old are you? ____________ (Age must be > 18, if not  DNQ)

Do you have any medical conditions?_______________________________________________

If patient has/had: cardiovascular disease, kidney disease, liver disease, venous or arterial thromboembolic disease, adrenal insufficiency, depression requiring hospitalization in past 6 months, non-basal cell skin cancer, HIV, AIDS, non-pregnancy-related illness requiring hospitalization in past 6 months, then  DNQ

Are you taking any medications? Yes No________

If yes please list: __________________________________________________________________

If taking: glucocorticoids, atypical antipsychotics, weight loss medications (prescription, OTC, or herbal) then  DNQ

Do you plan to move outside of the Boston area in the next 6 months? Yes____ No___(DNQ if YES)

Self Reported Height: _______________ Pre-pregnancy self reported weight: ____________

Calculate pre-pregnancy BMI: ______, if not between 18 and 50 then  DNQ

Ethnicity (Hispanic or Latino/not Hispanic or Latino): __________ Race: _________
(Prompts: What is your race? White, Black or African American, Hispanic or Latino, American Indian or Alaska Native, Asian, Native Hawaiian or Other Pacific Islander? One or more may be selected.)

Are you currently enrolled in any other research studies? Yes_____ No_____

If NOT ELIGIBLE at this time, okay to keep info on file for future studies? YES ___ NO___ (fill in bold q’s above)

____Subject qualifies for booking ____Subject needs records reviewed before booking ____Subject DNQ

If QUALIFIES - Read Study Description:

Are you interested in participating in this research study? YES ___ NO___

If Subject mentions why NOT interested, check box:

• Unable to attend study visits

• Moving

• No time

• Distance from BWH

• Childcare

• Family obligations

• Work/School obligations

• Other ________________

• Other ____________________

CONTACT INFO: Name: ___________________ DOB:__________

(H): __________________(C/W): __________________

Address:________________________________________________

Email Address: __________________________________________

Who is your OB? (Name, Hospital) __________________________

Who is your PCP? (Name, Hospital) __________________________

What time of day is best to contact you? Circle preferred method of contact

Morning (8am-12pm) Afternoon (12pm-5pm) Evening (5pm-9pm)

Public reporting of this collection of information is estimated to average 8 minutes per response, including the time for reviewing instructions and completing and reviewing the collection of information. An agency many not conduct or sponsor, and a person is not required to respond to a collection of information unless it displays a current 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 (XXXX-XXXX)