BD-STEPS Questionnaire

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 [with [NOIB]; TAB: affected by a birth defect]. In order to do this, I need to start by asking you some dates.

A1. What was [NOIB]’s date of birth? / If [TAB]: On what date did the affected pregnancy end?

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 [[NOIB]’s birth; TAB: the affected pregnancy]? That is, when was [[NOIB]; TAB: the baby] expected to be born? [Note: If mom knows due date, CATI will calculate which pregnancy months correspond with calendar dates. If mom does not know due date, use the EDD recorded in the tracking database to calculate dates.]

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?

YES  SKIP TO A6
NO  CONTINUE TO A4
DK  SKIP TO A6
RF  SKIP TO A6

A4. What did s/he die of?

SPECIFY:__________
DK
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.

AGE:__________ DK RF

UNITS:__________ (Days, Weeks, Months, Years)

A6. What was your date of birth?

MM/DD/YYYY CAN USE DK OR RF FOR MM OR DD OR YYYY

A7. I would like to ask about [[NOIB]’s; TAB: 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?]

MM/DD/YYYY CAN USE DK OR RF FOR MM OR DD OR YYYY
DK WHO FATHER IS

Section B: MULTIPLE GESTATION

B1. In [your pregnancy with [NOIB]; TAB: the affected pregnancy], how many babies were you carrying? PROBE: Were you carrying a single baby, twins, or more babies?

Number of babies:__________
1. IF 1 (SINGLE BABY)  SKIP TO NEXT SECTION
2. IF ≥2 (TWINS OR HIGHER ORDER MULTIPLE)  CONTINUE TO B2; IF TAB: SKIP TO NEXT SECTION
3. DK  SKIP TO NEXT SECTION
4. RF  SKIP TO NEXT SECTION

B2. [Is the other baby/are the other babies] still living?

Yes, all other babies still living
Some babies still living, others are not
No, no other babies still living
DK
RF

B3. What was the sex of the [1^st, 2^nd, etc.] baby? [RECORD FOR EACH ADDITIONAL BABY (NUMBER REPORTED IN B1)]

Girl
Boy
Indeterminate
DK
RF

B4. Was this baby affected by a birth defect? [RECORD FOR EACH ADDITIONAL BABY]

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]

DEFECT (SPECIFY):___________________________
DK
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]

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 [[NOIB]; TAB: the pregnancy that ended on [DOIB]], including pregnancies that may have ended in miscarriages, stillbirths, induced abortions, or other outcomes?

NUMBER:__________
1. IF 0  SKIP TO NEXT SECTION
2. IF >0  CONTINUE TO C2
DK  SKIP TO NEXT SECTION
RF  SKIP TO NEXT SECTION

C2. When did the last pregnancy before [[NOIB]; TAB: the pregnancy that ended on [DOIB]] end?

MM/DD/YYYY CAN USE DK OR RF FOR MM OR DD OR YYYY OR
TIME PERIOD AGO:__________

YEARS
MONTHS
WEEKS

C3a. Did that pregnancy end with a live birth? [IF A MULTIPLE PREGNANCY HAD AT LEAST ONE FETUS BORN LIVE, SELECT YES]

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

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? [IF MORE THAN 1 OUTCOME AND OUTCOMES ENDED ON DIFFERENT DATES, RECORD THE LATEST DATE]

AMOUNT:______________ SKIP TO NEXT SECTION IF C1a=1/ CONTINUE TO C5 IF C1a>1

i. UNITS:___________(Days, Weeks, Months, Trimesters)

DK  SKIP TO NEXT SECTION IF C1a=1/CONTINUE TO C5 IF C1a>1
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 [(1^st, 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?

YES  SKIP TO NEXT SECTION/ASK ABOUT NEXT PREGNANCY
NO  CONTINUE TO C6
DK  SKIP TO NEXT SECTION/ASK ABOUT NEXT PREGNANCY
RF  SKIP TO NEXT SECTION/ASK ABOUT NEXT PREGNANCY

C6. Did that pregnancy end with (a/an) stillbirth, induced abortion, miscarriage, or some other outcome? [IF 2 OR MORE OUTCOMES IN 1 PREGNANCY ENTER IN 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?

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?

YES  CONTINUE TO D2
NO  SKIP TO D3
DK  SKIP TO D3
RF  SKIP TO D3

D2. What was it? / Anything else?

SPECIFY:___________________________
DK
RF

D3. IF FATHER UNKNOWN, SKIP TO D5: Did [[NOIB]’s; TAB: the] biological or natural father have a health problem at birth or a birth defect that was diagnosed in childhood?

YES  CONTINUE TO D4
NO  SKIP TO D5/NEXT SECTION
DK  SKIP TO D5/NEXT SECTION
RF  SKIP TO D5/NEXT SECTION

D4. What was it? / Anything else?

SPECIFY:___________________________
DK
RF

D5. IF PREVIOUS PREGNANCIES REPORTED: Did any of [[NOIB]’s; TAB: 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.

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?

SPECIFY:___________________________
DK
RF

Section E: FERTILITY

Now I have some questions specific to your pregnancy [with [NOIB]; TAB: that ended on [DOIB]].

E1. How long were you trying to get pregnant with [[NOIB]; TAB: the pregnancy affected by a birth defect] before you became pregnant? [READ OPTIONS]

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 [[NOIB]; TAB: 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?

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 (INDICATE ALL THAT APPLY):

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

E3. Which was the last procedure you used before getting pregnant with [[NOIB]; TAB: the affected pregnancy]?

IN-VITRO FERTILIZATION, OR IVF
INTRACYTOPLASMIC SPERM INJECTION, OR ICSI
ARTIFICIAL INSEMINATION
DK
RF

E4. What was the date of that procedure?

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]?

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]

Donor eggs
Donor sperm
Donor embryos
DK
RF

E7. Were frozen egg(s), frozen sperm, or frozen embryo(s) used on [DATE OF PROCEDURE, ANSWER E4]?

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]

Frozen eggs
Frozen sperm
Frozen embryos
DK
RF

E9. In the two months before you became pregnant with [[NOIB]; TAB: the pregnancy that ended on [DOIB]] did you take any medications to help you become pregnant?

YES
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.
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.
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?

YES  ASK E10a
NO
DK
RF

E9b. Did you take Letrozole/Femara?

YES  ASK E10b
NO
DK
RF

E9c. Did you take anything else?

E9d. What did you take? IF CAN’T RECALL, READ LIST:

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?

NUMBER:__________
DK
RF

E10b. IF E9b=YES: How many Letrozole/Femara pills per day did you take at your last cycle before getting pregnant?

NUMBER:__________
DK
RF

E11. IF REPORT ANY FERTILITY PROCEDURES OR MEDICATIONS: How many menstrual cycles with fertility treatments (complete or incomplete) did you have before [you got pregnant with [NOIB]; TAB: the pregnancy that ended on [DOIB]]?

1 cycle
2-3 cycles
4-6 cycles
more than 6 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 female issue, such as blocked fallopian tubes or Polycystic Ovary Syndrome  CONTINUE TO E13
A male issue, such as low sperm count or low motility  SKIP TO E14 IF PREVIOUS PREGNANCY REPORTED/E15 IF ONLY ONE PREGNANCY REPORTED
No male partner  SKIP TO E14/E15
Unexplained  SKIP TO E14/E15
DK  SKIP TO E14/E15
RF  SKIP TO E14/E15

E13. IF REPORT FEMALE FACTOR: What was the female issue? Was it… [READ OPTIONS; INDICATE ALL THAT APPLY]

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.	Ovulation stimulation pills, such as Clomid or Femara	YES	NO	DK	RF
E14c.	Artificial insemination	YES	NO	DK	RF
E14d.	In-vitro fertilization, or IVF	YES	NO	DK	RF
E14e.	Intracytoplasmic sperm injection, or ICSI	YES	NO	DK	RF

E15. During the first trimester of your pregnancy with [[NOIB]; TAB: the pregnancy that ended on [DOIB]], did you take any medications to prevent pregnancy complications or pregnancy loss, such as hormones, steroids, or injections?

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…?]

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 [MEDICINE, ANSWER E16] to prevent complications or pregnancy loss? (For day can indicate beginning, middle, or end of month) [CAN USE DK OR RF FOR MM OR DD OR YY]

MM/DD/YYYY OR
MONTH OF PREGNANCY (P1, P2, P3, T1)
DK
RF

E18. When did you stop using [MEDICINE, ANSWER E16] for the last time during this time period? [CAN USE DK OR RF FOR MM OR DD OR YY]

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.

AMOUNT:__________

Days
Weeks
Months

E20. How often did you use [MEDICINE, ANSWER E16] 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.

AMOUNT:__________ Per Day/Per Week/Per Month/Per Time Period/DK/RF

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?

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]?

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 [[NOIB]; TAB: the affected pregnancy]? [READ LIST]

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?

YES  GO TO F5
NO  SKIP TO F7
DK  SKIP TO F7
RF  SKIP TO F7

F5. Did you discuss these options before your pregnancy began?

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?

AMOUNT:__________
UNITS:

Days
Weeks
Months
Trimesters

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.

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

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…?]

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

ANSWER F9-F18 FOR ALL DRUGS SELECTED IN F8.

F9. Did you use [DRUG, ANSWER F8] for the entire time from the month before your pregnancy through your third month of pregnancy, that is from [B1] to [P4(-1)]?

YES  SKIP TO F13
NO  CONTINUE TO F10
DK  CONTINUE TO F10
RF  CONTINUE TO F10

F10. When did you start using [DRUG, ANSWER F8] for diabetes for the first time during this period? (For day can indicate beginning, middle, or end of month) [CAN USE DK OR RF FOR MM OR DD OR YY]

MM/DD/YYYY or
MONTH OF PREGNANCY (B1, P1, P2, P3)
DK
RF

F11. When did you stop using [DRUG, ANSWER F8] for the last time during this time period? [CAN USE DK OR RF FOR MM OR DD OR YY]

MM/DD/YYYY or
MONTH OF PREGNANCY (B1, P1, P2, P3)  IF VALID RESPONSE TO F10 AND F11, SKIP F12
DK
RF

F12. How long did you take it?

AMOUNT:__________

Days
Weeks
Months

F13. How often did you use [DRUG, ANSWER F8] 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

F14. Did you take the same dose of [DRUG, ANSWER F8] 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  CONTINUE TO F15
NO  SKIP TO F16a
DK  CONTINUE TO F15
RF  CONTINUE TO F15

F15. What dose of [DRUG, ANSWER F8] did you take each time you took it?

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)

UNITS:__________

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? [If mom knows she took more than one dosage, but can't remember how many, select 1 for the number of dosages and report the dosage info she does remember. You may put additional details in a comment field.]

AMOUNT:__________
RF

F16b. What dose of [DRUG, ANSWER F8] did you take the [1st, 2^nd, etc.] time?

AMOUNT:__________

DK  SKIP TO F17

RF  SKIP TO F17

UNITS:__________ DK RF

F17. When did you begin taking that dose? [CAN USE DK OR RF FOR MM OR DD OR YY]

MM/DD/YYYY or
MONTH OF PREGNANCY(B1, P1, P2, P3)
DK
RF

F18. When did you stop taking that dose?

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)
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)
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)
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. How long did you take it?

AMOUNT:__________ DK RF

Days
Weeks
Months

F19. ASK IF F7b OR F7c=YES: In order to modify your eating habits or control your weight, did you…? [READ OPTIONS AND ASK: “Did you do anything else?”]

Follow a diet specifically for diabetes?
Eat healthier but no specific diabetes diet?
Do physical exercise?
OTHER, SPECIFY____________________________
DK
RF

F20. IF F7d=YES: What else did you do to manage your diabetes and its complications? / Anything else?

SPECIFY:_____________________________
DK
RF

F21a. IF F7a = YES: How often did taking medications or other remedies work in controlling your diabetes? [READ OPTIONS.]

Always
Most of the time
Part of the time
Never or rarely
DK
RF

F21b. IF F7b = YES: How often did modifying your eating habits work in controlling your diabetes? [READ OPTIONS.]

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.]

Always
Most of the time
Part of the time
Never or rarely
DK
RF

F21d. IF F7d = YES: How often did ([ACTIVITY TO MANAGE DIABETES, ANSWER F20]) work in controlling your diabetes? [RE-WORD APPROPRIATELY IF F20 =DO NOT KNOW. READ OPTIONS.]

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 [NOIB]; TAB: the pregnancy that ended on [DOIB]], had a doctor or other health professional ever checked your glycosylated hemoglobin or “A one C”?

YES  CONTINUE TO F23
NO  SKIP TO NEXT SECTION
DK  SKIP TO NEXT SECTION
RF  SKIP TO NEXT SECTION

F23. What was your “A one C” level at the time it was tested closest to when you became pregnant with [NOIB]; TAB: the pregnancy that ended on [DOIB]]? 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?

MM/DD/YYYY OR
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

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?

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.

SPECIFY:__________
DK
RF

G3. How old were you when you were diagnosed with cancer for the first time?

AGE:_______________________
DK
RF

G4. What is the current status of your cancer? (READ OPTIONS)

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?

TIME:__________

Years
Months
Weeks
Days

Section H: HEART PROBLEMS

H1. Do you have a heart problem that has been present since birth?

YES  CONTINUE TO H2
NO  SKIP TO H15
DK  SKIP TO H15
RF  SKIP TO H15

H2. What is it?

SPECIFY:__________
DK
RF

H3. Did you take any medications or remedies for [HEART PROBLEM, ANSWER H2] during the month before your pregnancy through the third month of your (pregnancy with [[NOIB]; TAB: the pregnancy that ended on [DOIB]]?

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?

SPECIFY:__________
DK  SKIP TO H15
RF  SKIP TO H15

H5. Did you use [MEDICINE, ANSWER H4] for the entire time from the month before your pregnancy through your third month of pregnancy, that is from [B1] through [P4(-1)]?

YES  SKIP TO H9
NO  CONTINUE TO H6
DK  CONTINUE TO H6
RF  CONTINUE TO H6

H6. When did you start using [MEDICINE, ANSWER H4] for the first time during this period? (For day can indicate beginning, middle, or end of month) [CAN USE DK OR RF FOR MM OR DD OR YY]

MM/DD/YYYY or
MONTH OF PREGNANCY (B1, P1, P2, P3)
DK
RF

H7. When did you stop using [MEDICINE, ANSWER H4] for the last time during this time period? [CAN USE DK OR RF FOR MM OR DD OR YY]

MM/DD/YYYY or
MONTH OF PREGNANCY (B1, P1, P2, P3)  IF VALID RESPONSE TO H6 AND H7, SKIP H8
DK
RF

H8. How long did you take it?

AMOUNT:__________

Days
Weeks
Months

H9. How often did you use [MEDICINE, ANSWER H4] 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

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.

YES  CONTINUE TO H11
NO  SKIP TO H12a
DK  CONTINUE TO H11
RF  CONTINUE TO H11

H11. What dose of [MEDICINE, ANSWER H4] did you take each time you took it?

AMOUNT:__________  SKIP TO H15

DK  SKIP TO H15

RF  SKIP TO H15

UNITS:__________  SKIP TO H15

DK  SKIP TO H15

RF  SKIP TO H15

H12a. How many different dosage amounts do you remember taking? [If mom knows she took more than one dosage, but can't remember how many, select 1 for the number of dosages and report the dosage info she does remember. You may put additional details in a comment field.]

AMOUNT:__________
RF

H12b. What dose of [MEDICINE, ANSWER H4] did you take the [1st, 2^nd, etc.] time?

AMOUNT:__________

DK  SKIP TO H13

RF  SKIP TO H13

UNITS:__________

H13. When did you begin taking that dose?

MM/DD/YYYY or
MONTH OF PREGNANCY(B1, P1, P2, P3)
DK
RF

H14. When did you stop taking that dose?

MM/DD/YYYY or
MONTH OF PREGNANCY(B1, P1, P2, P3)  IF VALID RESPONSE TO H13 AND H14, SKIP H14a
DK
RF

H14a. How long did you take it?

AMOUNT:__________

Days
Weeks
Months

H15. Have you ever been diagnosed with cardiac arrhythmias?

YES  CONTINUE TO H16
NO  SKIP TO H28
DK  SKIP TO H28
RF  SKIP TO H28

H16. Did you take any medication for arrhythmias during the month before your pregnancy through the third month of pregnancy?

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]:

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 [DRUG, ANSWER H17] for the entire time from the month before your pregnancy through the third month of pregnancy, that is from [B1] to [P4(-1)]?

YES  SKIP TO H22
NO  CONTINUE TO H19
DK  CONTINUE TO H19
RF  CONTINUE TO H19

H19. When did you start using [DRUG, ANSWER H17] for arrhythmias for the first time during this period? [CAN USE DK OR RF FOR MM OR DD OR YY]

MM/DD/YYYY or
MONTH OF PREGNANCY(B1, P1, P2, P3)
DK
RF

H20. When did you stop using [DRUG, ANSWER H17] for arrhythmias for the last time during this time period? [CAN USE DK OR RF FOR MM OR DD OR YY]

MM/DD/YYYY or
MONTH OF PREGNANCY(B1, P1, P2, P3)  IF VALID RESPONSE TO H19 AND H20, SKIP H21
DK
RF

H21. How long did you take it?

AMOUNT:__________

Days
Weeks
Months

H22. How often did you use [DRUG, ANSWER H17] 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

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.

YES  CONTINUE TO H24
NO  SKIP TO H25a
DK  CONTINUE TO H24
RF  CONTINUE TO H24

H24. What dose of [DRUG, ANSWER H17] did you take each time you took it?

AMOUNT:__________  SKIP TO H28

UNITS:__________

DK  SKIP TO H28
RF  SKIP TO H28

H25a. How many different dosage amounts do you remember taking? [If mom knows she took more than one dosage, but can't remember how many, select 1 for the number of dosages and report the dosage info she does remember. You may put additional details in a comment field.]

AMOUNT:__________
RF

H25b. What dose of [DRUG, ANSWER H17] did you take the [1st, 2^nd, etc.] time?

AMOUNT:__________

DK  SKIP TO H26

RF  SKIP TO H26

UNITS:__________

H26. When did you begin taking that dose?

MM/DD/YYYY or
MONTH OF PREGNANCY(B1, P1, P2, P3)
DK
RF

H27. When did you stop taking that dose?

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?

AMOUNT:__________

Days
Weeks
Months

H28. Were you ever in your life told by a doctor that you had high blood pressure?

YES  CONTINUE TO H29
NO  SKIP TO NEXT SECTION
DK  SKIP TO NEXT SECTION
RF  SKIP TO NEXT SECTION

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.

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?

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?

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?

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?

YES  CONTINUE TO H34
NO  SKIP TO NEXT SECTION
DK  SKIP TO NEXT SECTION
RF  SKIP TO NEXT SECTION

H34. What did you take? / Did you take anything else? IF CAN’T RECALL, READ FROM DRUG LIST:

Accupril
Adalat
Altace
Amlodipine
Atenolol
Avapro
Benazepril HCL
Benicar
Calan
Capoten
Cardizem
Covera -HS
Cozaar
Diltiazem HCL
Diovan
Enalapril Maleate
Hydralazine
Hydrochlorothiazide
Inderal
Irbesartan
Labetalol
Lisinopril
Losartan Potassium
Lotensin
Methyldopa
Metoprolol
Microzide
Nifedipine
Normodyne
Norvasc
Olmesartan Medoxomil
Prinivil
Procardia
Propranolol
Quinapril HCL
Ramipril
Tenormin
Tiazac
Trandate
Valsartan
Vasotec
Verapamil
Verelan
Zestril
OTHER (SPECIFY):__________
DK  SKIP TO NEXT SECTION
RF  SKIP TO NEXT SECTION

H35. Did you use [DRUG, ANSWER H34] for the entire time from the month before your pregnancy through your third month of pregnancy, that is from [B1] to [P4(-1)]?

YES  SKIP TO H39
NO  CONTINUE TO H36
DK  CONTINUE TO H36
RF  CONTINUE TO H36

H36. When did you start using [DRUG, ANSWER H34] for high blood pressure for the first time during this period? [CAN USE DK OR RF FOR MM OR DD OR YY]

MM/DD/YYYY or
MONTH OF PREGNANCY(B1, P1, P2, P3)
DK
RF

H37. When did you stop using [DRUG, ANSWER H34] for the last time during this time period? [CAN USE DK OR RF FOR MM OR DD OR YY]

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?

AMOUNT:__________

Days
Weeks
Months

H39. How often did you use [DRUG, ANSWER H34] 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

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.

YES  CONTINUE TO H41
NO  SKIP TO H42a
DK  CONTINUE TO H41
RF  CONTINUE TO H41

H41. What dose of [DRUG, ANSWER H34] did you take each time you took it?

AMOUNT:__________

DK  SKIP TO NEXT SECTION

RF  SKIP TO NEXT SECTION

UNITS:__________

H42a. How many different dosage amounts do you remember taking? [If mom knows she took more than one dosage, but can't remember how many, select 1 for the number of dosages and report the dosage info she does remember. You may put additional details in a comment field.]

AMOUNT:__________
RF

H42b. What dose of [DRUG, ANSWER H34] did you take the [1st, 2^nd, etc.] time?

AMOUNT:__________

DK  SKIP TO H43

RF  SKIP TO H43

UNITS:__________ DK RF

H43. When did you begin taking that dose?

MM/DD/YYYY or
MONTH OF PREGNANCY(B1, P1, P2, P3)
DK
RF

H44. When did you stop taking that dose?

MM/DD/YYYY or
MONTH OF PREGNANCY(B1, P1, P2, P3)  IF VALID RESPONSE TO H43 and H44, SKIP H44a
DK
RF

H44a. How long did you take it?

AMOUNT:__________

Days
Weeks
Months

Section I: THYROID DISEASE

I1. Have you ever been diagnosed with thyroid disease, not including thyroid cancer, which we have already talked about?

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; ASK ALL OPTIONS AND ALLOW MULTIPLE TYPES]

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

I3. When was [THYROID DISEASE, ANSWER I2] first diagnosed relative to [your pregnancy with [NOIB]; TAB: the pregnancy that ended on [DOIB]]? [READ LIST]

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

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?

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?

All
Part
DK
RF

I6. When did you have this surgery?

MM/DD/YYYY OR
AGE:__________ or
Time period ago:__________

Years
Months
Weeks
Days

I7. Did you have treatment with radioactive iodine?

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?

MM/DD/YYYY or
AGE:__________ or
Time period ago:__________

Years
Months
Weeks
Days

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?

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?

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?

AMOUNT:__________
UNITS:

Days
Weeks
Months
Trimesters

I12. Did you take any medications or remedies for [THYROID DISEASE, ANSWER I2] during the month before your pregnancy through the third month of pregnancy, that is from [B1] to [P4(-1)]?

YES  CONTINUE TO I13
NO  SKIP TO NEXT SECTION
DK  SKIP TO NEXT SECTION
RF  SKIP TO NEXT SECTION

I13. What did you take? / Did you take anything else?

IF CAN’T RECALL, READ FROM LIST:

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?

YES  SKIP TO I18
NO  CONTINUE TO I15
DK  CONTINUE TO I15
RF  CONTINUE TO I15

I15. When did you start using [MEDICINE, ANSWER I13] for [THYROID DISEASE, ANSWER I2] for the first time during this period? [CAN USE DK OR RF FOR MM OR DD OR YY]

MM/DD/YYYY or
MONTH OF PREGNANCY(B1, P1, P2, P3)
DK
RF

I16. When did you stop using [MEDICINE, ANSWER I13] for [THYROID DISEASE, ANSWER I2] for the last time during this time period? [CAN USE DK OR RF FOR MM OR DD OR YY]

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?

AMOUNT:__________

Days
Weeks
Months

I18. How often did you use [MEDICINE, ANSWER I13] 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

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.

YES  CONTINUE TO I20
NO  SKIP TO I21a
DK  CONTINUE TO I20
RF  CONTINUE TO I20

I20. What dose of [MEDICINE, ANSWER I13] did you take each time you took it?

AMOUNT:__________ DK RF SKIP TO NEXT SECTION

UNITS:__________

I21a. How many different dosage amounts do you remember taking? [If mom knows she took more than one dosage, but can't remember how many, select 1 for the number of dosages and report the dosage info she does remember. You may put additional details in a comment field]

AMOUNT:__________
RF

I21b. What dose of [MEDICINE, ANSWER I13] did you take the [1st, 2^nd, etc.] time?

AMOUNT:__________

DK  SKIP TO I22

RF  SKIP TO I22

UNITS:__________ DK RF

I22. When did you begin taking that dose?

MM/DD/YYYY OR
MONTH OF PREGNANCY(B1, P1, P2, P3)
DK
RF

I23. When did you stop taking that dose?

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?

AMOUNT:__________

Days
Weeks
Months

Section J: ASTHMA

J1. Have you ever been diagnosed with asthma or reactive airway disease?

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 [your pregnancy with [NOIB]; TAB: the pregnancy that ended on [DOIB]]? [READ LIST]

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.

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?

J5. During that 4 month period how often did you wake up at night because of your asthma? [READ OPTIONS]

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?

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?

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?

AMOUNT:__________ DK RF
UNITS:

Days
Weeks
Months
Trimesters

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?

YES  CONTINUE TO J10a
NO  SKIP TO J45
DK  SKIP TO J45
RF  SKIP TO J45

J10a. Did you use any nasal sprays?

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

Flonase
Flunisolide
Fluticasone Nasal Spray
Nasonex Nasal Spray
Omnaris Nasal Spray
Qnasl Nasal Aerosol
Rhinocort
OTHER (SPECIFY):__________
DK  SKIP TO J22a
RF  SKIP TO J22a

ASK J12-J21, AS APPROPRIATE FOR EACH DRUG USED IN J10b: [Note: Question J11 Removed]

J12. Did you use [NASAL SPRAY, ANSWER J10b] for the entire time from the month before your pregnancy through your third month of pregnancy?

YES  SKIP TO J16
NO  CONTINUE TO J13
DK  CONTINUE TO J13
RF  CONTINUE TO J13

J13. When did you start using [NASAL SPRAY, ANSWER J10b] for asthma or reactive airway disease for the first time during this period? [CAN USE DK OR RF FOR MM OR DD OR YY]

MM/DD/YYYY OR
MONTH OF PREGNANCY(B1, P1, P2, P3)
DK
RF

J14. When did you stop using [NASAL SPRAY, ANSWER J10b] for the last time during this time period? [CAN USE DK OR RF FOR MM OR DD OR YY]

MM/DD/YYYY or
MONTH OF PREGNANCY(B1, P1, P2, P3)  IF VALID RESPONSE TO J13 AND J14, SKIP J15
DK
RF

J15. How long did you take it?

AMOUNT:__________

Days
Weeks
Months

J16. How often did you use [NASAL SPRAY, ANSWER J10b] 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

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.

YES  J18
NO  SKIP TO J19a
DK  CONTINUE TO J18
RF  CONTINUE TO J18

J18. What dose of [NASAL SPRAY, ANSWER J10b] did you take each time you took it?

AMOUNT:__________  SKIP TO J22a

UNITS:__________

DK  SKIP TO J22a
RF  SKIP TO J22a

J19a. How many different dosage amounts do you remember taking? [If mom knows she took more than one dosage, but can't remember how many, select 1 for the number of dosages and report the dosage info she does remember. You may put additional details in a comment field.]

AMOUNT:__________
RF

J19b. What dose of [NASAL SPRAY, ANSWER J10b did you take the [1st, 2^nd, etc.] time?

AMOUNT:__________

DK  SKIP TO J20

RF  SKIP TO J20

UNITS:__________ DK RF

J20. When did you begin taking that dose?

MM/DD/YYYY or
MONTH OF PREGNANCY(B1, P1, P2, P3)
DK
RF

J21. When did you stop taking that dose?

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?

AMOUNT:__________ DK RF

Days
Weeks
Months

J22a. Did you use any oral inhalants, that is medicine you sprayed in your mouth?

YES  CONTINUE TO J22b
NO  SKIP TO J34a
DK  SKIP TO J34a
RF  SKIP TO J34a

J22b. What did you take? / Did you take anything else? IF CAN’T RECALL, READ FROM DRUG LIST:

ORAL INHALANTS

Advair
Aerobid
Aerospan Hfa
Alvesco Inhaler
Asmanex Twisthaler
Budesonide Inhalation Suspension
Dulera
Flovent
Foradil
Formoterol Fumarate
Perforomist
Pulmicort
Qvar HFA Inhaler
Salmeterol Xinafoate
Serevent
Symbicort
OTHER (SPECIFY):__________

DK  SKIP TO J34a
RF  SKIP TO J34a

ASK J23-J32, AS APPROPRIATE FOR EACH DRUG USED IN J22b:

J23. Did you use [ORAL INHALANT, ANSWER J22b] for the entire time from the month before your pregnancy through your third month of pregnancy?

YES  SKIP TO J27
NO  CONTINUE TO J24
DK  CONTINUE TO J24
RF  CONTINUE TO J24

J24. When did you start using [ORAL INHALANT, ANSWER J22b] for asthma or reactive airway disease for the first time during this period? [CAN USE DK OR RF FOR MM OR DD OR YY]

MM/DD/YYYY OR
MONTH OF PREGNANCY(B1, P1, P2, P3)
DK
RF

J25. When did you stop using [ORAL INHALANT, ANSWER J22b] for the last time during this time period? [CAN USE DK OR RF FOR MM OR DD OR YY]

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?

AMOUNT:__________

Days
Weeks
Months

J27. How often did you use [ORAL INHALANT, ANSWER J22b] 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

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.

YES  J29
NO  SKIP TO J30a
DK  CONTINUE TO J29
RF  CONTINUE TO J29

J29. What dose of [ORAL INHALANT, ANSWER J22b] did you take each time you took it?

AMOUNT:___________  SKIP TO J34a

UNITS:__________

DK  SKIP TO J34a
RF  SKIP TO J34a

J30a. How many different dosage amounts do you remember taking?

AMOUNT:__________
RF

J30b. What dose of [ORAL INHALANT, ANSWER J22b] did you take the [1^st, 2^nd, etc.] time?

AMOUNT:__________

DK  SKIP TO J31

RF  SKIP TO J31

UNITS:__________ DK RF

J31. When did you begin taking that dose?

MM/DD/YYYY or
MONTH OF PREGNANCY(B1, P1, P2, P3)
DK
RF

J32. When did you stop taking that dose?

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?

AMOUNT:__________ DK RF

Days
Weeks
Months

J33 [QUESTION NUMBER NOT USED]

J34a. Did you use any pills you took by mouth?

YES  CONTINUE TO J34b
NO  SKIP TO J45
DK  SKIP TO J45
RF  SKIP TO J45

J34b. What did you take? / Did you take anything else? IF CAN’T RECALL, READ FROM DRUG LIST:

ORAL TABLETS/CAPS

Accolate
Montelukast Sodium
Singulair
Zafirlukast
Zileuton
Zyflo
OTHER (SPECIFY):__________
DK  SKIP TO J45
RF  SKIP TO J45

ASK J35-J44, AS APPROPRIATE FOR EACH DRUG USED IN J34b:

J35. Did you use [ORAL TABLET/CAP, ANSWER J34b] for the entire time from the month before your pregnancy through your third month of pregnancy?

YES  SKIP TO J39
NO  CONTINUE TO J36
DK  CONTINUE TO J36
RF  CONTINUE TO J36

J36. When did you start using [ORAL TABLET/CAP, ANSWER J34b] for asthma or reactive airway disease for the first time during this period? [CAN USE DK OR RF FOR MM OR DD OR YY]

MM/DD/YYYY OR
MONTH OF PREGNANCY(B1, P1, P2, P3)
DK
RF

J37. When did you stop using [ORAL TABLET/CAP, ANSWER J34b] for the last time during this time period? [CAN USE DK OR RF FOR MM OR DD OR YY]

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?

AMOUNT:__________

Days/Weeks/Months

J39. How often did you use [ORAL TABLET/CAP, ANSWER J34b] 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

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.

YES  J41
NO  SKIP TO J42a
DK  CONTINUE TO J41
RF  CONTINUE TO J41

J41. What dose of [ORAL TABLET/CAP, ANSWER J34b] did you take each time you took it?

AMOUNT:_____  SKIP TO J45

UNITS:__________

DK  SKIP TO J45
RF  SKIP TO J45

J42a. How many different dosage amounts do you remember taking? [If mom knows she took more than one dosage, but can't remember how many, select 1 for the number of dosages and report the dosage info she does remember. You may put additional details in a comment field.]

AMOUNT:__________
RF

J42b. What dose of [ORAL TABLET/CAP, ANSWER J34b] did you take the [1^st, 2^nd, etc.] time?

AMOUNT:__________

DK  SKIP TO J43

RF  SKIP TO J43

UNITS:__________ DK RF

J43. When did you begin taking that dose?

MM/DD/YYYY OR
MONTH OF PREGNANCY(B1, P1, P2, P3)
DK
RF

J44. When did you stop taking that dose?

MM/DD/YYYY OR
MONTH OF PREGNANCY(B1, P1, P2, P3)  IF VALID RESPONSE TO J43 and J44, SKIP J44a
DK
RF

J44a. How long did you take it?

AMOUNT:__________ DK RF

Days
Weeks
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?

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.]

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 [MEDICINE, J46 OTHER SPECIFIED] from a pill that you swallowed or from a shot?

Pill
Shot (injection)
Inhaler
DK
RF

ASK J48-J50, AS APPROPRIATE FOR EACH DRUG USED IN J46:

J48. How often did you use [MEDICINE, ANSWER J48] 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.

AMOUNT:__________ Per Day/Per Week/Per Month/Per Time Period/DK/RF

J49. Did you use [MEDICINE, ANSWER J48] for 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"]

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 [MEDICINE, ANSWER J48D] during the month before your pregnancy, which was [B1] to [P1]?

AMOUNT:__________ Per Day/Per Week/Per Month/Per Time Period/Per Year/DK/RF
DID NOT TAKE

J50b. How often did you use [MEDICINE, ANSWER J48] during the first month of your pregnancy, which was [P1] to [P2(-1)]?

AMOUNT:__________ Per Day/Per Week/Per Month/ Per Time Period/Per Year/DK/RF
DID NOT TAKE

J50c. How often did you use [MEDICINE, ANSWER J48] during the second month of your pregnancy, which was [P2] to [P3(-1)]?

AMOUNT:__________ Per Day/Per Week/Per Month/ Per Time Period/Per Year/DK/RF
DID NOT TAKE

J50d. How often did you use [MEDICINE, ANSWER J48] during the third month of your pregnancy, which was [P3] to [P4(-1)]?

AMOUNT:__________ Per Day/Per Week/Per Month/ Per Time Period/Per Year/DK/RF
DID NOT TAKE

Section K: EPILEPSY

K1. Were you ever told by a doctor that you had epilepsy?

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:

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 [your pregnancy with [[NOIB]; TAB: the pregnancy that ended on [DOIB]]? [READ LIST]

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?

YES  GO TO K5
NO  SKIP TO K7
DK  SKIP TO K7
RF  SKIP TO K7

K5. Did you discuss these options before your pregnancy began?

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?

AMOUNT:__________ DK RF

Days
Weeks
Months
Trimesters

K7. Did you take any medications or remedies for epilepsy during the month before your pregnancy through the third month of pregnancy?

YES  CONTINUE TO K8
NO  SKIP TO K19
DK  SKIP TO K19
RF  SKIP TO K19

K8. What did you take? / Did you take anything else? [IF CAN’T RECALL, READ FROM DRUG LIST]:

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 [MEDICINE, ANSWER K8] for the entire time from the month before your pregnancy through your third month of pregnancy, that is from [B1] to [P4(-1)]?

YES  SKIP TO K13
NO  CONTINUE TO K10
DK  CONTINUE TO K10
RF  CONTINUE TO K10

K10. When did you start using [MEDICINE, ANSWER K8] for epilepsy for the first time during this period? [CAN USE DK OR RF FOR MM OR DD OR YY]

MM/DD/YYYY OR
MONTH OF PREGNANCY(B1, P1, P2, P3)
DK
RF

K11. When did you stop using [MEDICINE, ANSWER K8] for the last time during this time period? [CAN USE DK OR RF FOR MM OR DD OR YY]

MM/DD/YYYY OR
MONTH OF PREGNANCY(B1, P1, P2, P3)  IF VALID RESPONSE TO K10 and K11, SKIP K12
DK
RF

K12. How long did you take it?

AMOUNT:________________

Days
Weeks
Months

K13. How often did you use [MEDICINE, ANSWER K8] 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

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.

YES  CONTINUE TO K15
NO  SKIP TO K16a
DK  CONTINUE TO K15
RF  CONTINUE TO K15

K15. What dose of [MEDICINE, ANSWER K8] did you take each time you took it?

AMOUNT:__________  SKIP TO K19

UNITS:____________

DK  SKIP TO K19
RF  SKIP TO K19

K16a. How many different dosage amounts do you remember taking? [If mom knows she took more than one dosage, but can't remember how many, select 1 for the number of dosages and report the dosage info she does remember. You may put additional details in a comment field.]

AMOUNT:__________
RF

K16b. What dose of [MEDICINE, ANSWER K8] did you take the [1^st, 2^nd, etc.] time?

AMOUNT:__________

DK  SKIP TO K17

RF  SKIP TO K17

UNITS:__________ DK RF

K17. When did you begin taking that dose?

MM/DD/YYYY or
MONTH OF PREGNANCY(B1, P1, P2, P3)
DK
RF

K18. When did you stop taking that dose?

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?

AMOUNT:________________

Days
Weeks
Months

K19. Did you have any seizures in the month before your pregnancy through the third month of pregnancy?

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?

AMOUNT:__________
DK
RF

Section L: MIGRAINE

L1. Have you ever had a migraine headache, also sometimes called a sick headache?

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?

AGE:___________
DK
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)]?

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?

How many?:__________ DK RF OR
Frequency – UNIT:__________

Total
Per day
Per week
Per month

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?

YES  CONTINUE TO L6
NO  SKIP TO NEXT SECTION
DK  SKIP TO NEXT SECTION
RF  SKIP TO NEXT SECTION

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:

Ibuprofen (G)
Advil
Aleve
Amitriptyline (G)
Aspirin
Atenolol
Botox
Calan
Cyproheptadine HCL
Depakote
Divalproex Sodium
Doxepin
Effexor
Excedrin Extra Strength Caplets/Tablets/Geltabs
Gabapentin
Inderal
Innopran XL
Lamictal
Lamotrigine (G)
Lisinopril (G)
Motrin
Motrin Ib
Nadolol
Naproxen Sodium
Neurontin
Nortriptyline (G)
Pamelor
Propranolol (G)
Protriptyline HCL
Timolol
Topamax
Topiramate (G)
Valproate Sodium
Valproic Acid (G)
Venlafaxine (G)
Verapamil (G)
Verelan
Vivactil
Zestril

OVER-THE-COUNTER PAIN MEDICATIONS:

Ibuprofen
Acetaminophen
Advil
Aleve
Aspirin
Excedrin Migraine
Motrin
Naproxen Sodium
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. Tylenol with Codeine

xxx. Zolmitriptan

yyy. Zomig

zzz. OTHER (SPECIFY):__________

aaaa. DK SKIP TO NEXT SECTION

bbbb. RF SKIP TO NEXT SECTION

ASK L7-L16, AS APPROPRIATE FOR EACH DRUG USED IN L6:

L7. Did you use [MEDICINE, ANSWER L6] for the entire time from the month before your pregnancy through your third month of pregnancy?

YES  SKIP TO L11
NO  CONTINUE TO L8
DK  CONTINUE TO L8
RF  CONTINUE TO L8

L8. When did you start using [MEDICINE, ANSWER L6] for migraines for the first time during this period? [CAN USE DK OR RF FOR MM OR DD OR YY]

MM/DD/YYYY or
MONTH OF PREGNANCY (B1, P1, P2, P3)
DK
RF

L9. When did you stop using [MEDICINE, ANSWER L6] for the last time during this time period? [CAN USE DK OR RF FOR MM OR DD OR YY]

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?

AMOUNT:________________

Days
Weeks
Months

L11. How often did you use [MEDICINE, ANSWER L6] 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

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.

YES  CONTINUE TO L13
NO  SKIP TO L14a
DK  CONTINUE TO L13
RF  CONTINUE TO L13

L13. What dose of [MEDICINE, ANSWER L6] did you take each time you took it?

AMOUNT:__________  SKIP TO NEXT SECTION

UNITS:__________

DK  SKIP TO NEXT SECTION
RF  SKIP TO NEXT SECTION

L14a. How many different dosage amounts do you remember taking? [If mom knows she took more than one dosage, but can't remember how many, select 1 for the number of dosages and report the dosage info she does remember. You may put additional details in a comment field.]

AMOUNT:__________ RF

L14b. What dose of [MEDICINE, ANSWER L6] did you take the [1^st, 2^nd, etc.] time?

AMOUNT:__________

DK  SKIP TO L15

RF  SKIP TO L15

UNITS:__________ DK RF

L15. When did you begin taking that dose?

MM/DD/YYYY or
MONTH OF PREGNANCY(B1, P1, P2, P3)
DK
RF

L16. When did you stop taking that dose?

MM/DD/YYYY or
MONTH OF PREGNANCY(B1, P1, P2, P3)  IF VALID RESPONSE TO L15 and L16, SKIP L16a
DK
RF

L16a. How long did you take it?

AMOUNT:__________

Days
Weeks
Months

Section M: AUTOIMMUNE DISEASE

M1. Have you ever been diagnosed with any of the following? Indicate all that apply. [READ EACH UP TO RESPONSES PRECEEDED BY "OTHER" THEN ASK: "Other autoimmune disease (not including diabetes or thyroid disorders, which we have already discussed)" THEN, IF CAN'T RECALL, READ RESPONSES PRECEEDED BY "OTHER"] [IF REPORTS OSTEOARTHRITIS, DO NOT RECORD ANSWER, BUT SAY: I’ll ask about osteoarthritis later. Have you ever been diagnosed with any (other) autoimmune disease?]

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:
1. Immune/idiopathic thrombocytopenic purpura
2. Interstitial cystitis
3. Antiphospholipid antibody syndrome/lupus anticoagulant syndrome/APLS
4. Addison’s disease
5. Pernicious anemia
6. Myasthenia gravis
7. Autoimmune hemolytic anemia
8. Berger’s disease/IgA nephropathy
9. Alopecia, universalis or areata
10. Vitiligo
11. Juvenile arthritis
12. Guillain Barre syndrome
13. Scleroderma, morphea
14. Sjögren's syndrome/Sicca syndrome
15. Ankylosing spondylitis
16. Rheumatic fever
17. OTHER (SPECIFY):__________
18. NONE  SKIP TO NEXT SECTION
19. DK  SKIP TO NEXT SECTION
20. RF  SKIP TO NEXT SECTION

IF YES TO ANY, CONTINUE TO M2

ASK FOLLOWING QUESTIONS FOR EACH CONDITION IF MORE THAN ONE CONDITION REPORTED:

M2. When were you first diagnosed with [AUTOIMMUNE DISEASE, ANSWER M1] relative to [your pregnancy with [NOIB]; TAB: the pregnancy that ended on [DOIB]]? [READ OPTIONS.]

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 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?

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?

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?

AMOUNT:__________ DK RF

UNITS:

Days
Weeks
Months
Trimesters

M6. Did you take any medications or remedies for [AUTOIMMUNE DISEASE, ANSWER M1] in the month before your pregnancy through the third month of pregnancy, that is from [B1] TO [P4(-1)]?

YES  CONTINUE TO M7
NO  SKIP TO NEXT SECTION
DK  SKIP TO NEXT SECTION
RF  SKIP TO NEXT SECTION

M7. What did you take? / Did you take anything else? [IF CAN’T RECALL, READ FROM DRUG LIST FOR DISEASE REPORTED IN SQUARE BRACKETS].

[LUPUS]:

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

[Rheumatoid arthritis]:

Abatacept
Actemra
Adalimumab
Advil
Aleve
Anakinra
Arava
Azasan
Azathioprine
Azulfidine
Certolizumab Pegol
Cimzia
Cyclophosphamide
Cyclosporine
Cytoxan
Dynacin
Enbrel
Etanercept
Gengraf
Golimumab
Humira
Hydroxychloroquine Sulfate
Ibuprofen
Imuran
Infliximab
Kineret
Leflunomide
Methotrexate
Minocin
Minocycline
Motrin
Naproxen Sodium
Neoral
Orencia
Plaquenil
Prednisone
Remicade
Rituxan
Rituximab
Sandimmune
Simponi
Sulfasalazine
Tocilizumab
Trexall
OTHER, SPECIFY:______________
DK  SKIP TO NEXT CONDITION/NEXT SECTION
RF  SKIP TO NEXT CONDITION/NEXT SECTION

Multiple sclerosis [MS]:

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

Crohn’s disease and ulcerative colitis [CROHNS]:

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

[Psoriasis]:

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 [MEDICINE, ANSWER M7] for the entire time from the month before your pregnancy through the third month of pregnancy?

YES  SKIP TO M12
NO  CONTINUE TO M9
DK  CONTINUE TO M9
RF  CONTINUE TO M9

M9. When did you start using [MEDICINE, ANSWER M7] for [CONDITION, ANSWER M1] for the first time during this period? [CAN USE DK OR RF FOR MM OR DD OR YY]

MM/DD/YYYY or
MONTH OF PREGNANCY(B1, P1, P2, P3)
DK
RF

M10. When did you stop using [MEDICINE, ANSWER M7] for the last time during this time period? [CAN USE DK OR RF FOR MM OR DD OR YY]

MM/DD/YYYY or
MONTH OF PREGNANCY(B1, P1, P2, P3)  IF VALID START AND STOP DATE, SKIP M11
DK
RF

M11. How long did you take it?

AMOUNT:__________

Days
Weeks
Months

M12. How often did you use [MEDICINE, ANSWER M7] 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

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.

YES  CONTINUE TO M14
NO  SKIP TO M15a
DK  CONTINUE TO M14
RF  SKIP TO M14

M14. What dose of [MEDICINE, ANSWER M7] did you take each time you took it?

AMOUNT:__________  SKIP TO NEXT SECTION

UNITS:__________

DK  SKIP TO NEXT SECTION
RF  SKIP TO NEXT SECTION

M15a. How many different dosage amounts do you remember taking? [If mom knows she took more than one dosage, but can't remember how many, select 1 for the number of dosages and report the dosage info she does remember. You may put additional details in a comment field.]

AMOUNT:__________
RF

M15b. What dose of [MEDICINE, ANSWER M7] did you take the [1^st, 2^nd, etc.] time?

AMOUNT:__________

DK  SKIP TO M16

RF  SKIP TO M16

UNITS:__________ DK RF

M16. When did you begin taking that dose?

MM/DD/YYYY or
MONTH OF PREGNANCY(B1, P1, P2, P3)
DK
RF

M17. When did you stop taking that dose?

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?

AMOUNT:__________

Days
Weeks
Months

Section N: TRANSPLANT RECEIPT

N1. Have you ever received an organ or tissue transplant?

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?

SPECIFY:_________________________ DK RF

N3. What was the date of the transplant?

MM/DD/YYYY
DK
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)]?

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]

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

N6. Did you use [MEDICINE, ANSWER N5] for the entire time from the month before your pregnancy through your third month of pregnancy?

YES  SKIP TO N10
NO  CONTINUE TO N7
DK  CONTINUE TO N7
RF  CONTINUE TO N7

N7. When did you start using [MEDICINE, ANSWER N5] for your transplant for the first time during this period? [CAN USE DK OR RF FOR MM OR DD OR YY]

MM/DD/YYYY or
MONTH OF PREGNANCY(B1, P1, P2, P3)
DK
RF

N8. When did you stop using [MEDICINE, ANSWER N5] for the last time during this time period? [CAN USE DK OR RF FOR MM OR DD OR YY]

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?

AMOUNT:__________ DK RF

Days
Weeks
Months

N10. How often did you use [MEDICINE, ANSWER N5] 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

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.

YES  CONTINUE TO N12
NO  SKIP TO N13a
DK  CONTINUE TO N12
RF  CONTINUE TO N12

N12. What dose of [MEDICINE, ANSWER N5] did you take each time you took it?

AMOUNT:__________  SKIP TO NEXT SECTION

UNITS:__________

DK  SKIP TO NEXT SECTION
RF  SKIP TO NEXT SECTION

N13a. How many different dosage amounts do you remember taking? [If mom knows she took more than one dosage, but can't remember how many, select 1 for the number of dosages and report the dosage info she does remember. You may put additional details in a comment field.]

AMOUNT:__________
RF

N13b. What dose of [MEDICINE, ANSWER N5] did you take the [1^st, 2^nd, etc.] time?

AMOUNT:__________

DK  SKIP TO N14

RF  SKIP TO N14

UNITS:__________ DK RF

N14. When did you begin taking that dose?

MM/DD/YYYY or
MONTH OF PREGNANCY(B1, P1, P2, P3)
DK
RF

N15. When did you stop taking that dose?

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?

AMOUNT:__________

Days
Weeks
Months

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?

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?

SPECIFY:___________ DK RF

O3. When were you first diagnosed relative to [your pregnancy with [NOIB]; TAB: the pregnancy that ended on [DOIB]]? [READ LIST]

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?

YES  CONTINUE TO O5
If NO/DK/RF, and YES to O1  CONTINUE TO O6
If NO/DK/RF, and NO/DK/RF to O1  SKIP TO NEXT SECTION

O5. When were you first diagnosed with depression relative to [your pregnancy with [NOIB]; TAB: the pregnancy that ended on [DOIB]]? [READ LIST]

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

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)]?

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?

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 O4 = YES, ASK O8 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?

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?

YES  SKIP TO O11
NO  GO TO O10
DK  SKIP TO O11
RF  SKIP TO O11

O10. How far along were you in your pregnancy when you discussed treatment options with your provider?

AMOUNT:__________ DK RF

UNITS:

Days
Weeks
Months
Trimesters

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?"]

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?

YES  CONTINUE TO O13
NO  SKIP TO NEXT SECTION
DK  SKIP TO NEXT SECTION
RF  SKIP TO NEXT SECTION

O13. What did you take? / Did you take anything else? IF CAN’T RECALL, READ FROM DRUG LIST

Abilify
Alprazolam
Anafranil
Aripiprazole
Ativan
Bupropion
Buspar
Buspirone
Celexa
Citalopram
Clomipramine
Clonazepam
Cymbalta
Diazepam
Duloxetine
Effexor
Escitalopram
Fluoxetine
Imipramine
Inderal
Klonopin
Lexapro
Lorazepam
Paroxetine
Paxil
Propranolol
Prozac
Sertraline
St. John’s Wort
Tofranil
Valium
Venlafaxine
Wellbutrin
Xanax
Zoloft
OTHER (SPECIFY):__________
DK  SKIP TO NEXT SECTION
RF  SKIP TO NEXT SECTION

O14. Did you use [MEDICINE, ANSWER O13] for the entire time from the month before your pregnancy through your third month of pregnancy?

YES  SKIP TO O18
NO  CONTINUE TO O15
DK  CONTINUE TO O15
RF  CONTINUE TO O15

O15. When did you start using [MEDICINE, ANSWER O13] for your condition(s) for the first time during this period? [CAN USE DK OR RF FOR MM OR DD OR YY]

MM/DD/YYYY or
MONTH OF PREGNANCY(B1, P1, P2, P3)
DK
RF

O16. When did you stop using [MEDICINE, ANSWER O13] for the last time during this time period? [CAN USE DK OR RF FOR MM OR DD OR YY]

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?

AMOUNT:__________

Days
Weeks
Months

O18. How often did you use [MEDICINE, ANSWER O13] 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

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.

YES  CONTINUE TO O20
NO  SKIP TO O21a
DK  CONTINUE TO O20
RF  CONTINUE TO O20

O20. What dose of [MEDICINE, ANSWER O13] did you take each time you took it?

AMOUNT:__________  SKIP TO NEXT SECTION

UNITS:__________

DK  SKIP TO NEXT SECTION
RF  SKIP TO NEXT SECTION

O21a. How many different dosage amounts do you remember taking? [If mom knows she took more than one dosage, but can't remember how many, select 1 for the number of dosages and report the dosage info she does remember. You may put additional details in a comment field.]

AMOUNT:__________
RF

O21b. What dose of [MEDICINE, ANSWER O13] did you take the [1^st, 2^nd, etc.] time?

AMOUNT:__________

DK  SKIP TO O22

RF  SKIP TO O22

UNITS:__________ DK RF

O22. When did you begin taking that dose?

MM/DD/YYYY or
MONTH OF PREGNANCY(B1, P1, P2, P3)
DK
RF

O23. When did you stop taking that dose?

MM/DD/YYYY or
MONTH OF PREGNANCY(B1, P1, P2, P3)  IF VALID START AND STOP DATE in O22 and O23, SKIP O23a
DK
RF

O23a. How long did you take it?

AMOUNT:__________

Days
Weeks
Months

Section P: ATTENTION DEFICIT HYPERACTIVITY DISORDER (ADHD)

P1. Have you EVER been told by a doctor or other health professional that you had Attention-Deficit/Hyperactivity Disorder (ADHD) or Attention-Deficit Disorder (ADD)?

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?

Attention Deficit Hyperactivity Disorder
Attention Deficit Disorder
OTHER (SPECIFY):__________
DK
RF

P3. When were you diagnosed with [DIAGNOSED CONDITION, ANSWER P2] relative to [your pregnancy with [NOIB]; TAB: the pregnancy that ended on [DOIB]]? [READ LIST]

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?

YES  GO TO P5
NO  SKIP TO P7
DK  SKIP TO P7
RF  SKIP TO P7

P5. Did you discuss these options before your pregnancy began?

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?

AMOUNT:__________

UNITS:

Days
Weeks
Months
Trimesters

P7. Did you take any medications to treat your [DIAGNOSED CONDITION, ANSWER P2] during the month before your pregnancy through the third month of pregnancy, that is from [B1] to [P4(-1)]?

YES  CONTINUE TO P8
NO  SKIP TO NEXT SECTION
DK  SKIP TO NEXT SECTION
RF  SKIP TO NEXT SECTION

P8. What did you take? / Did you take anything else? IF CAN’T RECALL, READ FROM DRUG LIST

Adderall
Adderall XR
Amphetamine
Atomoxetine
Celexa
Citalopram
Clonidine HCL
Concerta
Daytrana Patch
Dexedrine
Dexmethylphenidate
Dextroamphetamine
Dextrostat
Focalin
Focalin XR
Guanfacine
Intuniv
Kapvay
Lisdexamfetamine
Metadate CD
Methylin
Methylphenidate
Prozac
Ritalin
Ritalin LA
Ritalin SR
Sertraline
Strattera
Vyvanse
Zoloft
OTHER, SPECIFY: ____________
DK  SKIP TO NEXT SECTION
RF  SKIP TO NEXT SECTION

P9. Did you use [MEDICINE, ANSWER P8] for the entire time from the month before your pregnancy through your third month of pregnancy?

YES  SKIP TO P13
NO  CONTINUE TO P10
DK  CONTINUE TO P10
RF  CONTINUE TO P10

P10. When did you start using [MEDICINE, ANSWER P8] for [DIAGNOSED CONDITION, ANSWER P2] for the first time during this period? [CAN USE DK OR RF FOR MM OR DD OR YY]

MM/DD/YYYY or
MONTH OF PREGNANCY(B1, P1, P2, P3)
DK
RF

P11. When did you stop using [MEDICINE, ANSWER P8] for the last time during this time period? [CAN USE DK OR RF FOR MM OR DD OR YY]

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?

AMOUNT:__________

Days
Weeks
Months

P13. How often did you use [MEDICINE, ANSWER P8] 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

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.

YES  CONTINUE TO P15
NO  SKIP TO P16a
DK  CONTINUE TO P15
RF  CONTINUE TO P15

P15. What dose of [MEDICINE, ANSWER P8] did you take each time you took it?

AMOUNT:__________  SKIP TO NEXT SECTION
1. UNITS:__________
DK  SKIP TO NEXT SECTION
RF  SKIP TO NEXT SECTION

P16a. How many different dosage amounts do you remember taking? [If mom knows she took more than one dosage, but can't remember how many, select 1 for the number of dosages and report the dosage info she does remember. You may put additional details in a comment field]

AMOUNT:__________
RF

P16b. What dose of [MEDICINE, ANSWER P8] did you take the [1^st, 2^nd, etc.] time?

AMOUNT:__________

DK  SKIP TO P17

RF  SKIP TO P17

UNITS:__________ DK RF

P17. When did you begin taking that dose?

MM/DD/YYYY or
MONTH OF PREGNANCY(B1, P1, P2, P3)
DK
RF

P18. When did you stop taking that dose?

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?

AMOUNT:__________

Days
Weeks
Months

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.]

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]

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 [CHRONIC DISEASE, ANSWER Q2] was diagnosed?

AGE:_____________________
1. Years
2. Months
DK
RF

Q4. Did you take any medications or remedies for [CHRONIC DISEASE, ANSWER Q2] during the month before your pregnancy through the third month of pregnancy, that is from [B1] to [P4(-1)]?

YES  CONTINUE TO Q5
NO  SKIP TO NEXT SECTION
DK  SKIP TO NEXT SECTION
RF  SKIP TO NEXT SECTION

Q5. What did you take? / Did you take anything else?

SPECIFY:____________________________
DK  SKIP TO NEXT SECTION
RF  SKIP TO NEXT SECTION

Q6. Did you use [MEDICINE, ANSWER Q5] for the entire time from the month before your pregnancy through your third month of pregnancy?

YES  SKIP TO Q10
NO  CONTINUE TO Q7
DK  CONTINUE TO Q7
RF  CONTINUE TO Q7

Q7. When did you start using [MEDICINE, ANSWER Q5] for [CHRONIC DISEASE, ANSWER Q2] for the first time during this period? [CAN USE DK OR RF FOR MM OR DD OR YY]

MM/DD/YYYY or
MONTH OF PREGNANCY(B1, P1, P2, P3)
DK
RF

Q8. When did you stop using [MEDICINE, ANSWER Q5] for the last time during this time period? [CAN USE DK OR RF FOR MM OR DD OR YY]

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?

AMOUNT:__________
1. Days
2. Weeks
3. Months
DK
RF

Q10. How often did you use [MEDICINE, ANSWER Q5] 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

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.

YES  CONTINUE TO Q12
NO  SKIP TO Q13a
DK  CONTINUE TO Q12
RF  CONTINUE TO Q12

Q12. What dose of [MEDICINE, ANSWER Q5] did you take each time you took it?

AMOUNT:__________  SKIP TO NEXT SECTION
1. UNITS:__________
DK  SKIP TO NEXT SECTION
RF  SKIP TO NEXT SECTION

Q13a. How many different dosage amounts do you remember taking? [If mom knows she took more than one dosage, but can't remember how many, select 1 for the number of dosages and report the dosage info she does remember. You may put additional details in a comment field.]

AMOUNT:__________
RF

Q13b. What dose of [MEDICINE, ANSWER Q5] did you take the [1^st, 2^nd, etc.] time?

AMOUNT:__________ DK or RF  SKIP TO Q14
UNITS:__________ DK RF

Q14. When did you begin taking that dose?

MM/DD/YYYY or
MONTH OF PREGNANCY(B1, P1, P2, P3)
DK
RF

Q15. When did you stop taking that dose?

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?

AMOUNT:__________ DK RF

Days
Weeks
Months

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?

YES  CONTINUE TO R2
NO  SKIP TO R15
DK  SKIP TO R15
RF  SKIP TO R15

ASK THE FOLLOWING QUESTIONS FOR EACH INFECTION REPORTED:

R2. Was the infection diagnosed by a doctor?

R3. 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 take any medications or remedies for your infection?

YES  CONTINUE TO R4
NO  SKIP TO R15
DK  SKIP TO R15
RF  SKIP TO R15


		ASK THIS SERIES FOR EACH MEDICINE USED:
ROW #		QUESTION	RESPONSE
1	R4. R18. R32.	What did you take? / Did you take anything else?	MEDICATION:______________________ DK RF
		R4, R18 (UTI OR PID MEDS): PROBE: IF CAN’T RECALL, READ FROM DRUG LIST: 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	R4: IF NO/DK/RF  SKIP TO R15 R18: IF NO/DK/RF  SKIP TO R29 R32: IF NO/DK/RF  SKIP TO R43

		R32 (STD MEDS): [PROBE: IF CAN’T RECALL, READ FROM DRUG LIST] Acyclovir (G) Aldara Condylox Famciclovir (G) Famvir Imiquimod Podofilox Podophyllin Trichloroacetic acid (TCA) Valacyclovir (G) Valtrex Zovirax Zyclara
2	R5. R19. R33.	Did you use [MEDICINE, ANSWER R4, R18, R32] for the entire time from the month before your pregnancy through your third month of pregnancy?	YES  SKIP TO ROW 6 NO DK RF CONTINUE TO ROW 3
3	R6. R20. R34.	When did you start using [MEDICINE, ANSWER R4, R18, R32] 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 [MEDICINE, ANSWER R4, R18, R32] 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 Months DK RF
6	R9. R23. R37.	How often did you use [MEDICINE, ANSWER R4, R18, R32] 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
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 [MEDICINE, ANSWER R4, R18, R32] 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?	AMOUNT:__________ RF
10	R12b. R26b. R40b.	What dose of [MEDICINE, ANSWER R4, R18, R32] did you take the [1^st, 2^nd, etc.] time?	AMOUNT:______ DK, RF SKIP UNITS UNITS:_________ DK RF
11	R13. R27. R41a.	When did you begin taking that dose?	MM/DD/YYYY __ /__ /____ or MONTH OF PREGNANCY(B1, P1, P2, P3) DK RF
12	R14. R28. R41b.	When did you stop taking that dose?	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.	Or How long did you take it?	AMOUNT:__________ Days Weeks Months DK RF

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.

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?

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?

R17. 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 take any medications or remedies for your pelvic inflammatory disease or PID?

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 a sexually transmitted disease, such as chlamydia, HPV, herpes, syphilis, genital warts, or gonorrhea?

YES  CONTINUE TO R29a
NO  SKIP TO R43
DK  SKIP TO R43
RF  SKIP TO R43

R29a. What was it? _____________________

DK  SKIP TO R43
RF  SKIP TO R43

R30. Was the [STD, ANSWER R29a] diagnosed by a doctor?

R31. 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 take any medications or remedies for your [STD, ANSWER R29a]? This includes medicines applied by yourself or a provider.

YES  CONTINUE TO R32 IN TABLE ABOVE
NO  SKIP TO R43
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?

YES  CONTINUE TO R44
NO  SKIP TO NEXT SECTION
DK or RF  SKIP TO NEXT SECTION

R44. Was the yeast infection diagnosed by a doctor?

R45. 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 take any medications or remedies for your yeast infection?

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?

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?

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

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?

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.]

NUMBER:__________

S3. What was the cause of the [1^st, 2^nd, etc.] fever?

CAUSE:__________
DK
RF

S4. When you had [CAUSE OF FEVER, ANSWER S3], during which of those months did you have a fever?

S5. What was the highest temperature recorded during your fever?

VALUE:__________ DK RF NOT RECORDED SKIP UNITS
1. UNITS: F or C

S6. Did you take any medications or remedies for the fever?

YES  CONTINUE TO S7
NO  SKIP TO NEXT SECTION
DK  SKIP TO NEXT SECTION
RF  SKIP TO NEXT SECTION

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…?]

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 [DRUG, ANSWER S7] for this [CAUSE OF FEVER, ANSWER S3] for the first time during this period? [CAN USE DK OR RF FOR MM OR DD OR YY]

MM/DD/YYYY or
MONTH OF PREGNANCY(B1, P1, P2, P3)
DK
RF

S9. When did you stop using [DRUG, ANSWER S7] for the last time during this time period? [CAN USE DK OR RF FOR MM OR DD OR YY]

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?

AMOUNT:__________
1. Days
2. Weeks
3. Months
DK
RF

S11. How often did you use [DRUG, ANSWER S7] 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

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 (FOLLOW-UPS BEGIN WITH T3 on page 91)
		QUESTION	RESPONSES
		During [B1] to [P4(-1)] did you take…./did you get any vaccines (T154)?	IF YES, ASK FOLLOW-UP QUESTIONS	IF NO, ASK NEXT CATEGORY	IF DK, ASK NEXT CATEGORY	IF RF, ASK NEXT CATEGORY
	T1.	Birth control pills (T3)	Y	N	DK	RF
	T18.	Antibiotics (T20)	Y	N	DK	RF
	T35.	Over-the-counter pain relievers (T37)	Y	N	DK	RF
	T52.	Prescription pain relievers (T54)	Y	N	DK	RF
	T69.	Medicines to help you lower your cholesterol (“statins”) (T71)	Y	N	DK	RF
	T86.	Medicines to help you quit smoking (T88)	Y	N	DK	RF
	T103.	Medicines to help with allergies or cold symptoms (e.g. runny nose, cough) (T105)	Y	N	DK	RF
	T120.	Medicine to treat an infection with a virus, like the flu (“antiviral”) (T122)	Y	N	DK	RF
	T137.	Medicine to help you sleep (“sleep aid”) (T139)	Y	N	DK	RF
	T154.	Vaccines (WILL ONLY CAPTURE NAME & DATE OF VACCINES) (T156)	Y	N	DK	RF
	T171.	Medicines to treat nausea or vomiting (T173)	Y	N	DK	RF

	T3.	What was the name of the medication? / Did you take any other medicine in this category? PROBE: READ LIST IF NECESSARY	NAME:_____________________ DK  SKIP TO NEXT CATEGORY RF  SKIP TO NEXT CATEGORY
		BIRTH CONTROL PILLS PROMPTS:	SELECT EACH YES:
		Apri	Y
		Aviane (21)	Y
		Beyaz	Y
		Brevicon (21,28)	Y
		Camila	Y
		Cryselle 28	Y
		Cyclessa	Y
		Desogen	Y
		Jolivette	Y
		Kariva	Y
		Levora	Y
		Lo Loestrin Fe	Y
		Lo/Ovral 21	Y
		LoSeasonique	Y
		Low-Ogestrel (21,28)	Y
		Micronor	Y
		Mircette	Y
		Nor-QD	Y
		Nora-BE	Y
		Nordette (21,28)	Y
		Ogestrel 0.5/50	Y
		Ortho Tri-Cyclen	Y
		Ortho Tri-Cyclen Lo	Y
		Ortho-Cept	Y
		Ortho-Cyclen	Y
		Ortho-Novum 1/35	Y
		Ortho-Novum 7/7/7	Y
		Ovcon 35 (21, 28)	Y
		Ovcon 50 (21, 28)	Y
		Portia 28	Y
		Seasonale	Y
		Seasonique	Y
		Sprintec	Y
		TriNessa	Y
		Tri-Norinyl (21, 28)	Y
		Tri-Sprintec 28	Y
		Trivora	Y
		Yasmin	Y
		Yaz	Y
		OTHER, SPECIFY:	Y
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? PROBE: READ LIST IF NECESSARY	NAME:_____________________ DK  SKIP TO NEXT CATEGORY RF  SKIP TO NEXT CATEGORY
		ANTIBIOTICS PROMPTS:	SELECT EACH YES:
		Amoxicillin	Y
		Amoxil	Y
		Augmentin	Y
		Biaxin	Y
		Cipro	Y
		Ciprofloxacin	Y
		Cleocin	Y
		Doxycycline	Y
		Erythromycin	Y
		Flagyl	Y
		Macrodantin	Y
		Nitrofurantoin	Y
		Penicillin	Y
		Sulfamethoxazole/Trimethoprim	Y
		Vancocin	Y
		Vibramycin	Y
		Zithromax	Y
		Z-Pak	Y
		OTHER, SPECIFY:	Y
FOR EACH REPORTED DRUG ABOVE, CONTINUE WITH T4/ROW 1-T24/ROW 4.

	T37.	What was the name of the medication? / Did you take any other medicine in this category? PROBE: READ LIST IF NECESSARY	NAME:_____________________ DK  SKIP TO NEXT CATEGORY RF  SKIP TO NEXT CATEGORY
		OVER-THE-COUNTER PAIN RELIEVERS PROMPTS:	SELECT EACH YES:
		Acetaminophen	Y
		Advil	Y
		Aleve	Y
		Aspirin	Y
		Excedrin Extra Strength Caplets/Tablets/Geltabs	Y
		Ibuprofen	Y
		Motrin	Y
		Naproxen Sodium	Y
		Tylenol	Y
		OTHER, SPECIFY:	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? PROBE: READ LIST IF NECESSARY	NAME:_____________________ DK  SKIP TO NEXT CATEGORY RF  SKIP TO NEXT CATEGORY
		PRESCRIPTION PAIN RELIEVERS	SELECT EACH YES:
		Celebrex	Y
		Hydrocodone Bitartrate/ APAP	Y
		Lorcet	Y
		Lortab	Y
		Neurontin	Y
		Oxycodone/Acetaminophen-NOS	Y
		Oxycontin	Y
		Percocet-NOS	Y
		Roxicet-NOS	Y
		Tramadol	Y
		Tramadol HCL/ Acetaminophen	Y
		Tylenol #1,#2,#3,#4	Y
		Ultram	Y
		Vicodin –NOS	Y
		OTHER, SPECIFY:	Y
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? PROBE: READ LIST IF NECESSARY	NAME:_____________________ DK  SKIP TO NEXT CATEGORY RF  SKIP TO NEXT CATEGORY
		MEDICINES TO HELP LOWER YOUR CHOLESTEROL (“STATINS”)	SELECT EACH YES:
		Altoprev	Y
		Atorvastatin	Y
		Crestor	Y
		Fluvastatin	Y
		Lescol	Y
		Lipitor	Y
		Livalo	Y
		Lovastatin	Y
		Mevacor	Y
		Pitavastatin	Y
		Pravachol	Y
		Pravastatin Sodium	Y
		Rosuvastatin Calcium	Y
		Simvastatin	Y
		Zocor	Y
		OTHER, SPECIFY:	Y
FOR EACH REPORTED DRUG ABOVE, CONTINUE WITH T4/ROW 1 THROUGH T6/ROW 3 AND SKIP TO T8/ROW 5.

	T88.	What was the name of the medication? / Did you take any other medicine in this category? PROBE: READ LIST IF NECESSARY	NAME:_____________________ DK  SKIP TO NEXT CATEGORY RF  SKIP TO NEXT CATEGORY
		MEDICINES TO HELP YOU QUIT SMOKING	SELECT EACH YES:
		Budeprion SR	Y
		Bupropion HCL	Y
		Chantix	Y
		Clonidine	Y
		Nicoderm CQ	Y
		Nicorette Gum	Y
		Nicotine Gum NOS	Y
		Nicotine Inhaler NOS	Y
		Nicotrol Inhaler	Y
		Nortriptyline	Y
		Pamelor	Y
		Varenicline Tartrate	Y
		Wellbutrin	Y
		Wellbutrin XL	Y
		Zyban	Y
		OTHER, SPECIFY:	Y
FOR EACH REPORTED DRUG ABOVE, CONTINUE WITH T4/ROW 1 THROUGH T6/ROW 3 AND SKIP TO T8/ROW 5.

	T105.	What was the name of the medication? / Did you take any other medicine in this category? PROBE: READ LIST IF NECESSARY	NAME:_____________________ DK  SKIP TO NEXT CATEGORY RF  SKIP TO NEXT CATEGORY
		MEDICINES TO HELP WITH ALLERGIES OR COLD SYMPTOMS (E.G. RUNNY NOSE, COUGH)	SELECT EACH YES:
		Afrin 12 Hour Nasal Spray	Y
		Allegra	Y
		Allegra D	Y
		Benadryl	Y
		Clarinex	Y
		Clarinex D	Y
		Claritin	Y
		Claritin D	Y
		Delsym 12 Hour Cough Relief	Y
		Mucinex	Y
		Mucinex Dm	Y
		Phenylephrine	Y
		Pseudoephedrine	Y
		Sudafed PE Nasal Decongestant	Y
		Sudafed Nasal Decongestant	Y
		Zyrtec	Y
		Zyrtec D	Y
		OTHER, SPECIFY:	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”)	SELECT EACH YES:
		Acyclovir	Y
		Amantadine	Y
		Combivir	Y
		Oseltamivir Phosphate	Y
		Relenza	Y
		Tamiflu	Y
		Zanamivir	Y
		OTHER, SPECIFY:	Y
FOR EACH REPORTED DRUG ABOVE, CONTINUE WITH T4/ROW 1-T24/ROW 4.

	T139.	What was the name of the medication? / Did you take any other medicine in this category? PROBE: READ LIST IF NECESSARY	NAME:_____________________ DK  SKIP TO NEXT CATEGORY RF  SKIP TO NEXT CATEGORY
		MEDICINE TO HELP YOU SLEEP (“SLEEP AID”)	SELECT EACH YES:
		Ambien	Y
		Benadryl	Y
		Compoz (New Form 1984)	Y
		Diphenhydramine	Y
		Doxylamine	Y
		Eszopiclone	Y
		Kava-Kava, Herb	Y
		L-Tryptophan	Y
		Lunesta	Y
		Melatonin	Y
		Nytol (New Form 1984)	Y
		Prosom	Y
		Ramelteon	Y
		Restoril	Y
		Rozerem	Y
		Sleepinal	Y
		Sominex (New Form 1988)	Y
		Sonata	Y
		Tryptophan	Y
		Valerian Extract	Y
		Zaleplon	Y
		Zolpidem Tartrate	Y
		Zzzquil Liquicaps Sleep-Aid	Y
		Zzzquil Liquid Sleep-Aid	Y
		OTHER, SPECIFY:	Y
FOR EACH REPORTED DRUG ABOVE, CONTINUE WITH T4/ROW 1 THROUGH T6/ROW 3 AND SKIP TO T8/ROW 5.

	T156.	Which vaccines did you get? PROBE: READ LIST IF NECESSARY	NAME:_____________________ DK  SKIP TO NEXT CATEGORY RF  SKIP TO NEXT CATEGORY
		VACCINES	SELECT EACH YES:
		Chickenpox Vaccine- NOS	Y
		Flu Vaccine NOS	Y
		Hepatitis A Vaccine	Y
		Hepatitis B Vaccine	Y
		HPV Vaccine NOS (Human Papillomavirus)	Y
		Measles, Mumps, Rubella Vaccine	Y
		NOS-Meningococcal Vaccine	Y
		Pneumococcal Vaccine, Polyvalent	Y
		Shingles Vaccine-NOS	Y
		OTHER, SPECIFY_______________________	Y
	T157.	When did you get the [NAME OF VACCINE]?	a. MM/DD/YYYY or b. MONTH OF PREGNANCY(B1, P1, P2, P3) c. DK d. RF
SKIP TO CONTINUE TO T171, NEXT CATEGORY.

	T173.	What was the name of the medication? / Did you take any other medicine in this category? PROBE: READ LIST IF NECESSARY	NAME:_____________________ DK  SKIP TO SPECIFIC MEDICINES RF  SKIP TO SPECIFIC MEDICINES
		MEDICINES TO TREAT NAUSEA OR VOMITING	SELECT EACH YES:
		Benadryl	Y
		Bonine	Y
		Diphenhydramine	Y
		Doxylamine	Y
		Ginger	Y
		Metoclopramide	Y
		Ondansetron	Y
		Phenergan	Y
		Preggie Pops (Various Flavors)	Y
		Promethazine	Y
		Reglan	Y
		Tigan	Y
		Unisom Tablets	Y
		Vitamin B6	Y
		Zofran	Y
		OTHER, SPECIFY	Y
FOR EACH REPORTED DRUG ABOVE, CONTINUE WITH T4/ROW 1-T24/ROW 4.

ASK THIS SERIES FOR EACH MEDICINE USED IN T1 THROUGH T137 AND T171. NOT ASKED OF VACCINES.

Row

Quex #

Question Text

Responses

T4 T21 T38 T55 T72 T89 T106 T123 T140 T174

Did you already tell me about taking [this medication] earlier in the interview? [PROBE: Did you tell me about [SAY MEDICATION TOPIC] earlier in the interview?]

a. YES  CONTINUE TO T5/ROW2

b. NO  CONTINUE TO T24/ROW 4 or SKIP TO T8/ROW 5

c. DK  CONTINUE TO T24/ROW 4 or SKIP TO T8/ROW 5

d. RF  CONTINUE TO T24/ROW 4 or SKIP TO T8/ROW 5

T5 T22 T39 T56 T73 T90 T107 T124 T141 T175

Could you please remind me of the medical condition you took this for?

CONDITION______________________
DK
RF

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

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.

T24 T41 T58 T109 T126 T177

Why did you take [this medication]?

a. REASON:__________

b. DK

c. RF

T8 T25 T42 T59 T76 T93 T110 T127 T144 T178

Did you use [this medication] for the entire time from the month before your pregnancy through your third month of pregnancy?

a. YES  SKIP TO T12/ROW 9

b. NO  CONTINUE TO T9/ROW 6

c. DK  CONTINUE TO T9/ROW 6

d. RF  CONTINUE TO T9/ROW 6

T9 T26 T43 T60 T77 T94 T111 T128 T145 T179

When did you start using [this medication] 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

T10 T27 T44 T61 T78 T95 T112 T129 T146 T180

When did you stop using [this medication] 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

T11 T28 T45 T62 T79 T96 T113 T130 T147 T181

Or how long did you take [this medication]?

AMOUNT_______

Days Weeks Months

DK RF

T12 T29 T46 T63 T80 T97 T114 T131 T148 T182

How often did you use [this medication] 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

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.

a. YES  CONTINUE TO T14a/ROW 11

b. NO  SKIP TO T15a/ROW 12

c. DK  CONTINUE TO T14/ROW 11

d. RF  CONTINUE TO T14/ROW 11

T14 T31 T48 T65 T82 T99 T116 T133 T150 T184

What dose of [this medication] did you take each time you took it?

AMOUNT:______ DK, RF SKIP UNITS

UNITS:_________ DK RF

SKIP TO T18/NEXT CATEGORY

T15a

T32a T49a T66a T83a T100a T117a T134a T151a T185a

How many different dosage amounts do you remember taking? [If mom knows she took more than one dosage, but can't remember how many, select 1 for the number of dosages and report the dosage info she does remember. You may put additional details in a comment field.]

AMOUNT_______ RF

T15b T32b T49b T66b

T83b T100b T117b T134b T151b T185b

What dose of [this medication] did you take the [1st, 2^nd, etc.] time?

AMOUNT:______ DK, RF SKIP UNITS

UNITS:_________ DK RF

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

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

T17a T34a T51a T68a T85a T102a T119a T136a T153a T187a

Or how long did you take it?

AMOUNT_______

Days Weeks Months

DK RF

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.

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:		IF YES, ASK NEXT QUESTION IN ROW 17	IF NO, ASK NEXT DRUG	IF DK, ASK NEXT DRUG	IF RF, ASK NEXT DRUG
	T188.	Prozac		Y	N	DK	RF
	T203.	Wellbutrin		Y	N	DK	RF
	T218.	Paxil		Y	N	DK	RF
	T233.	Zoloft		Y	N	DK	RF
	T248.	Effexor		Y	N	DK	RF
	T263.	Celexa		Y	N	DK	RF
	T278.	Lexapro		Y	N	DK	RF
	T293.	Cymbalta		Y	N	DK	RF
	T308.	Abilify		Y	N	DK	RF
	T323.	Seroquel		Y	N	DK	RF
	T338.	Zyprexa		Y	N	DK	RF
	T353.	Depakene, Depakote, or Valproic acid		Y	N	DK	RF
	T368.	Dilantin or Phenytoin		Y	N	DK	RF
	T383.	Felbatol		Y	N	DK	RF
	T398.	Klonopin or Clonazepam		Y	N	DK	RF
	T413.	Lamictal		Y	N	DK	RF
	T428.	Phenobarbital		Y	N	DK	RF
	T443.	Topiramate or Topamax		Y	N	DK	RF
	T458.	Furadantin		Y	N	DK	RF
	T473.	Macrodantin		Y	N	DK	RF
	T488.	Qsymia		Y	N	DK	RF
	T503.	Thalidomide		Y	N	DK	RF
	T518.	Accutane or Isotretinoin		Y	N	DK	RF
	T533.	CellCept		Y	N	DK	RF
	T548.	Myfortic		Y	N	DK	RF
	T563.	Cytotec		Y	N	DK	RF
	T578.	Misoprostol		Y	N	DK	RF
	T593.	Methotrexate		Y	N SKIP TO T608	DK SKIP TO T608	RF SKIP TO T608
ASK THIS SERIES FOR EACH MEDICATION TAKEN IN T188-T593:
ROW	Quex #	Question Text	Responses
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	Did you already tell me about taking this medication earlier in the interview?	a. YES  CONTINUE TO T190/ROW 18 b. NO  SKIP TO T192/ROW 20 c. DK  SKIP TO T192/ROW 20 d. RF  SKIP TO T192/ROW 20
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?	CONDITION_____________ DK RF
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?	a. YES  CONTINUE TO T192/ROW 20 b. NO  SKIP TO T203/NEXT MEDICINE c. DK  SKIP TO T203/NEXT MEDICINE d. RF  SKIP TO T203/NEXT MEDICINE
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 [MEDICINE]?	a. REASON:__________ b. DK c. RF
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 [MEDICINE] for the entire time from the month before your pregnancy through your third month of pregnancy?	a. YES  SKIP TO T197/ROW 25 b. NO  CONTINUE TO T194/ROW 22 c. DK  CONTINUE TO T194/ROW 22 d. RF  CONTINUE TO T194/ROW 22
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 [MEDICINE] 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
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 [MEDICINE] 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 T196/ROW 24 c. DK d. RF
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	Or how long did you take [PMEDICINE]?	AMOUNT_______ Days Weeks Months DK RF
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 [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.	AMOUNT:__________ Per day/Per week/Per month/Per time period DK RF
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.	a. YES  CONTINUE TO T199/ROW 27 b. NO  SKIP TO T200/ROW 28 c. DK  CONTINUE TO T199/ROW 27 d. RF  CONTINUE TO T199/ROW 27
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 [MEDICINE] did you take each time you took it?	AMOUNT:______ DK, RF SKIP UNITS UNITS:_________ DK RF
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? [If mom knows she took more than one dosage, but can't remember how many, select 1 for the number of dosages and report the dosage info she does remember. You may put additional details in a comment field.]	AMOUNT_______ RF
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 [MEDICINE] did you take the [1st, 2^nd, etc.] time?	AMOUNT:______ DK, RF SKIP UNITS UNITS:_________ DK RF
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?	a. MM/DD/YYYY or b. MONTH OF PREGNANCY(B1, P1, P2, P3) c. DK d. RF
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
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	Or how long did you take it?	AMOUNT_______ Days Weeks Months DK RF

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.		a. YES  CONTINUE TO T609 b. NO  SKIP TO T615 c. DK  SKIP TO T615 d. RF  SKIP TO T615
	T609.	Between [START DATE OF B1] to [P4(-1)END DATE OF P3] what herbs or folk medicines did you take? / Anything else?	HERBALS_____________ DK  SKIP TO T615 RF  SKIP TO T615
ASK THIS SERIES FOR EACH HERBAL PRODUCT USED:
	T610.	Did you use [Name of herb/medicine] for the entire time from the month before your pregnancy through your third month of pregnancy?	YES  SKIP TO T614 NO  CONTINUE TO T611 DK  CONTINUE TO T611 RF  CONTINUE TO T611
	T611.	When did you start using [Name of herb/medicine] 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 [Name of herb/medicine] 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.	Or how long did you take [Name of herb/medicine]?	AMOUNT_______ Days Weeks Months DK RF
	T614.	How often did you use [Name of herb/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.	AMOUNT:__________ Per day/Per week/Per month/Per time period DK RF

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 the third month of pregnancy, which would be [B1] to [P4(-1)], did you take any multivitamins, prenatal vitamins, or folic acid supplements?	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?	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?	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?	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?	YES NO DK RF

Catch-All Medication Question
	T620.	During this time period, did you take any medications, remedies, or treatments that we haven’t already talked about?/Any others?	YES  CONTINUE TO T621 NO  SKIP TO NEXT SECTION DK  SKIP TO NEXT SECTION RF  SKIP TO NEXT SECTION
	T621.	What medicine did you take?	SPECIFY______________ DK  SKIP TO NEXT SECTION RF  SKIP TO NEXT SECTION
	T622.	Why did you take [ANSWER T621]?	a. REASON:__________ b. DK c. RF
	T623.	Did you use [MEDICINE, ANSWER 621] for the entire time from the month before your pregnancy through your third month of pregnancy?	YES  SKIP TO T627 NO  CONTINUE TO T624 DK  CONTINUE TO T624 RF  CONTINUE TO T624
	T624.	When did you start using [MEDICINE, ANSWER 621] 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 [MEDICINE, ANSWER 621] 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 T626 c. DK d. RF
	T626.	Or how long did you take [MEDICINE, ANSWER T621]?	AMOUNT_______ Days Weeks Months DK RF
	T627.	How often did you use [MEDICINE, ANSWER T621during 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 [MEDICINE, ANSWER T621] each time you took it throughout [B1] to [P4(-1)]?	YES  CONTINUE TO T629 NO  SKIP TO T630a DK  CONTINUE TO T629 RF  CONTINUE TO T629
	T629.	What dose of [MEDICINE, ANSWER T621] did you take each time you took it?	AMOUNT:______ DK, RF SKIP UNITS UNITS:_________ DK RF SKIP TO NEXT SECTION
	T630a.	How many different dosage amounts do you remember taking?	AMOUNT_______ RF
	T630b.	What dose of [MEDICINE, ANSWER T621] did you take the [1^st, 2^nd, etc.] time?	AMOUNT:______ DK, RF SKIP UNITS UNITS:_________ DK RF
	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.	OR how long did you take it?	AMOUNT_______ Days Weeks Months DK RF

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 3^rd 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 3^rd month of pregnancy, did you experience any serious relationship difficulties with your husband or partner or become separated or divorced?

U2. During this same time period, did you or your husband or partner have any serious legal or financial problems?

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”]

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”]

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”]

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?

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?

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?

U9. During this same time period, how often did you feel nervous and stressed? Would you say…[READ CHOICES]

Never
Almost never
Sometimes
Somewhat often
Very often
DK
RF

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)]

Days Per Week: ______

IF 0  SKIP TO INTRODUCTION TO V3

IF 1 – 7  CONTINUE TO V2

DK  SKIP TO INTRODUCTION TO V3
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)] [REMINDER: IF THEY ANSWER LESS THAN 10 MINUTES, REMIND THEM WE ARE ONLY INTERESTED IN ACTIVITIES DONE AT LEAST 10 MINUTES AT A TIME.]

Hours Per Day:__________  SKIP TO INTRODUCTION TO V3
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.]
DK  CONTINUE TO V2b
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.]

Hours:__________
Minutes:_________
DK
RF

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 (P3). Child care includes dressing, bathing, grooming, feeding, or occasional lifting.]

Days Per Week:__________

IF 0  SKIP TO INTRODUCTION TO V5
IF 1 – 7  CONTINUE TO V4

DK  SKIP TO INTRODUCTION TO V5
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)] [REMINDER: IF THEY ANSWER LESS THAN 10 MINUTES, REMIND THEM WE ARE ONLY INTERESTED IN ACTIVITIES DONE AT LEAST 10 MINUTES AT A TIME.]

Hours Per Day:__________  SKIP TO INTRODUCTION TO V5
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.]
DK  CONTINUE TO V4b
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.

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.

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)]

Days Per Week:____________

IF 0  SKIP TO INTRODUCTION TO V7
IF 1 – 7  CONTINUE TO V6

DK or RF  SKIP TO INTRODUCTION TO V7

V6. How much time did you usually spend walking on one of those days? (P6) [REMINDER: IF THEY ANSWER LESS THAN 10 MINUTES, REMIND THEM WE ARE ONLY INTERESTED IN ACTIVITIES DONE AT LEAST 10 MINUTES AT A TIME.]

Hours Per Day:__________  SKIP TO INTRODUCTION TO V7
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.]
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?

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)]

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.]

Hours:__________
Minutes:__________
DK
RF

Section W: OBESITY

Now I have some questions about weight changes before [your pregnancy with [NOIB]; TAB: your pregnancy].

What is your height without shoes?

Feet:__________
Inches:__________ OR
Centimeters:__________
DK
RF

How much did you weigh before [your pregnancy with [NOIB]; TAB: your pregnancy]?
1. WEIGHT:__________
  1. Pounds
  2. Kilograms
2. DK
3. RF

Not including pregnancy, when you gain weight, where on your body do you mostly add the weight? [READ OPTIONS A-D]:

Waist and/or upper body?
Hips, bottom and/or upper thighs?
Evenly over your body?
Don’t gain weight?
DK
RF

Which describes the underlying shape of your body, regardless of weight gain or loss?

[READ OPTIONS A-C]:

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

What is the most you have ever weighed outside of pregnancy?

WEIGHT:__________

POUNDS
KILOGRAMS

What was your age when you were that weight?

AGE:__________
DK
RF

What is the least you have weighed outside of pregnancy in the last 5 years?

WEIGHT:__________
1. POUNDS
2. KILOGRAMS
DK
RF

What was your age when you were that weight?

AGE:__________
DK
RF

In the year before [your pregnancy with [NOIB]; TAB: your pregnancy], did your weight change by more than 20 pounds/9 kilograms?

YES  CONTINUE TO W10
NO  SKIP TO W12
DK  SKIP TO W12
RF  SKIP TO W12

How much did your weight change? [NOTE: REFERENCE WEIGHT = THEIR WEIGHT AT THE START OF THEIR PREGNANCY]

AMOUNT:__________
1. POUNDS
2. KILOGRAMS
DK
RF

Was this change related to a pregnancy?

Have you ever had surgery to help you lose weight? This does not include cosmetic procedures such as liposuction.

YES  CONTINUE TO W13
NO  SKIP TO W14
DK  SKIP TO W14
RF  SKIP TO W14

What procedure did you have?

Gastric bypass
Belly band / lap band / gastric banding
Gastric sleeve / sleeve gastrectomy
OTHER (SPECIFY): _______
DK
RF

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]

Vegetarian
Vegan
Low carbohydrate / low “carb”
Low fat
Gluten free
Dairy free
OTHER (SPECIFY):__________
NONE OF THE ABOVE
DK
RF

Section X: DENTAL PROCEDURES

The next set of questions is about dental visits you may have had right before and early in your pregnancy.

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?

YES  CONTINUE TO X2
NO  SKIP TO NEXT SECTION
DK  SKIP TO NEXT SECTION
RF  SKIP TO NEXT SECTION

How many times did you go to the dentist during that time period?

NUMBER:__________
DK
RF

What dental procedures did you receive at that visit/those visits? IF DON’T KNOW GIVE OPTIONS. CAN REPORT MULTIPLE PROCEDURES.

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

Did you have any x-rays taken during the visit/visits?

YES  CONTINUE TO X5
NO  SKIP TO X6
DK  SKIP TO X6
RF  SKIP TO X6

Did they provide a protective cover for your body during the x-rays?

Yes for all X-rays
Yes for some, but not all X-rays
No for all X-rays
DK
RF

Did you receive a shot to numb your mouth during the visit/at least one of the visits (an injectable anesthetic)?

Did you receive “laughing gas”, also called nitrous oxide, during the visit/ at least one of the visits?

Were you prescribed any medications for your dental visit/visits or at the visit/visits?

YES  CONTINUE TO X9
NO  SKIP TO X14
DK  SKIP TO X14
RF  SKIP TO X14

X9. What medicine were you prescribed / Anything else? [PROBE: IF CAN’T RECALL, READ FROM LIST. MULTIPLE MEDICATIONS CAN BE REPORTED.]

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

ASK SERIES FOR EACH DRUG in X9:

X10. When did you start taking [ANSWER X9]? [CAN USE DK OR RF FOR MM OR DD OR YY]

MM/DD/YYYY or
MONTH OF PREGNANCY(B1, P1, P2, P3)
DIDN’T TAKE IT (ONLY RECEIVED PRESCRIPTION; DIDN’T FILL IT)
DK
RF

When did you stop using [ANSWER X9] for the last time during this time period? [CAN USE DK OR RF FOR MM OR DD OR YY]

MM/DD/YYYY or
MONTH OF PREGNANCY(B1, P1, P2, P3)  IF VALID RESPONSE TO X10 and X11, SKIP X12
DK
RF

How long did you take it?

AMOUNT:__________ DK RF
1. Days
2. Weeks
3. Months

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.

AMOUNT:__________ Per Day/Per Week/Per Month/Per Time Period/DK/RF

Did you take any over-the-counter medicines just before your dental visit/visits or just after your visit/visits?

YES  CONTINUE TO X15
NO  SKIP TO X20
DK  SKIP TO X20
RF  SKIP TO X20

What did you take? / Anything else? [IF CAN’T RECALL, READ FROM LIST. MULTIPLE MEDICATIONS CAN BE REPORTED.]

Acetaminophen
Advil
Anbesol liquid /gel
Aspirin
Bayer aspirin
Chloraseptic liquid/spray
Ibuprofen
Motrin
Nuprin
Ora-jel
Tylenol
Xylocaine
OTHER (SPECIFY):__________
DK  SKIP TO X20/X21
RF  SKIP TO X20/X21

When did you start taking [ANSWER X15] for your dental visit? [CAN USE DK OR RF FOR MM OR DD OR YY]

MM/DD/YYYY or
MONTH OF PREGNANCY(B1, P1, P2, P3)
DK
RF

When did you stop using [ANSWER X15] for the last time during this time period? [CAN USE DK OR RF FOR MM OR DD OR YY]

MM/DD/YYYY or
MONTH OF PREGNANCY(B1, P1, P2, P3)  IF VALID RESPONSE TO X16 and X17, SKIP X18
DK
RF

How long did you take it?
1. AMOUNT:__________
  1. Per day
  2. Per week
  3. Per month
  4. Per time period
2. DK
3. RF
How often did you use [ANSWER X15] 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

IF THEY REPORTED HAVING A CAVITY FILLED IN X3 SKIP X20 AND CONTINUE TO X21.

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?

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?

NUMBER:__________ DK RF

X21b. During the [1^st, 2^nd, etc.] visit in which you had a dental filling placed, how many dental fillings do you remember having placed? IF THEY REPORT MULTIPLE VISITS CONFIRM THAT THEY HAVE SUMMED ACROSS VISITS.

NUMBER:__________

X22. What was the date of the [1^st, 2^nd, etc.] visit when the filling(s) was/were placed? [ASK FOR EACH VISIT IF MULTIPLE VISITS]

MM/DD/YYYY OR
MONTH OF PREGNANCY(B1, P1, P2, P3)
DK
RF

X23. 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.]

Amalgam / silver-colored
Composite resin / tooth-colored
DK
RF

Section Y: SMOKING

The next questions are about cigarette use.

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.]

YES  CONTINUE TO Y2
NO  SKIP TO NEXT SECTIONY3
DK  SKIP TO Y3
RF  SKIP TO Y3

During which months did you smoke? INDICATE ALL THAT APPLY

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? [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.]

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?

Every Day
Some Days
Rarely
DK
RF

Section Z: ALCOHOL

Now I’m going to ask you some questions about drinking alcoholic beverages.

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?

YES  CONTINUE TO Z2
NO  SKIP TO NEXT SECTION
DK  SKIP TO NEXT SECTION
RF  SKIP TO NEXT SECTION

During which months did you drink any alcoholic beverages?

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.

NUMBER:__________
DK
RF

Section AA: RESIDENCE HISTORY

We would like to know the address at which you lived when [you became pregnant with [NOIB]; TAB: the affected pregnancy began] so that we can study possible environmental exposures.

What is your current address? [REMEMBER TO ASK ABOUT AN APARTMENT NUMBER IF NONE GIVEN]
1. ADDRESS:__________
2. DK
3. RF

Do you currently live at the same address that you did at the time [you became pregnant with [NOIB]; TAB: the affected pregnancy began]?

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 [your pregnancy with [NOIB]; TAB: the affected pregnancy] began? This would be on or around [START DATE OF P1]. [REMEMBER TO ASK ABOUT AN APARTMENT NUMBER IF NONE GIVEN]

ADDRESS:__________  SKIP TO NEXT SECTION
DK  SKIP TO NEXT SECTION
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.

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?

YES  SKIP TO BB4
NO  CONTINUE TO BB2
DK  CONTINUE TO BB2
RF  CONTINUE TO BB2

Were you [READ CHOICES] or did you do something else?

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

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-the-job training, such as an apprenticeship, internship, practicum or clinical experience?

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. SELECT ALL THAT APPLY.]:

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?) [PROBE: LIST ALL EMPLOYERS, INCLUDING “SELF EMPLOYED”.]

SPECIFY:__________________________________
DK IF MOTHER RESPONDS DK, ENTER UNKNOWN IN RESPONSE BOX.
RF

BB6. At the company that did [BB5 RESPONSE], what was your job title there? [ASK FOR EACH EMPLOYER]

SPECIFY:__________________________________
DK
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]

SPECIFY:___________________________________
DK
RF

Section CC: RACE / ACCULTURATION / EDUCATION

Now I will be asking about your ethnic background.

Were you born in the U.S.?
1. YES  SKIP TO CC4
2. NO  CONTINUE TO CC2
3. DK  SKIP TO CC4
4. RF  SKIP TO CC4

Where were you born?

COUNTRY:__________DK
RF

OTHER (SPECIFY):__________

How many years have you lived in the US?

YEARS:__________
DK
RF

CC4. What language do you usually speak at home? [READ FROM LIST ONLY IF NECESSARY TO CLARIFY]

LANGUAGE:__________DK
RF
OTHER (SPECIFY):________

CC5. Are you Hispanic or Latina?

YES  CONTINUE TO CC6
NO  SKIP TO CC7
DK  SKIP TO CC7
RF  SKIP TO CC7

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.?]

GROUP:__________
DK
RF
OTHER (SPECIFY):________

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.

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

IF CC7 = b OR d: What country? PROBE: Referring to Asian, Native Hawaiian or other Pacific Island countries

COUNTRY:__________
DK
RF
OTHER (SPECIFY):_________

IF CC7 = a: What tribe do you consider yourself a member of?

TRIBE:__________
DK
RF
OTHER (SPECIFY):________

What was the highest grade or year of school or college that you had completed [at the time [NOIB] was born; TAB: by [DOIB]]? [PROBE: IF RESPONDENT HESITATES, BEGIN READING]CATEGORIES.

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 [[NOIB]’s; TAB: the] biological or natural father.

Was he born in the U.S.?

YES  SKIP TO CC14
NO  CONTINUE TO CC12
DK  SKIP TO CC14
RF  SKIP TO CC14

Where was he born?

COUNTRY:__________
DK
RF
OTHER (SPECIFY):_________

How many years has he lived in the U.S.?

YEARS:__________
DK
RF

Is the father Hispanic or Latino?

Yes  ASK CC15
NO  SKIP TO CC16
DK  SKIP TO CC16
RF  SKIP TO CC16

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.?]

GROUP:__________
DK
RF
OTHER (SPECIFY):__________

How would you describe his race? I’m going to read you a list and then please tell me all categories that apply to him. You can select more than one category.

American Indian or Alaska Native  ASK CC18
Asian  ASK CC17
Black or African American  SKIP TO CC19, UNLESS (CC16a), (CC16b), OR (CC16d) ALSO SELECTED
Native Hawaiian or Other Pacific Islander  ASK CC17
White  SKIP TO CC19, UNLESS (CC16a), (CC16b), OR (CC16d) ALSO SELECTED
DK  SKIP TO CC 19
RF  SKIP TO CC19

IF CC16 = b or d: What country? [READ FROM LIST ONLY IF NECESSARY TO CLARIFY] [PROBE: Referring to Asian, Native Hawaiian or other Pacific Island countries.]

COUNTRY:__________
DK
RF
OTHER (SPECIFY):__________

IF CC16 = a: What tribe does he consider himself a member of?

TRIBE:__________
DK
RF
OTHER (SPECIFY):__________

What was the highest grade or year of school or college that he had completed [at the time [NOIB] was born; TAB: by [DOIB]]? [IF RESPONDENT HESITATES, BEGIN READING CATEGORIES.]

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

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).

In the month before your pregnancy began, were you covered by health insurance or some other kind of health care plan?

YES  CONTINUE TO DD2
NO  SKIP TO DD3
DK  SKIP TO DD3
RF  SKIP TO DD3

What was the name of your insurance? / Any other insurance? [PROBE: PROVIDE EXAMPLE IF NEEDED: Blue Cross/Blue Shield, Wellpoint, UnitedHealth, Wellmark, Medicaid, Medicare, Tricare]

NAME:__________
DK
RF

During your pregnancy, were you covered by health insurance or some other kind of health care plan?

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

What was the name of your insurance? / Any other insurance? [PROBE: PROVIDE EXAMPLES IF NEEDED: Blue Cross/Blue Shield, Wellpoint, UnitedHealth, Wellmark, Medicaid, Medicare, Tricare]

NAME:__________
DK
RF

Section EE: CLOSING

[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?

YES  CONTINUE TO EE2
NO  SKIP TO EE3b
DK  SKIP TO EE3b

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

EMAIL ADDRESS 1:______________________________
EMAIL ADDRESS 2:______________________________
EMAIL ADDRESS 3:______________________________
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?

YES  SKIP TO EE6
NO  SKIP TO EE6
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?

YES  SKIP TO EE5
NO  SKIP TO EE6
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?

YES  CONTINUE TO EE5
NO  SKIP TO EE6
DK  SKIP TO EE6

EE5. What is your email address?

NOTE TO INTERVIEWERS: READ BACK THE EMAIL ADDRESS AND CONFIRM THAT IT HAS BEEN RECORDED CORRECTLY

EMAIL ADDRESS 1:______________________________
EMAIL ADDRESS 2:______________________________
EMAIL ADDRESS 3:______________________________
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.

YES  CONTINUE TO EE7
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
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:________________________
RELATIONSHIP:______________________
HOME PHONE:______________________
WORK PHONE:______________________
STREET/APARTMENT:________________
CITY/STATE/ZIP:_____________________
COUNTRY:_______________
DK
RF

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?

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
NO  CONTINUE TO EE9
DK  CONTINUE TO EE9
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 NON-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. 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?

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
NO  CONTINUE TO EE9
DK  CONTINUE TO EE9
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:____________________________

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]

Amazon
Target
Wal-Mart
CVS

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]

Amazon
Target
Wal-Mart
CVS

EE11. We publish an electronic newsletter yearly to update participants on the progress of the study. We post each new newsletter on the www.bdsteps.org website. Will you be able to access the newsletter on our website? IF ‘NO’, THEN ASK: We want to make sure families without access to the internet can also receive the newsletter. Would you like us to mail you a paper copy of the newsletter?

YES to internet
NO to internet; YES to newsletter
NO to internet; NO to newsletter
DK
RF

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.

Section FF: INTERVIEWER REMARKS

The overall quality of this interview was:

HIGH QUALITY
GENERALLY RELIABLE
QUESTIONABLE
UNSATISFACTORY

Did the father contribute to the mother’s answers? SKIP IF FATHER UNKNOWN

Did some other person contribute to the mother’s answers?

YES  CONTINUE TO FF4
NO  SKIP TO FF5
DK  SKIP TO FF5

Who was it?

SPECIFY:__________
DK

IF FF1 = C OR D: The main reason for questionable or unsatisfactory quality of information was because the respondent: INDICATE ALL THAT APPLY

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):__________

Was the majority of the interview done in English or Spanish?

ENGLISH
SPANISH
BOTH EQUALLY

ZZ1 INTERVIEW IS COMPLETE. PLEASE CLICK THE FINISH BUTTON

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).

File Type	application/vnd.openxmlformats-officedocument.wordprocessingml.document
Author	Sarah C Tinker
File Modified	0000-00-00
File Created	2021-01-23

BD-STEPS Questionnaire

Birth Defects Study to Evaluate Pregnancy exposureS (BD-STEPS)

AttG1_BDSTEPS_CATI_English.tfs4_kb

Mother's Questionnaire

OMB: 0920-0010

Contents

OPENING STATEMENT

Section A: ESTABLISHING DATES

Section B: MULTIPLE GESTATION

Section C: PREGNANCY HISTORY

Section D: FAMILY HISTORY

Section E: FERTILITY

Maternal Health Introduction

Section F: DIABETES

Section G: CANCER

Section H: HEART PROBLEMS

Section I: THYROID DISEASE

Section J: ASTHMA

Section K: EPILEPSY

Section L: MIGRAINE

Section M: AUTOIMMUNE DISEASE

Section N: TRANSPLANT RECEIPT

Section O: DEPRESSION / ANXIETY

Section P: ATTENTION DEFICIT HYPERACTIVITY DISORDER (ADHD)

Section Q: CHRONIC DISEASE CATCH-ALL QUESTION

Section R: GENITOURINARY INFECTIONS

Section S: FEVERS

Section T: MEDICATIONS/HERBALS/VITAMINS

Section U: STRESS

Section V: PHYSICAL ACTIVITY

Section W: OBESITY

Section X: DENTAL PROCEDURES

Section Y: SMOKING

Section Z: ALCOHOL

Section AA: RESIDENCE HISTORY

Section BB: MATERNAL OCCUPATION

Section CC: RACE / ACCULTURATION / EDUCATION

Section DD: INSURANCE STATUS

Section EE: CLOSING

Section FF: INTERVIEWER REMARKS