Supplemental Stillbirth Computer Assisted Telephone Inte

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

AttI1_BDSTEPS_SB-Suppl Questionnaire_English

Intro Phone Script including Consent to Supplemental Stillbirth

OMB: 0920-0010

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Form Approved

OMB No. 0920-0010

Exp. Date: 01/31/2017


















Centers for Birth Defects Research and Prevention

Supplemental Stillbirth

Computer-Assisted Telephone Interview









Questionnaire Version 1, Draft 2.0









Contents













OPENING STATEMENT

In this interview we will ask you questions mainly about your pregnancy with {name of infant}, who was born on {infant’s birth date} (for liveborns)/ that ended on {pregnancy end date} (for stillbirths).

Section A: PREVIOUS Pregnancy History

I am going to start by asking you about your previous pregnancy experiences.

A1. Has a prior pregnancy ended in a stillbirth?

  1. Yes CONTINUE TO A2

  2. No SKIP TO NEXT SECTION

  3. DK SKIP TO NEXT SECTION

  4. RF SKIP TO NEXT SECTION


A2. Was an autopsy or other type of exam done for the baby who died?

  1. Yes CONTINUE TO A3

  2. No SKIP TO NEXT SECTION

  3. DK SKIP TO NEXT SECTION

  4. RF SKIP TO NEXT SECTION


A3. Did a healthcare provider tell you about the autopsy results or why he/she thought the baby died?

  1. Yes CONTINUE TO A4

  2. No SKIP TO NEXT SECTION

  3. DK SKIP TO NEXT SECTION

  4. RF SKIP TO NEXT SECTION


A4. What was the reason? __________________________


INDEX PREGNANCY: Pregnancy-Specific Conditions

Now, I’m going to ask you about your pregnancy experiences for your pregnancy with {name of infant}, who was born on {infant’s birth date} (for liveborns)/ that ended on {pregnancy end date} (for stillbirths).

Section B. Maternal Perception of Fetal Movements

B1. Do you remember the month when the baby first started moving?

  1. Yes CONTINUE TO B2

  2. No SKIP TO B3

  3. DK SKIP TO B3

  4. RF SKIP TO B3



B2. In what month did the movements start? [RECORD ONE]

  1. ___weeks OR

  2. ___ months OR

  3. ___ trimester OR

  4. __ __ /__ __ /__ __ __ __ date [mm/dd /yyyy]

  5. DK

  6. RF

B3. During the last three months you were pregnant, did you notice any change in the frequency of fetal movements?

  1. Yes CONTINUE TO B4

  2. No SKIP TO B7

  3. DK SKIP TO B7

  4. RFSKIP TO B7


B4. Did the frequency of movements

  1. Increase? SKIP TO B7

  2. Stay the same? SKIP TO B7

  3. Decrease? CONTINUE TO B5

  4. DK SKIP TO B7

  5. RF SKIP TO B7


B5. When was the first time you experienced reduced fetal movement in your pregnancy? [RECORD ONE]

  1. ___weeks OR

  2. ___ months OR

  3. ___ trimester OR

  4. __ __ /__ __ /__ __ __ __ date [mm/dd /yyyy]

  5. DK

  6. RF


B6. Was the reduced fetal movement severe enough for you to call, mention, or notify your healthcare provider?

  1. YES

  2. NO

  3. DK

  4. RF


B7. During the last three months you were pregnant, did you notice any change in the strength of fetal movement?

  1. Yes CONTINUE TO B8

  2. No SKIP TO B11

  3. DK SKIP TO B11

  4. RF SKIP TO B11




B8. Did the strength of the movements

  1. Increase? SKIP TO B11

  2. Stay the same? SKIP TO B11

  3. Decrease? CONTINUE TO B9

  4. DK SKIP TO B11

  5. RF SKIP TO B11

B9. When was the first time you noticed a decrease in the strength of the fetal movements?

  1. ___weeks OR

  2. ___ months OR

  3. ___ trimester OR

  4. __ __ /__ __ /__ __ __ __ date [mm/dd /yyyy]

  5. DK

  6. RF


B10. Was the decrease in the strength of fetal movement severe enough for you to call, to mention, or notify your healthcare provider?

  1. YES

  2. NO

  3. DK

  4. RF

B11. Did you ever notice that the fetal movements had completely stopped?

  1. Yes GO TO B12

  2. No SKIP TO B13

  3. DK SKIP TO B13

  4. RF SKIP TO B13


B12. When was the first time you noticed that the fetal movements had completely stopped?


  1. ___weeks OR

  2. ___ months OR

  3. ___ trimester OR

  4. __ __ /__ __ /__ __ __ __ date [mm/dd /yyyy]

  5. DK

  6. RF


B13. During the last three months of your pregnancy, did you feel rhythmic movements or your baby having hiccups (short jerking movements occurring at regular intervals, for a period of time)?

  1. Yes

  2. No

  3. DK

  4. RF

Section C. Maternal Sleeping Position

C1. What is your usual sleep position when you are not pregnant?

  1. On back

  2. On stomach, facing down

  3. Left

  4. Right

  5. Combination of positions

  6. DK

  7. RF

C2. What was your usual sleep position during the last month of your pregnancy?

  1. On back

  2. On stomach, facing down

  3. Left

  4. Right

  5. Combination of positions

  6. DK

  7. RF

Section D. Fetal growth

D1. Did a healthcare provider tell you that the baby was not growing normally during pregnancy?

  1. Yes CONTINUE TO D2

  2. No SKIP TO D3

  3. DK SKIP TO D3

  4. RF SKIP TO D3

D2. What did the healthcare provider tell you?_______________________________


D3. Did you have an ultrasound during your pregnancy that showed that your baby’s growth was restricted?


a. YES When was it done? ____weeks OR ___ months OR___ trimester OR

__ __ /__ __ /__ __ __ __ date [mm/dd /yyyy]

b. NO

c. DK

d. RF


D4. Did you have any tests during your pregnancy that showed any problems involving the placenta or umbilical cord, such as placenta previa or cord knots?

a. YES What problem was found? __________________________

Anything else? __________________________

b. NO

c. DK

d. RF


if outcome of the participant’s pregnancy was liveborn, skip to Section E (Vaginal Bleeding)

if outcome of the participant’s pregnancy was Stillbirth, continue with D5


D5. Was an autopsy or other type of exam done for the baby who died?

  1. Yes Continue to D6

  2. No SKIP TO D8

  3. Not sure SKIP TO D8

  4. RF SKIP TO D8


D6. Did a healthcare provider tell you about the autopsy results or why he/she thought the baby died?

  1. Yes Continue to D7

  2. No SKIP TO D8

  3. Not sure SKIP TO D8

  4. RF SKIP TO D8


D7. What were you told was the reason? __________________


D8. Did a healthcare provider do any genetic tests because the baby died?

  1. Yes CONTINUE TO D9

  2. No SKIP TO NEXT SECTION

  3. DK SKIP TO NEXT SECTION

  4. RF SKIP TO NEXT SECTION


D9. Do you remember which tests were done?

  1. Yes CONTINUE TO D10

  2. No SKIP TO NEXT SECTION

  3. DK SKIP TO NEXT SECTION

  4. RF SKIP TO NEXT SECTION


D10. What were the results? ­­­­­­­­­_____________________________________


Section E. Vaginal Bleeding

E1. At any time during your pregnancy, did you experience more than one pad's worth of bleeding during a one-day period?

  1. YES CONTINUE TO E2

  2. NO SKIP TO NEXT SECTION

  3. DK SKIP TO NEXT SECTION

  4. RF SKIP TO NEXT SECTION




E2. When was the first time you experienced this amount of bleeding in your pregnancy? [RECORD ONE]

  1. ___weeks OR

  2. ___ months OR

  3. ___ trimester OR

  4. __ __ /__ __ /__ __ __ __ date [mm/dd /yyyy]

  5. DK

  6. RF


E3. Before delivery, when was the last time you experienced this amount of bleeding? [RECORD ONE]

  1. ___weeks OR

  2. ___ months OR

  3. ___ trimester OR

  4. __ __ /__ __ /__ __ __ __ date [mm/dd /yyyy] OR

  5. DK

  6. RF


E4. Was the bleeding severe enough for you to call, to mention, or to notify your healthcare provider?

  1. YES

  2. NO

  3. DK

  4. RF

Section F. Loss of AMNIOTIC Fluid

F1. At any time during your pregnancy, did you experience enough leaking fluid to wear a pad?

  1. YES CONTINUE TO F2

  2. NO SKIP TO NEXT SECTION

  3. DK SKIP TO NEXT SECTION

  4. RF SKIP TO NEXT SECTION


F2. When was the first time you experienced leaking fluid in your pregnancy? [RECORD ONE]

  1. ___weeks OR

  2. ___ months OR

  3. ___ trimester OR

  4. __ __ /__ __ /__ __ __ __ date [mm/dd /yyyy] OR

  5. DK

  6. RF


F3. Was the leaking fluid severe enough for you to call, to mention, or to notify your healthcare provider?

  1. YES

  2. NO

  3. DK

  4. RF


Section G. Abdominal Pain

G1. During this pregnancy, did you experience severe abdominal pain?

  1. Yes CONTINUE TO G2

  2. No SKIP TO NEXT SECTION

  3. DK SKIP TO NEXT SECTION

  4. RF SKIP TO NEXT SECTION


G2. When was the first time you experienced severe abdominal pain in your pregnancy? [RECORD ONE]

  1. ___weeks OR

  2. ___ months OR

  3. ___ trimester OR

  4. __ __ /__ __ /__ __ __ __ date [mm/dd /yyyy]

  5. DK

  6. RF


G3. Was this abdominal pain severe enough for you to call, to mention, or to notify your healthcare provider?

  1. Yes

  2. No

  3. DK

  4. RF

INDEX PREGNACY: Specific Exposures

Section H. Specific Exposures


H1. Did you take any medications to maintain your pregnancy or to prevent premature delivery; examples of such medications: 17-hydroxyprogesterone, aspirin, magnesium sulfate?

a. Yes What did you take? ___________________

Start date ________ Stop date ________

Anything else?_______________

b. No

c. DK

d. RF


H2. At any time from {second trimester start date} until the end of your pregnancy, did you smoke cigarettes?

a. YES GO TO H2a

b. NO SKIP TO H3

c. DK SKIP TO H3

d. RF SKIP TO H3

H2a. During which months did you smoke?

a. MONTH OF PREGNANCY (P4 /P5 / P6 / P7 / P8 /P9)

g. DK

h. RF

H2b. How many cigarettes did you smoke per day?

a. NUMBER __________

b. DK

c. RF


H3. At any time from {second trimester start date} until the end of your pregnancy, did you use electronic cigarettes, also known as e-cigarettes?

a. YES IF YES, GO TO H3a

b. NO SKIP TO H4

c. DK SKIP TO H4

d. RF SKIP TO H4

H3a. How often did you use e-cigarettes?

a. EVERYDAY

b. SOMEDAYS

c. RARELY

d. DK

e. RF


H4. From {second trimester start date} until the end of your pregnancy, did you drink any wine, beer, mixed drinks or shots of liquor?

a. YES GO TO H4a

b. NO SKIP TO H5

c. DK SKIP TO H5

d. RF SKIP TO H5

H4a. During which months did you drink any alcoholic beverages?

  1. __________________ (P4, P5, P6, P7, P8, P9)

  2. DK

  3. RF



H4b. What was the greatest number of drinks you had on one occasion during this time period? We define one drink as one beer, one glass of wine, one mixed drink, or one shot of liquor.

a. NUMBER _______

b. DK

c. RF


H5. During your pregnancy, did any healthcare worker ever suspect you had exposure to carbon monoxide (from causes such as smoke from a fire, using faulty water heaters, using gas powered tools, vehicles, or poorly ventilated areas, car exhaust.)

  1. Yes

  2. No

  3. DK

  4. RF


Illnesses and their treatment

Introduction: During your previous telephone interview, we focused on the first trimester of your pregnancy. In this part of the interview, we will ask about some of the previously-covered topics, but this time our interest is mostly in the later period of your pregnancy, from the beginning of your second trimester until the end of your pregnancy. We will also cover some new topics. If you filled out the medication worksheet that we sent you earlier, it will be helpful if you have it in front of you when answering these questions.

Note: A medication worksheet covering the second and third trimesters will be sent with the introductory materials.

These questions will require the interviewer to have access to the participant’s responses in the Primary CATI.

Section I. Diabetes

IF THE PARTICIPANT DID NOT REPORT A PREVIOUS DIAGNOSIS OF DIABETES [PRIMARY CATI F1 = NO, DK, RF] SKIP TO NEXT SECTION

IF THE PARTICIPANT PREVIOUSLY REPORTED A DIAGNOSIS OF DIABETES [PRIMARY CATI F1 = YES] READ:


You previously told us that you had diabetes. Now I would like to ask some additional questions about your diabetes and any medications you may have taken to treat your diabetes from the beginning of your second trimester, that is from {second trimester start date}, until the end of your pregnancy.


I1. What type of diabetes did you or do you currently have? Was it [READ LIST]


  1. Gestational, that is, during pregnancy only CONTINUE TO I2

  2. Insulin-dependent diabetes, also called Type 1, or Juvenile SKIP TO I4

  3. Non-insulin-dependent diabetes, also called Type 2, or Adult onset SKIP TO I4

  4. DK SKIP TO I4

  5. RF SKIP TO I4


I2. When were you first diagnosed with gestational diabetes? [READ LIST, a-c]


  1. During a previous pregnancy only SKIP TO NEXT SECTION

  2. During this [index] pregnancy only CONTINUE TO I3

  3. During this [index] pregnancy and a previous pregnancy CONTINUE TO I3

  4. DK SKIP TO I4

  5. RF SKIP TO I4


I3. When was gestational diabetes diagnosed during your [index] pregnancy?


  1. __ __ /__ __ /__ __ __ __ date [mm/dd /yyyy]

  2. Month of pregnancy (P1, P2, P3, P4, P5, P6, P7, P8, P9)

  3. DK

  4. RF


I4. From {second trimester start date} until the end of your pregnancy, did you take any medications to manage your diabetes and its complications?


  1. YES CONTINUE TO I5

  2. NO SKIP TO NEXT SECTION

  3. DK SKIP TO NEXT SECTION

  4. RF SKIP TO NEXT SECTION


I5. What medications did you take? /Did you take anything else? LIST ALL. IF CAN’T RECALL, READ FROM DRUG LIST. Did you take…?


a. Actos

b. Amaryl

c. Byetta

d. Diabeta

e. Diabinese

f. Glucophage

g. Glucotrol

h. Glucotrol XL

i. Glumetza

j. Glyburide

k. Glynase PresTab

l. Humalog

m. Humulin N

n. Humulin R

o. Januvia

p. Lantus

q. Levemir

r. Metformin HCL

s. Micronase

t. Novolin N

u. Novolin R

v. Novolog

w. Onglyza

x. Prandin

y. Precose

z. Starlix

aa. Victoza

bb. OTHER (SPECIFY)

cc. DK SKIP TO NEXT SECTION

dd. RF SKIP TO NEXT SECTION


I6. When did you start using {medication} for diabetes during this time period?


a. __ __ /__ __ /__ __ __ __ date [mm/dd /yyyy] or

b. MONTH OF PREGNANCY (P4, P5, P6, P7, P8, P9)

c. DK

d. RF



I7. When did you stop using {medication} during this time period?


a. __ __ /__ __ /__ __ __ __ date [mm/dd /yyyy] or

b. MONTH OF PREGNANCY (P4, P5, P6, P7, P8, P9) IF VALID RESPONSE TO I6 AND I7, SKIP I8

c. DK

d. RF


I8. Or, From {second trimester start date} until the end of your pregnancy, how long did you take it?

a. AMOUNT:__________

i. Days

ii. Weeks

iii. Months

b. DK

c. RF


I9. How often did you use {medication} during this time period? You can say the number of times per day, per week, or per month.


  1. AMOUNT:__________ Per Day/Per Week/Per Month/ DK/RF

  2. DK

  3. RF



I10. Did you use {medication} at any other time from {second trimester start date} until the end of your pregnancy?



a. YES RETURN TO H6, RECORD ADDITIONAL DATES AND FREQUENCY OF USE INFORMATION, AND THEN CONTINUE TO I11

b. NO CONTINUE TO I11



I11. Did you take anything else for diabetes?



a. YES RETURN TO I5

b. NO CONTINUE TO NEXT SECTION



Section J. High blood pressure


IF THE PARTICIPANT DID NOT REPORT A DIAGNOSIS OF HYPERTENSION [PRIMARY CATI H28 = NO, DK, RF] SKIP TO NEXT SECTION.


IF THE PARTICIPANT PREVIOUSLY REPORTED A DIAGNOSIS OF HYPERTENSION [PRIMARY CATI H28 = YES] READ:


In the previous interview, you told us that you had been diagnosed with high blood pressure in the past. Now I would like to ask some additional questions about your high blood pressure and any medications that you took to treat it from the beginning of your second trimester, that is from {second trimester start date}, until the end of your pregnancy.


J1. What type of high blood pressure did you or do you have? Was it pregnancy-related – that is during pregnancy only? 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.


  1. Pregnancy related CONTINUE TO J2

  2. Chronic high blood pressure SKIP TO J4

  3. Both CONTINUE TO J2

  4. DK SKIP TO J4

  5. RF SKIP TO J4


J2. When did you have pregnancy-related high blood pressure? [READ LIST, a-c]


    1. During a previous pregnancy only IF J1 = BOTH SKIP TO J4

IF J1 = PREGNANCY-RELATED SKIP TO NEXT SECTION

    1. During this [index] pregnancy only CONTINUE TO J3

    2. During this [index] pregnancy and a previous pregnancy CONTINUE TO J3

    3. DK SKIP TO J4

    4. RF SKIP TO J4


J3. When was high blood pressure diagnosed during your [index] pregnancy?


a. Date ____________

b. Month of pregnancy (P1, P2, P3, P4, P5, P6, P7, P8, P9)

c. DK

d. RF


J4. From {second trimester start date} until the end of your pregnancy, did you take any medications or remedies for high blood pressure?


a. YES CONTINUE TO J5

b. NO SKIP TO NEXT SECTION

c. DK SKIP TO NEXT SECTION

d. RF SKIP TO NEXT SECTION



J5. What did you take? / Did you take anything else? IF CAN’T RECALL, READ FROM DRUG LIST:


  1. Accupril

  2. Adalat

  3. Altace

  4. Amlodipine

  5. Atenolol

  6. Avapro

  7. Benazepril HCL

  8. Benicar

  9. Calan

  10. Capoten

  11. Cardizem

  12. Covera -HS

  13. Cozaar

  14. Diltiazem HCL

  15. Diovan

  16. Enalapril Maleate

  17. Hydralazine

  18. Hydrochlorothiazide

  19. Inderal

  20. Irbesartan

  21. Labetalol

  22. Lisinopril

  23. Losartan Potassium

  24. Lotensin

  25. Methyldopa

  26. Metoprolol

  27. Microzide

  28. Nifedipine

  29. Normodyne

  30. Norvasc

  31. Olmesartan Medoxomil

  32. Prinivil

  33. Procardia

  34. Propranolol

  35. Quinapril HCL

  36. Ramipril

  37. Tenormin

  38. Tiazac

  39. Trandate

  40. Valsartan

  41. Vasotec

  42. Verapamil

  43. Verelan

  44. Zestril

  45. OTHER (SPECIFY):__________

  46. DK SKIP TO NEXT SECTION

  47. RF SKIP TO NEXT SECTION


J6. When did you start using {medication} for high blood pressure during this time period?


  1. __ __ /__ __ /__ __ __ __ date [mm/dd /yyyy] or

  2. MONTH OF PREGNANCY (P4, P5, P6, P7, P8, P9)

  3. DK

  4. RF


J7. When did you stop using {medication} during this time period?


  1. __ __ /__ __ /__ __ __ __ date [mm/dd /yyyy] or

  2. MONTH OF PREGNANCY (P4, P5, P6, P7, P8, P9) IF VALID RESPONSE TO J6 and J7, SKIP J8

  3. DK

  4. RF


J8. From {second trimester start date} until the end of your pregnancy, how long did you take it?


  1. AMOUNT:__________

i. Days

ii. Weeks

iii. Months

  1. DK

  2. RF


J9. How often did you use {medication} during this time period? You can say the number of times per day, per week, or per month.


  1. AMOUNT:__________ Per Day/Per Week/Per Month/DK/RF



J10. Did you use {medication} at any other time from {second trimester start date} until the end of your pregnancy?



a. YES RETURN TO J6, RECORD ADDITIONAL DATES AND FREQUENCY OF USE INFORMATION, AND THEN CONTINUE TO J11

b. NO CONTINUE TO J11



J11. Did you take anything else for high blood pressure?



a. YES RETURN TO J5

b. NO CONTINUE TO NEXT SECTION



Section K. Preeclampsia/Eclampsia


K1. Did a doctor or other healthcare professional tell you that you had toxemia, pre-eclampsia, or eclampsia at any time during your [index] pregnancy?


  1. YES CONTINUE TO K2

  2. NO SKIP TO NEXT SECTION

  3. DK SKIP TO NEXT SECTION

  4. RF SKIP TO NEXT SECTION


K2. Which condition(s) did you have? [READ ALL, RECORD ALL]


    1. Toxemia/pre-eclampsia When was it diagnosed (month of pregnancy) ____

    2. Eclampsia When was it diagnosed (month of pregnancy) ____

    3. DK

    4. RF



K3. From {second trimester start date} until the end of your pregnancy, did you take any medications or remedies for {specific condition(s)}?


a. YES CONTINUE TO K4

b. NO SKIP TO NEXT SECTION

c. DK SKIP TO NEXT SECTION

d. RF SKIP TO NEXT SECTION


K4. What did you take? / Did you take anything else? IF CAN’T RECALL, READ FROM DRUG LIST:


  1. Accupril

  2. Adalat

  3. Altace

  4. Amlodipine

  5. Atenolol

  6. Avapro

  7. Benazepril HCL

  8. Benicar

  9. Calan

  10. Capoten

  11. Cardizem

  12. Covera -HS

  13. Cozaar

  14. Diltiazem HCL

  15. Diovan

  16. Enalapril Maleate

  17. Hydralazine

  18. Hydrochlorothiazide

  19. Inderal

  20. Irbesartan

  21. Labetalol

  22. Lisinopril

  23. Losartan Potassium

  24. Lotensin

  25. Magnesium sulfate

  26. Methyldopa

  27. Metoprolol

  28. Microzide

  29. Nicardipine

  30. Nifedipine

  31. Nitroprusside

  32. Normodyne

  33. Norvasc

  34. Olmesartan Medoxomil

  35. Prinivil

  36. Procardia

  37. Propranolol

  38. Quinapril HCL

  39. Ramipril

  40. Steroid NOS

  41. Tenormin

  42. Tiazac

  43. Trandate

  44. Valsartan

  45. Vasotec

  46. Verapamil

  47. Verelan

  48. Zestril

  49. OTHER (SPECIFY):__________

  50. DK SKIP TO NEXT SECTION

  51. RF SKIP TO NEXT SECTION


K5. When did you start using {medication} for {specific condition(s)} during this time period?


  1. __ __ /__ __ /__ __ __ __ date [mm/dd /yyyy] or

  2. ___ MONTH OF PREGNANCY (P4, P5, P6, P7, P8, P9)

  3. DK

  4. RF


K6. When did you stop using {medication} during this time period?



  1. __ __ /__ __ /__ __ __ __ date [mm/dd /yyyy] or

  2. MONTH OF PREGNANCY (P4, P5, P6, P7, P8, P9) IF VALID RESPONSE TO K5 and K6, SKIP K7

  3. DK

  4. RF


K7. From {second trimester start date} until the end of your pregnancy, how long did you take it?


  1. AMOUNT:__________

i. Days

ii. Weeks

iii. Months

  1. DK

  2. RF


K8. How often did you use {medication} during this time period? You can say the number of times per day, per week, or per month.


  1. AMOUNT:__________ Per Day/Per Week/Per Month/DK/RF


K9. Did you use {medication} at any other time from {second trimester start date} until the end of your pregnancy?


a. YES RETURN TO K5, RECORD ADDITIONAL DATES AND FREQUENCY OF USE INFORMATION, AND THEN CONTINUE TO K10

b. NO CONTINUE TO K10


K10. Did you take anything else for {specific condition(s)}?


a. YES RETURN TO K4

b. NO CONTINUE TO NEXT SECTION


Section L. Epilepsy/seizures


IF THE PARTICIPANT DID NOT REPORT A PREVIOUS DIAGNOSIS OF EPILEPSY [PRIMARY CATI K1 = NO, DK, RF OR K1 = YES AND K3 = AFTER THE PREGNANCY, DK, RF] SKIP TO L11


IF THE PARTICIPANT PREVIOUSLY REPORTED A DIAGNOSIS OF EPILEPSY THAT OCCURRED BEFORE THE END OF THE INDEX PREGNANCY [PRIMARY CATI K1 = YES AND K3 = MORE THAN 2 YEARS BEFORE (PREGNANCY), IN THE 2 YEARS BEFORE, DURING THE FIRST TRIMESTER, AFTER THE FIRST TRIMESTER BUT STILL DURING PREGNANCY] READ:


In the previous interview, you told us that you had been diagnosed with epilepsy in the past. Now I would like to ask some questions specifically about your condition from the beginning of your second trimester, {second trimester start date}, until the end of your pregnancy.


L1. From {second trimester start date} until the end of your pregnancy, did you take any medications to treat your epilepsy?


  1. YES CONTINUE TO L2

  2. NO SKIP TO L9

  3. DK SKIP TO L9

  4. RF SKIP TO L9


L2. What did you take? / Did you take anything else? IF CAN’T RECALL, READ FROM DRUG LIST:


  1. Carbamazepine

  2. Carbatrol

  3. Clonazepam

  4. Depacon

  5. Depakene Capsules

  6. Depakote

  7. Dilantin

  8. Epitol

  9. Equetro

  10. Felbatol

  11. Keppra

  12. Klonopin

  13. Lamictal

  14. Lamotrigine

  15. Phenobarbital

  16. Phenytoin

  17. Stavzor

  18. Tegretol

  19. Topamax

  20. Topiramate

  21. Trileptal

  22. Valproic Acid

  23. OTHER (SPECIFY)

  24. DK SKIP TO L9

  25. RF SKIP TO L9



L3. When did you start using {medication} for epilepsy during this time period?


  1. __ __ /__ __ /__ __ __ __ date [mm/dd /yyyy] or

  2. MONTH OF PREGNANCY (P4, P5, P6, P7, P8, P9)

  3. DK

  4. RF


L4. When did you stop using {medication} during this time period?


  1. __ __ /__ __ /__ __ __ __ date [mm/dd /yyyy] or

  2. MONTH OF PREGNANCY (P4, P5, P6, P7, P8, P9) IF VALID RESPONSE TO L3 and L4, SKIP L5

  3. DK

  4. RF


L5. From {second trimester start date} until the end of your pregnancy, how long did you take it?


  1. AMOUNT:________________

i. Days

ii. Weeks

iii. Months

  1. DK

  2. RF



L6. How often did you use {medication} during this time period? You can say the number of times per day, per week, or per month.


  1. AMOUNT:__________ Per Day/Per Week/Per Month/ DK /RF


L7. Did you use {medication} at any other time from {second trimester start date} until the end of your pregnancy?


a. YES RETURN TO L3, RECORD ADDITIONAL DATES AND FREQUENCY OF USE INFORMATION, AND THEN CONTINUE TO L8

b. NO CONTINUE TO L8


L8. Did you take anything else for epilepsy?


a. YES RETURN TO L2

b. NO CONTINUE TO L9


L9. From {second trimester start date} until the end of your pregnancy, did you have any seizures?


  1. YES CONTINUE TO L10

  2. NO SKIP TO NEXT SECTION

  3. DK SKIP TO NEXT SECTION

  4. RF SKIP TO NEXT SECTION


L10. How many seizures did you have altogether during that time?


  1. AMOUNT:__________ THEN SKIP TO NEXT SECTION

  2. DK SKIP TO NEXT SECTION

  3. RF SKIP TO NEXT SECTION



L11. At any time from the month before you became pregnant through the end of your pregnancy did you have any seizures?

  1. YES CONTINUE TO L12

  2. NO SKIP TO NEXT SECTION

  3. DK SKIP TO NEXT SECTION

  4. RF SKIP TO NEXT SECTION

L12. How many seizures did you have altogether during that time?

  1. AMOUNT:__________

  2. DK

  3. RF

L13. At any time from the month before you became pregnant through the end of your pregnancy, did you take any medications to treat this condition or to prevent seizures?

  1. YES CONTINUE TO L14

  2. NO SKIP TO NEXT SECTION

  3. DK SKIP TO NEXT SECTION

  4. RF SKIP TO NEXT SECTION



L14. What did you take? / Did you take anything else? IF CAN’T RECALL, READ FROM DRUG LIST:

  1. Carbamazepine

  2. Carbatrol

  3. Clonazepam

  4. Depacon

  5. Depakene Capsules

  6. Depakote

  7. Dilantin

  8. Epitol

  9. Equetro

  10. Felbatol

  11. Keppra

  12. Klonopin

  13. Lamictal

  14. Lamotrigine

  15. Phenobarbital

  16. Phenytoin

  17. Stavzor

  18. Tegretol

  19. Topamax

  20. Topiramate

  21. Trileptal

  22. Valproic Acid

  23. OTHER (SPECIFY)

  24. DK SKIP TO NEXT SECTION

  25. RF SKIP TO NEXT SECTION



L15. When did you start using {medication} for epilepsy during this time period?

  1. __ __ /__ __ /__ __ __ __ date [mm/dd /yyyy] or

  2. MONTH OF PREGNANCY (B1, P1, P2, P3, P4, P5, P6, P7, P8, P9)

  3. DK

  4. RF



L16. When did you stop using {medication} during this time period?

  1. __ __ /__ __ /__ __ __ __ date [mm/dd /yyyy] or

  2. MONTH OF PREGNANCY (B1, P1, P2, P3, P4, P5, P6, P7, P8, P9) IF VALID RESPONSE TO L15 and L16, SKIP L17

  3. DK

  4. RF



L17. How long did you take it during this time period?

  1. AMOUNT:________________

i. Days

ii. Weeks

iii. Months

  1. DK

  2. RF



L18. How often did you use {medication} during this time period? You can say the number of times per day, per week, or per month.

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

L19. Did you use {medication} at any other time from the month before you became pregnant until the end of your pregnancy?


  1. YES RETURN TO L15, RECORD ADDITIONAL DATES AND FREQUENCY OF USE INFORMATION, AND THEN CONTINUE TO L20

  2. NO CONTINUE TO L20



L20. Did you take anything else for your condition?

  1. YES RETURN TO L14

  2. NO CONTINUE NEXT SECTION

Section M. Migraine


IF THE PARTICIPANT DID NOT REPORT MIGRAINES PREVIOUSLY [Primary CATI L1 = NO, DK, RF] SKIP TO NEXT SECTION


IF THE PARTICIPANT REPORTED MIGRAINES PREVIOUSLY [Primary CATI L1 = YES] READ:


In the previous interview, you told us that you have had migraines in the past. Now I would like to ask you some questions about your condition from the beginning of your second trimester, {second trimester start date}, until the end of your pregnancy.


M1. From {second trimester start date} until the end of your pregnancy, did you have any migraines?

  1. YES CONTINUE TO M2

  2. NO SKIP TO M3

  3. DK SKIP TO M3

  4. RF SKIP TO M3


M2. From {second trimester start date} until the end of your pregnancy, how many migraines did you have altogether?


    1. Total number:__________ / DK /RF or

    2. Frequency – AMOUNT:__________

i. Per day

ii. Per week

iii. Per month


M3. 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.


From {second trimester start date} until the end of your pregnancy, did you take any medications or remedies for migraines?


  1. YES CONTINUE TO M4

  2. NO SKIP TO NEXT SECTION

  3. DK SKIP TO NEXT SECTION

  4. RF SKIP TO NEXT SECTION


M4. 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

  1. Advil

  2. Aleve

  3. Amitriptyline

  4. Aspirin

  5. Atenolol

  6. Botox

  7. Calan

  8. Carbamazepine

  9. Carbatrol

  10. Cyproheptadine HCL

  11. Depacon

  12. Depakene

  13. Depakote

  14. Diltiazem

  15. Divalproex Sodium

  16. Doxepin

  17. Effexor

  18. Epitol

  19. Equetro

  20. Excedrin Extra Strength Caplets/Tablets/Geltabs

  21. Gabapentin

  22. Ibuprofen

  23. Inderal

  24. Innopran XL

  25. Lamictal

  26. Lamotrigine

  27. Lisinopril

  28. Metoprolol

  29. Motrin

  30. Motrin Ib

  31. Nadolol

  32. Naproxen Sodium

  33. Neurontin

  34. Nifedipine

  35. Nimodipine

  36. Nortriptyline

  37. Pamelor

  38. Propranolol

  39. Protriptyline HCL

  40. Tegretol

  41. Timolol

  42. Topamax

  43. Topiramate

  44. Valproate Sodium

  45. Valproic Acid

  46. Venlafaxine

  47. Verapamil

  48. Verelan

  49. Vivactil

  50. Zestril


OVER-THE-COUNTER PAIN MEDICATIONS

  1. Acetaminophen

  2. Advil

  3. Aleve

  4. Aspirin

  5. Excedrin Migraine

  6. Ibuprofen

  7. Motrin

  8. Naproxen Sodium

  9. Tylenol


PRESCRIPTION PAIN MEDICATIONS

  1. Acetaminophen with Codeine

  2. Almotriptan Maleate

  3. Amerge

  4. Axert

  5. Cafergot

  6. Dihydroergotamine

  7. Eletriptan Hydrobromide

  8. Ergotamine

  9. Fioricet

  10. Frova

  11. Frovatriptan Succinate

  12. Imitrex

  13. Indomethacin

  14. Maxalt

  15. Migergot Suppositories

  16. Migranal

  17. Naproxen Sodium / Sumatriptan Succinate

  18. Naratriptan

  19. Relpax

  20. Rizatriptan

  21. Sumatriptan Succinate

  22. Treximet

  23. Zolmitriptan

  24. Zomig

  25. OTHER (SPECIFY):__________

  26. DK SKIP TO NEXT SECTION

  27. RF SKIP TO NEXT SECTION


M5. When did you start using {medication} for migraines during this time period?


  1. __ __ /__ __ /__ __ __ __ date [mm/dd /yyyy] or

  2. MONTH OF PREGNANCY (P4, P5, P6, P7, P8, P9)

  3. DK

  4. RF


M6. When did you stop using {medication} during this time period?


  1. __ __ /__ __ /__ __ __ __ date [mm/dd /yyyy] or

  2. MONTH OF PREGNANCY (P4, P5, P6, P7, P8, P9) IF VALID RESPONSE TO M5 and M6, SKIP M7

  3. DK

  4. RF


M7. From {second trimester start date} until the end of your pregnancy, how long did you take it?


  1. AMOUNT:________________

i. Days

ii. Weeks

iii. Months

  1. DK

  2. RF


M8. How often did you use {medication} during this time period? You can say the number of times per day, per week, or per month.


  1. AMOUNT:__________ Per Day/Per Week/Per Month/DK/RF


M9. Did you use {medication} at any other time from {second trimester start date} until the end of your pregnancy?


a. YES RETURN TO M5, RECORD ADDITIONAL DATES AND FREQUENCY OF USE INFORMATION, AND THEN CONTINUE TO M10

b. NO CONTINUE TO M10


M10. Did you take anything else for migraines?



a. YES RETURN TO M4

b. NO CONTINUE TO NEXT SECTION


Section N. Depression / Anxiety



IF THE PARTICIPANT DID NOT REPORT A DIAGNOSIS OF ANXIETY OR DEPRESSION BEFORE THE END OF THE INDEX PREGNANCY

[PRIMARY CATI O1 = NO, DK, RF AND O4= NO, DK, RF

OR

PRIMARY CATI O1 = NO, DK, RF AND O4 = YES AND O5= AFTER THE PREGNANCY

OR

PRIMARY CATI O1= YES AND O3 = AFTER THE PREGNANCY AND O4= NO, DK, RF

OR

PRIMARY CATI O1= YES AND O3 = AFTER THE PREGNANCY AND O4 = YES AND O5= AFTER THE PREGNANCY]

SKIP TO NEXT SECTION


IF THE PARTICIPANT PREVIOUSLY REPORTED A DIAGNOSIS OF ANXIETY OR DEPRESSION THAT OCCURRED BEFORE THE END OF THE INDEX PREGNANCY

[PRIMARY CATI O1 = YES AND O3 = MORE THAN 2 YEARS BEFORE (PREGNANCY), IN THE 2 YEARS BEFORE, DURING THE FIRST TRIMESTER, AFTER THE FIRST TRIMESTER BUT STILL DURING PREGNANCY

AND/ OR

O4 =YES AND O5= MORE THAN 2 YEARS BEFORE (PREGNANCY), IN THE 2 YEARS BEFORE, DURING THE FIRST TRIMESTER, AFTER THE FIRST TRIMESTER BUT STILL DURING PREGNANCY]

READ:


In the previous interview, you told us that you were diagnosed in the past with depression [IF PRIMARY CATI O4 = YES] / {anxiety condition from O2} [IF O1 = YES]. Now I would like to ask you about your condition from the beginning of your second trimester, {second trimester start date}, until the end of your pregnancy.

N1. Did you experience any symptoms from {second trimester start date}, until the end of your pregnancy?

  1. YES CONTINUE TO N2

  2. NO SKIP TO N3

  3. DK SKIP TO N3

  4. RF SKIP TO N3


N2. What were the symptoms you experienced?


a. Specify: ________________________________ /DK /RF


N3. From {second trimester start date} until the end of your pregnancy, did you use any medications to treat your condition?


  1. YES CONTINUE TO N4

  2. NO SKIP TO NEXT SECTION

  3. DK SKIP TO NEXT SECTION

  4. RF SKIP TO NEXT SECTION


N4. What did you take? / Did you take anything else? IF CAN’T RECALL, READ FROM DRUG LIST


  1. Abilify

  2. Alprazolam

  3. Anafranil

  4. Aripiprazole

  5. Ativan

  6. Bupropion

  7. Buspar

  8. Buspirone HCL

  9. Carbamazepine

  10. Carbatrol

  11. Celexa

  12. Citalopram Hydrobromide

  13. Clomipramine

  14. Clonazepam

  15. Cymbalta

  16. Depacon

  17. Depakene

  18. Depakote

  19. Diazepam

  20. Duloxetine HCL

  21. Effexor

  22. Epitol

  23. Equetro

  24. Escitalopram Oxolate

  25. Fluoxetine HCL

  26. Imipramine

  27. Inderal

  28. Klonopin

  29. Lamictal

  30. Lamotrigine

  31. Lexapro

  32. Lorazepam

  33. Paroxetine HCL

  34. Paxil

  35. Propranolol

  36. Prozac

  37. Sertraline HCL

  38. St. John’s Wort

  39. Tegretol

  40. Tofranil

  41. Valium

  42. Valproic acid

  43. Venlafaxine

  44. Wellbutrin

  45. Xanax

  46. Zoloft

  47. OTHER (SPECIFY):__________

  48. DK SKIP TO NEXT SECTION

  49. RF SKIP TO NEXT SECTION


N5. When did you start using {medication} for your condition during this time period?


  1. __ __ /__ __ /__ __ __ __ date [mm/dd /yyyy] or

  2. MONTH OF PREGNANCY (P4, P5, P6, P7, P8, P9)

  3. DK

  4. RF


N6. When did you stop using {medication} during this time period?


  1. __ __ /__ __ /__ __ __ __ date [mm/dd /yyyy] or

  2. MONTH OF PREGNANCY (P4, P5, P6, P7, P8, P9) IF VALID RESPONSE TO N5 AND N6, SKIP N7

  3. DK

  4. RF


N7. From {second trimester start date} until the end of your pregnancy, how long did you take it?


  1. AMOUNT:__________

i. Days

ii. Weeks

iii. Months

  1. DK

  2. RF


N8. How often did you use {medication} during this time period? You can say the number of times per day, per week, or per month.


  1. AMOUNT:__________ Per Day/Per Week/Per Month/DK/RF


N9. Did you use {medication} at any other time from {second trimester start date} until the end of your pregnancy?


a. YES RETURN TO N5, RECORD ADDITIONAL DATES AND FREQUENCY OF USE INFORMATION, AND THEN CONTINUE TO N10

b. NO CONTINUE TO N10


N10. Did you take anything else for this condition?


a. YES RETURN TO N4

b. NO CONTINUE TO NEXT SECTION


Section O. Bleeding/Clotting Disorders


O1. Did a doctor or other healthcare provider ever tell you that had a bleeding disorder or a clotting disorder?


  1. YES CONTINUE TO O2

  2. NO SKIP TO O7

  3. DK SKIP TO O7

  4. RF SKIP TO O7


O2. What was the name of the bleeding or clotting disorder?


  1. __________________ (specify)

  2. DK

  3. RF


O3. When were you diagnosed with this condition?


    1. __ __ /__ __ /__ __ __ __ date [mm/dd /yyyy] or____________(Age in years)

    2. DK

    3. RF


O4. At any time during your pregnancy, did you have any complications from this condition, for example, significant bleeding or a blood clot?


          1. YES CONTINUE TO O5

          2. NO SKIP TO O7

          3. DK SKIP TO O7

          4. RF SKIP TO O7


O5. What were the complications?


  1. _____________________ (specify)

  2. DK

  3. RF



O6. When did it occur? Any other times?


  1. __ __ /__ __ /__ __ __ __ date [mm/dd /yyyy] OR

  2. ___ MONTH OF PREGNANCY (P4, P5, P6, P7, P8, P9)

  3. DK

  4. RF



O7. At any time during your pregnancy, did you take any medications or receive any treatments for a bleeding or clotting disorder? Please include anything you may have taken to prevent a problem.


  1. YES CONTINUE TO O8

  2. NO SKIP TO NEXT SECTION

  3. DK SKIP TO NEXT SECTION

  4. RF SKIP TO NEXT SECTION


O8. What did you take? / Did you take anything else?


    1. SPECIFY:____________________________

    2. DK SKIP TO NEXT SECTION

    3. RF SKIP TO NEXT SECTION


O9. When did you start using {medication} for your condition during your pregnancy?


    1. __ __ /__ __ /__ __ __ __ date [mm/dd /yyyy] or

    2. MONTH OF PREGNANCY (P1, P2, P3, P4, P5, P6, P7, P8, P9)

    3. DK

    4. RF


O10. When did you stop using {medication}?


    1. __ __ /__ __ /__ __ __ __ date [mm/dd /yyyy] or

    2. MONTH OF PREGNANCY (P1, P2, P3, P4, P5, P6, P7, P8, P9) IF VALID RESPONSE TO O9 and O10, SKIP O11

    3. DK

    4. RF


O11. How long did you take it during your pregnancy?


    1. AMOUNT:__________

i. Days

ii. Weeks

iii. Months

    1. DK

    2. RF


O12. How often did you take {medication} during your pregnancy? You can say the number of times per day, per week, or per month.


  1. AMOUNT:__________ Per Day/Per Week/Per Month/DK/RF


O13. Did you use {medication} at any other time during your pregnancy?


a. YES RETURN TO O9, RECORD ADDITIONAL DATES AND FREQUENCY OF USE INFORMATION, AND THEN CONTINUE TO O14

b. NO CONTINUE TO O14


O14. Did you take anything else for this condition?


a. YES RETURN TO O8

b. NO CONTINUE TO NEXT SECTION





Section P. Autoimmune disease


IF THE PARTICIPANT DID NOT REPORT A PREVIOUS DIAGNOSIS OF AN AUTOIMMUNE DISEASE [PRIMARY CATI M1 = NONE, DK, RF OR M1 = YES AND M2 = AFTER THE PREGNANCY] SKIP TO NEXT SECTION


IF THE PARTICIPANT PREVIOUSLY REPORTED A DIAGNOSIS OF AN AUTOIMMUNE DISEASE THAT OCCURRED BEFORE THE END OF THE INDEX PREGNANCY [PRIMARY CATI M1 = YES AND M2 = MORE THAN 2 YEARS BEFORE (PREGNANCY), IN THE 2 YEARS BEFORE, DURING THE FIRST TRIMESTER, AFTER THE FIRST TRIMESTER BUT STILL DURING PREGNANCY] READ:


In the previous interview, you told us that you were diagnosed in the past with {specific condition(s) from M1}. Now I would like to ask you about your condition(s) from the beginning of your second trimester, {second trimester start date}, until the end of your pregnancy.


ASK THESE QUESTIONS FOR EACH CONDITION GIVEN IN PRIMARY CATI M1


P1. From {second trimester start date} until the end of your pregnancy, did you take any medications to treat {specific condition}?


    1. YES CONTINUE TO P2

    2. NO SKIP TO NEXT CONDITION OR IF NONE, TO NEXT SECTION

    3. DK SKIP TO NEXT CONDITION OR IF NONE, TO NEXT SECTION

    4. RF SKIP TO NEXT CONDITION OR IF NONE, TO NEXT SECTION


P2. What did you take? / Did you take anything else? SPECIFY: ______________

IF CAN’T RECALL, READ FROM DRUG PROMPT LISTS FOR THESE 4 CONDITIONS, BUT DRUGS ASKED FOR EACH CONDITION.


P2a. Lupus:

  1. Advil

  2. Aleve

  3. Arava

  4. Azasan

  5. Azathioprine

  6. Belimumab

  7. Benlysta

  8. Cellcept

  9. Cyclophosphamide

  10. Cytoxan

  11. Hydroxychloroquine Sulfate

  12. Leflunomide

  13. Methotrexate

  14. Motrin

  15. Mycophenolate Mofetil

  16. Plaquenil

  17. Prednisone

  18. Trexall

  19. OTHER, SPECIFY:______________

  20. DK SKIP TO NEXT CONDITION/NEXT SECTION

  21. RF SKIP TO NEXT CONDITION/NEXT SECTION


P2b. Rheumatoid arthritis:

  1. Abatacept

  2. Actemra

  3. Adalimumab

  4. Advil

  5. Aleve

  6. Anakinra

  7. Arava

  8. Azasan

  9. Azathioprine

  10. Azulfidine

  11. Certolizumab Pegol

  12. Cimzia

  13. Cyclophosphamide

  14. Cyclosporine

  15. Cytoxan

  16. Dynacin

  17. Enbrel

  18. Etanercept

  19. Gengraf

  20. Golimumab

  21. Humira

  22. Hydroxychloroquine Sulfate

  23. Ibuprofen

  24. Imuran

  25. Infliximab

  26. Kineret

  27. Leflunomide

  28. Methotrexate

  29. Minocin

  30. Minocycline

  31. Motrin

  32. Naproxen Sodium

  33. Neoral

  34. Orencia

  35. Plaquenil

  36. Prednisone

  37. Remicade

  38. Rituxan

  39. Rituximab

  40. Sandimmune

  41. Simponi

  42. Sulfasalazine

  43. Tocilizumab

  44. Trexall

  45. OTHER, SPECIFY:______________

  46. DK SKIP TO NEXT CONDITION/NEXT SECTION

  47. RF SKIP TO NEXT CONDITION/NEXT SECTION


P2c. Multiple sclerosis:

  1. Amantadine

  2. Ampyra

  3. Amrix

  4. Aubagio

  5. Avonex

  6. Baclofen

  7. Betaseron

  8. Copaxone

  9. Cyclobenzaprine

  10. Dalfampridine

  11. Extavia

  12. Fingolimod

  13. Flexeril

  14. Gilenya

  15. Glatiramer Acetate

  16. Lioresal

  17. Methylprednisolone

  18. Mitoxantrone HCL

  19. Natalizumab

  20. Prednisone

  21. Rebif

  22. Solu-Medrol

  23. Tecfidera

  24. Teriflunomide

  25. Tizanidine HCL

  26. Tysabri

  27. Zanaflex

  28. OTHER, SPECIFY:______________

  29. DK SKIP TO NEXT CONDITION/NEXT SECTION

  30. RF SKIP TO NEXT CONDITION/NEXT SECTION


P2d. Crohn’s disease and ulcerative colitis:

  1. Adalimumab

  2. Apriso

  3. Asacol

  4. Azasan

  5. Azathioprine

  6. Azulfidine

  7. Balsalazide Disodium

  8. Certolizumab Pegol

  9. Cimzia

  10. Cipro

  11. Ciprofloxacin HCL

  12. Colazal

  13. Cyclosporine

  14. Dipentum

  15. Flagyl

  16. Gengraf

  17. Humira

  18. Imuran

  19. Infliximab

  20. Lialda

  21. Mercaptopurine

  22. Mesalamine

  23. Methotrexate

  24. Metronidazole

  25. Natalizumab

  26. Neoral

  27. Olsalazine Sodium

  28. Purinethol

  29. Remicade

  30. Rheumatrex

  31. Sandimmune

  32. Sulfasalazine

  33. Tysabri

  34. OTHER (SPECIFY):__________

  35. DK SKIP TO NEXT CONDITION/NEXT SECTION

  36. RF SKIP TO NEXT CONDITION/NEXT SECTION


P2e. Psoriasis:

  1. Anthralin

  2. Calcipotriene

  3. Coal Tar

  4. Dovonex

  5. Elidel

  6. Protopic Ointment

  7. Retin-A

  8. Salicylic Acid

  9. Tazorac

  10. Tazarotene

  11. Tretinoin

  12. OTHER (SPECIFY):__________

  13. DK SKIP TO NEXT CONDITION/NEXT SECTION

  14. RF SKIP TO NEXT CONDITION/NEXT SECTION


P3. When did you start using {medication} for {specific condition} during this time period?


  1. __ __ /__ __ /__ __ __ __ date [mm/dd /yyyy] or

  2. MONTH OF PREGNANCY (P4, P5, P6, P7, P8, P9)

  3. DK

  4. RF


P4. When did you stop using {medication} during this time period?


  1. __ __ /__ __ /__ __ __ __ date [mm/dd /yyyy] or

  2. MONTH OF PREGNANCY (P4, P5, P6, P7, P8, P9) IF VALID RESPONSE TO P3 AND P4, SKIP P5

  3. DK

  4. RF


P5. From {second trimester start date} until the end of your pregnancy, how long did you take it?


  1. AMOUNT:__________

i. Days

ii. Weeks

iii. Months

  1. DK

  2. RF


P6. How often did you use {medication} during this time period? You can say the number of times per day, per week, or per month.


  1. AMOUNT:__________ Per Day/Per Week/Per Month/DK/RF


P7. Did you use {medication} at any other time from {second trimester start date} until the end of your pregnancy?


a. YES RETURN TO P3, RECORD ADDITIONAL DATES AND FREQUENCY OF USE INFORMATION, AND THEN CONTINUE TO P8

b. NO CONTINUE TO P8


P8. Did you take anything else for this condition?


a. YES RETURN TO P2

b. NO CONTINUE TO NEXT CONDITION OR IF NONE, TO NEXT SECTION



Section Q. Fever


Q1. From the beginning of your second trimester, {second trimester start date}, until the end of your pregnancy, 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?


    1. YES CONTINUE TO Q2

    2. NO SKIP TO NEXT SECTION

    3. DK SKIP TO NEXT SECTION

    4. RF SKIP TO NEXT SECTION


Q2. From {second trimester start date} until the end of your pregnancy, how many fevers do you remember having? IF DK NUMBER, SELECT 1 AND ASK MOM FOR DETAILS ABOUT 1 FEVER SHE REMEMBERS.

    1. NUMBER:__________

    2. DK

    3. RF


Q3. What was the cause of the {first, then second, etc.} fever?


    1. CAUSE:__________

    2. DK

    3. RF


Q4. When you had {cause}, during which of those months did you have a fever?

    1. P4

    2. P5

    3. P6

    4. P7

    5. P8

    6. P9

    7. DK

    8. RF


Q5. What was the highest temperature recorded during your fever?

    1. VALUE:__________

      1. UNITS: F or C ______

    2. DK

    3. RF

Q6. Did you take any medications or remedies for this fever?

    1. YES CONTINUE TO Q7

    2. NO RETURN TO Q3 AND ASK ABOUT NEXT EPISODE OF FEVER. IF ALL EPISODES HAVE BEEN COVERED SKIP TO NEXT SECTION

    3. DK RETURN TO Q3 AND ASK ABOUT NEXT EPISODE OF FEVER. IF ALL EPISODES HAVE BEEN COVERED SKIP TO NEXT SECTION

    4. RF RETURN TO Q3 AND ASK ABOUT NEXT EPISODE OF FEVER. IF ALL EPISODES HAVE BEEN COVERED SKIP TO NEXT SECTION


Q7. What did you take? Did you take anything else? CODE ALL THAT APPLY. IF CAN’T RECALL, READ FROM DRUG LIST: Did you take…?

    1. Acetaminophen

    2. Advil

    3. Aleve

    4. Ibuprofen

    5. Motrin

    6. Naproxen sodium

    7. Nuprin

    8. Tylenol

    9. OTHER (SPECIFY):__________

    10. DK RETURN TO Q3 AND ASK ABOUT NEXT EPISODE OF FEVER. IF ALL EPISODES HAVE BEEN COVERED SKIP TO NEXT SECTION

    11. RF RETURN TO Q3 AND ASK ABOUT NEXT EPISODE OF FEVER. IF ALL EPISODES HAVE BEEN COVERED SKIP TO NEXT SECTION


Q8. When did you start using {medication} for this fever?


    1. __ __ /__ __ /__ __ __ __ date [mm/dd /yyyy] or

    2. MONTH OF PREGNANCY (P4, P5, P6, P7, P8, P9)

    3. DK

    4. RF


Q9. When did you stop using {medication} for this fever?


    1. __ __ /__ __ /__ __ __ __ date [mm/dd /yyyy] or

    2. MONTH OF PREGNANCY (P4, P5, P6, P7, P8, P9) IF VALID RESPONSE TO Q8 and Q9, SKIP Q10

    3. DK

    4. RF


Q10. How long did you take it for this fever?

    1. AMOUNT:__________

i. Days

ii. Weeks

iii. Months

    1. DK

    2. RF

Q11. How often did you use {medication} for this fever? You can say the number of times per day, per week, or per month.


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


Q12. Did you use {medication} for the fever you had with {cause} at any other time from {second trimester start date} until the end of your pregnancy?


a. YES RETURN TO Q8, RECORD ADDITIONAL DATES AND FREQUENCY OF USE INFORMATION, AND THEN CONTINUE TO Q13

b. NO CONTINUE TO Q13


Q13. Did you take anything else for the fever you had with {cause}?


a. YES RETURN TO Q7

b. NO RETURN TO Q3 AND ASK ABOUT NEXT EPISODE OF FEVER


WHEN ALL FEVER EPISODES HAVE BEEN COVERED CONTINUE TO NEXT SECTION


Section R. Asthma


IF THE PARTICIPANT DID NOT REPORT A PREVIOUS DIAGNOSIS OF ASTHMA [PRIMARY CATI J1 = NO, DK, RF OR J1 = YES AND J2 = AFTER THE PREGNANCY] SKIP TO NEXT SECTION


IF THE PARTICIPANT PREVIOUSLY REPORTED A DIAGNOSIS OF ASTHMA THAT OCCURRED BEFORE THE END OF THE INDEX PREGNANCY [PRIMARY CATI J1 = YES AND J2 = MORE THAN 2 YEARS BEFORE (PREGNANCY), IN THE 2 YEARS BEFORE, DURING THE FIRST TRIMESTER, AFTER THE FIRST TRIMESTER BUT STILL DURING PREGNANCY] READ:


In the previous interview, you told us that you were diagnosed in the past with asthma. Now I would like to ask you some additional questions about your asthma. In these questions, I am referring to your pregnancy with {name of infant} (for liveborns)/ that ended on {pregnancy end date} (for stillbirths).


R1. At any time during the year before you became pregnant . . .


R1a. Were you hospitalized overnight because of your asthma?

a. YES CONTINUE TO R1b

b. NO SKIP TO R1c

c. DK SKIP TO R1c

d. RF SKIP TO R1c


R1b. When were you hospitalized?


a. __ __ /__ __ /__ __ __ __ date [mm/ dd /yyyy THEN ASK: Any other times?


R1c. Did you go to an emergency room for increased asthma symptoms (but did not require hospitalization)?


a. YES CONTINUE TO R1d

b. NO SKIP TO R1e

c. DK SKIP TO R1e

d. RF SKIP TO R1e


R1d. When did you go to an emergency room?


a. __ __ /__ __ /__ __ __ __ date [mm/ dd /yyyy THEN ASK: Any other times?



R1e. Did you have to make an urgent visit to a physician or clinic for increased asthma symptoms (other than the above)?


a. YES CONTINUE TO R1f

b. NO SKIP TO R1g

c. DK SKIP TO R1g

d. RF SKIP TO R1g


R1f. When did you make the urgent visit?


a. __ __ /__ __ /__ __ __ __ date [mm/ dd /yyyy THEN ASK: Any other times?


R1g. Were you given steroids (ex. Prednisone) as tablet, injection or IV?


a. YES CONTINUE TO R1h

b. NO SKIP TO R2

c. DK SKIP TO R2

d. RF SKIP TO R2


R1h. When were you given steroids?


a. ____________ Date THEN ASK: Any other times?


R2. And now some more questions about the year before you became pregnant.


R2a. How much of the time did your asthma interfere with getting your work done at home or on the job?


a. NEVER

b. SOMETIMES

c. OFTEN

d. CONSTANTLY


R2b. How often did you have shortness of breath due to your asthma?


a. __________ Number of times per day or per period


R2c. How often did your asthma wake you up at night or earlier than usual in the morning?


          1. __________ Number of times per day or per period


R2d. How often did you use an inhaler for immediate relief of asthma symptoms?


a. __________ Number of times per day or per period


R2e. How would you rate your asthma control?


a. COMPLETELY CONTROLLED

b. WELL CONTROLLED

c. SOMEWHAT CONTROLLED

d. POORLY CONTROLLED

e. NOT AT ALL CONTROLLED


R3. The next questions are about your asthma during your pregnancy. At any time during your pregnancy . . .


R3a. Were you hospitalized overnight because of your asthma?

a. YES CONTINUE TO R3b

b. NO SKIP TO R3c

c. DK SKIP TO R3c

d. RF SKIP TO R3c


R3b. When were you hospitalized?


a. ____________ Date THEN ASK: Any other times?


R3c. Did you go to an emergency room for increased asthma symptoms (but did not require hospitalization)?


a. YES CONTINUE TO R3d

b. NO SKIP TO R3e

c. DK SKIP TO R3e

d. RF SKIP TO R3e



R3d. When did you go to an emergency room?


          1. ____________ Date THEN ASK: Any other times?


R3e. Did you have to make an urgent visit to a physician or clinic for increased asthma symptoms (other than the above)?


a. YES CONTINUE TO R3f

b. NO SKIP TO R3g

c. DK SKIP TO R3g

d. RF SKIP TO R3g


R3f. When did you make the urgent visit?


a. ____________ Date THEN ASK: Any other times?


R3g. Were you given steroids (ex. Prednisone) as tablet, injection or IV?


a. YES CONTINUE TO R3h

b. NO SKIP TO R4

c. DK SKIP TO R4

d. RF SKIP TO R4


R3h. When were you given steroids?


a. ____________ Date THEN ASK: Any other times?


R4. The next questions are about your asthma during the first trimester of your pregnancy. During the first trimester of your pregnancy . . .



R4a. How much of the time did your asthma interfere with getting your work done at home or on the job?


a. NEVER

b. SOMETIMES

c. OFTEN

d. CONSTANTLY


R4b. How often did you have shortness of breath due to your asthma?


a. __________ Number of times per day or per period



R4c. How often did your asthma wake you up at night or earlier than usual in the morning? Again, we want to know about the first trimester of your pregnancy.


a. __________ Number of times per day or per period


R4d. How often did you use an inhaler for immediate relief of asthma symptoms?


a. __________ Number of times per day or per period


R4e. How would you rate your asthma control? Again, we want to know about the first trimester of your pregnancy.


a. COMPLETELY CONTROLLED

b. WELL CONTROLLED

c. SOMEWHAT CONTROLLED

d. POORLY CONTROLLED

e. NOT AT ALL CONTROLLED


R5. Next we’d like to ask about your asthma from the beginning of your second trimester, {second trimester start date}, until the end of your pregnancy. During that time period . . .



R5a. How much of the time did your asthma interfere with getting your work done at home or on the job?


a. NEVER

b. SOMETIMES

c. OFTEN

d. CONSTANTLY


R5b. How often did you have shortness of breath due to your asthma?


a. __________ Number of times per day or per period


R5c. How often did your asthma wake you up at night or earlier than usual in the morning? Again, now we want to know about the time from the beginning of your second trimester until the end of your pregnancy.


a. __________ Number of times per day or per period


R5d. How often did you use an inhaler for immediate relief of asthma symptoms?


a. __________ Number of times per day or per period


R5e. How would you rate your asthma control? Again, now we want to know about the time from the beginning of your second trimester until the end of your pregnancy.


a. COMPLETELY CONTROLLED

b. WELL CONTROLLED

c. SOMEWHAT CONTROLLED

d. POORLY CONTROLLED

e. NOT AT ALL CONTROLLED


R6. Finally, from {second trimester start date} until the end of your pregnancy, did you take any medications for your asthma? Please tell me about maintenance medications and remedies you may take for long-term control of your asthma and fast-acting, or “rescue”, medications you may take for treatment of an asthma attack.


a. YES CONTINUE to R7

b. NO SKIP TO NEXT SECTION


R7. What did you take? / Did you take anything else?


NASAL SPRAYS

a. Flonase

b. Flunisolide

c. Fluticasone Nasal Spray

d. Nasonex Nasal Spray

e. Omnaris Nasal Spray

f. Qnasl Nasal Aerosol

g. Rhinocort

h. OTHER (SPECIFY):__________


ORAL INHALANTS

i. Advair

j. Aerobid

k. Aerospan Hfa

l. Alvesco Inhaler

m. Asmanex Twisthaler

n. Budesonide Inhalation Suspension

o. Dulera

p. Flovent

q. Foradil

r. Formoterol Fumarate

s. Perforomist

t. Pulmicort

u. Qvar HFA Inhaler

v. Salmeterol Xinafoate

w. Serevent

x. Symbicort

y. OTHER (SPECIFY):__________


ORAL TABLETS/CAPS

z. Accolate

aa. Montelukast Sodium

bb. Singulair

cc. Zafirlukast

dd. Zileuton

ee. Zyflo

ff. OTHER (SPECIFY):__________



FAST ACTING OR “RESCUE” MEDICATIONS

gg. Albuterol

hh. Asthmanefrin

ii. Atrovent HFA

jj. Ipratropium Bromide

kk. Levalbuterol Tartrate

ll. Maxair

mm. Pirbuterol Acetate

nn. ProAir HFA Inhaler

oo. Ventolin HFA

pp. Xopenex HFA

qq. OTHER (SPECIFY):__________


DON’T KNOW/REFUSED

rr. DK SKIP TO NEXT SECTION

ss. RF SKIP TO NEXT SECTION


R8. When did you start using {medication} for asthma during this time period?


a. __ __ /__ __ /__ __ __ __ date [mm/dd /yyyy] or

b. MONTH OF PREGNANCY (P4, P5, P6, P7, P8, P9)

c. DK

d. RF


R9. When did you stop using {medication} during this time period?


a. __ __ /__ __ /__ __ __ __ date [mm/dd /yyyy] or

b. MONTH OF PREGNANCY ((P4, P5, P6, P7, P8, P9) IF VALID RESPONSE TO R8 and R9, SKIP R10

c. DK

d. RF


R10. From {second trimester start date} until the end of your pregnancy, how long did you take it?


a. AMOUNT:__________

i. Days

ii. Weeks

iii. Months

b. DK

c. RF


R11. How often did you use {medication} during this time period? You can say the number of times per day, per week, or per month.


a. AMOUNT:__________ Per Day/Per Week/Per Month/ DK /RF


R12. Did you use {medication} at any other time from {second trimester start date} until the end of your pregnancy?


a. YES RETURN TO R8, RECORD ADDITIONAL DATES AND FREQUENCY OF USE INFORMATION, AND THEN CONTINUE TO R13

b. NO CONTINUE TO R13


R13. Did you take anything else for this condition?


a. YES RETURN TO R7

b. NO CONTINUE TO NEXT SECTION


Section S. INJURY


S1. From the beginning of your second trimester, {second trimester start date}, until the end of your pregnancy, did you have physical harm to your body due to injury, abuse, or crime?

a. YES CONTINUE TO S2

b. NO SKIP TO NEXT SECTION

c. DK SKIP TO NEXT SECTION

d. RF SKIP TO NEXT SECTION

S2. Did you seek medical care for this injury?


a. YES CONTINUE TO S3

b. NO SKIP TO NEXT SECTION

c. DK SKIP TO NEXT SECTION

d. RF SKIP TO NEXT SECTION


S3. Were you hospitalized?

a. YES

b. NO

c. DK

d. RF


Section T. Specific Medication Exposures

T1. Now I’m going to read you a list of specific medications. You may have already told me about some of these medications in the earlier questions, so please remind me if I repeat something. Please let me know if you have taken any of these medications from {second trimester start date} until the end of your pregnancy.

T1a. Pre-natal vitamins If YES,

T1a1. Start date:

a. __ __ /__ __ /__ __ __ __ date [mm/dd/yyyy] OR

b. ___ Months OR

c. ___ Trimester

  1. DK

  2. RF

T1a2. Stop date:

a. __ __ /__ __ /__ __ __ __ date [mm/dd/yyyy] OR

b. ___ Months OR

c. ___ Trimester

d. DK

e. RF

T1a3. How long did you take it? (IF VALID RESPONSE TO T1a1 and T1a2, SKIP T1a3)

a. AMOUNT:__________

i. Days

ii. Weeks

iii. Months

b. DK

c. RF



T1b. Folic acid If YES,

T1b1. Start date:

a. __ __ /__ __ /__ __ __ __ date [mm/dd/yyyy] OR

b. ___ Months OR

c. ___ Trimester

  1. DK

  2. RF

T1b2. Stop date:

a. __ __ /__ __ /__ __ __ __ date [mm/dd/yyyy] OR

b. ___ Months OR

c. ___ Trimester

d. DK

e. RF

T1b3. How long did you take it? (IF VALID RESPONSE TO T1a1 and T1a2, SKIP T1a3)

a. AMOUNT:__________

i. Days

ii. Weeks

iii. Months

b. DK

c. RF



T1c. Alka-seltzer If YES

T1c1. Start date:

a. __ __ /__ __ /__ __ __ __ date [mm/dd/yyyy] OR

b. ___ Months OR

c. ___ Trimester

  1. DK

  2. RF

T1c2. Stop date:

a. __ __ /__ __ /__ __ __ __ date [mm/dd/yyyy] OR

b. ___ Months OR

c. ___ Trimester

d. DK

e. RF

T1c3. How long did you take it? (IF VALID RESPONSE TO T1a1 and T1a2, SKIP T1a3)

a. AMOUNT:__________

i. Days

ii. Weeks

iii. Months

b. DK

c. RF



T1d. Pepto bismol If YES,

T1d1. Start date:

a. __ __ /__ __ /__ __ __ __ date [mm/dd/yyyy] OR

b. ___ Months OR

c. ___ Trimester

  1. DK

  2. RF

T1d2. Stop date:

a. __ __ /__ __ /__ __ __ __ date [mm/dd/yyyy] OR

b. ___ Months OR

c. ___ Trimester

d. DK

e. RF

T1d3. How long did you take it? (IF VALID RESPONSE TO T1a1 and T1a2, SKIP T1a3)

a. AMOUNT:__________

i. Days

ii. Weeks

iii. Months

b. DK

c. RF



T1e. Aspirin If YES

T1e1. Start date:

a. __ __ /__ __ /__ __ __ __ date [mm/dd/yyyy] OR

b. ___ Months OR

c. ___ Trimester

  1. DK

  2. RF

T1e2. Stop date:

a. __ __ /__ __ /__ __ __ __ date [mm/dd/yyyy] OR

b. ___ Months OR

c. ___ Trimester

d. DK

e. RF

T1e3. How long did you take it? (IF VALID RESPONSE TO T1a1 and T1a2, SKIP T1a3)

a. AMOUNT:__________

i. Days

ii. Weeks

iii. Months

b. DK

c. RF



T1f. Aleve/Naprosyn/naproxen If YES

T1f1. Start date:

a. __ __ /__ __ /__ __ __ __ date [mm/dd/yyyy] OR

b. ___ Months OR

c. ___ Trimester

  1. DK

  2. RF

T1f2. Stop date:

a. __ __ /__ __ /__ __ __ __ date [mm/dd/yyyy] OR

b. ___ Months OR

c. ___ Trimester

d. DK

e. RF

T1f3. How long did you take it? (IF VALID RESPONSE TO T1a1 and T1a2, SKIP T1a3)

a. AMOUNT:__________

i. Days

ii. Weeks

iii. Months

b. DK

c. RF



T1g. Advil/Motrin/ibuprofen If YES

T1g1. Start date:

a. __ __ /__ __ /__ __ __ __ date [mm/dd/yyyy] OR

b. ___ Months OR

c. ___ Trimester

  1. DK

  2. RF

T1g2. Stop date:

a. __ __ /__ __ /__ __ __ __ date [mm/dd/yyyy] OR

b. ___ Months OR

c. ___ Trimester

d. DK

e. RF

T1g3. How long did you take it? (IF VALID RESPONSE TO T1a1 and T1a2, SKIP T1a3)

a. AMOUNT:__________

i. Days

ii. Weeks

iii. Months

b. DK

c. RF



T1h. Tylenol/acetaminophen

T1h1. Start date:

a. __ __ /__ __ /__ __ __ __ date [mm/dd/yyyy] OR

b. ___ Months OR

c. ___ Trimester

  1. DK

  2. RF

T1h2. Stop date:

a. __ __ /__ __ /__ __ __ __ date [mm/dd/yyyy] OR

b. ___ Months OR

c. ___ Trimester

d. DK

e. RF

T1h3. How long did you take it? (IF VALID RESPONSE TO T1a1 and T1a2, SKIP T1a3)

a. AMOUNT:__________

i. Days

ii. Weeks

iii. Months

b. DK

c. RF



T1i. Sudafed/pseudoephedrine If YES

T1i1. Start date:

a. __ __ /__ __ /__ __ __ __ date [mm/dd/yyyy] OR

b. ___ Months OR

c. ___ Trimester

  1. DK

  2. RF

T1i2. Stop date:

a. __ __ /__ __ /__ __ __ __ date [mm/dd/yyyy] OR

b. ___ Months OR

c. ___ Trimester

d. DK

e. RF

T1i3. How long did you take it? (IF VALID RESPONSE TO T1a1 and T1a2, SKIP T1a3)

a. AMOUNT:__________

i. Days

ii. Weeks

iii. Months

b. DK

c. RF



T1j. Afrin/oxymetazoline If YES

T1j1. Start date:

a. __ __ /__ __ /__ __ __ __ date [mm/dd/yyyy] OR

b. ___ Months OR

c. ___ Trimester

  1. DK

  2. RF

T1j2. Stop date:

a. __ __ /__ __ /__ __ __ __ date [mm/dd/yyyy] OR

b. ___ Months OR

c. ___ Trimester

d. DK

e. RF

T1j3. How long did you take it? (IF VALID RESPONSE TO T1a1 and T1a2, SKIP T1a3)

a. AMOUNT:__________

i. Days

ii. Weeks

iii. Months

b. DK

c. RF



T1k. Neosynephrine/phenylephrine If YES

T1k1. Start date:

a. __ __ /__ __ /__ __ __ __ date [mm/dd/yyyy] OR

b. ___ Months OR

c. ___ Trimester

  1. DK

  2. RF

T1k2. Stop date:

a. __ __ /__ __ /__ __ __ __ date [mm/dd/yyyy] OR

b. ___ Months OR

c. ___ Trimester

d. DK

e. RF

T1k3. How long did you take it? (IF VALID RESPONSE TO T1a1 and T1a2, SKIP T1a3)

a. AMOUNT:__________

i. Days

ii. Weeks

iii. Months

b. DK

c. RF



T1l. Adderall If YES

T1l1. Start date:

a. __ __ /__ __ /__ __ __ __ date [mm/dd/yyyy] OR

b. ___ Months OR

c. ___ Trimester

  1. DK

  2. RF

T1l2. Stop date:

a. __ __ /__ __ /__ __ __ __ date [mm/dd/yyyy] OR

b. ___ Months OR

c. ___ Trimester

d. DK

e. RF

T1l3. How long did you take it? (IF VALID RESPONSE TO T1a1 and T1a2, SKIP T1a3)

a. AMOUNT:__________

i. Days

ii. Weeks

iii. Months

b. DK

c. RF



T1m. Concerta/Ritalin/methylphenidate If YES

T1m1. Start date:

a. __ __ /__ __ /__ __ __ __ date [mm/dd/yyyy] OR

b. ___ Months OR

c. ___ Trimester

  1. DK

  2. RF

T1m2. Stop date:

a. __ __ /__ __ /__ __ __ __ date [mm/dd/yyyy] OR

b. ___ Months OR

c. ___ Trimester

d. DK

e. RF

T1m3. How long did you take it? (IF VALID RESPONSE TO T1a1 and T1a2, SKIP T1a3)

a. AMOUNT:__________

i. Days

ii. Weeks

iii. Months

b. DK

c. RF



T1n. Stattera/atomoxetine If YES

T1n1. Start date:

a. __ __ /__ __ /__ __ __ __ date [mm/dd/yyyy] OR

b. ___ Months OR

c. ___ Trimester

  1. DK

  2. RF

T1n2. Stop date:

a. __ __ /__ __ /__ __ __ __ date [mm/dd/yyyy] OR

b. ___ Months OR

c. ___ Trimester

d. DK

e. RF

T1n3. How long did you take it? (IF VALID RESPONSE TO T1a1 and T1a2, SKIP T1a3)

a. AMOUNT:__________

i. Days

ii. Weeks

iii. Months

b. DK

c. RF



T1o. Vyvanse/lisdexamfetamine If YES

T1o1. Start date:

a. __ __ /__ __ /__ __ __ __ date [mm/dd/yyyy] OR

b. ___ Months OR

c. ___ Trimester

  1. DK

  2. RF

T1o2. Stop date:

a. __ __ /__ __ /__ __ __ __ date [mm/dd/yyyy] OR

b. ___ Months OR

c. ___ Trimester

d. DK

e. RF

T1o3. How long did you take it? (IF VALID RESPONSE TO T1a1 and T1a2, SKIP T1a3)

a. AMOUNT:__________

i. Days

ii. Weeks

iii. Months

b. DK

c. RF



T1p. Amphetamines, methamphetamine, cocaine, crack? If YES

T1p1. Start date:

a. __ __ /__ __ /__ __ __ __ date [mm/dd/yyyy] OR

b. ___ Months OR

c. ___ Trimester

  1. DK

  2. RF

T1p2. Stop date:

a. __ __ /__ __ /__ __ __ __ date [mm/dd/yyyy] OR

b. ___ Months OR

c. ___ Trimester

d. DK

e. RF

T1p3. How long did you take it? (IF VALID RESPONSE TO T1a1 and T1a2, SKIP T1a3)

a. AMOUNT:__________

i. Days

ii. Weeks

iii. Months

b. DK

c. RF

T1q. Any other medications used in this time period? If YES, specify all:

T1q1. Start date:

a. __ __ /__ __ /__ __ __ __ date [mm/dd/yyyy] OR

b. ___ Months OR

c. ___ Trimester

  1. DK

  2. RF

T1q2. Stop date:

a. __ __ /__ __ /__ __ __ __ date [mm/dd/yyyy] OR

b. ___ Months OR

c. ___ Trimester

d. DK

e. RF

T1q3. How long did you take it? (IF VALID RESPONSE TO T1a1 and T1a2, SKIP T1a3)

a. AMOUNT:__________

i. Days

ii. Weeks

iii. Months

b. DK

c. RF



Section U: other questions


U1. Do you have any thoughts or ideas about what may cause stillbirths? [ASK OPEN-ENDED]

____________________________________________________________________

____________________________________________________________________

FINAL REMARK

In closing, we would like to sincerely thank you for your time and efforts. Your contribution to this important study will help us greatly in our work to better understand the causes of poor pregnancy outcomes. Thank you!

Public reporting burden of this collection of information is estimated to average 25 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 Typeapplication/vnd.openxmlformats-officedocument.wordprocessingml.document
AuthorKothari, Monica
File Modified0000-00-00
File Created2021-01-23

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