Pregnant Women Enrollment Questionnaire - English

Form Approved

OMB Control No.: 0920-XXXX

Expiration date: XX/XX/XXXX

Site code	Participant code	Pregnant Woman
I I	I I I I	I 0 I

Today’s date: _____/______/________

MM DD YYYY

ZIKV RNA Persistence (ZIRP): Pregnant Woman Enrollment Questionnaire

TO BE COMPLETED BY PATIENT

Part I:Demographics

Thank you for agreeing to participate in this study. If you at any point have any questions about the questions in this form please ask the study staff. First, we will start by asking you some questions about yourself.

1. What was your pre-pregnancy weight/height?

Weight ________ ₁ Pounds ₂ Kilograms ₇₇ Don’t know ₈₈ Refuse

Height ________ ₁ Inches ₂ Centimeters ₇₇ Don’t know ₈₈ Refuse

2. What is your birthdate? __ __/__ __ /__ __ __ __ ₇₇ Don’t know ₈₈ Refuse

M M D D Y Y Y Y

3. What is the highest level of education that you have completed?

₁ Less than primary ₂ Primary ₃ Secondary ₄ Technical ₅ University or +

₇₇ Don’t know ₈₈ Refuse

4. What is your marital status?

₁ Single ₂ Married or domestic partnership ₃ Widowed ₄ Divorced ₅Separated ₆ Other ₇₇ Don’t know ₈₈ Refuse

5. What type of medical insurance do you have?

₁ Reforma (Medicaid) ₂ Private (through work, spouse or parents) ₃ Self-paid ₄ None ₇₇ Don’t know ₈₈ Refuse

6. What type of home do you live in?

₁ House/apartment (owned) ₂ House/apartment (rented) ₃ Public housing ₄ Lives with friends or relatives ₅ Homeless ₈₈ Refuse

Part II:Medical History

We will now ask you questions about your past medical history.

7. Please indicate if you have had of any of the following conditions by marking “yes” or “no”. If you mark yes in any of the conditions please fill out the third column to the right of each individual condition. If you are unsure about the diagnosis date please provide your best guess or mark “not sure”.

	Yes	No	Don’t know	If yes……,
Asthma				Diagnosis Date (mm/dd/yyyy): _______  Not Sure
Blood transfusion				Date of Last Transfusion: (mm/dd/yyyy): _______  Not Sure
Cancer				Type: _________________________ Diagnosis Date (mm/dd/yyyy): _______  Not Sure
Cardiovascular (Heart) Disease				 Pulmonary Embolism  Rheumatic Heart Disease  Congenital Heart Disease  Peripheral Arterial Disease  Aortic Aneurysm and Dissection  Deep venous thrombosis  Pulmonary Embolism  Stroke  Other  Don’t Know Diagnosis Date (mm/dd/yyyy): _______  Not Sure
Diabetes				Type:  Type I  Type II  Gestational diabetes  Not Sure Diagnosis Date (mm/dd/yyyy): _______  Not Sure
Hepatitis				Type:  A  B  C  D  E  Don’t Know Diagnosis Date (mm/dd/yyyy): _______  Not Sure
High Blood Pressure				Diagnosis Date(mm/dd/yyyy): _______  Not Sure
HIV				Diagnosis Date (mm/dd/yyyy): _______  Not Sure
Kidney Disease				Diagnosis Date (mm/dd/yyyy): _______  Not Sure
Liver Disease				Diagnosis Date (mm/dd/yyyy): _______  Not Sure
Mosquito-borne illnesses				2 Dengue Diagnosis Date (mm/dd/yyyy): _______  Not Sure Diagnosis Date (mm/dd/yyyy): _______  Not Sure Diagnosis Date (mm/dd/yyyy): _______  Not Sure Diagnosis Date (mm/dd/yyyy): _______  Not Sure 3 Chikungunya Diagnosis Date (mm/dd/yyyy): _______  Not Sure
Sexually Transmitted Disease				Type:  Chlamydia  Gonorrhea  Genital Herpes  Genital Warts  Syphillis  Crabs  Trichomoniasis  Other  Don’t Know Diagnosis Date (mm/dd/yyyy): _______  Not Sure

Part III: Pregnancy

We will now ask you questions about your pregnancy history.

8. Do you know the first day of your last menstrual cycle? ₁ Yes ₀ No

8.1 If Yes, what was the date?, __ __/__ __ /__ __ __ __

M M D D Y Y Y Y

9. Do you know your due date? ₁ Yes ₀ No

9.1 If Yes, what is your due date?, __ __/__ __ /__ __ __ __

M M D D Y Y Y Y

10. How many babies are you expecting?: ₁ Single ₂ Twins ₃ Triplets ₄ Other

11. How many times were you pregnant before this pregnancy?

_________ times ₁ This is my first pregnancy ₇₇ Don’t know ₈₈ Refuse

12. During this pregnancy, have you been told you have gestational diabetes?

₁ Yes ₀ No ₇₇ Don’t know ₈₈ Refuse

Part IV: Sexual History

We will now ask you questions about your sexual history.

13. How many men have you had unprotected sex with during your pregnancy?

₁ 1 ₂ 2 ₃ 3 or more ₄ None ₇₇ Don’t know ₈₈ Refuse

14. Since the start of your pregnancy, how often have you had vaginal sex with a man? Choose the best answer.

₁ Once a day or more

₂ Two or more times a week

₃ Once a month

₄ Less than once a month

₅ Never

₇₇ Don’t know

₈₈ Refuse

15. Since the start of your pregnancy, when you had sex, how often has your partner used a condom?

₁ Always ₂ Very often ₃ Sometimes ₄ Rarely ₅ Never ₆ Not applicable ₇₇ Don’t know ₈₈ Refuse

Part V: Medications

We will now ask you questions about any prescription medications, over the counter medications, and supplements you are currently taking

16. Are you taking any prescription medications? ₁ Yes ₀ No ₇₇ Don’t know ₈₈ Refuse

16.1 If Yes, Name_______________________________ Dose ________________________________

Name_______________________________ Dose ________________________________

Name_______________________________ Dose ________________________________

Name_______________________________ Dose ________________________________

Name_______________________________ Dose ________________________________

17. Are you taking any over the counter medications? ₁ Yes ₀ No ₇₇ Don’t know ₈₈ Refuse

17.1 If Yes, Name_______________________________ Dose ________________________________

Name_______________________________ Dose ________________________________

Name_______________________________ Dose ________________________________

Name_______________________________ Dose ________________________________

Name_______________________________ Dose ________________________________

18. Are you taking any vitamins/minerals/supplements? ₁ Yes ₀ No ₇₇ Don’t know ₈₈ Refuse

18.1 If Yes, Name_______________________________ Dose ________________________________

Name_______________________________ Dose ________________________________

Name_______________________________ Dose ________________________________

Name_______________________________ Dose ________________________________

Name_______________________________ Dose ________________________________

TO BE COMPLETED THROUGH MEDICAL RECORD ABSTRACTION

Part I: Demographics

1. What is the patient’s current weight/height?

Weight ________ ₁ Pounds ₂ Kilograms ₇₇ Don’t know ₈₈ Refused

Height ________ ₁ Inches ₂ Centimeters ₇₇ Don’t know ₈₈ Refused

2. Has the patient been vaccinated for…?

Yellow fever	1 Yes 0 No 77 Don’t know
	If yes, Date of most recent vaccination (mm/dd/yyyy): _______
Dengue	1 Yes 0 No 77 Don’t know
	If yes, Date of most recent vaccination (mm/dd/yyyy): _______
Influenza	1 Yes 0 No 77 Don’t know
	If yes, Date of most recent vaccination (mm/dd/yyyy): _______

Part II: Obstetric History

Complete if patient reported having previous pregnacies.

3. Did the patient have any of the following in their previous pregnancies…

Live Birth	1 Yes 0 No 77 Don’t know
	If yes, # of pregnancies: __________, year __________ year __________ year __________ year __________ year __________
Miscarriage (loss before 20th week)	1 Yes 0 No 77 Don’t know
	If yes, # of pregnancies: __________, year __________ year __________ year __________ year __________ year __________
Stillbirth (loss at or after the 20th week)	1 Yes 0 No 77 Don’t know
	If yes, # of pregnancies: __________, year __________ year __________ year __________ year __________ year __________
Abortion	1 Yes 0 No 77 Don’t know
	If yes, # of pregnancies: __________, year __________ year __________ year __________ year __________ year __________
Ectopic or molar pregnancy	1 Yes 0 No 77 Don’t know
	If yes, # of pregnancies: __________, year __________ year __________ year __________ year __________ year __________

4. During any of the patient's previous pregnancies, did they …?

Have gestational diabetes (diabetes diagnosed in pregnancy)	1 Yes 0 No 77 Don’t know
Have a premature birth (delivery before 37 weeks)	1 Yes 0 No 77 Don’t know
Have a Cesarean section	1 Yes 0 No 77 Don’t know
Have a baby with a major birth defect	1 Yes 0 No 77 Don’t know

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Version No.12.0

Public reporting burden of this collection of information is estimated to average 8 minutes per response, 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 Information Collection Review Office, 1600 Clifton Road NE, MS D-74,  Atlanta, Georgia 30333; ATTN:  PRA (xxx-xxxx).