Study Questionnaire for Licensed Anglers - Paper

Biomonitoring of Great Lakes Populations Program III

7b.StudyQuestionnaire_LicAng_paper

Study Questionnaire - Licensed Anglers - Paper

OMB: 0923-0056

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Biomonitoring of Great Lakes Populations Program III

Form Approved

OMB No. 0923-17IY

Exp. Date xx/xx/201x

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Attachment 7b. Study Questionnaire for Licensed Anglers (paper)


ACKNOWLEDGEMENT OF RECEIPT OF CONSENT MATERIALS

You should have received a copy of the Consent Form [FOR MAILED SURVEY: along with this survey] [FOR ONLINE SURVEY: in the email we sent you with the link to this questionnaire]. Please take a few minutes to read the Consent Form.


I have received and reviewed the Consent Form. I understand that completing this questionnaire implies my consent to do so.


CONTACT INFORMATION

This section will ask you for your contact information. This will help us get you your lab results and tell you about the results of this study.


  1. What is your full name?
    First: __________________ Last: __________________ Middle initial: ___


  1. Do you have a phone number where we can reach you? This can be the phone number of a friend, relative, or someone who will know how to find you.

Yes 2a. What is it?: _____________________
2b. What type of phone number is this?
Home Work Cell Other

No

Don’t know

Prefer not to answer

  1. Do you have an email address?

Yes 3a. What is it? ________________________________________

No

Don’t know

Prefer not to answer





ATSDR estimates the average public reporting burden for this collection of information as 30 minutes per response, including the time for reviewing instructions, searching existing data/information sources, gathering and maintaining the data/information 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 (0923-17IY).

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  1. What is your address?

Street Number and name: ____________________

Apartment Unit or Number: ______________

City: _____________________ State: _______ ZIP Code: _____________


  1. Is your mailing address different from your street address?

Yes 5a. What is your mailing address?

Street Number and name: ____________________

Apartment Unit or Number: ______________

City: _____________________ State: _______ ZIP Code: _____________

No

Don’t know

Prefer not to answer


SEX, AGE, RACE, ETHNICITY

Now we will ask you some questions about your sex, age, race and ethnicity.

  1. What is your sex?

Male

Female


  1. What is your birthdate?

____ / _____ / _______

mm dd yyyy


  1. Do you consider yourself to be Hispanic or Latino?

Hispanic or Latino

Not Hispanic or Latino

Prefer not to answer


  1. What race do you consider yourself to be?

American Indian or Alaska Native

Asian Answer #9a

Black or African American

Native Hawaiian or Other Pacific Islander

White

Prefer not to answer



9a. Are you of Burmese descent?

Yes

No

Prefer not to answer

RESIDENTIAL HISTORY

Now we will ask you some questions about where you have lived.

  1. How long have you lived in the Milwaukee, Wisconsin area?

_____ years

Don’t know

Prefer not to answer


  1. How long have you lived at your current address?

_____ years

Don’t know

Prefer not to answer


  1. When was this home built? Please enter four digits for the year, such as 1999. If you are unsure what year it was built, please make your best guess.

Approximate year: __________


  1. Have you lived anywhere outside the Milwaukee area?

Yes

No SKIP to #15

Don’t know SKIP to #15

Prefer not to answer SKIP to #15


  1. Where did you live before coming to Milwaukee?


14a. Location #1 (specify city, state, country): ________________________

How long did you live there? _____ years (Please round to the nearest full year)

Don’t know

Prefer not to answer


14b. Have you lived anywhere else before coming to Milwaukee?

Yes Where did you live before coming to Milwaukee?

Specify city, state, country: ________________________

How long did you live there? _____ years (Please round to the nearest whole year.)

No SKIP to #15

Don’t know

Prefer not to answer



FISH AND SHELLFISH EATEN IN THE LAST 30 DAYS

These next few sections will ask you about the fish and shellfish you eat. We will ask you about fish and shellfish that you may have bought at a store or restaurant, as well as fish and shellfish that you or someone you know caught from lakes, rivers, or streams in Wisconsin. First, we will ask several questions on fish and shellfish eaten in the last 30 days.


  1. In the last 30 days, how many times did you eat SHELLFISH, such as shrimp, oysters, lobster, clams, crab, or crayfish?

_______ total number of shellfish meals eaten in the last 30 days

Don’t know

Prefer not to answer


16. In the last 30 days, how many times did you eat FISH such as fresh, canned, or frozen fish, fish fillets, fish sticks, fish sandwiches, and tuna fish?

_______ total number of fish meals eaten in the last 30 days

Don’t know SKIP to #18

Prefer not to answer SKIP to #18


17. In the last 30 days, how many of these fish meals were caught by you or someone you know from any lakes, rivers, and streams in Wisconsin? These are sometimes called ‘sport-caught fish’.

_______ total number of meals eaten in the last 30 days

Don’t know

Prefer not to answer



FISH EATEN IN THE LAST 12 MONTHS

Now we will ask you some questions about fish you ate that were caught by you or someone you know. These fish are sometimes called ‘sport-caught fish’ or ‘sportfish’. We will be asking you to estimate how many fish meals you have eaten in the last 12 months. We understand that you might need a few minutes to think about these questions, so please take your time.

  1. In the last 12 months, how many times did you eat any fish caught by you or someone you know?

__________ total number of meals in the last 12 months

Don’t know

Prefer not to answer



  1. Please look at this picture of lakes, rivers, and streams near Milwaukee. In the last 12 months, have you eaten any fish caught by you or someone you know from the lakes, rivers, and streams shown here? Please think about these locations only. (Will include an image of the MKE AOC water bodies)
    __________ total number of meals in the last 12 months

Don’t know

Prefer not to answer

  1. Please look at the picture of lakes, rivers, and streams near Milwaukee. For fish caught in any of the lakes, rivers, and streams in the picture, how has the total amount of fish you eat changed during the past five years? (Will include map/picture of water bodies)

Eat less

Same or about the same

Eat more

Don’t know

Prefer not to answer

  1. Please look at this picture of lakes, rivers, and streams near Milwaukee. The following questions are about types of fish you have eaten that were caught by you or someone you know. When answering these questions, please think only about fish caught in the lakes, rivers, and streams pictured and listed here. (Will include map/picture of water bodies)


In the last 12 months, have you eaten:


Yes

No

Don’t know

Prefer not to answer

If YES, approximately how many times did you eat it in the last 12 months?

Black crappie





Number: ______

Don’t know how many

Bluegill





Number: ______

Don’t know how many

Bullhead





Number: ______

Don’t know how many

Carp





Number: ______

Don’t know how many

Channel catfish





Number: ______

Don’t know how many

Chubs





Number: ______

Don’t know how many

Salmon





Number: ______

Don’t know how many

Northern pike





Number: ______

Don’t know how many

Redhorse





Number: ______

Don’t know how many

Rockbass





Number: ______

Don’t know how many

Largemouth bass





Number: ______

Don’t know how many

Smallmouth bass





Number: ______

Don’t know how many

Smelt





Number: ______

Don’t know how many

Walleye





Number: ______

Don’t know how many

White sucker





Number: ______

Don’t know how many

Yellow perch





Number: ______

Don’t know how many

Brown trout





Number: ______

Don’t know how many

Lake trout





Number: ______

Don’t know how many

Rainbow trout





Number: ______

Don’t know how many

Other fish types (please specify):





Number: ______

Don’t know how many

Other fish types (please specify):





Number: ______

Don’t know how many

Other fish types (please specify):





Number: ______

Don’t know how many


PURCHASED FISH EATEN IN THE LAST 12 MONTHS

Now we will ask you to think about fish and shellfish you have bought in store, restaurant or market. We will be asking you to estimate how many fish meals you have eaten in the last 12 months. We understand that you might need a few minutes to think about these questions, so please take your time.

  1. These next questions will ask you about fish you have eaten which came from a store, restaurant, fish vendor, market, or supermarket.

Thinking about the last 12 months, have you eaten:


Yes

No

Don’t know

Prefer not to answer

If YES, approximately how many times did you eat it in the last 12 months?

King mackerel





Number: ______

Don’t know how many

Tilefish





Number: ______

Don’t know how many

Shark





Number: ______

Don’t know how many

Swordfish





Number: ______

Don’t know how many

Salmon (including canned)





Number: ______

Don’t know how many

Canned light tuna





Number: ______

Don’t know how many

Canned white or albacore tuna





Number: ______

Don’t know how many

Fresh or frozen tuna





Number: ______

Don’t know how many

Tilapia





Number: ______

Don’t know how many

Halibut





Number: ______

Don’t know how many

Cod





Number: ______

Don’t know how many

Shellfish (such as shrimp, mussels, etc.)





Number: ______

Don’t know how many

Other fish not listed here, please specify:






Number: ______

Don’t know how many


FISH CLEANING AND COOKING PRACTICES

We will now ask you some questions about how you typically clean and cook the fish you eat.



  1. These next questions will ask you about how you clean and prepare the fish you eat. Here is a picture to show you the different parts of the fish we are asking about. (Will include picture of each fish part)

When preparing fish, how often do you eat or prepare meals using:

Never

Sometimes

Always

Don’t know

Prefer not to answer

The skin of the fish






The head of the fish






The guts, organs, or other innards of the fish






The belly fat of the fish







  1. The next questions will ask you about how you cook fish.

When cooking fish, how often do you:

Never

Sometimes

Always

Don’t know

Prefer not to answer

Smoke or dry fish






Pickle fish






Use fish to make fish paste






Pan fry






Grill, or roast fish






Deep fry fish






Boil or poach fish






Use fish or fish parts to make broth/stock, curry, or soup








  1. Please look at this picture of a 6 ounce serving of cooked fish. Compared to this model, would you say that a typical meal of fish you eat is usually: (Will include picture to illustrate serving size)

Less (smaller than the picture)

Same or about the same

More (larger than the picture)

Don’t know

Prefer not to answer


  1. During which season(s) do you eat fish? (check all that apply)
    Spring (March, April, May)
    Summer
    (June, July, August)
    Fall
    (September, October, November)
    Winter
    (December, January, February)
    Don’t know
    Prefer not to answer


  2. During which season(s) do you catch fish? (check all that apply)
    Spring (March, April, May)
    Summer
    (June, July, August)
    Fall
    (September, October, November)
    Winter
    (December, January, February)
    I don’t catch fish
    Don’t know
    Prefer not to answer



ADVISORY AWARENESS

Now we will be asking you a few questions about the safe-eating guidelines for fish caught in Wisconsin. We are not asking you about the regulations on what size of fish and how many fish you can keep from a water body. These questions are about the health-based advisories written to protect you from contaminants like mercury and PCBs.

  1. Have you heard about the safe-eating guidelines for fish caught in Wisconsin?

Yes

No SKIP to #31

Don’t know SKIP to #31
Prefer not to answer SKIP to #31

29. How much would you say that you know about these guidelines?
Nothing
A little bit
Some
Quite a bit
A great deal
Prefer not to answer

30. How closely do you follow the advice provided in these guidelines?
Not at all
A little bit
Somewhat
Very
Extremely
Prefer not to answer



  1. Have you ever heard about the safe-eating guidelines for fish caught in the Milwaukee River and harbor mouth at Lake Michigan, Menomonee River, Lincoln Creek, or Cedar Creek?
    Yes
    No
    SKIP to #34
    Don’t know
    SKIP to #34
    Prefer not to answer
    SKIP to #34

32. How much would you say that you know about these guidelines?
Nothing
A little bit
Some
Quite a bit
A great deal
Prefer not to answer

33. How closely do you follow the advice provided in these guidelines?
Not at all
A little bit
Somewhat
Very
Extremely
Prefer not to answer

34. Have you ever made any of the following changes to avoid contaminants such as mercury and PCBs? (check all that apply)

Eaten fewer fish meals
Eaten different types or species of fish

Avoided eating certain parts of fish (head, fat, belly, skin)
Avoided eating fish from some fishing locations

None of these
Prefer not to answer

  1. The next questions will ask you how you get information about fish consumption advice, and how useful you think these sources are. Remember, we are asking you about the safe-eating guidelines, NOT any regulations about size and number of fish you can keep.

Do you get information about Wisconsin fish consumption advice from:

If yes:

How useful is this source of information

Do you find this source easy to understand?

Do you use this source when making decisions about eating fish?

Fishing club newsletters or websites or other sports club publications

Yes

No

Prefer not to

answer

Not useful

Somewhat useful

Very useful

Prefer not to

answer

Yes

No

Prefer not to

answer

Yes

No

Prefer not to answer

Wisconsin Department of Natural Resources website or publications

Yes

No

Prefer not to

answer

Not useful

Somewhat useful

Very useful

Prefer not to

answer

Yes

No

Prefer not to

answer

Yes

No

Prefer not to answer

Wisconsin Department of Health Services website or publications

Yes

No

Prefer not to

answer

Not useful

Somewhat useful

Very useful

Prefer not to

answer

Yes

No

Prefer not to

answer

Yes

No

Prefer not to answer

Federal agencies, such as the Environmental Protection Agency (EPA) or the Food and Drug Administration (FDA)

Yes

No

Prefer not to

answer

Not useful

Somewhat useful

Very useful

Prefer not to

answer

Yes

No

Prefer not to

answer

Yes

No

Prefer not to answer

Friends or family members

Yes

No

Prefer not to

answer

Not useful

Somewhat useful

Very useful

Prefer not to

answer

Yes

No

Prefer not to

answer

Yes

No

Prefer not to answer

Fishing regulations booklet distributed with fishing license, pictured here

Yes

No

Prefer not to

answer

Not useful

Somewhat useful

Very useful

Prefer not to

answer

Yes

No

Prefer not to

answer

Yes

No

Prefer not to answer

Choose Wisely – a health guide for eating fish in Wisconsin, pictured here

Yes

No

Prefer not to

answer

Not useful

Somewhat useful

Very useful

Prefer not to

answer

Yes

No

Prefer not to

answer

Yes

No

Prefer not to answer

Tackle or sporting goods stores

Yes

No

Prefer not to

answer

Not useful

Somewhat useful

Very useful

Prefer not to

answer

Yes

No

Prefer not to

answer

Yes

No

Prefer not to answer

County health office or website

Yes

No

Prefer not to

answer

Not useful

Somewhat useful

Very useful

Prefer not to

answer

Yes

No

Prefer not to

answer

Yes

No

Prefer not to answer

Grocery store or food market

Yes

No

Prefer not to

answer

Not useful

Somewhat useful

Very useful

Prefer not to

answer

Yes

No

Prefer not to

answer

Yes

No

Prefer not to answer

Fish eating guidelines posted near waters that I fish (see example picture)

Yes

No

Prefer not to

answer

Not useful

Somewhat useful

Very useful

Prefer not to

answer

Yes

No

Prefer not to

answer

Yes

No

Prefer not to answer

Television, radio and/or newspaper messages/reports

Yes

No

Prefer not to

answer

Not useful

Somewhat useful

Very useful

Prefer not to

answer

Yes

No

Prefer not to

answer

Yes

No

Prefer not to answer

My health care provider

Yes

No

Prefer not to

answer

Not useful

Somewhat useful

Very useful

Prefer not to

answer

Yes

No

Prefer not to

answer

Yes

No

Prefer not to answer

Charter boat operators or guides

Yes

No

Prefer not to

answer

Not useful

Somewhat useful

Very useful

Prefer not to

answer

Yes

No

Prefer not to

answer

Yes

No

Prefer not to answer

iPhone/Smartphone apps (e.g., DNR Pocket Ranger Fish and Wildlife app), pictured here

Yes

No

Prefer not to

answer

Not useful

Somewhat useful

Very useful

Prefer not to

answer

Yes

No

Prefer not to

answer

Yes

No

Prefer not to answer
















WILD BIRDS AND ANIMALS

Now we will ask you about any wild birds or animals you may have eaten in the last 12 months.


Please look at the picture of lakes, rivers, and streams near Milwaukee. These next questions will ask you about the types of wild animals and waterfowl you have eaten, which were harvested near areas in the picture here. (Will include map/picture of water bodies, and picture of each bird/animal)

36. Thinking about the last 12 months, have you eaten:


Yes

No

Don’t know

Prefer not to answer

If YES, approximately how many times did you eat it in the last 12 months?

Waterfowl (ducks, geese, or seagulls)





Number: ______

Don’t know how many

Crows or other scavenger birds





Number: ______

Don’t know how many

Deer





Number: ______

Don’t know how many

Frogs or toads





Number: ______

Don’t know how many

Rats or mice





Number: ______

Don’t know how many

Rabbits





Number: ______

Don’t know how many

Groundhogs





Number: ______

Don’t know how many

Squirrels





Number: ______

Don’t know how many


37. In the past 12 months, have you eaten waterfowl (such as ducks or geese) that were harvested in any other locations not listed/pictured here?

YES: 37a. Please tell us where: _________________

NO

Don’t know

Prefer not to answer


LIFESTYLE AND ACTIVITIES

Now we will ask you some questions about your lifestyle and some activities you might do in your free-time.

  1. On most days, do you take or use any herbal medicine or supplements?

Yes

No

Don’t know

Prefer not to answer


  1. On most days, do you take or use fish oil supplements?

Yes

No

Don’t know

Prefer not to answer


  1. Have you smoked at least 100 cigarettes (or 5 packs) in your lifetime?

Yes (Ever smoker)

No (Never smoker) SKIP to #43

Don’t know SKIP to #43

Prefer not to answer SKIP to #43


  1. Do you smoke cigarettes now?

Yes

No SKIP to #43

Don’t know SKIP to #43

Prefer not to answer SKIP to #43


  1. How many cigarettes do you smoke per day? (1 pack=20 cigarettes)

1-5 per day

6-10 per day

11-20 per day (>1/2 and <1 pack per day)

>20 per day (>1 pack per day)

Don’t know

Prefer not to answer


  1. Do you use chewing tobacco or snuff?

Yes

No SKIP to #45

Don’t know SKIP to #45

Prefer not to answer SKIP to #45


  1. How often do you use chewing tobacco or snuff?

Daily

Weekly

Monthly

Don’t know

Prefer not to answer


  1. Please look at this picture of lakes, rivers, and streams in the Milwaukee area. Do you swim, dive, or wade in any of these lakes, rivers, and streams? (Will include map/picture of water bodies)

Yes: 45a. How many times in the past year? ______

No

Don't know

Prefer not to answer



  1. Have you or anyone else in your household done any of the following activities in the last 12 months?

Activity:

Yes

No

Don’t know

Prefer not to answer

Dyeing material





Electronics assembly





Gardening or farming





Glass crafting, metal work, painting or glazing,





Metal work





Painting and glazing





Packing ammunition





Print making





Wood working





Home renovation/repair






HOUSEHOLD INFORMATION

Now we will ask you a few questions about your household, including how many people live in your home with you.

  1. Do you live alone, or with others?

With others 47a. How many people live with you? Please count all adults, children

and infants. Do not count yourself. ________

Live alone SKIP to #50

Don’t know SKIP to #50

Prefer not to answer SKIP to #50


  1. Do you live with any women between the ages of 15 and 45 years old?

Yes 48a. How many women between the ages of 14 and 45 live with you? _______

No SKIP to #49

Don’t know SKIP to #49

Prefer not to answer SKIP to #49


48b. Do any of these women eat locally caught fish?
Yes

No

Don’t know

Prefer not to answer


  1. Do you live with any children under the age of 15?

Yes 49a. How many children under the age of 15 live with you? _______

No SKIP to #50

Don’t know SKIP to #50

Prefer not to answer SKIP to #50


49b. Do any of these children eat locally caught fish?

Yes

No

Don’t know

Prefer not to answer


EDUCATION, MARITAL STATUS, WORK HISTORY, AND INCOME

Now we will ask some questions about your work history, education, income, and marital status.

  1. What is the highest grade level of school or degree you have completed?

8th grade or less

Some high school, no diploma or GED

High school diploma or GED

Some college, no diploma

Associate degree

Bachelor’s degree

Postgraduate, professional, or doctoral degree

Don’t know

Prefer not to answer


  1. What is your current marital status?

Married

Living with someone in a marriage-like relationship

Separated

Divorced

Widowed

Never married
Prefer not to answer



  1. Do you currently work outside the home?

Yes, Full-time (answer 52a)

Yes, Part-time (answer 52a)

No SKIP to #53

Don’t know SKIP to #53

Prefer not to answer SKIP to #53


52a. What is your current job?

Title_______________________________

Who is your employer? ___________________________________________

How many hours a week do you work? _____ hours per week

What are your usual activities or duties? __________________________________



52b. Do you have a second job?

Yes answer 52bi

No SKIP to #53

Don’t know SKIP to #53

Prefer not to answer SKIP to #53


52bi. What is your second job?

Title_______________________________

Who is your employer? ___________________________________________

What are your usual activities or duties?__________________________________


52c. Have you worked at any (other) job in the past year?

Yes, Full-time answer 52ci

No SKIP to #53

Don’t know SKIP to #53

Prefer not to answer SKIP to #53


52ci. What was this other job?

Title_______________________________

Who is your employer? ___________________________________________

What are your usual activities or duties?__________________________________


53. Can you tell me your total family income in 2016 before taxes? (check one only)

Less than $15,000

$15,000 to less than $25,000

$25,000 to less than $35,000

$35,000 to less than $50,000

$50,000 to less than $75,000

$75,000 to less than $100,000

$100,000 or more

Don’t know

Prefer not to answer



HEALTH HISTORY

These next questions will ask you about any health conditions you have or have had.

Have you ever been told by a doctor that you had/have any of the following health conditions:

54. Heart/Circulatory Conditions:

Yes

If yes: year of diagnosis

No

Don’t know

Prefer not to answer

Coronary heart disease


Heart attack


Angina (pain from coronary heart disease)


Hypertension or high blood pressure


Stroke


High fat or cholesterol in your blood


Aneurysm


55. Thyroid conditions:

Yes

If yes: year of diagnosis

No

Don’t know

Prefer not to answer

Benign (non-cancerous) thyroid tumor


Hashimoto’s Disease


Grave’s Disease


An underactive thyroid or hypothyroidism


An overactive thyroid or hyperthyroidism


A goiter or enlarged thyroid gland


Some other thyroid or endocrine problem : __________________


56. Liver conditions:

Yes

If yes: year of diagnosis

No

Don’t know

Prefer not to answer

Hepatitis


Cirrhosis of the liver


Yellow jaundice


Fatty liver disease, not caused by drinking alcohol)


Some other type of liver condition: _________________


57. Other health conditions:

Yes

If yes: year of diagnosis

No

Don’t know

Prefer not to answer

Diabetes


Pre-diabetes (impaired fasting glucose, impaired glucose tolerance, borderline diabetes or higher blood sugar than normal but not high enough to be called diabetes or sugar diabetes)


Chronic kidney disease (CKD; chronic renal insufficiency)


Porphyria (decreased red blood cell production due to abnormal porphyrin metabolism)


Cancer

Type 1:


Type 2:


Type 3:




PRESCRIPTION MEDICATIONS


These next questions will ask you about medications you may currently be taking.

Are you currently taking prescription medications for:

Yes

No

Don’t know

Prefer not to answer

58. A thyroid condition

59. Diabetes

YES

IF YES, what kind:

Insulin

Oral medication

Both

60. High blood pressure

61. High cholesterol

62. Other health conditions


If you are a male, we have no more questions for you at this time. Please remember to bring this questionnaire with you to your in-person appointment. Thank you for completing this questionnaire.


If you are a female, please answer these questions about reproductive history.


REPRODUCTIVE HISTORY - FEMALE


63. Have you ever been pregnant?

Yes: 63a. How many times have you been pregnant? _______

No go to go to END SURVEY

Don’t know go to go to END SURVEY

Prefer not to answer go to go to END SURVEY


64. Did any of these pregnancies result in a live birth?

Yes 64a. How many pregnancies resulted in live birth? ______

Never go to go to END SURVEY

Don’t know go to go to END SURVEY

Prefer not to answer go to go to END SURVEY



65. Have you ever breastfed any children?

Yes answer 65a.

No go to go to END SURVEY

Don’t know go to END SURVEY

Prefer not to answer go to END SURVEY


65a. Tell me about the children you have breastfed from the first to the most recent child, including any children you are breastfeeding now.



Birth Year (YYYY)

Birthplace

(city/state/country)

Number of months breastfeeding?

If number of months is unknown ask:

At what age did they stop breast feeding?

1st





2nd





3rd





4th





5th





6th





7th





8th





9th





10th







END OF QUESTIONNAIRE

Thank you for completing this questionnaire. Please remember to bring it with you for your in-person appointment.

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