Bdsteps_cati_v8.0

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

BD-STEPSII_CATI_v8_20200317_track

Mother's Consent Script and Computer Assisted Telephone Interview

OMB: 0920-0010

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REVISION FOR

BD-STEPS II

Form Approved

OMB No. 0920-0010

Exp. Date: 02/28/2023

Centers for Birth Defects Research and Prevention

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

Computer-Assisted Telephone Interview









Questionnaire Version 8.0.2

For CATI version 8.1.1

English Version

March 5, 2020



OPENING STATEMENT



In this interview we will be asking you questions about your family, health, and lifestyle. The questions cover many topics because we don’t know what causes most birth defects. We will study the answers from thousands of mothers hoping to learn something new about the causes of birth defects. Your individual responses are being collected with an assurance of confidentiality.

ENTER DATE OF CONSENT: MM/DD/YYYY (TODAY’S DATE IF UNKNOWN)

Section A: ESTABLISHING DATES



NOTE: THE WORDING FOR TABS AND STILLBIRTHS ARE THE SAME.

I’m going to ask many questions about the time before and during [your pregnancy with NOIB]; TAB/STILLBIRTH: the affected pregnancy]. In order to do this, I need to start by asking you some dates.



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

    1. MM/DD/YYYY CAN USE DK OR RF FOR MM OR DD OR YY

A2. What date did the doctor or other health care provider give you as a due date for [NOIB]’s birth; TAB: the affected pregnancy]? That is, when was [[NOIB]; TAB: the baby] expected to be born? [Note: IF MOM KNOWS DUE DATE, CATI WILL CALCULATE WHICH PREGNANCY MONTHS CORRESPOND WITH CALENDAR DATES. IF MOM DOES NOT KNOW DUE DATE, USE THE EDD RECORDED IN THE TRACKING DATABASE TO CALCULATE DATES.]

  1. MM/DD/YYYY CAN USE DK OR RF FOR MM OR DD OR YY

IF NOIB IS TAB OR STILLBIRTH, SKIP TO A6

A3. Is [NOIB] still living?

  1. YES SKIP TO A6

  2. NO CONTINUE TO A4

  3. DK SKIP TO A6

  4. RF SKIP TO A6

A4. What did s/he die of? IF NEEDED, ASK THE MOTHER TO BE AS SPECIFIC AS POSSIBLE

  1. SPECIFY:__________ DK RF





A5. How old was s/he when s/he died? NOTE: IF THE BABY LIVED LESS THAN 24 HOURS, THE RESPONSE LESS THAN 1 DAY CAN BE RECORDED AS 1 DAY.

  1. AGE:__________ DK RF

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

A6. What is your date of birth? MOTHER’S

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

A7. I would like to ask about [[NOIB]’s; TAB: the baby’s] biologic or natural father. What is his date of birth? [PROBE: IF DK: You don’t know the date of birth or you don’t know the biologic father?]

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

  2. DK WHO FATHER IS

Section B: MULTIPLE GESTATION



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

    1. Number of babies:__________

      1. IF 1 (SINGLE BABY) SKIP TO NEXT SECTION

      2. IF ≥2 (TWINS OR HIGHER ORDER MULTIPLE) CONTINUE TO B2; IF TAB: SKIP TO NEXT SECTION

      3. DK SKIP TO NEXT SECTION

      4. RF SKIP TO NEXT SECTION

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

  1. Yes, all other babies still living

  2. Some babies still living, others are not

  3. No, no other babies still living

  4. DK

  5. RF

B3. In addition to the baby we have already discussed, what was the sex of the [B1=2: other; B1 >2: [1st, 2nd, etc.] additional] baby? [RECORD FOR EACH ADDITIONAL BABY]

  1. Girl

  2. Boy

  3. Indeterminate

  4. DK

  5. RF

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

  1. YES CONTINUE TO B5

  2. NO SKIP TO B6/NEXT SECTION

  3. DK SKIP TO B6/NEXT SECTION

  4. RF SKIP TO B6/NEXT SECTION

B5. What was the birth defect? / Anything else? [RECORD FOR EACH ADDITIONAL BABY] [PROBE: IF CAN’T RECALL, READ FROM PROMPTS PROVIDED IN QxQ]

  1. DEFECT (SPECIFY):___________________________

  2. DK

  3. RF

B6. FOR SAME SEX TWINS ONLY: The next question is to see how similar your twins’ appearances are. There are three options. Would you say that your twins: [READ OPTIONS]

  1. Look/ed virtually the same, as physically alike as “two peas in a pod”; or

  2. As similar as typical brothers or sisters at the same age; or

  3. Do not look very much alike at all?

  4. DK

  5. RF

Section C: PREGNANCY HISTORY



Now I’m going to ask you about your previous pregnancy experiences.

C1. Before [[NOIB]; TAB: the pregnancy that ended on [DOIB/DOPT]], how many times were you pregnant, including pregnancies that may have ended in miscarriages, stillbirths, induced abortions, or other outcomes?

    1. NUMBER:__________

      1. IF 0 SKIP TO NEXT SECTION

      2. IF >0 CONTINUE TO C2

    2. DK SKIP TO NEXT SECTION

    3. RF SKIP TO NEXT SECTION



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

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

  2. TIME PERIOD AGO:__________

      1. YEARS

      2. MONTHS

      3. WEEKS

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

  1. YES SKIP TO NEXT SECTION IF C1a = 1/SKIP TO C5b if C1a=2/ SKIP TO C5a IF C1a > 2

  2. NO CONTINUE TO C3b

  3. DK SKIP TO NEXT SECTION IF C1a = 1/ SKIP TO C5b if C1a=2/ SKIP TO C5a IF C1a > 2

  4. RF SKIP TO NEXT SECTION IF C1a = 1/ SKIP TO C5b if C1a=2/ SKIP TO C5a IF C1a > 2

C3b. Did that pregnancy end with (a/an) (READ CATEGORIES: stillbirth, induced abortion, miscarriage, or some other outcome)? IF 2 OR MORE OUTCOMES IN 1 PREGNANCY SELECT OTHER

  1. Stillbirth CONTINUE TO C4

  2. Induced abortion CONTINUE TO C4

  3. Miscarriage CONTINUE TO C4

  4. Some other outcome (SPECIFY) CONTINUE TO C4

  5. DK CONTINUE TO C4

  6. RF CONTINUE TO C4

C4. IF REPORTING ANY OUTCOME BESIDES LIVE BIRTH: How far along were you in your pregnancy when the pregnancy ended? For example, what week or month? [IF MORE THAN 1 OUTCOME AND OUTCOMES ENDED ON DIFFERENT DATES, RECORD THE LATEST DATE]

  1. AMOUNT:______________ SKIP TO NEXT SECTION IF C1a=1/ SKIP TO C5b if C1a=2/ CONTINUE TO C5a IF C1a>2

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

  1. DK SKIP TO NEXT SECTION IF C1a=1/ SKIP TO C5b if C1a=2/ CONTINUE TO C5a IF C1a>2

  2. RF SKIP TO NEXT SECTION IF C1a=1/ SKIP TO C5b if C1a=2/ CONTINUE TO C5a IF C1a>2


C5a. IF MORE THAN 1 PREVIOUS PREGNANCY: Now, I would like to get some information about your other pregnancies, starting with the first one.


C5b. INTERVIEWER, PLEASE ENTER IN (C1# - 1) BELOW


C5c. Did your [1st, etc ] pregnancy end in a live birth?



  1. YES SKIP TO NEXT SECTION/ASK ABOUT NEXT PREGNANCY

  2. NO CONTINUE TO C6

  3. DK SKIP TO NEXT SECTION/ASK ABOUT NEXT PREGNANCY

  4. RF SKIP TO NEXT SECTION/ASK ABOUT NEXT PREGNANCY

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



a. Stillbirth CONTINUE TO C7

b. Induced abortion CONTINUE TO C7

c. Miscarriage CONTINUE TO C7

d. Other (SPECIFY) CONTINUE TO C7

e. DK CONTINUE TO C7

f. RF CONTINUE TO C7


C7. IF REPORTING ANY OUTCOME BESIDES LIVE BIRTH: How far along were you in your pregnancy when the pregnancy ended? For example, the week or month? [IF MORE THAN 1 OUTCOME AND OUTCOMES ENDED ON DIFFERENT DATES, RECORD THE LATEST DATE]


  1. AMOUNT:______________ SKIP TO NEXT SECTION/ASK ABOUT NEXT PREGNANCY

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

b. DK SKIP TO NEXT SECTION/ASK ABOUT NEXT PREGNANCY

c. RF SKIP TO NEXT SECTION/ASK ABOUT NEXT PREGNANCY

Section D: FAMILY HISTORY



D1. Did you have a health problem at birth or a birth defect that was diagnosed in childhood?

    1. YES CONTINUE TO D2

    2. NO SKIP TO D3

    3. DK SKIP TO D3

    4. RF SKIP TO D3

D2. What was the health problem or birth defect? / Anything else? [PROBE: IF CAN’T RECALL, READ FROM PROMPTS PROVIDED IN QxQ]

  1. Specify:___________________________

  2. DK

  3. RF

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

  1. YES CONTINUE TO D4

  2. NO SKIP TO D5/NEXT SECTION

  3. DK SKIP TO D5/NEXT SECTION

  4. RF SKIP TO D5/NEXT SECTION

D4. What was the problem at birth or birth defect? / Anything else? [PROBE: IF CAN’T RECALL, READ FROM PROMPTS PROVIDED IN QxQ]

  1. SPECIFY:___________________________

  2. DK

  3. RF



D5. IF PREVIOUS PREGNANCIES REPORTED: Did any of [[NOIB]’s; TAB: the] brothers or sisters have a health problem at birth or a birth defect that was diagnosed during pregnancy or in childhood? Please do not include half-siblings or step-siblings. Please do include full siblings who are not still living, including previous pregnancies that ended in a miscarriage, stillbirth, or induced abortion.

  1. YES CONTINUE TO D6

  2. NO SKIP TO NEXT SECTION

  3. DK SKIP TO NEXT SECTION

  4. RF SKIP TO NEXT SECTION

D6. What was the health problem or birth defect? / Anything else? [PROBE: IF CAN’T RECALL, READ FROM PROMPTS PROVIDED IN QxQ]

  1. SPECIFY:___________________________

  2. DK

  3. RF



Section E: FERTILITY



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

E1. How long were you trying to get pregnant with [[NOIB]; TAB: the pregnancy that ended on [DOIB/DOPT]], before you became pregnant? [READ OPTIONS]

    1. We were not trying SKIP TO E14b IF PREVIOUS PREGNANCIES; SKIP TO E15 IF NO PREVIOUS PREGNANCIES

    2. Less than 6 months

    3. 6 months or more, but less than a year

    4. A year or more, but less than 3 years

    5. 3 years or more, but less than 5 years

    6. 5 years or more, but less than 7 years

    7. 7 years or more

    8. DK

    9. RF



E2a. In the two months before you became pregnant with [[NOIB]; TAB: the pregnancy that ended on [DOIB/DOPT]] did you use In-vitro fertilization, also known as IVF, Intracytoplasmic sperm injection, also known as ICSI, or Artificial insemination to help you become pregnant?

  1. YES CONTINUE TO E2b

  2. NO SKIP TO E9

  3. DK SKIP TO E9

  4. RF SKIP TO E9

E2b. Which procedure or procedures did you use? READ LIST (INDICATE ALL THAT APPLY):

  1. In-vitro fertilization, or IVF

  2. Intracytoplasmic sperm injection, or ICSI

  3. Artificial insemination

  4. DK SKIP TO E9

  5. RF SKIP TO E9

IF YES TO ONLY ONE PROCEDURE SKIP TO E4

IF YES TO MORE THAN ONE PROCEDURE CONTINUE TO E3

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

  1. IN-VITRO FERTILIZATION, OR IVF

  2. INTRACYTOPLASMIC SPERM INJECTION, OR ICSI

  3. ARTIFICIAL INSEMINATION

  4. DK

  5. RF

E4. What was the date of that procedure?

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

E5. Were donor egg(s), donor sperm, or donor embryo(s) used on [DATE]/ [(IF UNSPECIFIED DATE) during this last procedure]?

  1. YES CONTINUE TO E6

  2. NO SKIP TO E7

  3. DK SKIP TO E7

  4. RF SKIP TO E7

E6. Which of these were used? [SELECT ALL THAT APPLY]

  1. Donor eggs

  2. Donor sperm

  3. Donor embryos

  4. DK

  5. RF

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

  1. YES CONTINUE TO E8

  2. NO SKIP TO E9

  3. DK SKIP TO E9

  4. RF SKIP TO E9

E8. Which of these were used? [SELECT ALL THAT APPLY]

  1. Frozen eggs

  2. Frozen sperm

  3. Frozen embryos

  4. DK

  5. RF

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

  1. YES ASK E9a

  2. NO IF E2a = YES SKIP TO E11. IF E2a = NO/DK/RF AND IF C1 = 0 SKIP TO E15. IF E2a = NO/DK/RF AND IF C1 = >0 SKIP TO E14b.

  3. DK IF E2a = YES SKIP TO E11. IF E2a = NO/DK/RF AND IF C1 = 0 SKIP TO E15. IF E2a = NO/DK/RF AND IF C1 = >0 SKIP TO E14b.

  4. RF IF E2a = YES SKIP TO E11. IF E2a = NO/DK/RF AND IF C1 = 0 SKIP TO E15. IF E2a = NO/DK/RF AND IF C1 = >0 SKIP TO E14b.

E9a. Did you take Clomid or clomiphene citrate?

  1. YES ASK E10a

  2. NO ASK E9b

  3. DK ASK E9b

  4. RF ASK E9b

E9b. Did you take Letrozole/Femara?

  1. YES ASK E10b

  2. NO ASK E9c

  3. DK ASK E9c

  4. RF ASK E9c

E9c. Did you take anything else?

  1. YES ASK E9d

  2. NO IF E2a = YES SKIP TO E11. IF E2a = NO/DK/RF AND IF C1 = 0 SKIP TO E15. IF E2a = NO/DK/RF AND IF C1 = >0 SKIP TO E14b

  3. DK IF E2a= YES SKIP TO E11. IF E2a = NO/DK/RF AND IF C1 = 0 SKIP TO E15. IF E2a = NO/DK/RF AND IF C1 = >0 SKIP TO E14b

  4. RF IF E2a = YES SKIP TO E11. IF E2a = NO/DK/RF AND IF C1 = 0 SKIP TO E15. IF E2a = NO/DK/RF AND IF C1 = >0 SKIP TO E14b

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

        1. Bromocriptine

        2. Danazol

        3. Danocrine

        4. Depo-Provera

        5. Factrel

        6. Lupron

        7. Lutrepulse

        8. Metrodin

        9. Parlodel

        10. Pergonal

        11. Pregnyl

        12. Profasi HP

        13. Provera

        14. Serophene

        15. Synarel

        16. OTHER, SPECIFY:_____________

        17. DK

        18. RF

E10a. IF E9a=YES: How many Clomid or clomiphene citrate pills per day did you take at your last cycle before getting pregnant?

  1. NUMBER:__________

  2. DK

  3. RF
    GO BACK TO E9b

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

  1. NUMBER:__________

  2. DK

  3. RF

GO BACK TO E9c

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

  1. 1 cycle

  2. 2-3 cycles

  3. 4-6 cycles

  4. more than 6 cycles

  5. DK

  6. RF

E12. INDICATE ALL THAT APPLY IF REPORT ANY FERTILITY PROCEDURES OR MEDICATIONS: What was the reason(s) for fertility treatments? Was it… [READ OPTIONS]

  1. A female issue, such as blocked fallopian tubes or Polycystic Ovary Syndrome CONTINUE TO E13

  2. A male issue, such as low sperm count or low motility SKIP TO E14b IF PREVIOUS PREGNANCY REPORTED/E15 IF ONLY ONE PREGNANCY REPORTED

  3. No male partner SKIP TO E14b/E15

  4. Unexplained SKIP TO E14b/E15

  5. DK SKIP TO E14b/E15

  6. RF SKIP TO E14b/E15

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

  1. Blocked fallopian tubes

  2. Polycystic Ovary Syndrome (PCOS)

  3. Endometriosis

  4. Ovulation problems (irregular periods)

  5. OTHER (SPECIFY):_______________

  6. DK

  7. RF

E14. IF PREVIOUS PREGNANCY REPORTED: Have you ever conceived a previous pregnancy using… [READ ALL, INDICATE ALL THAT APPLY]:

E14b.

Ovulation stimulation pills, such as Clomid or Femara

YES

NO

DK

RF

E14c.

Artificial insemination

YES

NO

DK

RF

E14d.

In-vitro fertilization, or IVF

YES

NO

DK

RF

E14e.

Intracytoplasmic sperm injection, or ICSI

YES

NO

DK

RF



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

  1. YES CONTINUE TO E16

  2. NO SKIP TO NEXT SECTION

  3. DK SKIP TO NEXT SECTION

  4. RF SKIP TO NEXT SECTION

E16. What did you take? / Did you take anything else? [LIST ALL. IF CAN’T RECALL, READ LIST: Was it…?]

  1. Depo-Provera

  2. Magnesium Sulfate

  3. Progesterone

  4. Rho(D) immune globulin

  5. Rhogam

  6. Calcium Channel Blockers

  7. Steroid

  8. OTHER, SPECIFY:________

  9. DK SKIP TO NEXT SECTION

  10. RF SKIP TO NEXT SECTION

E17. When in the first trimester did you start using [MEDICINE, ANSWER E16] to prevent complications or pregnancy loss? FOR DAY CAN INDICATE BEGINNING, MIDDLE, OR END OF MONTH.CAN USE DK OR RF FOR MM OR DD OR YY

  1. MM/DD/YYYY OR

  2. MONTH OF PREGNANCY (P1, P2, P3, T1)

  3. DK

  4. RF

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

  1. MM/DD/YYYY OR

  2. MONTH OF PREGNANCY(P1, P2, P3, T1) IF VALID START AND STOP DATE, SKIP TO E20

  3. DK

  4. RF

OR

E19. How long did you take it? You can say the length of time in days, weeks or months.

  1. AMOUNT:__________

  1. Days

  2. Weeks

  3. Months

  1. DK

  2. RF

E20. How often did you use [MEDICINE, ANSWER E16] in the first three months of your pregnancy? You can say the number of times per day, per week, per month, or during the entire 3 month period.

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

(THE FOLLOWING SPECIAL CODES ARE ALSO INCLUDED IN ALL THE RESPONSE OPTIONS FOR ALL MEDICATION FREQUENCY QUESTIONS:

  • IV (Any) (includes IV Continuous and IV pump)

  • Patch (worn continuously)

  • Schedule varied/only as needed (NOTE: Only use this code as a last resort, and always document what Subject said in a Comment.)

  • Tapering frequency (document what Subject said in a Comment)

  • Per time period (Refers to the number of times Subject took a drug between the dates she reported.)



Maternal Health Introduction



At this time, and at other times during this interview, I will be asking you about illnesses you may have had and various kinds of medications or remedies you may have used. Many of these questions will refer to the 4 month period from the month before your pregnancy began through the end of your third month of pregnancy. Please include medications prescribed by a health care practitioner and medications you might have obtained without a prescription from stores, pharmacies, friends or relatives, as well as herbal and home remedies. If you filled out the medication worksheet we included in your introductory packet, it will be helpful for you to have it in front of you for these questions. Now I have some questions about your health.





Section F: DIABETES



F1. Were you ever told by a doctor or other health care provider that you had diabetes (including gestational diabetes), sometimes called sugar diabetes or diabetes mellitus?

    1. YES CONTINUE TO F2

    2. NO SKIP TO NEXT SECTION

    3. DK SKIP TO NEXT SECTION

    4. RF SKIP TO NEXT SECTION

F2. What type of diabetes did you or do you currently have? Was it [READ LIST]?

  1. Gestational, that is, during pregnancy only

  2. Type 1, also called insulin-dependent diabetes, or Juvenile

  3. Type II, also called non-insulin-dependent diabetes, , or adult onset

  4. DK

  5. RF

F3. When were you first diagnosed with diabetes in relation to your pregnancy with [[NOIB]; TAB: the affected pregnancy]? [READ LIST]

  1. Before this pregnancy and not during any other pregnancy?

  2. During a previous pregnancy?

  3. During this pregnancy?

  4. DK

  5. RF

IF F2=a, d, or e OR F3=b, c, d, e THEN SKIP TO F7 [ONLY ASK F4 if F2 = b or c AND F3=a]

F4. Either before or during [[your pregnancy with NOIB]: TAB/STILLBIRTH: the affected pregnancy]], did you speak with a healthcare provider about your treatment options during pregnancy?

  1. YES GO TO F5

  2. NO SKIP TO F7

  3. DK SKIP TO F7

  4. RF SKIP TO F7

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

  1. YES SKIP TO F7

  2. NO GO TO F6

  3. DK SKIP TO F7

  4. RF SKIP TO F7

F6. How far along were you in your pregnancy when you discussed treatment options with your provider?

  1. AMOUNT:__________

  2. UNITS:

      1. Days

      2. Weeks

      3. Months

      4. Trimesters

  1. DK

  2. RF

F7. How did you manage your diabetes and its complications during the time between the month before your pregnancy and the end of the third month of your pregnancy? GIVE OPTIONS; INDICATE ALL THAT APPLY.

  1. Take medications or other remedies IF YES, CONTINUE TO F8 AFTER QUERYING F7b-F7d

  2. Modify your eating habits IF YES, ASK F19

  3. Control your weight or weight gain IF YES, ASK F19

  4. Do anything else IF YES, ASK F20

  5. NONE OF THE ABOVE SKIP TO F22

  6. DK SKIP TO F22

  7. RF SKIP TO F22

F8. IF F7=a: What medications did you take? / Did you take anything else? LIST ALL. [IF CAN’T RECALL, READ FROM DRUG LIST. Did you take…?]

      1. Actos

      2. Amaryl

      3. Byetta

      4. Diabeta

      5. Diabinese

      6. Glucophage

      7. Glucotrol

      8. Glucotrol XL

      9. Glumetza

      10. Glyburide

      11. Glynase PresTab

      12. Humalog

      13. Humulin N

      14. Humulin R

      15. Januvia

      16. Lantus

      17. Levemir

      18. Metformin HCL

      19. Micronase

      20. Novolin N

      21. Novolin-R

      22. Novolog

      23. Onglyza

      24. Prandin

      25. Precose

      26. Starlix

      27. Victoza

      28. OTHER (SPECIFY): _______

      29. DK SKIP TO F19/F20 OR F21

      30. RF SKIP TO F19/F20 OR F21


ANSWER F9-F18 FOR ALL DRUGS SELECTED IN F8.


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

  1. YES SKIP TO F13

  2. NO CONTINUE TO F10

  3. DK CONTINUE TO F10

  4. RF CONTINUE TO F10

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


  1. MM/DD/YYYY or

  2. MONTH OF PREGNANCY (B1, P1, P2, P3)

  3. DK

  4. RF

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

  1. MM/DD/YYYY or

  2. MONTH OF PREGNANCY (B1, P1, P2, P3) IF VALID RESPONSE TO F10 AND F11, SKIP F12

  3. DK

  4. RF

OR

F12. How long did you take it?

  1. AMOUNT:__________

  1. Days

  2. Weeks

  3. Months

  1. DK

  2. RF

F13. How often did you use [DRUG, ANSWER F8] during the month before your pregnancy through the end of your third month of pregnancy? You can say the number of times per day, per week, per month, or during the entire 4 month period.

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

F14. Did you take the same dose of [DRUG, ANSWER F8] each time you took it throughout [B1] TO [P4(-1)]? That is, for example, the same number of milligrams of medicine in each dose.

  1. YES CONTINUE TO F15

  2. NO SKIP TO F16a

  3. DK CONTINUE TO F15

  4. RF CONTINUE TO F15

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

  1. AMOUNT:_______________ SKIP TO F19 (IF F7b OR F7c also =YES), OR

SKIP TO F20 (IF F7b AND F7c=NO AND F7d=YES)

SKIP TO F21a (IF F7b, F7c, AND F7d=NO)

  1. UNITS:__________

DK or RF SKIP TO F19 (IF F7b OR F7c=YES) OR F20 (IF F7b AND F7c=NO AND F7d=YES) OR F21a (IF F7b, F7c, AND F7d=NO)

FOR EACH DRUG UNIT RESPONSE IN SECTION F THROUGH X, THESE ARE THE OPTIONS:

  • MICROGRAMS

  • MILLIGRAM(S)

  • MILLILITER(S)

  • TEASPOON(S)

  • TABLESPOON(S)

  • INTERNATIONAL UNITS

  • PILL/CAPSULE/CAPLET(S)

  • PUFF(S)

  • DROP(S)

  • OTHER, SPECIFY

  • DK, RF

F16a. How many different dosage amounts do you remember taking? [If mom knows she took more than one dosage, but can't remember how many, select 1 for the number of dosages and report the dosage info she does remember. You may put additional details in a comment field.]

  1. AMOUNT:__________ RF



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

  1. AMOUNT:__________

  2. DK SKIP TO F17

  3. RF SKIP TO F17

  1. UNITS:__________ DK RF



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

  1. MM/DD/YYYY or

  2. MONTH OF PREGNANCY(B1, P1, P2, P3)

  3. DK

  4. RF

F18. When did you stop taking that dose?

  1. MM/DD/YYYY OR CONTINUE TO F19 (IF F7b OR F7c=YES) OR F20 (IF F7b AND F7c=NO AND F7d=YES) OR F21 (IF F7b, F7c, AND F7d=NO)

  2. MONTH OF PREGNANCY (B1, P1, P2, P3) IF VALID RESPONSE TO F17 AND F18, SKIP F18a. CONTINUE TO F19 (IF F7b OR F7c=YES) OR F20 (IF F7b AND F7c=NO AND F7d=YES) OR F21 (IF F7b, F7c, AND F7d=NO)

  3. DK CONTINUE TO F19 (IF F7b OR F7c=YES) OR F20 (IF F7b AND F7c=NO AND F7d=YES) OR F21 (IF F7b, F7c, AND F7d=NO)

  4. RF CONTINUE TO F19 (IF F7b OR F7c=YES) OR F20 (IF F7b AND F7c=NO AND F7d=YES) OR F21 (IF F7b, F7c, AND F7d=NO)

OR

F18a. How long did you take it?

  1. AMOUNT:__________ DK RF

  1. Days

  2. Weeks

  3. Months

(ANSWER F16b – F18a FOR ALL DOSES REPORTED IN F16a)

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

  1. Follow a diet specifically for diabetes

  2. Eat healthier but no specific diabetes diet

  3. Do physical exercise

  4. OTHER, SPECIFY____________________________

  5. DK

  6. RF

F20. IF F7d=YES: What else did you do to manage your diabetes and its complications during the month before your pregnancy through the end of your third month of pregnancy? / Anything else?

  1. SPECIFY:_____________________________

  2. DK

  3. RF

F21a. IF F7a = YES: How often did taking medications or other remedies work in controlling your diabetes during the month before your pregnancy through the end of your third month of pregnancy? [READ OPTIONS.]

  1. Always

  2. Most of the time

  3. Part of the time

  4. Never or rarely

  5. DK

  6. RF

F21b. IF F7b = YES: How often did modifying your eating habits work in controlling your diabetes during the month before your pregnancy through the end of your third month of pregnancy? [READ OPTIONS.]

  1. Always

  2. Most of the time

  3. Part of the time

  4. Never or rarely

  5. DK

  6. RF

F21c. IF F7c = YES: How often did controlling your weight gain work in controlling your diabetes during the month before your pregnancy through the end of your third month of pregnancy? [READ OPTIONS.]

  1. Always

  2. Most of the time

  3. Part of the time

  4. Never or rarely

  5. DK

  6. RF

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

  1. Always

  2. Most of the time

  3. Part of the time

  4. Never or rarely

  5. DK

  6. RF

F22. Glycosylated (GLY-CO-SYL-AT-ED) hemoglobin or the “A one C” test measures your average level of blood sugar for the past 3 months, and usually ranges between 5.0 and 13.9. At the time that you became pregnant with [NOIB]; TAB: the pregnancy that ended on [DOIB/DOPT]], had a doctor or other health care provider ever checked your glycosylated hemoglobin or “A one C”?

  1. YES CONTINUE TO F23

  2. NO SKIP TO NEXT SECTION

  3. DK SKIP TO NEXT SECTION

  4. RF SKIP TO NEXT SECTION

F23. What was your “A one C” level at the time it was tested closest to when you became pregnant with [NOIB]; TAB: the pregnancy that ended on [DOIB/DOPT]]? PROBE: If you can't remember the actual number, do you know if it was normal or high?


AMOUNT:__________/High/Normal/DK/RF


F24. When was the “A one C” test conducted?

  1. MM/DD/YYYY OR

  2. RELATIVE TO PREGNANCY:

  1. 1 month to 3 months before pregnancy

  2. 4 months to 6 months before pregnancy

  3. 6 months to 1 year before pregnancy

  4. Greater than 1 year before pregnancy

  1. DK

  2. RF

Section G: CANCER

G1. Have you ever been told by a doctor or other health care provider that you had cancer or a malignancy of any kind?

    1. YES CONTINUE TO G2

    2. NO SKIP TO NEXT SECTION

    3. DK SKIP TO NEXT SECTION

    4. RF SKIP TO NEXT SECTION

G2. What kind of cancer was it? CAN ENTER MULTIPLE SITES IF APPLICABLE.

  1. SPECIFY:__________

  2. DK

  3. RF

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

  1. AGE:_______________________

  2. DK

  3. RF



G4. What is the current status of your cancer? (READ OPTIONS) IF MOTHER SAYS “IN PARTIAL REMISSION”, RECORD AS ‘ACTIVE”.

  1. Active SKIP TO NEXT SECTION

  2. In remission CONTINUE TO G5

  3. DK SKIP TO NEXT SECTION

  4. RF SKIP TO NEXT SECTION

G5. How long has it been in remission?

  1. TIME:__________

      1. Years

      2. Months

      3. Weeks

      4. Days

  1. DK

  2. RF

Section H: HEART PROBLEMS



H1. Do you have a heart problem that has been present since birth? Please do not include problems that went away on their own. PROBE: Please do not include arrhythmia, as we will be discussing this later.

    1. YES CONTINUE TO H2

    2. NO SKIP TO H15

    3. DK SKIP TO H15

    4. RF SKIP TO H15

H2. What is it?

  1. SPECIFY:__________

  2. DK

  3. RF

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

  1. YES CONTINUE TO H4

  2. NO SKIP TO H15

  3. DK SKIP TO H15

  4. RF SKIP TO H15



H4. What did you take? / Did you take anything else?

  1. SPECIFY:__________

  2. DK SKIP TO H15

  3. RF SKIP TO H15

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

  1. YES SKIP TO H9

  2. NO CONTINUE TO H6

  3. DK CONTINUE TO H6

  4. RF CONTINUE TO H6

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

  1. MM/DD/YYYY or

  2. MONTH OF PREGNANCY (B1, P1, P2, P3)

  3. DK

  4. RF

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

  1. MM/DD/YYYY or

  2. MONTH OF PREGNANCY (B1, P1, P2, P3) IF VALID RESPONSE TO H6 AND H7, SKIP H8

  3. DK

  4. RF

OR

H8. How long did you take it?

  1. AMOUNT:__________

      1. Days

      2. Weeks

      3. Months

  1. DK

  2. RF

H9. How often did you use [MEDICINE, ANSWER H4] during the month before your pregnancy through the end of your third month of pregnancy? You can say the number of times per day, per week, per month, or during the entire 4 month period.

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

H10. Did you take the same dose of medicine each time you took it throughout [B1] to [P4 (-1)]? That is, for example, the same number of milligrams of medicine in each dose.

  1. YES CONTINUE TO H11

  2. NO SKIP TO H12a

  3. DK CONTINUE TO H11

  4. RF CONTINUE TO H11

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

  1. AMOUNT:__________ SKIP TO H15

DK SKIP TO H15

RF SKIP TO H15

  1. UNITS:__________ SKIP TO H15

DK SKIP TO H15

RF SKIP TO H15

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

  1. AMOUNT:__________ RF

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

  1. AMOUNT:__________

DK SKIP TO H13

RF SKIP TO H13

  1. UNITS:__________ DK RF



H13. When did you begin taking that dose?

  1. MM/DD/YYYY or

  2. MONTH OF PREGNANCY(B1, P1, P2, P3)

  3. DK

  4. RF

H14. When did you stop taking that dose?

  1. MM/DD/YYYY or

  2. MONTH OF PREGNANCY(B1, P1, P2, P3) IF VALID RESPONSE TO H13 AND H14, SKIP H14a

  3. DK

  4. RF

OR

H14a. How long did you take it?

  1. AMOUNT:__________

  1. Days

  2. Weeks

  3. Months

  1. DK

  2. RF

(ANSWER H12b-H14a FOR ALL DOSES REPORTED IN H12a.)

H15. Have you ever been diagnosed with cardiac arrhythmias?

  1. YES CONTINUE TO H16

  2. NO SKIP TO H28

  3. DK SKIP TO H28

  4. RF SKIP TO H28

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

  1. YES CONTINUE TO H17

  2. NO SKIP TO H28

  3. DK SKIP TO H28

  4. RF SKIP TO H28

H17. What did you take? / Did you take anything else? [IF CAN’T RECALL, READ FROM DRUG LIST]:

  1. Amiodarone

  2. Atenolol

  3. Betapace

  4. Cardizem

  5. Cartia XT

  6. Carvedilol

  7. Cordarone

  8. Diltiazem HCL

  9. Labetolol

  10. Lopressor

  11. Metoprolol

  12. Pacerone

  13. Propafenone HCL

  14. Propranolol

  15. Rythmol

  16. Sotalol

  17. Toprol XL

  18. Verapamil

  19. OTHER (SPECIFY)

  20. DK SKIP TO H28

  21. RF SKIP TO H28

H18. Did you use [DRUG, ANSWER H17] for the entire time from the month before your pregnancy through the third month of pregnancy, that is from [B1] to [P4 (-1)]?

  1. YES SKIP TO H22

  2. NO CONTINUE TO H19

  3. DK CONTINUE TO H19

  4. RF CONTINUE TO H19

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

  1. MM/DD/YYYY or

  2. MONTH OF PREGNANCY(B1, P1, P2, P3)

  3. DK

  4. RF

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

  1. MM/DD/YYYY or

  2. MONTH OF PREGNANCY(B1, P1, P2, P3) IF VALID RESPONSE TO H19 AND H20, SKIP H21

  3. DK

  4. RF

OR

H21. How long did you take it?

  1. AMOUNT:__________

  1. Days

  2. Weeks

  3. Months

  1. DK

  2. RF

H22. How often did you use [DRUG, ANSWER H17] during the month before your pregnancy through the end of your third month of pregnancy? You can say the number of times per day, per week, per month, or during the entire 4 month period.

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

H23. Did you take the same dose of medicine each time you took it throughout [B1] to [P4(-1)]? That is, for example, the same number of milligrams of medicine in each dose.

  1. YES CONTINUE TO H24

  2. NO SKIP TO H25a

  3. DK CONTINUE TO H24

  4. RF CONTINUE TO H24

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

  1. AMOUNT:__________ SKIP TO H28

  1. UNITS:__________

  1. DK SKIP TO H28

  2. RF SKIP TO H28

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

  1. AMOUNT:__________ RF

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

  1. AMOUNT:__________

DK SKIP TO H26

RF SKIP TO H26

  1. UNITS:__________ DK RF

H26. When did you begin taking that dose?

  1. MM/DD/YYYY or

  2. MONTH OF PREGNANCY(B1, P1, P2, P3)

  3. DK

  4. RF

H27. When did you stop taking that dose?

  1. MM/DD/YYYY or

  2. MONTH OF PREGNANCY(B1, P1, P2, P3) IF VALID RESPONSE TO H26 and H27, SKIP H27a

  3. DK

  4. RF

OR





H27a. How long did you take it?

  1. AMOUNT:__________ DK RF

  1. Days

  2. Weeks

  3. Months

ANSWER H25b-H27a FOR ALL DOSES REPORTED IN H25a.

H28. Were you ever in your life told by a doctor or other health care provider that you had high blood pressure?

  1. YES CONTINUE TO H29

  2. NO SKIP TO NEXT SECTION

  3. DK SKIP TO NEXT SECTION

  4. RF SKIP TO NEXT SECTION



H29. Did you have high blood pressure [when you were pregnant with [NOIB]; TAB: this pregnancy]?

a. YES

b. NO

c. DK

d. RF


H30. What type of high blood pressure did you or do you have? Was it pregnancy-related – that is during pregnancy only? This might also be called pregnancy-induced toxemia or pre-eclampsia or eclampsia. Or is it chronic high blood pressure or chronic hypertension? This is high blood pressure that is not related to your pregnancy. This may have been diagnosed during pregnancy but did not go away after the pregnancy ended.

  1. Pregnancy related

  2. Chronic hypertension

  3. Both

  4. DK

  5. RF

IF H30=a, d, or e THEN SKIP TO H34 (ONLY ASK H31 if H30=b, c)

H31. Either before or during your pregnancy, did you speak with a healthcare provider about your treatment options during pregnancy?

  1. YES GO TO H32

  2. NO SKIP TO H34

  3. DK SKIP TO H34

  4. RF SKIP TO H34

H32. Did you discuss these options before your pregnancy began?

  1. YES SKIP TO H34

  2. NO GO TO H33

  3. DK SKIP TO H34

  4. RF SKIP TO H34



H33. How far along were you in your pregnancy when you discussed treatment options with your provider?

  1. AMOUNT:__________ Days/Weeks/Months/Trimesters/DK/RF

H34. Did you take any medications or remedies for high blood pressure during the month before your pregnancy through the third month of pregnancy?

  1. YES CONTINUE TO H35

  2. NO SKIP TO NEXT SECTION

  3. DK SKIP TO NEXT SECTION

  4. RF SKIP TO NEXT SECTION

H35. 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



H36. Did you use [DRUG, ANSWER H35] for the entire time from the month before your pregnancy through your third month of pregnancy, that is from [B1] to [P4 (-1)]?



  1. YES SKIP TO H39

  2. NO CONTINUE TO H36

  3. DK CONTINUE TO H36

  4. RF CONTINUE TO H36

H37. When did you start using [DRUG, ANSWER H35] for high blood pressure for the first time during this period? [CAN USE DK OR RF FOR MM OR DD OR YY]

  1. MM/DD/YYYY or

  2. MONTH OF PREGNANCY(B1, P1, P2, P3)

  3. DK

  4. RF



H38. When did you us [DRUG, ANSWER H34] for the last time during this time period? [CAN USE DK OR RF FOR MM OR DD OR YY]



  1. MM/DD/YYYY or

  2. MONTH OF PREGNANCY(B1, P1, P2, P3) IF VALID RESPONSE TO H37 and H38, SKIP H39

  3. DK

  4. RF

OR

H39. How long did you take it?



  1. AMOUNT:__________ DK RF

  1. Days

  2. Weeks

  3. Months

H40. How often did you use [DRUG, ANSWER H35] during the month before your pregnancy through the end of your third month of pregnancy? You can say the number of times per day, per week, per month, or during the entire 4 month period.

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

H41. Did you take the same dose of medicine each time you took it throughout [B1] to [P4 (-1)]? That is, for example, the same number of milligrams of medicine in each dose.

  1. YES CONTINUE TO H42

  2. NO SKIP TO H43a

  3. DK CONTINUE TO H42

  4. RF CONTINUE TO H42



H42. What dose of [DRUG, ANSWER H34] did you take each time you took it?

  1. AMOUNT:__________

DK SKIP TO NEXT SECTION

RF SKIP TO NEXT SECTION

  1. UNITS:__________ DK RF



H43a. How many different dosage amounts do you remember taking? [If mom knows she took more than one dosage, but can't remember how many, select 1 for the number of dosages and report the dosage info she does remember. You may put additional details in a comment field.]

  1. AMOUNT:__________ RF

H43b. What dose of [DRUG, ANSWER H34] did you take the [1st, 2nd, etc.] time?

  1. AMOUNT:__________

DK SKIP TO H44

RF SKIP TO H44

  1. UNITS:__________ DK RF

H44. When did you begin taking that dose?

  1. MM/DD/YYYY or

  2. MONTH OF PREGNANCY(B1, P1, P2, P3)

  3. DK

  4. RF

H45. When did you stop taking that dose?

  1. MM/DD/YYYY or

  2. MONTH OF PREGNANCY(B1, P1, P2, P3) IF VALID RESPONSE TO H43 and H44, SKIP H44a

  3. DK

  4. RF

OR

H45a. How long did you take it?

  1. AMOUNT:__________ DK RF

  1. Days

  2. Weeks

  3. Months

Section I: THYROID DISEASE



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

    1. YES CONTINUE TO I2

    2. NO SKIP TO NEXT SECTION

    3. DK SKIP TO NEXT SECTION

    4. RF SKIP TO NEXT SECTION

I2. What type of thyroid disease were you diagnosed with originally? Was it… [READ ALL; ASK ALL OPTIONS AND ALLOW MULTIPLE TYPES]

          1. Hypothyroidism, also called having an “underactive” thyroid

          2. Hashimoto’s Disease or autoimmune thyroiditis

          3. Hyperthyroidism, also called having an “overactive” thyroid

          4. Graves’ Disease

          5. OTHER, SPECIFY:_______________________________________

NOTE: THYROID CANCER COVERED EARLIER

          1. DK SKIP TO NEXT SECTION

          2. RF SKIP TO NEXT SECTION

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

  1. More than 2 years before

  2. In the 2 years before

  3. During the first trimester

  4. After the first trimester but still during pregnancy

  5. After the pregnancy

  6. DK

  7. RF



I4. [IF REPORTING HYPERTHYROIDISM/OVERACTIVE THYROID/GRAVES’ DISEASE CONTINUE, OTHERWISE, SKIP TO I9]: Have you had surgery to remove all or part of your thyroid gland?



  1. YES CONTINUE TO I5

  2. NO SKIP TO I7

  3. DK SKIP TO I7

  4. RF SKIP TO I7

I5. Did you have all or part of your thyroid gland removed?

  1. All

  2. Part

  3. DK

  4. RF

I6. When did you have this surgery?

  1. MM/DD/YYYY OR

  2. AGE:__________ or

  3. Time period ago:__________

  1. Years

  2. Months

  3. Weeks

  4. Days

  1. DK

  2. RF

I7. Did you have treatment with radioactive iodine?

  1. YES CONTINUE TO I8

  2. NO, DK, RF SKIPSKIP TO I9

I8. When did you have this procedure?

  1. MM/DD/YYYY or

  2. AGE:__________ or

  3. Time period ago:__________ DK RF

  1. Years

  2. Months

  3. Weeks

  4. Days

IF I3=c, d, e, f, OR g THEN SKIP TO I12 (ONLY ASK I9 IF I3=a or b)

I9. Either before or during your pregnancy, did you speak with a healthcare provider about your treatment options during pregnancy?

  1. YES GO TO I10

  2. NO SKIP TO I12

  3. DK SKIP TO I12

  4. RF SKIP TO I12

I10. Did you discuss these options before your pregnancy began?

  1. YES SKIP TO I12

  2. NO GO TO I11

  3. DK SKIP TO I12

  4. RF SKIP TO I12

I11. How far along were you in your pregnancy when you discussed treatment options with your provider?

  1. AMOUNT:__________ DK RF

  2. UNITS:

  1. Days

  2. Weeks

  3. Months

  4. Trimesters


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

  1. YES CONTINUE TO I13

  2. NO SKIP TO NEXT SECTION

  3. DK SKIP TO NEXT SECTION

  4. RF SKIP TO NEXT SECTION

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

IF CAN’T RECALL, READ FROM LIST:

  1. Armour Thyroid

  2. Carbimazole

  3. Cytomel

  4. Levothroid

  5. Levothyroxine Sodium

  6. Levoxyl

  7. Liothyronine

  8. Liotrix

  9. Methimazole

  10. Nature-throid

  11. Propylthiouracil (PTU)

  12. Synthroid

  13. Thiamazole

  14. Thyrolar

  15. Tirosint

  16. Unithroid

  17. Westhroid

  18. OTHER (SPECIFY):__________

  19. DK SKIP TO NEXT SECTION

  20. RF SKIP TO NEXT SECTION

I14. Did you use [MEDICINE, ANSWER I13] for the entire time from the month before your pregnancy through the third month of your pregnancy?

  1. YES SKIP TO I18

  2. NO CONTINUE TO I15

  3. DK CONTINUE TO I15

  4. RF CONTINUE TO I15

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

  1. MM/DD/YYYY or

  2. MONTH OF PREGNANCY(B1, P1, P2, P3)

  3. DK

  4. RF

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

  1. MM/DD/YYYY OR

  2. MONTH OF PREGNANCY(B1, P1, P2, P3) IF VALID RESPONSE TO I15 AND I16, SKIP I17

  3. DK

  4. RF

OR



I17. How long did you take it?

  1. AMOUNT:__________

  1. Days

  2. Weeks

  3. Months

  1. DK

  2. RF

I18. How often did you use [MEDICINE, ANSWER I13] during the month before your pregnancy through the end of your third month of pregnancy? You can say the number of times per day, per week, per month, or during the entire 4 month period.

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

I19. Did you take the same dose of medicine each time you took it throughout [B1] to [P4 (-1)]? That is, for example, the same number of milligrams of medicine in each dose.

  1. YES CONTINUE TO I20

  2. NO SKIP TO I21a

  3. DK CONTINUE TO I20

  4. RF CONTINUE TO I20

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

          1. AMOUNT:__________ DK or RF SKIP TO NEXT SECTION

  1. UNITS:__________

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

  1. AMOUNT:__________ RF

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

  1. AMOUNT:__________

DK SKIP TO I22

RF SKIP TO I22

  1. UNITS:__________ DK RF

I22. When did you begin taking that dose?

  1. MM/DD/YYYY OR

  2. MONTH OF PREGNANCY(B1, P1, P2, P3)

  3. DK

  4. RF

I23. When did you stop taking that dose?

  1. MM/DD/YYYY or

  2. MONTH OF PREGNANCY(B1, P1, P2, P3) IF VALID RESPONSE TO I22 and I23, SKIP I23a

  3. DK

  4. RF

OR

I23a. How long did you take it?

  1. AMOUNT:__________ DK RF

  1. Days

  2. Weeks

  3. Months



Section J: ASTHMA



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

    1. YES CONTINUE TO J2

    2. NO SKIP TO NEXT SECTION

    3. DK SKIP TO NEXT SECTION

    4. RF SKIP TO NEXT SECTION

J2. When was your asthma or reactive airway disease first diagnosed, relative to [your pregnancy with [NOIB]; TAB: the pregnancy that ended on [DOIB/DOPT]]? [READ LIST]

  1. More than 2 years before

  2. In the 2 years before

  3. During the first trimester

  4. After the first trimester but still during pregnancy

  5. After the pregnancy

  6. RF

  7. DK

J3. Did you have any asthma symptoms in the month before your pregnancy through your third month of pregnancy, that is from [B1] to [P4 (-1)]? These symptoms include shortness of breath, chest tightness or pain, coughing or wheezing, or low peak expiratory flow (PEF) readings.

  1. YES CONTINUE TO J4

  2. NO SKIP TO J6

  3. DK SKIP TO J6

  4. RF SKIP TO J6



J4. During that 4 month period did you miss any work, school, or normal daily activities because of your asthma?

  1. YES

  2. NO

  3. DK

  4. RF

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

  1. Not at all

  2. Less than once per month

  3. Once or twice per month

  4. More than twice per month

  5. DK

  6. RF

IF J2=c, d, e, f, g THEN SKIP TO J9 (ONLY ASK J6 IF J2=a, b).

J6. Either before or during your pregnancy, did you speak with a healthcare provider about your treatment options during pregnancy?

  1. YES GO TO J7

  2. NO SKIP TO J9

  3. DK SKIP TO J9

  4. RF SKIP TO J9

J7. Did you discuss these options before your pregnancy began?

  1. YES SKIP TO J9

  2. NO GO TO J8

  3. DK SKIP TO J9

  4. RF SKIP TO J9

J8. How far along were you in your pregnancy when you discussed treatment options with your provider?

  1. AMOUNT:__________ DK RF

  2. UNITS:

      1. Days

      2. Weeks

      3. Months

      4. Trimesters



Now I am going to ask about maintenance medications and remedies for long-term control of your asthma and then fast-acting, or “rescue”, medications for treatment of an asthma attack. First…

J9. Did you take any maintenance medications or remedies for long-term control of your asthma during the month before your pregnancy through the third month of pregnancy?

  1. YES CONTINUE TO J10a

  2. NO SKIP TO J45

  3. DK SKIP TO J45

  4. RF SKIP TO J45

J10a. First, I will ask about use of nasal sprays, then inhalers, and then pills used to control your asthma. Did you use any nasal sprays?

  1. YES CONTINUE TO J10b

  2. NO SKIP TO J22a

  3. DK SKIP TO J22a

  4. RF SKIP TO J22a

J10b. What did you take? / Did you take anything else? [IF CAN’T RECALL, READ FROM DRUG LIST]

NASAL SPRAYS

  1. Flonase

  2. Flunisolide

  3. Fluticasone Nasal Spray

  4. Nasonex Nasal Spray

  5. Omnaris Nasal Spray

  6. Qnasl Nasal Aerosol

  7. Rhinocort

  8. OTHER (SPECIFY):__________

  9. DK SKIP TO J22a

  10. RF SKIP TO J22a

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

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

  1. YES SKIP TO J16

  2. NO CONTINUE TO J13

  3. DK CONTINUE TO J13

  4. RF CONTINUE TO J13

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

  1. MM/DD/YYYY OR

  2. MONTH OF PREGNANCY(B1, P1, P2, P3)

  3. DK

  4. RF

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

  1. MM/DD/YYYY or

  2. MONTH OF PREGNANCY(B1, P1, P2, P3) IF VALID RESPONSE TO J13 AND J14, SKIP J15

  3. DK

  4. RF

OR

J15. How long did you take it?

  1. AMOUNT:__________ DK RF

  1. Days

  2. Weeks

  3. Months

J16. How often did you use [NASAL SPRAY, ANSWER J10b] during the month before your pregnancy through the end of your third month of pregnancy? You can say the number of times per day, per week, per month, or during the entire 4 month period.

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

J17 Did you take the same dose of medicine each time you took it throughout [B1] to [P4(-1)]? That is, for example, the same number of milligrams of medicine in each dose.

  1. YES J18

  2. NO SKIP TO J19a

  3. DK CONTINUE TO J18

  4. RF CONTINUE TO J18

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

  1. AMOUNT:__________ SKIP TO J22a

  1. UNITS:__________

  1. DK SKIP TO J22a

  2. RF SKIP TO J22a

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

  1. AMOUNT:__________ RF

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

  1. AMOUNT:__________

DK SKIP TO J20

RF SKIP TO J20

  1. UNITS:__________ DK RF

J20. When did you begin taking that dose?

  1. MM/DD/YYYY or

  2. MONTH OF PREGNANCY(B1, P1, P2, P3)

  3. DK

  4. RF

J21. When did you stop taking that dose?

  1. MM/DD/YYYY or

  2. MONTH OF PREGNANCY(B1, P1, P2, P3) IF VALID RESPONSE TO J20 and J21, SKIP J21a

  3. DK

  4. RF

OR

J21a. How long did you take it?

  1. AMOUNT:__________ DK RF

  1. Days

  2. Weeks

  3. Months

J22a. Did you use any oral inhalants, that is medicine you sprayed in your mouth? As a reminder, here I’m asking about long-term medications to control your asthma; I will ask about use of rescue inhalers later.

  1. YES CONTINUE TO J22b

  2. NO SKIP TO J34a

  3. DK SKIP TO J34a

  4. RF SKIP TO J34a

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

ORAL INHALANTS

  1. Advair

  2. Aerobid

  3. Aerospan Hfa

  4. Alvesco Inhaler

  5. Asmanex Twisthaler

  6. Budesonide Inhalation Suspension

  7. Dulera

  8. Flovent

  9. Foradil

  10. Formoterol Fumarate

  11. Perforomist

  12. Pulmicort

  13. Qvar HFA Inhaler

  14. Salmeterol Xinafoate

  15. Serevent

  16. Symbicort

  17. OTHER (SPECIFY):__________

  1. DK SKIP TO J34a

  2. RF SKIP TO J34a

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

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

  1. YES SKIP TO J27

  2. NO CONTINUE TO J24

  3. DK CONTINUE TO J24

  4. RF CONTINUE TO J24

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

  1. MM/DD/YYYY OR

  2. MONTH OF PREGNANCY(B1, P1, P2, P3)

  3. DK

  4. RF

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

  1. MM/DD/YYYY OR

  2. MONTH OF PREGNANCY(B1, P1, P2, P3) IF VALID RESPONSE TO J24 and J25, SKIP J26

  3. DK

  4. RF

OR

J26. How long did you take it?

  1. AMOUNT:__________ DK RF

  1. Days

  2. Weeks

  3. Months

J27. How often did you use [ORAL INHALANT, ANSWER J22b] during the month before your pregnancy through the end of your third month of pregnancy? You can say the number of times per day, per week, per month, or during the entire 4 month period.

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

J28 Did you take the same dose of medicine each time you took it throughout [B1] to [P4(-1)]? That is, for example, the same number of milligrams of medicine in each dose.

  1. YES J29

  2. NO SKIP TO J30a

  3. DK CONTINUE TO J29

  4. RF CONTINUE TO J29

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

  1. AMOUNT:___________ SKIP TO J34a

  1. UNITS:__________

  1. DK SKIP TO J34a

  2. RF SKIP TO J34a

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

  1. AMOUNT:__________ RF

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

  1. AMOUNT:__________

DK SKIP TO J31

RF SKIP TO J31

  1. UNITS:__________ DK RF

J31. When did you begin taking that dose?

  1. MM/DD/YYYY or

  2. MONTH OF PREGNANCY(B1, P1, P2, P3)

  3. DK

  4. RF

J32. When did you stop taking that dose?

  1. MM/DD/YYYY or

  2. MONTH OF PREGNANCY(B1, P1, P2, P3) IF VALID RESPONSE TO J31 and J32, SKIP J32a

  3. DK

  4. RF

OR

J32a. How long did you take it?

  1. AMOUNT:__________ DK RF

  1. Days

  2. Weeks

  3. Months

J33 [QUESTION NUMBER NOT USED]

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

  1. YES CONTINUE TO J34b

  2. NO SKIP TO J45

  3. DK SKIP TO J45

  4. RF SKIP TO J45

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

ORAL TABLETS/CAPS

  1. Accolate

  2. Montelukast Sodium

  3. Singulair

  4. Zafirlukast

  5. Zileuton

  6. Zyflo

  7. OTHER (SPECIFY):__________

  8. DK SKIP TO J45

  9. RF SKIP TO J45

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

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

  1. YES SKIP TO J39

  2. NO CONTINUE TO J36

  3. DK CONTINUE TO J36

  4. RF CONTINUE TO J36

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

  1. MM/DD/YYYY OR

  2. MONTH OF PREGNANCY(B1, P1, P2, P3)

  3. DK

  4. RF

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

  1. MM/DD/YYYY OR

  2. MONTH OF PREGNANCY(B1, P1, P2, P3) IF VALID RESPONSE TO J36 and J37, SKIP J38

  3. DK

  4. RF

OR

J38. How long did you take it?

  1. AMOUNT:__________ DK RF

  1. Days/Weeks/Months

J39. How often did you use [ORAL TABLET/CAP, ANSWER J34b] during the month before your pregnancy through the end of your third month of pregnancy? You can say the number of times per day, per week, per month, or during the entire 4 month period.

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

J40. Did you take the same dose of medicine each time you took it throughout [B1] to [P4 (-1)]? That is, for example, the same number of milligrams of medicine in each dose.

  1. YES J41

  2. NO SKIP TO J42a

  3. DK CONTINUE TO J41

  4. RF CONTINUE TO J41

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

  1. AMOUNT:_____ SKIP TO J45

  1. UNITS:__________

  1. DK SKIP TO J45

  2. RF SKIP TO J45

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

  1. AMOUNT:__________ RF

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

  1. AMOUNT:__________

DK SKIP TO J43

RF SKIP TO J43

  1. UNITS:__________ DK RF

J43. When did you begin taking that dose?

  1. MM/DD/YYYY OR

  2. MONTH OF PREGNANCY(B1, P1, P2, P3)

  3. DK

  4. RF

J44. When did you stop taking that dose?

  1. MM/DD/YYYY OR

  2. MONTH OF PREGNANCY(B1, P1, P2, P3) IF VALID RESPONSE TO J43 and J44, SKIP J44a

  3. DK

  4. RF

OR

J44a. How long did you take it?

  1. AMOUNT:__________ DK RF

  1. Days

  2. Weeks

  3. Months

J45. Did you take any fast-acting, or “rescue” medications or remedies for treatment of an asthma attack during the month before your pregnancy through the third month of pregnancy?

  1. YES CONTINUE TO J46

  2. NO SKIP TO NEXT SECTION

  3. DK SKIP TO NEXT SECTION

  4. RF SKIP TO NEXT SECTION

J46. What did you take? / Did you take anything else? [IF CAN’T RECALL, READ FROM DRUG LIST: AFTER READING LIST, ASK "Other steroids, such as prednisone or methylprednisone ". RECORD RESPONSE IN "OTHER" BOX.]

  1. Albuterol SKIP TO J48

  2. Asthmanefrin SKIP TO J48

  3. Atrovent HFA SKIP TO J48

  4. Ipratropium Bromide SKIP TO J48

  5. Levalbuterol Tartrate SKIP TO J48

  6. Maxair SKIP TO J48

  7. Pirbuterol Acetate SKIP TO J48

  8. ProAir HFA Inhaler SKIP TO J48

  9. Ventolin HFA SKIP TO J48

  10. Xopenex HFA SKIP TO J48

  11. OTHER (SPECIFY):__________ CONTINUE TO J47

  12. DK SKIP TO K1

  13. RF SKIP TO K1

J47. Did you get [MEDICINE, J46 OTHER SPECIFIED] from a pill that you swallowed or from a shot?

  1. Pill

  2. Shot (injection)

  3. Inhaler

  4. DK

  5. RF

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

J48. How often did you use [MEDICINE, ANSWER J46] during the month before your pregnancy through the third month of your pregnancy? You can say the number of times per day, per week, per month, or during the entire 4 month period.


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

J49. Did you use [MEDICINE, ANSWER J46] for the entire time from a month before your pregnancy through the third month of your pregnancy? [IF TIME PERIOD IS "PER PERIOD", DO NOT READ THIS QUESTIONS AND CHOOSE "NA"]

    1. YES SKIP TO NEXT SECTION

    2. NO CONTINUE TO J50a

    3. DK CONTINUE TO J50a

    4. RF CONTINUE TO J50a

    5. NA SKIP TO NEXT SECTION WITHOUT READING THIS QUESTION

J50a. How often did you use [MEDICINE, ANSWER J46] during the month before your pregnancy, which was [B1] to [P1 (-1)]?

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

  2. DID NOT TAKE

J50b. How often did you use [MEDICINE, ANSWER J46] during the first month of your pregnancy, which was [P1] to [P2 (-1)]?

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

  2. DID NOT TAKE

J50c. How often did you use [MEDICINE, ANSWER J46] during the second month of your pregnancy, which was [P2] to [P3 (-1)]?

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

  2. DID NOT TAKE

J50d. How often did you use [MEDICINE, ANSWER J46] during the third month of your pregnancy, which was [P3] to [P4 (-1)]?

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

  2. DID NOT TAKE

Section K: EPILEPSY



K1. Were you ever told by a doctor or other health care provider that you had epilepsy? IF MOM REPORTS SHE HAD A SEIZURE ONCE, REPEAT THE QUESTION, EMPHASIZING, "…ever told by a doctor or health care provider that you had epilepsy"

    1. YES CONTINUE TO K2

    2. NO SKIP TO NEXT SECTION

    3. DK SKIP TO NEXT SECTION

    4. RF SKIP TO NEXT SECTION

K2. What type of epilepsy do you have? IF CAN’T RECALL, READ FROM LIST:

  1. Temporal Lobe Epilepsy

  2. Frontal Lobe Epilepsy

  3. Reflex Epilepsy

  4. Childhood Absence Epilepsy

  5. Juvenile Absence Epilepsy

  6. Generalized epilepsy

  7. Focal epilepsy

  8. Generalized and focal epilepsy

  9. OTHER, SPECIFY:____________

  10. DK

  11. RF

K3. When were you first diagnosed with epilepsy in relation to [your pregnancy with [[NOIB]; TAB: the pregnancy that ended on [DOIB/DOPT]]? [READ LIST]

  1. More than 2 years before

  2. In the 2 years before

  3. During the first trimester

  4. After the first trimester but still during pregnancy

  5. After the pregnancy

  6. RF

  7. DK



IF K3=c, d, e, f, g THEN SKIP TO K7 (ONLY ASK K4 if K3=a, b)



K4. Either before or during your pregnancy, did you speak with a healthcare provider about your treatment options during pregnancy?

  1. YES GO TO K5

  2. NO SKIP TO K7

  3. DK SKIP TO K7

  4. RF SKIP TO K7

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

  1. YES SKIP TO K7

  2. NO GO TO K6

  3. DK SKIP TO K7

  4. RF SKIP TO K7

K6. How far along were you in your pregnancy when you discussed treatment options with your provider?

  1. AMOUNT:__________ DK RF

      1. Days

      2. Weeks

      3. Months

      4. Trimesters

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

  1. YES CONTINUE TO K8

  2. NO SKIP TO K19

  3. DK SKIP TO K19

  4. RF SKIP TO K19

K8. 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. Phenobarbital

  12. Keppra

  13. Klonopin

  14. Phenytoin

  15. Lamictal

  16. Stavzor

  17. Tegretol

  18. Lamotrigine

  19. Topamax

  20. Topiramate

  21. Trileptal

  22. Valproic Acid

  23. OTHER (SPECIFY)

  24. DK or RF SKIP TO K19

K9. Did you use [MEDICINE, ANSWER K8] for the entire time from the month before your pregnancy through your third month of pregnancy, that is from [B1] to [P4 (-1)]?

  1. YES SKIP TO K13

  2. NO CONTINUE TO K10

  3. DK CONTINUE TO K10

  4. RF CONTINUE TO K10

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

  1. MM/DD/YYYY OR

  2. MONTH OF PREGNANCY(B1, P1, P2, P3)

  3. DK

  4. RF

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

  1. MM/DD/YYYY OR

  2. MONTH OF PREGNANCY(B1, P1, P2, P3) IF VALID RESPONSE TO K10 and K11, SKIP K12

  3. DK

  4. RF

OR

K12. How long did you take it?

  1. AMOUNT:________________ DK RF

  1. Days

  2. Weeks

  3. Months


K13. How often did you use [MEDICINE, ANSWER K8] during the month before your pregnancy through the end of your third month of pregnancy? You can say the number of times per day, per week, per month, or during the entire 4 month period.

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

K14. Did you take the same dose of medicine each time you took it throughout [B1] to [P4 1)]? That is, for example, the same number of milligrams of medicine in each dose.

  1. YES CONTINUE TO K15

  2. NO SKIP TO K16a

  3. DK CONTINUE TO K15

  4. RF CONTINUE TO K15

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

  1. AMOUNT:__________ SKIP TO K19

      1. UNITS:____________

  1. DK SKIP TO K19

  2. RF SKIP TO K19

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

  1. AMOUNT:__________ RF

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

  1. AMOUNT:__________

DK SKIP TO K17

RF SKIP TO K17

  1. UNITS:__________ DK RF

K17. When did you begin taking that dose?

  1. MM/DD/YYYY or

  2. MONTH OF PREGNANCY(B1, P1, P2, P3)

  3. DK

  4. RF

K18. When did you stop taking that dose?

  1. MM/DD/YYYY or

  2. MONTH OF PREGNANCY(B1, P1, P2, P3) IF VALID RESPONSE TO K17 and K18, SKIP K18a

  3. DK

  4. RF

OR

K18a. How long did you take it?

  1. AMOUNT:________________ DK RF

  1. Days

  2. Weeks

  3. Months

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

  1. YES CONTINUE TO K20

  2. NO SKIP TO NEXT SECTION

  3. DK SKIP TO NEXT SECTION

  4. RF SKIP TO NEXT SECTION

K20. How many seizures did you have altogether during that time?

  1. AMOUNT:__________ DK RF

Section L: MIGRAINE



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

    1. YES CONTINUE TO L2

    2. NO SKIP TO NEXT SECTION

    3. DK SKIP TO NEXT SECTION

    4. RF SKIP TO NEXT SECTION

L2. How old were you when you had the first migraine headache?

    1. AGE:___________ DK RF

L3. Did you have any migraine headaches in the month before your pregnancy through the third month of pregnancy, that is from [B1] to [P4 (-1)]?

  1. YES CONTINUE TO L4

  2. NO SKIP TO L5

  3. DK SKIP TO L5

  4. RF SKIP TO L5

L4. How many migraines did you have altogether during that time?

    1. How many?:__________ DK RF

    2. Frequency – UNIT:__________

      1. Total 4 month period

      2. Per day

      3. Per week

      4. Per month

      5. DK

      6. RF

      7. Other, Specify:________

Now I am going to ask about maintenance medications and remedies you may use for your migraines. Please include medications that you may use to keep from having or to prevent migraines and medications that you may use to treat migraine pain when it happens. Please include over-the-counter medications and prescription medications.

L5. Did you take any medications or remedies for migraines during the month before your pregnancy through the third month of pregnancy?

  1. YES CONTINUE TO L6

  2. NO SKIP TO NEXT SECTION

  3. DK SKIP TO NEXT SECTION

  4. RF SKIP TO NEXT SECTION

L6. What did you take? / Did you take anything else? [IF CAN’T RECALL: Was this a medication you used to prevent a migraine from starting or to treat pain from a migraine that already started? IF IT WAS PAIN MEDICATION: Was this over-the-counter or prescription? THEN READ FROM THE APPROPRIATE DRUG LIST:]


PREVENTION MEDICATIONS:

  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:


aaa. Acetaminophen with Codeine

bbb. Almotriptan Maleate

ccc. Amerge

ddd. Axert

eee. Cafergot

fff. Dihydroergotamine

ggg. Eletriptan Hydrobromide

hhh. Ergotamine

iii. Fioricet

jjj. Frova

kkk. Frovatriptan Succinate

lll. Imitrex

mmm. Indomethacin

nnn. Maxalt

ooo. Migergot Suppositories

ppp. Migranal

qqq. Naproxen Sodium / Sumatriptan Succinate

rrr. Naratriptan

sss. Relpax

ttt. Rizatriptan

uuu. Sumatriptan Succinate

vvv. Treximet

www. Tylenol with Codeine

xxx. Zolmitriptan

yyy. Zomig

zzz. OTHER (SPECIFY):__________

aaaa. DK SKIP TO NEXT SECTION

bbbb. RF SKIP TO NEXT SECTION

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

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

  1. YES SKIP TO L11

  2. NO CONTINUE TO L8

  3. DK CONTINUE TO L8

  4. RF CONTINUE TO L8

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

  1. MM/DD/YYYY or

  2. MONTH OF PREGNANCY (B1, P1, P2, P3)

  3. DK

  4. RF

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

  1. MM/DD/YYYY or

  2. MONTH OF PREGNANCY (B1, P1, P2, P3) IF VALID RESPONSE TO L8 and L9, SKIP L10

  3. DK

  4. RF

OR

L10. How long did you take it?

  1. AMOUNT:________________ DK RF

  1. Days

  2. Weeks

  3. Months

L11. How often did you use [MEDICINE, ANSWER L6] during the month before your pregnancy through the end of your third month of pregnancy? You can say the number of times per day, per week, per month, or during the entire 4 month period.

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

L12. Did you take the same dose of medicine each time you took it throughout [B1] to [P4 (-1)]? That is, for example, the same number of milligrams of medicine in each dose.

  1. YES CONTINUE TO L13

  2. NO SKIP TO L14a

  3. DK CONTINUE TO L13

  4. RF CONTINUE TO L13

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

  1. AMOUNT:__________ SKIP TO NEXT SECTION

  1. UNITS:__________

  1. DK SKIP TO NEXT SECTION

  2. RF SKIP TO NEXT SECTION

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

  1. AMOUNT:__________ RF

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

  1. AMOUNT:__________

DK SKIP TO L15

RF SKIP TO L15

  1. UNITS:__________ DK RF

L15. When did you begin taking that dose?

  1. MM/DD/YYYY or

  2. MONTH OF PREGNANCY(B1, P1, P2, P3)

  3. DK

  4. RF

L16. When did you stop taking that dose?

  1. MM/DD/YYYY or

  2. MONTH OF PREGNANCY(B1, P1, P2, P3) IF VALID RESPONSE TO L15 and L16, SKIP L16a

  3. DK

  4. RF

OR

L16a. How long did you take it?

  1. AMOUNT:__________ DK RF

  1. Days

  2. Weeks

  3. Months

Section M: AUTOIMMUNE DISEASE



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

    1. Lupus

    2. Rheumatoid arthritis

    3. Multiple sclerosis

    4. Celiac disease

    5. Crohn’s disease

    6. Ulcerative colitis; (PleasePlease note that we are not asking about general colitis here)

    7. Psoriasis

    8. Other autoimmune disease (not including diabetes or thyroid disorders, which we have already discussed) IF CAN’T RECALL, READ FROM LIST:

      1. Immune/idiopathic thrombocytopenic purpura

      2. Interstitial cystitis

      3. Antiphospholipid antibody syndrome/lupus anticoagulant syndrome/APLS

      4. Addison’s disease

      5. Pernicious anemia

      6. Myasthenia gravis

      7. Autoimmune hemolytic anemia

      8. Berger’s disease/IgA nephropathy

      9. Alopecia, universalis or areata

      10. Vitiligo

      11. Juvenile arthritis

      12. Guillain Barre syndrome

      13. Scleroderma, morphea

      14. Sjögren's syndrome/Sicca syndrome

      15. Ankylosing spondylitis

      16. Rheumatic fever

      17. OTHER (SPECIFY):__________

      18. NONE OF THE ABOVE SKIP TO NEXT SECTION

      19. DK SKIP TO NEXT SECTION

      20. RF SKIP TO NEXT SECTION



IF YES TO ANY, CONTINUE TO M2

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

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

  1. More than 2 years before

  2. In the 2 years before

  3. During the first trimester

  4. After the first trimester but still during pregnancy

  5. After the pregnancy

  6. DK

  7. RF

IF M2=c, d, e, f, g THEN SKIP TO M6 (ONLY ASK M3 IF M2=a or b)

M3. Either before or during your pregnancy, did you speak with a healthcare provider about your treatment options during pregnancy?

  1. YES GO TO M4

  2. NO SKIP TO M6

  3. DK SKIP TO M6

  4. RF SKIP TO M6

M4. Did you discuss these options before your pregnancy began?

  1. YES SKIP TO M6

  2. NO GO TO M5

  3. DK SKIP TO M6

  4. RF SKIP TO M6

M5. How far along were you in your pregnancy when you discussed treatment options with your provider?

  1. AMOUNT:__________ DK RF

UNITS:

  1. Days

  2. Weeks

  3. Months

  4. Trimesters

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

  1. YES CONTINUE TO M7

  2. NO SKIP TO NEXT SECTION OR M2 IF > 1 CONDITION IN M1

  3. DK SKIP TO NEXT SECTION OR M2 IF > 1 CONDITION IN M1

  4. RF SKIP TO NEXT SECTION OR M2 IF > 1 CONDITION IN M1

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

[LUPUS]:

  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


[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


Multiple sclerosis [MS]:

  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


Crohn’s disease and ulcerative colitis [CROHNS]:



  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

[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

M8. Did you use [MEDICINE, ANSWER M7] for the entire time from the month before your pregnancy through the third month of pregnancy?

  1. YES SKIP TO M12

  2. NO CONTINUE TO M9

  3. DK CONTINUE TO M9

  4. RF CONTINUE TO M9

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

  1. MM/DD/YYYY or

  2. MONTH OF PREGNANCY(B1, P1, P2, P3)

  3. DK

  4. RF

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

  1. MM/DD/YYYY or

  2. MONTH OF PREGNANCY(B1, P1, P2, P3) IF VALID START AND STOP DATE, SKIP M11

  3. DK

  4. RF

OR

M11. How long did you take it?

  1. AMOUNT:__________ DK RF

  1. Days

  2. Weeks

  3. Months



M12. How often did you use [MEDICINE, ANSWER M7] during the month before your pregnancy through the end of your third month of pregnancy? You can say the number of times per day, per week, per month, or during the entire 4 month period.

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

M13. Did you take the same dose of medicine each time you took it throughout [B1] to [P4 (-1)]? That is, for example, the same number of milligrams of medicine in each dose.

  1. YES CONTINUE TO M14

  2. NO SKIP TO M15a

  3. DK CONTINUE TO M14

  4. RF SKIP TO M14

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

  1. AMOUNT:__________ SKIP TO NEXT SECTION

  1. UNITS:__________

  1. DK SKIP TO NEXT SECTION

  2. RF SKIP TO NEXT SECTION

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

  1. AMOUNT:__________ RF

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

  1. AMOUNT:__________

DK SKIP TO M16

RF SKIP TO M16

  1. UNITS:__________ DK RF

M16. When did you begin taking that dose?

  1. MM/DD/YYYY or

  2. MONTH OF PREGNANCY(B1, P1, P2, P3)

  3. DK

  4. RF

M17. When did you stop taking that dose?

  1. MM/DD/YYYY or

  2. MONTH OF PREGNANCY(B1, P1, P2, P3) IF VALID START AND STOP DATE, SKIP M17a

  3. DK

  4. RF

OR



M17a. How long did you take it?

  1. AMOUNT:__________ DK RF

  1. Days

  2. Weeks

  3. Months





Section N: TRANSPLANT RECEIPT

N1. Have you ever received an organ or tissue transplant? DOES NOT INCLUDE BLOOD TRANSFUSIONS OR TISSUE TRANSFERS

    1. YES CONTINUE TO N2

    2. NO SKIP TO NEXT SECTION

    3. DK SKIP TO NEXT SECTION

    4. RF SKIP TO NEXT SECTION

N2. What organ or tissue was transplanted?

  1. SPECIFY:_________________________ DK RF

N3. What was the date of the transplant?

  1. MM/DD/YYYY

  2. DK

  3. RF

N4. Did you take any medications related to your transplant during the month before your pregnancy through your third month of pregnancy, that is from [B1] to [P4 (-1)]?

  1. YES CONTINUE TO N5

  2. NO SKIP TO NEXT SECTION

  3. DK SKIP TO NEXT SECTION

  4. RF SKIP TO NEXT SECTION

N5. What did you take? / Did you take anything else? [IF CAN’T RECALL, READ FROM DRUG LIST]

  1. ATGAM

  2. Azathioprine

  3. Cellcept

  4. Cyclosporine

  5. Mycophenolate Mofetil

  6. Myfortic

  7. Orthoclone OKT3

  8. Prednisone

  9. Prograf

  10. Sirolimus

  11. Tacrolimus

  12. Thymoglobulin

  13. OTHER (SPECIFY):__________

  14. DK SKIP TO NEXT CONDITION/NEXT SECTION

  15. RF SKIP TO NEXT CONDITION/NEXT SECTION

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

  1. YES SKIP TO N10

  2. NO CONTINUE TO N7

  3. DK CONTINUE TO N7

  4. RF CONTINUE TO N7

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

  1. MM/DD/YYYY or

  2. MONTH OF PREGNANCY(B1, P1, P2, P3)

  3. DK

  4. RF

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

  1. MM/DD/YYYY or

  2. MONTH OF PREGNANCY(B1, P1, P2, P3) IF VALID START AND STOP DATE, SKIP N9

  3. DK

  4. RF

OR

N9. How long did you take it?

  1. AMOUNT:__________ DK RF

      1. Days

      2. Weeks

      3. Months

N10. How often did you use [MEDICINE, ANSWER N5] during the month before your pregnancy through the end of your third month of pregnancy? You can say the number of times per day, per week, per month, or during the entire 4 month period.

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

N11. Did you take the same dose of medicine each time you took it throughout [B1] to [P4(-1)]? That is, for example, the same number of milligrams of medicine in each dose.

  1. YES CONTINUE TO N12

  2. NO SKIP TO N13a

  3. DK CONTINUE TO N12

  4. RF CONTINUE TO N12

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

  1. AMOUNT:__________ SKIP TO NEXT SECTION

  1. UNITS:__________

  1. DK SKIP TO NEXT SECTION

  2. RF SKIP TO NEXT SECTION

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

  1. AMOUNT:__________ RF

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

  1. AMOUNT:__________

DK SKIP TO N14

RF SKIP TO N14

  1. UNITS:__________ DK RF

N14. When did you begin taking that dose?

  1. MM/DD/YYYY or

  2. MONTH OF PREGNANCY(B1, P1, P2, P3)

  3. DK

  4. RF

N15. When did you stop taking that dose?

  1. MM/DD/YYYY or

  2. MONTH OF PREGNANCY(B1, P1, P2, P3) IF VALID START AND STOP DATE, SKIP N15a

  3. DK

  4. RF

OR

N15a. How long did you take it?

  1. AMOUNT:__________ DK RF

  1. Days

  2. Weeks

  3. Months





Section O: DEPRESSION / ANXIETY

O1. Has a doctor or other health care provider EVER told you that you had an anxiety disorder, including acute stress disorder, anxiety, generalized anxiety disorder, obsessive-compulsive disorder, panic disorder, phobia, posttraumatic stress disorder, or social anxiety disorder?

          1. YES CONTINUE TO O2

          2. NO SKIP TO O4

          3. DK SKIP TO O4

          4. RF SKIP TO O4

O2. What condition were you told you had / Anything else?

  1. SPECIFY:___________ DK RF

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

  1. More than 2 years before

  2. In the 2 years before

  3. During the first trimester

  4. After the first trimester but still during pregnancy

  5. After the pregnancy

  6. DK

  7. RF

O4. Has a doctor or other healthcare provider EVER told you that you had depression?

  1. YES CONTINUE TO O5

  2. If NO/DK/RF, and YES to O1 CONTINUE TO O6

  3. If NO/DK/RF, and NO/DK/RF to O1 SKIP TO NEXT SECTION

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

          1. More than 2 years before

          2. In the 2 years before

          3. During the first trimester

          4. After the first trimester but still during pregnancy

          5. After the pregnancy

          6. DK

          7. RF

O6. Did you experience any symptoms in the month before your pregnancy through the end of the third month of pregnancy, that is from [B1] to [P4 (-1)]?

          1. YES CONTINUE TO O7

          2. NO SKIP TO INSTRUCTIONS BEFORE O8

          3. DK SKIP TO INSTRUCTIONS BEFORE O8

          4. RF SKIP TO INSTRUCTIONS BEFORE O8

O7. What were the symptoms you experienced?

          1. SPECIFY:__________ DK RF

IF O1=a AND O4=a AND O3=c, d, e, f, g AND O5=c, d, e, f, g THEN SKIP TO O11 (REPORTED ANXIETY AND DEPRESSION, BUT BOTH WERE DIAGNOSED DURING OR AFTER PREGNANCY)

IF O1=b, c, d AND O4=a AND O5=c, d, e, f, g THEN SKIP TO O11 (REPORTED ONLY DEPRESSION DIAGNOSED DURING OR AFTER PREGNANCY)

IF O1 = a AND O4=b AND O3= c, d, e, f, g THEN SKIP TO O11 (REPORTED ONLY ANXIETY DIAGNOSED DURING OR AFTER PREGNANCY)

O8. IF O3 OR O5 = a or b, ASK O8 THROUGH REST OF SECTION JUST ONCE: Either before or during your pregnancy, did you speak with a healthcare provider about your treatment options during pregnancy?

          1. YES GO TO O9

          2. NO SKIP TO O11

          3. DK SKIP TO O11

          4. RF SKIP TO O11

O9. Did you discuss these options before your pregnancy began?

          1. YES SKIP TO O11

          2. NO GO TO O10

          3. DK SKIP TO O11

          4. RF SKIP TO O11

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

  1. AMOUNT:__________ DK RF

UNITS:

            1. Days

            2. Weeks

            3. Months

            4. Trimesters

O11. How did you treat your condition(s) in the month before your pregnancy through the end of the third month of pregnancy? [INDICATE ALL THAT APPLY. READ CHOICES. AFTER READING CHOICES, ASK: "Or something else?"]

  1. Under care of therapist/psychologist IF THIS ONLY SKIP TO NEXT SECTION

  2. With medication IF YES, CONTINUE WITH O12

  3. You didn’t receive any treatment IF THIS ONLY SKIP TO NEXT SECTION

  4. Or something else? (SPECIFY):__________IF THIS ONLY SKIP TO NEXT SECTION

  5. DK CONTINUE WITH O12

  6. RF IF THIS ONLY SKIP TO NEXT SECTION

O12. Did you use medication to treat your condition(s) in the month before your pregnancy through the third month of pregnancy?

  1. YES CONTINUE TO O13

  2. NO SKIP TO NEXT SECTION

  3. DK SKIP TO NEXT SECTION

  4. RF SKIP TO NEXT SECTION

O13. 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

  9. Carbatrol

  10. Celexa

  11. Citalopram

  12. Clomipramine

  13. Clonazepam

  14. Cymbalta

  15. Depacon

  16. Depakene

  17. Depakote

  18. Diazepam

  19. Duloxetine

  20. Effexor

  21. Epitol

  22. Equetro

  23. Escitalopram

  24. Fluoxetine

  25. Imipramine

  26. Inderal

  27. Klonopin

  28. Lamictal

  29. Lamotrigine

  30. Lexapro

  31. Lorazepam

  32. Paroxetine

  33. Paxil

  34. Propranolol

  35. Prozac

  36. Sertraline

  37. St. John’s Wort

  38. Tegretol

  39. Tofranil

  40. Valium

  41. Valproic Acid

  42. Venlafaxine

  43. Wellbutrin

  44. Xanax

  45. Zoloft

  46. Carbamazepine

  47. OTHER (SPECIFY):__________

  48. DK SKIP TO NEXT SECTION

  49. RF SKIP TO NEXT SECTION

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

          1. YES SKIP TO O18

          2. NO CONTINUE TO O15

          3. DK CONTINUE TO O15

          4. RF CONTINUE TO O15

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

  1. MM/DD/YYYY or

  2. MONTH OF PREGNANCY(B1, P1, P2, P3)

  3. DK

  4. RF

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

  1. MM/DD/YYYY or

  2. MONTH OF PREGNANCY(B1, P1, P2, P3) IF VALID START AND STOP DATE, SKIP O17

  3. DK

  4. RF

OR

O17. How long did you take it?

  1. AMOUNT:__________ DK RF

  1. Days

  2. Weeks

  3. Months

O18. How often did you use [MEDICINE, ANSWER O13] during the month before your pregnancy through the end of your third month of pregnancy? You can say the number of times per day, per week, per month, or during the entire 4 month period.

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

O19. Did you take the same dose of medicine each time you took it throughout [B1] to [P4 (-1)]? That is, for example, the same number of milligrams of medicine in each dose.

          1. YES CONTINUE TO O20

          2. NO SKIP TO O21a

          3. DK CONTINUE TO O20

          4. RF CONTINUE TO O20

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

  1. AMOUNT:__________ SKIP TO NEXT SECTION

  1. UNITS:__________

  1. DK SKIP TO NEXT SECTION

  2. RF SKIP TO NEXT SECTION

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

  1. AMOUNT:__________ RF

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

  1. AMOUNT:__________

DK SKIP TO O22

RF SKIP TO O22

  1. UNITS:__________ DK RF

O22. When did you begin taking that dose?

  1. MM/DD/YYYY or

  2. MONTH OF PREGNANCY(B1, P1, P2, P3)

  3. DK

  4. RF

O23. When did you stop taking that dose?

  1. MM/DD/YYYY or

  2. MONTH OF PREGNANCY(B1, P1, P2, P3) IF VALID START AND STOP DATE in O22 and O23, SKIP O23a

  3. DK

  4. RF

OR

O23a. How long did you take it?

  1. AMOUNT:__________ DK RF

  1. Days

  2. Weeks

  3. Months





Section P: ATTENTION DEFICIT HYPERACTIVITY DISORDER (ADHD)

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

    1. YES CONTINUE TO P2

    2. NO SKIP TO NEXT SECTION

    3. DK SKIP TO NEXT SECTION

    4. RF SKIP TO NEXT SECTION

P2. With which condition were you diagnosed? IF MOM SAYS SHE USED TO HAVE ONE KIND BUT NOW THEY SAY IT'S A DIFFERENT KIND, USE "Other, specify" AND ENTER BOTH TYPES

  1. Attention Deficit Hyperactivity Disorder

  2. Attention Deficit Disorder

  3. OTHER (SPECIFY):__________

  4. DK

  5. RF

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

          1. More than 2 years before

          2. In the 2 years before

          3. During the first trimester

          4. After the first trimester but still during pregnancy

          5. After the pregnancy

          6. DK

          7. RF

IF P3=c, d, e, f, g THEN SKIP TO P7 (ONLY ASK P4 if P3=a, b)

P4. Either before or during your pregnancy, did you speak with a healthcare provider about your treatment options during pregnancy?

    1. YES GO TO P5

    2. NO SKIP TO P7

    3. DK SKIP TO P7

    4. RF SKIP TO P7

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

  1. YES SKIP TO P7

  2. NO GO TO P6

  3. DK SKIP TO P7

  4. RF SKIP TO P7

P6. How far along were you in your pregnancy when you discussed treatment options with your provider?

  1. AMOUNT:__________ DK RF

UNITS:

      1. Days

      2. Weeks

      3. Months

      4. Trimesters



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

    1. YES CONTINUE TO P8

    2. NO SKIP TO NEXT SECTION

    3. DK SKIP TO NEXT SECTION

    4. RF SKIP TO NEXT SECTION

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

  1. Adderall

  2. Adderall XR

  3. Amphetamine

  4. Atomoxetine

  5. Celexa

  6. Citalopram

  7. Clonidine Hydrochloride

  8. Concerta

  9. Daytrana Patch

  10. Dexedrine

  11. Dexmethylphenidate

  12. Dextroamphetamine

  13. Dextrostat

  14. Focalin

  15. Focalin XR

  16. Guanfacine

  17. Intuniv

  18. Kapvay

  19. Lisdexamfetamine

  20. Metadate CD

  21. Methylin

  22. Methylphenidate

  23. Prozac

  24. Ritalin

  25. Ritalin LA

  26. Ritalin SR

  27. Sertraline

  28. Strattera

  29. Vyvanse

  30. Zoloft

  31. OTHER, SPECIFY: ____________

  32. DK SKIP TO NEXT SECTION

  33. RF SKIP TO NEXT SECTION


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

    1. YES SKIP TO P13

    2. NO CONTINUE TO P10

    3. DK CONTINUE TO P10

    4. RF CONTINUE TO P10

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

    1. MM/DD/YYYY or

    2. MONTH OF PREGNANCY(B1, P1, P2, P3)

    3. DK

    4. RF

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

    1. MM/DD/YYYY or

    2. MONTH OF PREGNANCY(B1, P1, P2, P3) IF VALID START AND STOP DATE, SKIP P12

    3. DK

    4. RF

OR

P12. How long did you take it?

  1. AMOUNT:__________ DK RF

      1. Days

      2. Weeks

      3. Months

P13. How often did you use [MEDICINE, ANSWER P8] during the month before your pregnancy through the end of your third month of pregnancy? You can say the number of times per day, per week, per month, or during the entire 4 month period.

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

P14. Did you take the same dose of medicine each time you took it throughout [B1] to [P4(-1)]? That is, for example, the same number of milligrams of medicine in each dose.

    1. YES CONTINUE TO P15

    2. NO SKIP TO P16a

    3. DK CONTINUE TO P15

    4. RF CONTINUE TO P15

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

    1. AMOUNT:__________ SKIP TO NEXT SECTION

      1. UNITS:__________

    2. DK SKIP TO NEXT SECTION

    3. RF SKIP TO NEXT SECTION

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

  1. AMOUNT:__________ RF

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

  1. AMOUNT:__________

DK SKIP TO P17

RF SKIP TO P17

  1. UNITS:__________ DK RF

P17. When did you begin taking that dose?

  1. MM/DD/YYYY or

  2. MONTH OF PREGNANCY(B1, P1, P2, P3)

  3. DK

  4. RF

P18. When did you stop taking that dose?

  1. MM/DD/YYYY or

  2. MONTH OF PREGNANCY(B1, P1, P2, P3) IF VALID START AND STOP DATE, SKIP P18a

  3. DK

  4. RF

OR

P18a. How long did you take it?

  1. AMOUNT:__________ DK RF

  1. Days

  2. Weeks

  3. Months





Section Q: CHRONIC DISEASE CATCH-ALL QUESTION



Q1. Have you ever been diagnosed with any other chronic diseases or long-term illnesses that we haven’t talked about such as fibromyalgia, hepatitis, blood clotting disorders, irritable bowel syndrome, sleep apnea or other sleep disorders, bipolar disorder, schizophrenia or other mental health conditions? [PROBE: This does not include short-term illnesses such as colds.]

    1. YES CONTINUE TO Q2

    2. NO SKIP TO NEXT SECTION

    3. DK SKIP TO NEXT SECTION

    4. RF SKIP TO NEXT SECTION

Q2. What did you have? / Did you have anything else? [READ LIST IF NECESSARY] DO NOT INCLUDE ALLERGIES

    1. Fibromyalgia

    2. Hepatitis

    3. Blood clotting disorders

    4. Irritable bowel syndrome

    5. Sleep apnea or other sleep disorders

    6. Bipolar disorder

    7. Schizophrenia

    8. Other mental health conditions

    9. UNSPECIFIED CHRONIC DISEASE OR LONG-TERM ILLNESS

    10. SPECIFY:__________________ CONTINUE TO Q3

  1. RF SKIP TO NEXT SECTION

Q3. How old were you when the [CHRONIC DISEASE, ANSWER Q2] was diagnosed?

    1. AGE:_____________________ DK RF

      1. Years

      2. Months

Q4. Did you take any medications or remedies for [CHRONIC DISEASE, ANSWER Q2] during the month before your pregnancy through the third month of pregnancy, that is from [B1] to [P4 (-1)]? [DO NOT RECORD CPAP HERE]

    1. YES CONTINUE TO Q5

    2. NO SKIP TO NEXT SECTION

    3. DK SKIP TO NEXT SECTION

    4. RF SKIP TO NEXT SECTION

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

    1. SPECIFY:____________________________

    2. DK SKIP TO NEXT SECTION

    3. RF SKIP TO NEXT SECTION

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

    1. YES SKIP TO Q10

    2. NO CONTINUE TO Q7

    3. DK CONTINUE TO Q7

    4. RF CONTINUE TO Q7

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

    1. MM/DD/YYYY or

    2. MONTH OF PREGNANCY(B1, P1, P2, P3)

    3. DK

    4. RF

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

    1. MM/DD/YYYY or

    2. MONTH OF PREGNANCY(B1, P1, P2, P3) IF VALID RESPONSE TO Q7 and Q8, SKIP Q9

    3. DK

    4. RF

OR

Q9. How long did you take it?

    1. AMOUNT:__________ DK RF

      1. Days

      2. Weeks

      3. Months

Q10. How often did you use [MEDICINE, ANSWER Q5] during the month before your pregnancy through the end of your third month of pregnancy? You can say the number of times per day, per week, per month, or during the entire 4 month period.

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

Q11. Did you take the same dose of medicine each time you took it throughout [B1] to [P4(-1)]? That is, for example, the same number of milligrams of medicine in each dose.

    1. YES CONTINUE TO Q12

    2. NO SKIP TO Q13a

    3. DK CONTINUE TO Q12

    4. RF CONTINUE TO Q12

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

    1. AMOUNT:__________ SKIP TO NEXT SECTION

      1. UNITS:__________

    2. DK SKIP TO NEXT SECTION

    3. RF SKIP TO NEXT SECTION

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

  1. AMOUNT:__________ RF

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

  1. AMOUNT:__________ DK or RF SKIP TO Q14

  2. UNITS:__________ DK RF

Q14. When did you begin taking that dose?

    1. MM/DD/YYYY or

    2. MONTH OF PREGNANCY(B1, P1, P2, P3)

    3. DK

    4. RF

Q15. When did you stop taking that dose?

    1. MM/DD/YYYY

    2. MONTH OF PREGNANCY(B1, P1, P2, P3) IF VALID RESPONSE TO Q14 and Q15, SKIP Q15a

    3. DK

    4. RF

OR

Q15a. How long did you take it?

  1. AMOUNT:__________ DK RF

  1. Days

  2. Weeks

  3. Months

Section R: FEVERS


R1. From one month before you became pregnant to the end of the third month of your pregnancy, that is from [B1] to [P4(-1)], did you have any fevers? [PROBE: The fever could have been 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 S2

  2. NO SKIP TO NEXT SECTION

  3. DK SKIP TO NEXT SECTION

  4. RF SKIP TO NEXT SECTION


R2. How many fevers do you remember having? [IF DK NUMBER, SELECT 1 AND ASK MOM FOR DETAILS ABOUT 1 FEVER SHE REMEMBERS.] [ASK S3-S11 FOR EACH FEVER LISTED.]


a. NUMBER:


R3. What was the cause of the [1st, 2nd, etc.] fever?


  1. CAUSE:

  2. DK

  3. RF


R4. When you had [CAUSE OF FEVER, ANSWER R3], during which of these months did you have a fever?


  1. B1

  2. P1

  3. P2

  4. P3

  5. DK

  6. RF


R5. What was the highest temperature recorded during your fever?


  1. VALUE: DK RF NOT RECORDED SKIP UNITS

    1. UNITS: F or C


R6. Did you take any medications or remedies for the fever?


  1. YES CONTINUE TO R7

  2. NO SKIP TO NEXT SECTION

  3. DK SKIP TO NEXT SECTION

  4. RF SKIP TO NEXT SECTION


R7. 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 SKIP TO NEXT SECTION

  11. RF SKIP TO NEXT SECTION


R8. When did you start using [DRUG, ANSWER R7] for this [CAUSE OF FEVER, ANSWER R3] for the first time during this period? [CAN USE DK OR RF FOR MM OR DD OR YY]


  1. MM/DD/YYYY or

  2. MONTH OF PREGNANCY(B1, P1, P2, P3)

  3. DK

  4. RF


R9. When did you use [DRUG, ANSWER R7] for the last time during this time period? [CAN USE DK OR RF FOR MM OR DD OR YY]


  1. MM/DD/YYYY or DK or RF or

  2. MONTH OF PREGNANCY(B1, P1, P2, P3) IF VALID RESPONSE TO R8 and R9, SKIP R10


OR


R10. How long did you take it?


  1. AMOUNT: DK RF

    1. Days

    2. Weeks

    3. Months


R11. How often did you use [DRUG, ANSWER R7] during the month before your pregnancy through the end of your third month of pregnancy? You can say the number of times per day, per week, per month, or during the entire 4 month period.


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

Section S: GENITOURINARY INFECTIONS



S1. From the month before you became pregnant to the end of the third month of pregnancy, that is from [B1] to [P4 (-1)], did you have a kidney, bladder, or urinary tract infection? DO NOT INCLUDE KIDNEY STONES

    1. YES CONTINUE TO S2

    2. NO SKIP TO S15

    3. DK SKIP TO S15

    4. RF SKIP TO S15

ASK THE FOLLOWING QUESTIONS FOR EACH INFECTION REPORTED:

S2. Was the infection diagnosed by a doctor or other health care provider? IF ONLY DIAGNOSED WITH KIT TEST RESULT, ENTER "No".

    1. YES

    2. NO

    3. DK

    4. RF

S3. From the month before you became pregnant to the end of the third month of pregnancy, that is from [B1] to [P4 (-1)], did you take any medications or remedies for your infection?

    1. YES CONTINUE TO S4

    2. NO SKIP TO S15

    3. DK SKIP TO S15

    4. RF SKIP TO S15






ASK THIS SERIES FOR EACH MEDICINE USED:


ROW #


QUESTION

RESPONSE

1

S4. S18. S32.

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

MEDICATION:______________________


DK RF



S4, S18 (UTI OR PID MEDS): PROBE: IF CAN’T RECALL, READ FROM DRUG LIST:


Amoxicillin

Amoxil

Augmentin

Azithromycin

Bactrim

Biaxin

Ceftriaxone sodium

Cipro

Doxycycline

EES

Erythrocin

Erythromycin

Furadantin

Levaquin

Macrobid

Macrodantin

Nitrofurantoin

Nitrofurantoin Macrocrystals

Penicillin

Rebetol

Rebetron

Septra

Sulfamethoxazole/trimethoprim

Trimox

Vibramycin

Virazole

Zithromax

Antibiotic

S4: IF NO/DK/RF SKIP TO S15


S18: IF NO/DK/RF SKIP TO S29


S32: IF NO/DK/RF SKIP TO S43





S32 (STD MEDS): [PROBE: IF CAN’T RECALL, READ FROM DRUG LIST]


Acyclovir

Aldara

Condylox

Famciclovir

Famvir

Imiquimod

Podofilox

Podophyllin

Trichloroacetic acid (TCA)

Valacyclovir

Valtrex

Zovirax

Zyclara


2

S5. S19. S33.

Did you use [MEDICINE, ANSWER S4, S18, S32] for the entire time from the month before your pregnancy through your third month of pregnancy?

YES SKIP TO ROW 6


NO DK RF CONTINUE TO ROW 3

3

S6. S20. S34.

When did you start using [MEDICINE, ANSWER S4, S18, S32] for [the infection/CONDITION] for the first time during this period?

MM/DD/YYYY __ /__ /____ or

MONTH OF PREGNANCY(B1, P1, P2, P3)


DK RF

4

S7. S21. S35.

When did you use [MEDICINE, ANSWER S4, S18, S32] for the last time during this time period?

MM/DD/YYYY __ /__ /____ or

MONTH OF PREGNANCY(B1, P1, P2, P3) IF VALID START AND STOP DATE, SKIP ROW 5


DK RF

5

S8. S22. S36.

How long did you take it?

AMOUNT:__________

Days Weeks Months


DK RF

6

S9. S23. S37.

How often did you use [MEDICINE, ANSWER S4, S18, S32] during the month before your pregnancy through the end of your third month of pregnancy? You can say the number of times per day, per week, per month, or during the entire 4 month period.

AMOUNT:__________

Per day/Per week/Per month/Per time period


DK RF

7

S10. S24. S38.

Did you take the same dose of medicine each time you took it throughout [B1] to [P4(-1)]? That is, for example, the same number of milligrams of medicine in each dose.

YES, DK, RF CONTINUE TO ROW 8


NO SKIP TO ROW 9

8

S11. S25. S39.

What dose of [MEDICINE, ANSWER S4, S18, S32] did you take each time you took it?

AMOUNT:______ DK, RF SKIP UNITS

UNITS:_________ DK

S11 SKIP TO S15

S25 SKIP TO S29

S39 SKIP TO S43

9

S12a. S26a. S40a.

How many different dosage amounts do you remember taking?

AMOUNT:__________ RF

10

S12b. S26b. S40b.

What dose of [MEDICINE, ANSWER S4, S18, S32] did you take the [1st, 2nd, etc.] time?

AMOUNT:______ DK, RF SKIP UNITS

UNITS:_________ DK RF

11

S13. S27. S41a.

When did you begin taking that dose?

MM/DD/YYYY __ /__ /____ or

MONTH OF PREGNANCY(B1, P1, P2, P3)

DK RF

12

S14. S28. S41b.

When did you stop taking that dose?

MM/DD/YYYY __ /__ /____ or

MONTH OF PREGNANCY(B1, P1, P2, P3) IF VALID START AND STOP DATE, SKIP ROW 13

DK RF

13

S14a S28a

S42.

Or How long did you take it?

AMOUNT:__________

Days Weeks Months

DK RF

AFTER S14, CONTINUE WITH S15 BELOW. AFTER S28a, CONTINUE WITH S29 BELOW.

FOR S15-S28, FOR S29 –SXX, USE SAME RESPONSES AND SKIP PATTERNS AS FOR SIMILAR QUESTIONS IN S1-S14 ABOVE.

S15. From the month before you became pregnant to the end of the third month of pregnancy, that is from [B1] to [P4 (-1)], did you have pelvic inflammatory disease or PID?

  1. YES CONTINUE TO S16

  2. NO SKIP TO S29

  3. DK SKIP TO S29

  4. RF SKIP TO S29

S16. Was the pelvic inflammatory disease or PID diagnosed by a doctor or other health care provider?

  1. YES

  2. NO

  3. DK

  4. RF

S17. From the month before you became pregnant to the end of the third month of pregnancy, that is from [B1] to [P4 (-1)], did you take any medications or remedies for your pelvic inflammatory disease or PID?

  1. YES CONTINUE TO S18 IN TABLE ABOVE

  2. NO SKIP TO S29

  3. DK SKIP TO S29

  4. RF SKIP TO S29

AFTER S18 – S28 IN TABLE ABOVE, CONTINUE:

Questions S29-S42 were removed.

S43. From the month before you became pregnant to the end of the third month of pregnancy, that is from [B1] to [P4 (-1)], did you have a yeast infection?

  1. YES CONTINUE TO S29A

  2. NO SKIP TO NEXT SECTION

  3. DK or RF SKIP TO NEXT SECTION



S44. Was the yeast infection diagnosed by a doctor or other health care provider?

  1. YES

  2. NO

  3. DK

  4. RF

S45. From the month before you became pregnant to the end of the third month of pregnancy, that is from [B1] to [P4 (-1)], did you take any medications or remedies for your yeast infection?

  1. YES CONTINUE TO S46

  2. NO SKIP TO NEXT SECTION

  3. DK SKIP TO NEXT SECTION

  4. RF SKIP TO NEXT SECTION

S46. Did you take a medicine that a doctor prescribed for you or did you buy it “over-the-counter”, without a prescription? SELECT ALL THAT APPLY

    1. Prescription

    2. Over-the-counter

    3. DK

    4. RF

S47. Did you use a medicine that you inserted or applied on the outside or a pill that you swallowed? SELECT ALL THAT APPLY

    1. External or inserted product SKIP TO NEXT SECTION

    2. Pill SKIP TO NEXT SECTION

    3. OTHER (SPECIFY):__________ SKIP TO NEXT SECTION

    4. DK SKIP TO NEXT SECTION

    5. RF SKIP TO NEXT SECTION

Section T: INFECTIONS



INFECTIONS – Gateway Table


(FOLLOW-UP QUESTIONS FOR EVERY “YES” RESPONSE BEGIN IN NEXT TABLE

Has a doctor or other health care provider ever told you that you had any of the following infections?

IF YES, ASK FOLLOW-UP QUESTIONS

IF NO, ASK NEXT CATEGORY

IF DK, ASK NEXT CATEGORY

IF RF, ASK NEXT CATEGORY



YES

NO

DK

RF

T1

Coronavirus or COVID-19





.

Zika virus






Chikungunya






Dengue






Lyme disease






Malaria






West Nile






Hepatitis A






Hepatitis B






Hepatitis C






HIV






Syphilis






Chlamydia






Gonorrhea






Human papillomavirus (HPV)






Any other sexually transmitted disease, such as herpes or trichomoniasis?

What was it?





For each infection that the mother reported, ask the following questions:

T2.

When was your infection first diagnosed?

a. MM/DD/YYYY OR

b. Age in years OR

c. Time period ago

d. DK

e. RF

T3.

Did you have any symptoms during the 3 months before your pregnancy through the end of your [pregnancy with [NOIB]; TAB: the pregnancy that ended on [DOIB/DOPT]], that is from [B3] to the end of your pregnancy? Please note that this is a longer time period than most of my other questions.

a. YES CONTINUE TO T4

b. NO SKIP TO T5

c. DK SKIP TO T5

d. RF SKIP TO T5

T4.

During which months did you have symptoms?

a. B3

b. B2

c. B1

d. P1

e. P2

f. P3

g. T2

h. T3

i. DK

j. RF

T5.

Did you take any medications or remedies for [INFECTION] during the 3 months before your pregnancy through the end of your [pregnancy with [NOIB]; TAB: the pregnancy that ended on [DOIB/DOPT]]?

a. YES CONTINUE TO T6

b. NO SKIP TO NEXT INFECTION/SECTION

c. DK SKIP TO NEXT INFECTION/SECTION

d. RF SKIP TO NEXT INFECTION/SECTION

T6.

What did you take? Did you take anything else? [LIST ALL]

a. Medication:_______________

b. DK

c. RF

T7.

Did you use [MEDICINE] for the entire time from 3 months before your pregnancy through the end of your [pregnancy with [NOIB]; TAB: the pregnancy that ended on [DOIB/DOPT]]?

a. YES SKIP TO T11

b. NO CONTINUE TO T8

c. DK CONTINUE TO T8

d. RF CONTINUE TO T8

T8.

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

a. MM/DD/YYYY or

b. MONTH OF PREGNANCY (B3, B2, B1, P1, P2, P3, T2, T3)

c. DK

d. RF

T9.

When did you use [MEDICINE] for the last time during this period? [CAN USE DK OR RF FOR MM OR DD OR YY]



a. MM/DD/YYYY or

b. MONTH OF PREGNANCY (B3, B2, B1, P1, P2, P3, T2, T3)

c. DK

d. RF

T10.

OR


How long did you take it?

a. AMOUNT:__________

i. Days

ii. Weeks

iii. Months

b. DK

c. RF

T11.

How often did you use [MEDICINE] during the 3 months before your pregnancy through the end of your [pregnancy with [NOIB]; TAB: the pregnancy that ended on [DOIB/DOPT]]? You can say the number of times per day, per week, per month, or during the entire period.

a. AMOUNT:_____________

i. Per Day

ii. Per Week

iii. Per Month

vi. Per Time Period [Note to interviewers that this refers to B3-end of pregnancy; e.g., if the mother only took the medication once during that entire time period they would put AMOUNT=1 per time period]

b. DK

c. RF

T12.

Did you take the same dose of medicine each time you took it throughout [B3] to [DOIB/DOPT]? That is, for example, the same number of milligrams of medicine in each dose?

a. YES CONTINUE TO T13

b. NO SKIP TO T14

c. DK CONTINUE TO T13

d. RF CONTINUE TO T13

T13.

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

a. AMOUNT:____________ SKIP TO NEXT MEDICINE/INFECTION/SECTION

i. UNITS:_____________

b. DK SKIP TO NEXT MEDICINE/INFECTION/SECTION

c. RF SKIP TO NEXT MEDICINE/INFECTION/SECTION

T14.

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

a. AMOUNT:____________

b. RF

T15.

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

a. AMOUNT:_____________

i. UNITS:______________

b. DK

c. RF

T16.

When did you begin taking that dose?

a. MM/DD/YYYY or

b. MONTH OF PREGNANCY (B3, B2, B1, P1, P2, P3, T2, T3)

c. DK

d. RF

T17.

When did you stop taking that dose?

a. MM/DD/YYYY or

b. MONTH OF PREGNANCY (B3, B2, B1, P1, P2, P3, T2, T3)

c. DK

d. RF

T18.

OR


How long did you take it?

a. AMOUNT:__________

i. Days

ii. Weeks

iii. Months

b. DK

c. RF





Section U: TRAVEL HISTORY

The next questions are about places you may have traveled before and during your pregnancy.

U1. Did you spend any time outside the continental United States during the time period from 3 months before pregnancy through the end of pregnancy, that is from [B3] TO [DOIB/DOPT]? We are interested in travel you took to other countries, to Hawaii, or to U.S. territories such as Puerto Rico or the U.S. Virgin Islands. [Note to interviewers: We are not interested in travel to Alaska in this question, even though it can be considered outside of the continental Unites States.]

a. YES CONTINUE TO U2

b. NO SKIP TO NEXT SECTION

c. DK SKIP TO NEXT SECTION

d. RF SKIP TO NEXT SECTION


U2. Where did you travel to? Anywhere else?

[Interviewer guidance will be provided that multiple locations (e.g. different cities) within a trip to a country/U.S. territory would only be recorded as a single location here.]

Location [1]:

Location [2]:

Location [3]:

Etc…


ASK QUESTIONS U3 – U11 FOR EACH LOCATION, IF MULTIPLE TRIPS TO THE SAME LOCATION, RECORD EACH TRIP SEPARATELY

U3. What date did your trip to [Location[N]] start?

a. MM/DD/YYYY or MM/YYYY

b. MONTH OF PREGNANCY (B3, B2, B1, P1, P2, P3, T2, T3)

c. DK

d. RF


U4. When did your trip to [Location[N]] end?

a. MM/DD/YYYY

b. MONTH OF PREGNANCY (B3, B2, B1, P1, P2, P3, T2, T3)

c. DK

d. RF

OR


U4a. How long was your trip?

a. AMOUNT:_________________ DK RF

i. Days

ii. Weeks

iii. Months


U5. Did you get sick during your trip to [Location[N]] or within 2 weeks of your return to the U.S.?

a. YES CONTINUE TO U6

b. NO SKIP TO NEXT SECTION

c. DK SKIP TO NEXT SECTION

d. RF SKIP TO NEXT SECTION


U6. Did you have any of the following symptoms with this illness:

a. Rash: YES / NO / DK / RF

b. Conjunctivitis or “pink eye”: YES / NO / DK / RF

c. Pain behind eyes: YES / NO / DK / RF

d. Joint pain: YES / NO / DK / RF

e. Body pain in your muscles or bones: YES / NO / DK / RF

f. Chills: YES / NO / DK / RF

g. Headache: YES / NO / DK / RF

h. Persistent vomiting: YES / NO / DK / RF

i. Diarrhea: YES / NO / DK / RF

j. Nasal congestion: YES / NO / DK / RF

k. Cough: YES / NO / DK / RF

l. Sore throat: YES / NO / DK / RF

m. Difficulty breathing: YES / NO / DK / RF

n. Fever: YES / NO / DK / RF

o. None of the above


U7. Did you have any other symptoms with this illness?

a. YES CONTINUE TO U7a

b. NO SKIP TO U8

c. DK SKIP TO U8

d. RF SKIP TO U8


U7a. What other symptoms did you have?

Symptom 1:_____________________________

Symptom 2:_____________________________

[allow them to report as many additional symptoms as they had]

DK

RF


U8. Did you receive a diagnosis from a doctor or other healthcare provider?

a. YES CONTINUE TO U9

b. NO SKIP TO U10

c. DK SKIP TO U10

d. RF SKIP TO U10


U9. What diagnosis did they give you?

Diagnosis:____________________________

DK

RF

U10.

Did you take any medications or remedies for this illness in the 3 months before pregnancy through the end of pregnancy?

a. YES CONTINUE TO U10a

b. NO SKIP TO NEXT SECTION

c. DK SKIP TO NEXT SECTION

d. RF SKIP TO NEXT SECTION

U10a.

Did you already tell me about the medications you took for this illness?

a. YES SKIP TO NEXT SECTION

b. NO CONTINUE TO U11

c. DK CONTINUE TO U11

d. RF CONTINUE TO U11

U11.

What did you take? Did you take anything else? [LIST ALL]

a. Medication:_______________

b. DK

c. RF

U12.

Did you use [MEDICINE] for the entire time from the 3 months before pregnancy through the end of pregnancy?

a. YES SKIP TO U16

b. NO CONTINUE TO U13

c. DK CONTINUE TO U13

d. RF CONTINUE TO U13

U13 .

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

a. MM/DD/YYYY or

b. MONTH OF PREGNANCY (B1, P1, P2, P3)

c. DK

d. RF

U14.

When did you use [MEDICINE] for the last time during this period? [CAN USE DK OR RF FOR MM OR DD OR YY]



a. MM/DD/YYYY or

b. MONTH OF PREGNANCY (B1, P1, P2, P3)

c. DK

d. RF

U15.

OR


How long did you take it?

a. AMOUNT:__________

i. Days

ii. Weeks

iii. Months

b. DK

c. RF

U16.

How often did you use [MEDICINE] during the 3 months before pregnancy through the end of pregnancy? You can say the number of times per day, per week, per month, or during the entire 4 month period.

a. AMOUNT:_____________

i. Per Day

ii. Per Week

iii. Per Month

vi. Per Time Period [Note to interviewers that this refers to B3-end of pregnancy; e.g., if the mother only took the medication once during that entire time period they would put AMOUNT=1 per time period]

b. DK

c. RF

U17.

Did you take the same dose of medicine each time you took it throughout [B3] to [DOIB/DOPT]? That is, for example, the same number of milligrams of medicine in each dose?

a. YES CONTINUE TO U18

b. NO SKIP TO U19

c. DK CONTINUE TO U18

d. RF CONTINUE TO U18

U18.

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

a. AMOUNT:____________

i. UNITS:_____________

b. DK

c. RF

U19.

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

a. AMOUNT:____________

b. RF

U20.

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

a. AMOUNT:_____________

i. UNITS:______________

b. DK

c. RF

U21.

When did you begin taking that dose?

a. MM/DD/YYYY or

b. MONTH OF PREGNANCY (B3, B2, B1, P1, P2, P3, T2, T3)

c. DK

d. RF

U22.

When did you stop taking that dose?

a. MM/DD/YYYY or

b. MONTH OF PREGNANCY (B3, B2, B1, P1, P2, P3, T2, T3)

c. DK

d. RF

U23.

OR


How long did you take it?

a. AMOUNT:__________

i. Days

ii. Weeks

iii. Months

b. DK

c. RF

Section V: MEDICATIONS/HERBALS/VITAMINS

We are interested in medicines that you may have taken from 1 month before you became pregnant, which would be [B1], to the end of the third month of pregnancy, which would be [P4 (-1)]. These would include prescription and nonprescription medicines. Please include medicines prescribed to you by a healthcare provider and medicines you used that may have been prescribed to someone else. Some of these medicines we may have already discussed, but please report on them again in response to these questions. Sometimes the same medication can be used for different reasons, which is why some questions may seem repetitive. To begin, I’m going to ask you about whether you have used certain types of medicines, and then I’ll ask about your use of specific medicines. If you filled out the medication worksheet we included in your introductory packet, it will be helpful for you to have it in front of you for these questions. To keep you from having to repeat information we’ve already discussed, I may ask you for your help in remembering whether you’ve reported using a medication to me already and for what medical condition you reported taking it for. Unfortunately we are not able to see your responses from earlier in the interview.



Medication Categories

(FOLLOW-UPS BEGIN WITH V3 on page 97)





QUESTION

RESPONSES



During [B1] to [P4(-1)] did you take…./did you get any vaccines (V154)?

IF YES, ASK FOLLOW-UP QUESTIONS

IF NO, ASK NEXT CATEGORY

IF DK, ASK NEXT CATEGORY

IF RF, ASK NEXT CATEGORY


V1.

Birth control pills (V3)

Y

N

DK

RF


V18.

Antibiotics (V20)

Y

N

DK

RF


V35.

Over-the-counter pain relievers (T37)

Y

N

DK

RF


V52.

Prescription pain relievers (V54)

Y

N

DK

RF


V69.

Medicines to help you lower your cholesterol (“statins”) (V71)

Y

N

DK

RF


V86.

Medicines to help you quit smoking (V88)

Y

N

DK

RF


V103.

Medicines to help with allergies or cold symptoms (e.g. runny nose, cough) (V105)

Y

N

DK

RF


V120.

Medicine to treat an infection with a virus, like the flu (“antiviral”) (V122)

Y

N

DK

RF


V137.

Medicine to help you sleep (“sleep aid”) (V139)

Y

N

DK

RF


V154.

Vaccines (WILL ONLY CAPTURE NAME & DATE OF VACCINES) (V156)

Y

N

DK

RF


V171.

Medicines to treat nausea or vomiting (V173)

Y

N

DK

RF




V3.

What was the name of the medication? / Did you take any other medicine in this category?

PROBE: READ LIST IF NECESSARY


NAME:_____________________

DK SKIP TO NEXT CATEGORY

RF SKIP TO NEXT CATEGORY



BIRTH CONTROL PILLS PROMPTS:

SELECT EACH YES:



Apri

Y



Aviane (21, 28)

Y



Beyaz

Y



Brevicon (21,28)

Y



Camila

Y



Cryselle 28

Y



Cyclessa

Y



Desogen

Y



Jolivette

Y



Kariva

Y



Levora

Y



Lo Loestrin Fe

Y



Lo Ovral 21

Y



LoSeasonique

Y



Low-Ogestrel (21,28)

Y



Micronor

Y



Mircette

Y



Nor-QD

Y



Nora-BE

Y



Nordette (21,28)

Y



Ogestrel 0.5/50

Y



Ortho-Cept

Y



Ortho-Cyclen

Y



Ortho-Novum 1/35 (21, 28)

Y



Ortho-Novum 7/7/7 (21, 28)

Y



Ortho Tri-Cyclen

Y



Ortho Tri-Cyclen Lo

Y



Ovcon 35 (21, 28)

Y



Ovcon 50 (21, 28)

Y



Portia 28

Y



Seasonale

Y



Seasonique

Y



Sprintec

Y



TriNessa

Y



Tri-Norinyl (21, 28)

Y



Tri-Sprintec 28

Y



Trivora

Y



Yasmin

Y



Yaz

Y



OTHER, SPECIFY:

Y

FOR EACH REPORTED DRUG ABOVE, CONTINUE WITH V4/ROW 1 THROUGH V6/ROW 3 AND SKIP TO V8/ROW 5.




V20.

What was the name of the medication? / Did you take any other medicine in this category?

PROBE: READ LIST IF NECESSARY


NAME:_____________________

DK SKIP TO NEXT CATEGORY

RF SKIP TO NEXT CATEGORY



ANTIBIOTICS PROMPTS:

SELECT EACH YES:



Amoxicillin

Y



Amoxil

Y



Augmentin

Y



Biaxin

Y



Cipro

Y



Ciprofloxacin

Y



Cleocin

Y



Doxycycline

Y



Erythromycin

Y



Flagyl

Y



Macrodantin

Y



Nitrofurantoin

Y



Penicillin

Y



Sulfamethoxazole/Trimethoprim

Y



Vancocin

Y



Vibramycin

Y



Zithromax

Y



Z-Pak

Y



OTHER, SPECIFY:

Y

FOR EACH REPORTED DRUG ABOVE, CONTINUE WITH V4/ROW 1-V24/ROW 4.




V37.

What was the name of the medication? / Did you take any other medicine in this category?

PROBE: READ LIST IF NECESSARY


NAME:_____________________

DK SKIP TO NEXT CATEGORY

RF SKIP TO NEXT CATEGORY



OVER-THE-COUNTER PAIN RELIEVERS PROMPTS:

SELECT EACH YES:



Acetaminophen

Y



Advil

Y



Aleve

Y



Aspirin

Y



Excedrin Extra Strength Caplets/Tablets/Geltabs

Y



Ibuprofen

Y



Motrin

Y



Naproxen Sodium

Y



Tylenol

Y



OTHER, SPECIFY:

Y

FOR EACH REPORTED DRUG ABOVE, CONTINUE WITH V4/ROW 1-V24/ROW 4.










V54.

What was the name of the medication? / Did you take any other medicine in this category?

PROBE: READ LIST IF NECESSARY


NAME:_____________________

DK SKIP TO NEXT CATEGORY

RF SKIP TO NEXT CATEGORY



PRESCRIPTION PAIN RELIEVERS

SELECT EACH YES:



Celebrex

Y



Hydrocodone Bitartrate/ APAP

Y



Lorcet

Y



Lortab

Y



Neurontin

Y



Oxycodone/Acetaminophen

Y



Oxycontin

Y



Percocet

Y



Roxicet

Y



Tramadol

Y



Tramadol HCL/ Acetaminophen

Y



Tylenol #1,#2,#3,#4

Y



Ultram

Y



Vicodin

Y



OTHER, SPECIFY:

Y

FOR EACH REPORTED DRUG ABOVE, CONTINUE WITH V4/ROW 1-V24/ROW 4.




V71.

What was the name of the medication? / Did you take any other medicine in this category?

PROBE: READ LIST IF NECESSARY


NAME:_____________________

DK SKIP TO NEXT CATEGORY

RF SKIP TO NEXT CATEGORY



MEDICINES TO HELP LOWER YOUR CHOLESTEROL (“STATINS”)

SELECT EACH YES:



Altoprev

Y



Atorvastatin

Y



Crestor

Y



Fluvastatin

Y



Lescol

Y



Lipitor

Y



Livalo

Y



Lovastatin

Y



Mevacor

Y



Pitavastatin

Y



Pravachol

Y



Pravastatin Sodium

Y



Rosuvastatin Calcium

Y



Simvastatin

Y



Zocor

Y



OTHER, SPECIFY:

Y

FOR EACH REPORTED DRUG ABOVE, CONTINUE WITH V4/ROW 1 THROUGH V6/ROW 3 AND SKIP TO V8/ROW 5.




V88.

What was the name of the medication? / Did you take any other medicine in this category?

PROBE: READ LIST IF NECESSARY


NAME:_____________________

DK SKIP TO NEXT CATEGORY

RF SKIP TO NEXT CATEGORY



MEDICINES TO HELP YOU QUIT SMOKING

SELECT EACH YES:



Budeprion SR

Y



Bupropion HCL

Y



Chantix

Y



Clonidine

Y



Nicoderm CQ

Y



Nicorette Gum

Y



Nicotine Gum

Y



Nicotine Inhaler

Y



Nicotrol Inhaler

Y



Nortriptyline

Y



Pamelor

Y



Varenicline Tartrate

Y



Wellbutrin

Y



Wellbutrin XL

Y



Zyban

Y



OTHER, SPECIFY:

Y

FOR EACH REPORTED DRUG ABOVE, CONTINUE WITH V4/ROW 1 THROUGH V6/ROW 3 AND SKIP TO V8/ROW 5.












V105.

What was the name of the medication? / Did you take any other medicine in this category?

PROBE: READ LIST IF NECESSARY


NAME:_____________________

DK SKIP TO NEXT CATEGORY

RF SKIP TO NEXT CATEGORY



MEDICINES TO HELP WITH ALLERGIES OR COLD SYMPTOMS (E.G. RUNNY NOSE, COUGH)

SELECT EACH YES:



Afrin 12 Hour Nasal Spray

Y



Allegra

Y



Allegra D

Y



Benadryl

Y



Clarinex

Y



Clarinex D

Y



Claritin

Y



Claritin D

Y



Delsym 12 Hour Cough Relief

Y



Mucinex

Y



Mucinex Dm

Y



Phenylephrine

Y



Pseudoephedrine

Y



Sudafed PE  Nasal Decongestant

Y



Sudafed  Nasal Decongestant

Y



Zyrtec

Y



Zyrtec D

Y



OTHER, SPECIFY:

Y

FOR EACH REPORTED DRUG ABOVE, CONTINUE WITH V4/ROW 1-V24/ROW 4.




V122.

What was the name of the medication? / Did you take any other medicine in this category?


NAME:_____________________

DK SKIP TO NEXT CATEGORY

RF SKIP TO NEXT CATEGORY



MEDICINE TO TREAT AN INFECTION WITH A VIRUS, LIKE THE FLU (“ANTIVIRAL”)

SELECT EACH YES:



Acyclovir

Y



Amantadine

Y



Combivir

Y



Oseltamivir Phosphate

Y



Relenza

Y



Tamiflu

Y



Zanamivir

Y



OTHER, SPECIFY:

Y

FOR EACH REPORTED DRUG ABOVE, CONTINUE WITH V4/ROW 1-V24/ROW 4.


V139.

What was the name of the medication? / Did you take any other medicine in this category?

PROBE: READ LIST IF NECESSARY


NAME:_____________________

DK SKIP TO NEXT CATEGORY

RF SKIP TO NEXT CATEGORY



MEDICINE TO HELP YOU SLEEP (“SLEEP AID”)

SELECT EACH YES:



Ambien

Y



Benadryl

Y



Compoz

Y



Diphenhydramine

Y



Doxylamine

Y



Eszopiclone

Y



Kava-Kava, Herb

Y



L-Tryptophan

Y



Lunesta

Y



Melatonin

Y



Nytol

Y



Prosom

Y



Ramelteon

Y



Restoril

Y



Rozerem

Y



Sleepinal

Y



Sominex

Y



Sonata

Y



Tryptophan

Y



Valerian Extract

Y



Zaleplon

Y



Zolpidem Tartrate

Y



Zzzquil Liquicaps Sleep-Aid

Y



Zzzquil Liquid Sleep-Aid

Y



OTHER, SPECIFY:

Y

FOR EACH REPORTED DRUG ABOVE, CONTINUE WITH V4/ROW 1 THROUGH V6/ROW 3 AND SKIP TO V8/ROW 5.












V156.

Which vaccines did you get?

PROBE: READ LIST IF NECESSARY


NAME:_____________________

DK SKIP TO NEXT CATEGORY

RF SKIP TO NEXT CATEGORY



VACCINES

SELECT EACH YES:



Chickenpox Vaccine-

Y



Flu Vaccine

Y



Hepatitis A Vaccine

Y



Hepatitis B Vaccine

Y



HPV Vaccine (Human Papillomavirus)

Y



Measles, Mumps, Rubella Vaccine

Y



Meningococcal Vaccine

Y



Pneumococcal Vaccine, Polyvalent

Y



Shingles Vaccine-

Y



OTHER, SPECIFY_______________________

Y


V157.

When did you get the [NAME OF VACCINE]?

a. MM/DD/YYYY or

b. MONTH OF PREGNANCY(B1, P1, P2, P3) or

c. HOW LONG AGO (with units for days, weeks, months, years)

d. DK

e. RF

SKIP TO CONTINUE TO V171, NEXT CATEGORY.




V173.

What was the name of the medication? / Did you take any other medicine in this category?

PROBE: READ LIST IF NECESSARY


NAME:_____________________

DK SKIP TO SPECIFIC MEDICINES

RF SKIP TO SPECIFIC MEDICINES



MEDICINES TO TREAT NAUSEA OR VOMITING

SELECT EACH YES:



Benadryl

Y



Bonine

Y



Diphenhydramine

Y



Doxylamine

Y



Ginger

Y



Metoclopramide

Y



Ondansetron

Y



Phenergan

Y



Preggie Pops (Various Flavors)

Y



Promethazine

Y



Reglan

Y



Tigan

Y



Unisom Tablets

Y



Vitamin B6

Y



Zofran

Y



OTHER, SPECIFY

Y

FOR EACH REPORTED DRUG ABOVE, CONTINUE WITH V4/ROW 1-V24/ROW 4.



ASK THIS SERIES FOR EACH MEDICINE USED IN V1 THROUGH V137 AND V171. NOT ASKED OF VACCINES.

Row

Quex #

Question Text

Responses

1

V4 V21 V38 V55 V72 V89 V106 V123 V140 V174

Did you already tell me about taking [MEDICATION] earlier in the interview?

a. YES CONTINUE TO V5/ROW2

b. NO CONTINUE TO V24/ROW 4 or SKIP TO V8/ROW 5

c. DK CONTINUE TO V24/ROW 4 or SKIP TO V8/ROW 5

d. RF CONTINUE TO V24/ROW 4 or SKIP TO V8/ROW 5

2

V5 V22 V39 V56 V73 V90 V107 V124 V141 V175

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

  1. CONDITION______________________

  2. DK

  3. RF


3

V6 V23 V40 V57 V74 V91 V108 V125 V176

Did you take this medication for any other reasons that we have not already talked about?

a.. YES CONTINUE TO V24/ROW 4 OR SKIP TO V8/ROW 5

b.. NO/DK/RF CONTINUE TO NEXT MEDICATION CATEGORY OR SKIP TO SPECIFIC MEDICATIONS INTRO


FOR ALL MEDICATION CATEGORIES, EXCEPT BIRTH CONTROL PILLS, STATINS, SMOKING CESSATION MEDICATIONS, SLEEP AIDS, AND VACCINES ASK V24/ROW 4; FOR THE AFOREMENTIONED CATEGORIES, SKIP TO V8/ROW 5.


4

V24 V41 V58 V109 V126 V177

Why did you take [this medication]?

a. REASON:__________

b. DK

c. RF


5

V8 V25 V42 V59 V76 V93 V110 V127 V144 V178

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

a. YES SKIP TO V12/ROW 9

b. NO CONTINUE TO V9/ROW 6

c. DK CONTINUE TO V9/ROW 6

d. RF CONTINUE TO V9/ROW 6


6

V9 V26 V43 V60 V77 V94 V111 V128 V145 V179

When did you start using [this medication] during the month before your pregnancy through the third month of pregnancy?

a. MM/DD/YYYY or

b. MONTH OF PREGNANCY(B1, P1, P2, P3)

c. DK

d. RF


7

V10 V27 V44 V61 V78 V95 V112 V129 V146 V180

When did you use [this medication] for the last time during this time period?

a. MM/DD/YYYY or

b. MONTH OF PREGNANCY(B1, P1, P2, P3) IF VALID STOP AND START DATE, SKIP V11/ROW 8

c. DK

d. RF

8

V11 V28 V45 V62 V79 V96 V113 V130 V147 V181

Or how long did you take [this medication]?

AMOUNT_______

Days Weeks Months

DK RF

9

V12 V29 V46 V63 V80 V97 V114 V131 V148 V182

How often did you use [this medication] during the month before your pregnancy through the end of your third month of pregnancy? You can say the number of times per day, per week, per month, or during the entire 4 month period.

AMOUNT:__________

Per day/Per week/Per month/Per time period

DK RF

10

V13 V30 V47 V64 V81 V98 V115 V132 V149 V183

Did you take the same dose of medicine, each time that you took it, for the whole time that you took it during the month before your pregnancy through the end of your third month of pregnancy? That is, for example, the same number of milligrams of medicine in each dose.

a. YES CONTINUE TO V14/ROW 11

b. NO SKIP TO T15a/ROW 12

c. DK CONTINUE TO T14/ROW 11

d. RF CONTINUE TO T14/ROW 11

11

V14 V31 V48 V65 V82 V99 V116 V133 V150 V184

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

AMOUNT:______ DK, RF SKIP UNITS

UNITS:_________ DK


SKIP TO V18/NEXT CATEGORY

12

V15a

V32a V49a V66a V83a V100a V117a V134a V151a V185a

How many different dosage amounts do you remember taking? [IF MOM KNOWS SHE TOOK MORE THAN ONE DOSAGE, BUT CAN'T REMEMBER HOW MANY, SELECT 1 FOR THE NUMBER OF DOSAGES AND REPORT THE DOSAGE INFO SHE DOES REMEMBER. YOU MAY PUT ADDITIONAL DETAILS IN A COMMENT FIELD.]

AMOUNT_______ RF

13

V15b V32b V49b V66b

V83b V100b V117b V134b V151b V185b

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

AMOUNT:______ DK, RF SKIP UNITS

UNITS:_________ DK


14

V16 V33 V50 V67 V84 V101 V118 V135 V152 V186

When did you begin taking that dose?

a. MM/DD/YYYY or

b. MONTH OF PREGNANCY(B1, P1, P2, P3)

c. DK

d. RF

15

V17 V34 V51 V68 V85 V102 V119 V136 V153 V187

When did you stop taking that dose?

a. MM/DD/YYYY or

b. MONTH OF PREGNANCY(B1, P1, P2, P3) IF VALID STOP AND START DATE, SKIP V17a/ROW 16

c. DK

d. RF

16

V17a V34a V51a V68a V85a V102a V119a V136a V153a V187a

Or how long did you take it?

AMOUNT_______

Days Weeks Months

DK RF

AFTER V17, CONTINUE TO V18 AT BEGINNING OF TABLE, OR NEXT CATEGORY.

CYCLE BACK UP TO NEXT MEDICATION CATEGORY ON THE LIST AND CONTINUE WITH QUESTIONS UNTIL YOU HAVE ASKED ABOUT EACH MEDICATION CATEGORY THROUGH THOSE FOR NAUSEA AND VOMITING.

SPECIFIC MEDICATIONS:

Now I’m going to ask you about your use of specific medications. As I read the list, please tell me Yes or No for each medicine. We may have already discussed some of these medicines, but please report on them again in response to these questions.



During [B1] to [P4(-1)] did you take:

IF YES, ASK NEXT QUESTION IN ROW 17

IF NO, ASK NEXT DRUG

IF DK, ASK NEXT DRUG

IF RF, ASK NEXT DRUG


V188.

Prozac

Y

N

DK

RF


V203.

Wellbutrin

Y

N

DK

RF


V218.

Paxil

Y

N

DK

RF


V233.

Zoloft

Y

N

DK

RF


V248.

Effexor

Y

N

DK

RF


V263.

Celexa

Y

N

DK

RF


V278.

Lexapro

Y

N

DK

RF


V293.

Cymbalta

Y

N

DK

RF


V308.

Abilify

Y

N

DK

RF


V323.

Seroquel

Y

N

DK

RF


V338.

Zyprexa

Y

N

DK

RF


V353.

Depakene, Depakote, or Valproic acid

Y

N

DK

RF


V368.

Dilantin or Phenytoin

Y

N

DK

RF


V383.

Felbatol

Y

N

DK

RF


V398.

Klonopin or Clonazepam

Y

N

DK

RF


V413.

Lamictal

Y

N

DK

RF


V428.

Phenobarbital

Y

N

DK

RF


V443.

Topiramate or Topamax

Y

N

DK

RF


V458.

Furadantin

Y

N

DK

RF


V473.

Macrodantin

Y

N

DK

RF


V488.

Qsymia

Y

N

DK

RF


V503.

Thalidomide

Y

N

DK

RF


V518.

Accutane/isotretinoin

Y

N

DK

RF


V533.

CellCept

Y

N

DK

RF


V548.

Myfortic

Y

N

DK

RF


V563.

Cytotec

Y

N

DK

RF


V578.

Misoprostol

Y

N

DK

RF


V593.

Methotrexate

Y

N


SKIP TO V608

DK


SKIP TO V608

RF


SKIP TO V608


ASK THIS SERIES FOR EACH MEDICATION TAKEN IN V188-V593:

ROW

Quex #

Question Text

Responses

17

V189 V204 V219 V234 V249 V264 V279 V309 V324 V339 V354 V369 V384 V399 V414 V429 V444 V459 V474 V489 V504 V519 V534 V549 V564 V579 V594

Did you already tell me about taking [MEDICATION] earlier in the interview?

a. YES CONTINUE TO V190/ROW 18

b. NO SKIP TO V192/ROW 20

c. DK SKIP TO V192/ROW 20

d. RF SKIP TO V192/ROW 20

18

V190 V205 V220 V235 V250 V265 V280 V295 V310 V325 V340 V355 V370 V385 V400 V415 V430 V445 V460 V475 V490 V505 V520 V535 V550 V565 V580 V595

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

  1. CONDITION_____________

  2. DK

  3. RF

19

V191 V206 V221 V236 V251 V266 V281 V296 V311 V326 V341 V356 V371 V386 V401 V416 V431 V446 V461 V476 V491 V506 V521 V536 V551 V566 V581 V596

Did you take this medication for any other reasons that we have not already talked about?

a. YES CONTINUE TO V192/ROW 20

b. NO SKIP TO V203/NEXT MEDICINE

c. DK SKIP TO V203/NEXT MEDICINE

d. RF SKIP TO V203/NEXT MEDICINE

20

V192 V207 V222 V237 V252 V267 V282 V297 V312 V327 V342 V357 V372 V387 V402 V417 V432 V447 V462 V477 V492 V507 V522 V537 V552 V567 V582 V597

Why did you take [MEDICINE]?

a. REASON:__________

b. DK

c. RF

21

V193 V208 V223 V238 V253 V268 V283 V298 V313 V328 V343 V358 V373 V388 V403 V418 V433 V448 V463 V478 V493 V508 V523 V538 V553 V568 V583 V598

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

a. YES SKIP TO V197/ROW 25

b. NO CONTINUE TO V194/ROW 22

c. DK CONTINUE TO V194/ROW 22

d. RF CONTINUE TO V194/ROW 22

22

V194 V209 V224 V239 V254 V269 V284 V299 V314 V329 V344 V359 V374 V389 V404 V419 V434 V449 V464 V479 V494 V509 V524 V539 V554 V569 V584 V599

When did you start using [MEDICINE] during the month before your pregnancy through the third month of pregnancy?

a. MM/DD/YYYY or

b. MONTH OF PREGNANCY(B1, P1, P2, P3)

c. DK

d. RF

23

V195 V210 V225 V240 V255 V270 V285 V300 V315 V330 V345 V360 V375 V390 V405 V420 V435 V450 V465 V480 V495 V510 V525 V540 V555 V570 V585 V600

When did you use [MEDICINE] for the last time during this time period?

a. MM/DD/YYYY or

b. MONTH OF PREGNANCY(B1, P1, P2, P3) IF VALID STOP AND START DATE, SKIP V196/ROW 24

c. DK

d. RF

24

V196 V211 V226 V241 V256 V271 V286 V301 V316 V331 V346 V361 V376 V391 V406 V421 V436 V451 V466 V481 V496 V511 V526 V541 V556 V571 V586 V601

Or how long did you take [MEDICINE]?

AMOUNT_______

Days Weeks Months

DK RF

25

V197 V212 V227 V242 V257 V272 V287 V302 V317 V332 V347 V362 V377 V392 V407 V422 V437 V452 V467 V482 V497 V512 V527 V542 V557 V572 V587 V602

How often did you use [MEDICINE] during the month before your pregnancy through the end of your third month of pregnancy? You can say the number of times per day, per week, per month, or during the entire 4 month period.

AMOUNT:__________

Per day/Per week/Per month/Per time period

DK RF

26

V198 V213 V228 V243 V258 V273 V288 V303 V318 V333 V348 V363 V378 V393 V408 V423 V438 V453 V468 V483 V498 V513 V528 V543 V558 V573 V588 V603

Did you take the same dose of medicine, each time you took it, for the whole time that you took it during the month before your pregnancy through the end of your third month of pregnancy? That is, for example, the same number of milligrams of medicine in each dose.

a. YES CONTINUE TO V199/ROW 27

b. NO SKIP TO V200a/ROW 28

c. DK CONTINUE TO V199/ROW 27

d. RF CONTINUE TO V199/ROW 27

27

V199 V214 V229 V244 V259 V274 V289 V304 V319 V334 V349 V364 V379 V394 V409 V424 V439 V454 V469 V484 V499 V514 V529 V544 T559 V574 V589 V604.

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


AMOUNT:______ DK, RF

UNITS:_________ DK RF SKIP TO T203

28

V200a V215a V230a V245a V260a V275a V290a V305a V320a V335a V350a V365a V380a V395a V410a V425a V440a V455a V470a V485a V500a V515a V530a V545a V560a V575a V590a V605a

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

AMOUNT_______ RF

29

V200b V215b V230b V245b V260b V275b V290b V305b V320b V335b V350b V365b V380b V395b V410b V425b V440b V455b V470b V485b V500b V515b V530b V545b V560b V575b V590b V605b

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

AMOUNT:______ DK, RF SKIP UNITS

UNITS:_________ DK


30

V201 V216 V231 V246 V261 V276 V291 V306 V321 V336 V351 V366 V381 V396 V411 V426 V441 V456 V471 V486 V501 V516 V531 V546 V561 V576 V591 V606

When did you begin taking that dose?

a. MM/DD/YYYY or

b. MONTH OF PREGNANCY(B1, P1, P2, P3)

c. DK

d. RF

31

V202 V217 V232 V247 V262 V277 V292 V307 V322 V337 V352 V367 V382 V397 V412 V427 V442 V457 V472 V487 V502 V517 V532 V547 V562 V577 V592 V607

When did you stop taking that dose?

a. MM/DD/YYYY or

b. MONTH OF PREGNANCY(B1, P1, P2, P3) IF VALID STOP AND START DATE, SKIP V202a/ROW 32

c. DK

d. RF

32

V202a V217a V232a V247a V262a V277a V292a V307a V322a V337a V352a V367a V382a V397a V412a V427a V442a V457a V472a V487a V502a V517a V532a V547a V562a V577a V592a V607a

Or how long did you take it?

AMOUNT_______

Days Weeks Months

DK RF



HERBALS:


V608.

From the month before you became pregnant to the end of your third month of pregnancy, did you use any herbs or folk medicines to treat any medical conditions, to keep you healthy, or to lose weight? Please do not include herbal teas.

a. YES CONTINUE TO V609

b. NO SKIP TO V615

c. DK SKIP TO V615

d. RF SKIP TO V615


V609.

Between [START DATE OF B1] to [P4(-1)END DATE OF P3] what herbs or folk medicines did you take? / Anything else?

HERBALS_____________

DK SKIP TO V615

RF SKIP TO V615

ASK THIS SERIES FOR EACH HERBAL PRODUCT USED:


V610.

Did you use [Name of herb/medicine] for the entire time from the month before your pregnancy through your third month of pregnancy?

  1. YES SKIP TO V614

  2. NO CONTINUE TO V611

  3. DK CONTINUE TO V611

  4. RF CONTINUE TO V611


V611.

When did you start using [Name of herb/medicine] during the month before your pregnancy through the third month of pregnancy?

a. MM/DD/YYYY or

b. MONTH OF PREGNANCY(B1, P1, P2, P3)

c. DK

d. RF


V612.

When did you use [Name of herb/medicine] for the last time during this time period?

a. MM/DD/YYYY or

b. MONTH OF PREGNANCY(B1, P1, P2, P3) IF VALID STOP AND START DATE, SKIP V613

c. DK

d. RF


V613.

Or how long did you take [Name of herb/medicine]?

AMOUNT_______

Days Weeks Months

DK RF


V614.

How often did you use [Name of herb/medicine] during the month before your pregnancy through the end of your third month of pregnancy? You can say the number of times per day, per week, per month, or during the entire 4 month period.

AMOUNT:__________

Per day/Per week/Per month/Per time period

DK RF



VITAMINS:

Now I’m going to ask you about your vitamin use before and during your pregnancy.


V615.

From the month before you became pregnant to the end of the third month of pregnancy, which would be [B1] to [P4(-1)], did you take any multivitamins, prenatal vitamins, or folic acid supplements?

  1. YES CONTINUE TO V616

  2. NO SKIP TO V620

  3. DK SKIP TO V620

  4. RF SKIP TO V620


V616.

Did you begin using it before your pregnancy began?

  1. YES CONTINUE TO V617

  2. NO SKIP TO V618

  3. DK SKIP TO V618

  4. RF SKIP TO V618


V617.

Did you continue to use it after your pregnancy began?

  1. YES SKIP TO V620

  2. NO SKIP TO V620

  3. DK SKIP TO V620

  4. RF SKIP TO V620


V618.

Did you begin using it in the first month of pregnancy?

  1. YES SKIP TO V620

  2. NO CONTINUE TO V619

  3. DK SKIP TO V620

  4. RF SKIP TO V620


V619.

Did you begin using it after the first month of pregnancy?

  1. YES

  2. NO

  3. DK

  4. RF




Catch-All Medication Question


V620.

During this time period, did you take any medications, remedies, or treatments that we haven’t already talked about?/Any others?

  1. YES CONTINUE TO V621

  2. NO SKIP TO NEXT SECTION

  3. DK SKIP TO NEXT SECTION

  4. RF SKIP TO NEXT SECTION


V621.

What medicine did you take?



SPECIFY______________

DK SKIP TO NEXT SECTION

RF SKIP TO NEXT SECTION


V622.

Why did you take [ANSWER T621]?

a. REASON:__________

b. DK

c. RF


V623.

Did you use [MEDICINE, ANSWER 621] for the entire time from the month before your pregnancy through your third month of pregnancy?

  1. YES SKIP TO V627

  2. NO CONTINUE TO V624

  3. DK CONTINUE TO V624

  4. RF CONTINUE TO V624


V624.

When did you start using [MEDICINE, ANSWER 621] during the month before your pregnancy through the third month of pregnancy?

a. MM/DD/YYYY or

b. MONTH OF PREGNANCY(B1, P1, P2, P3)

c. DK

d. RF


V625.

When did you use [MEDICINE, ANSWER 621] for the last time during this time period?

a. MM/DD/YYYY or

b. MONTH OF PREGNANCY(B1, P1, P2, P3) IF VALID STOP AND START DATE, SKIP V626

c. DK

d. RF


V626.

Or how long did you take [MEDICINE, ANSWER T621]?

AMOUNT_______

Days Weeks Months

DK RF


V627.

How often did you use [MEDICINE, ANSWER T621during the month before your pregnancy through the end of your third month of pregnancy? You can say the number of times per day, per week, per month, or during the entire 4 month period.

AMOUNT:__________

Per day/Per week/Per month/Per time period

DK RF


V628.

Did you take the same dose of [MEDICINE, ANSWER T621] each time you took it throughout [B1] to [P4(-1)]?

  1. YES CONTINUE TO V629

  2. NO SKIP TO V630a

  3. DK CONTINUE TO V629

  4. RF CONTINUE TO V629


V629.

What dose of [MEDICINE, ANSWER T621] did you take each time you took it?

AMOUNT:______ DK, RF SKIP UNITS

UNITS:_________ DK RF


SKIP TO NEXT SECTION


V630a.

How many different dosage amounts do you remember taking?

AMOUNT_______ RF


V630b.

What dose of [MEDICINE, ANSWER T621] did you take the [1st, 2nd, etc.] time?

AMOUNT:______ DK, RF SKIP UNITS

UNITS:_________ DK RF



V631.

When did you begin taking that dose?

a. MM/DD/YYYY or

b. MONTH OF PREGNANCY(B1, P1, P2, P3)

c. DK

d. RF


V632.

When did you stop taking that dose?

a. MM/DD/YYYY or

b. MONTH OF PREGNANCY(B1, P1, P2, P3) IF VALID STOP AND START DATE, SKIP V632b

c. DK

d. RF


V632b.

OR how long did you take it?

AMOUNT_______

Days Weeks Months

DK RF







Section W: STRESS



The next series of questions will be about events that may have occurred in your life from the 3 months before you became pregnant through your 3rd month of pregnancy, which would be [START DATE OF B3] through [P4(-1)]. These questions will be a little bit different from some of the other questions we have asked because we are asking now about the three months before you became pregnant, as well as the first three months of your pregnancy. Most people experience periods of stress in their lives, caused by major events and daily life. We will be asking whether or not an event happened during that time period, but we will not be asking for further details.

W1. From 3 months before you became pregnant through your 3rd month of pregnancy, did you experience any serious relationship difficulties with your husband or partner or become separated or divorced?

    1. YES

    2. NO

    3. DK

    4. RF

W2. During this same time period, did you or your husband or partner have any serious legal or financial problems?

    1. YES

    2. NO

    3. DK

    4. RF

W3. During this same time period, were you or someone close to you a victim of abuse, violence, or crime? Remember you just have to indicate yes or no. [MOTHER MUST USE HER OWN JUDGEMENT ON WHAT SHE THINKS IS MEANT BY “SOMEONE CLOSE TO YOU”]

    1. YES

    2. NO

    3. DK

    4. RF

W4. During this same time period, did you or someone close to you have a serious illness or injury? [MOTHER MUST USE HER OWN JUDGEMENT ON WHAT SHE THINKS IS MEANT BY “SOMEONE CLOSE TO YOU”]

    1. YES

    2. NO

    3. DK

    4. RF

W5. During this same time period, did someone close to you die? [MOTHER MUST USE HER OWN JUDGEMENT ON WHAT SHE THINKS IS MEANT BY “SOMEONE CLOSE TO YOU”]

    1. YES

    2. NO

    3. DK

    4. RF

W6. During this same time period, could you count on anyone to provide you with emotional support such as talking over a problem or helping with a difficult decision, if you had needed it?

    1. YES

    2. NO

    3. DK

    4. RF

W7. During this same time period, could you count on anyone to provide you with help financially such as paying bills or providing food or clothes, if you had needed it?

    1. YES

    2. NO

    3. DK

    4. RF

W8. During this same time period, could you count on anyone to provide you with help with daily tasks such as grocery shopping, child care, or cooking, if you had needed it?

    1. YES

    2. NO

    3. DK

    4. RF

W9. During this same time period, how often did you feel nervous and stressed? Would you say…[READ CHOICES]

    1. Never

    2. Almost never

    3. Sometimes

    4. Somewhat often

    5. Very often

    6. DK

    7. RF

Section X: PHYSICAL ACTIVITY



I am going to ask you about the time you spent being physically active in the three months before you became pregnant. Please answer each question even if you do not consider yourself to be an active person. Think about the activities you do at work, as part of your house and yard work, to get from place to place, and in your spare time for recreation, exercise, or sport.

Now think about all the vigorous activities which take hard physical effort that you did in the three months before you became pregnant. Vigorous activities make you breathe much harder than normal and may include heavy lifting, digging, aerobics, running, or fast bicycling. Think only about those physical activities you did for at least 10 minutes at a time.

X1. During the three months before you became pregnant, in a typical week on how many days did you do vigorous physical activities? [PROBE: Think only about those physical activities that you did for at least 10 minutes at a time.] (P1)

    1. Days Per Week: ______

IF 0 SKIP TO INTRODUCTION TO X3

IF 1 – 7 CONTINUE TO X2

    1. DK SKIP TO INTRODUCTION TO X3

    2. RF SKIP TO INTRODUCTION TO X3

X2. How much time did you usually spend doing vigorous physical activities on one of those days? [PROBE: Think only about those physical activities that you do for at least 10 minutes at a time. (P2)] [REMINDER: IF THEY ANSWER LESS THAN 10 MINUTES, REMIND THEM WE ARE ONLY INTERESTED IN ACTIVITIES DONE AT LEAST 10 MINUTES AT A TIME.]

    1. Hours Per Day:__________ SKIP TO INTRODUCTION TO X3

    2. Minutes Per Day:__________ SKIP TO INTRODUCTION TO X3 [REMINDER: IF THEY ANSWER LESS THAN 10 MINUTES, REMIND THEM THAT WE ARE ONLY INTERESTED IN ACTIVITIES DONE AT LEAST 10 MINUTES AT A TIME.]

    3. DK CONTINUE TO X2b

    4. RF CONTINUE TO X2b

X2b. In the three months before you became pregnant, how much time in total would you spend in a typical week doing vigorous physical activities? [PROBE: Think only about those physical activities that you do for at least 10 minutes at a time.]

  1. Hours:__________

  2. Minutes:_________

  3. DK

  4. RF

Now think about activities which take moderate physical effort that you did in the three months before you became pregnant. Moderate physical activities make you breathe somewhat harder than normal and may include child care while standing, carrying light loads at home or work, scrubbing or mopping floors, or bicycling at a regular pace. Do not include walking. Again, think only about those physical activities that you do for at least 10 minutes at a time.

X3. During the three months before you became pregnant, in a typical week on how many days did you do moderate physical activities? [PROBE: Think only about those physical activities that you do for at least 10 minutes at a time (P3). Child care includes dressing, bathing, grooming, feeding, or occasional lifting.]

  1. Days Per Week:__________

      1. IF 0 SKIP TO INTRODUCTION TO X5

      2. IF 1 – 7 CONTINUE TO X4

  1. DK SKIP TO INTRODUCTION TO X5

  2. RF SKIP TO INTRODUCTION TO X5

X4. How much time did you usually spend doing moderate physical activities on one of those days? [PROBE: Think only about those physical activities that you do for at least 10 minutes at a time. (P4)] [REMINDER: IF THEY ANSWER LESS THAN 10 MINUTES, REMIND THEM WE ARE ONLY INTERESTED IN ACTIVITIES DONE AT LEAST 10 MINUTES AT A TIME.]

  1. Hours Per Day:__________ SKIP TO INTRODUCTION TO X5

  2. Minutes Per Day:__________ SKIP TO INTRODUCTION TO X5 [REMINDER: IF THEY ANSWER LESS THAN 10 MINUTES, REMIND THEM THAT WE ARE ONLY INTERESTED IN ACTIVITIES DONE AT LEAST 10 MINUTES AT A TIME.]

  3. DK CONTINUE TO X4b

  4. RF CONTINUE TO X4b

X4b. In the three months before you became pregnant, what is the total amount of time you spent in a typical week doing moderate physical activities? PROBE: Think only about those physical activities that you do for at least 10 minutes at a time.

  1. HOURS:__________

  2. MINUTES:__________

  3. DK

  4. RF

Now think about the time you spent walking in the three months before you became pregnant. This includes at work and at home, walking to travel from place to place, and any other walking that you might do solely for recreation, sport, exercise, or leisure.

X5. During the three months before you became pregnant, in a typical week on how many days did you walk for at least 10 minutes at a time? [PROBE: Think only about the walking that you do for at least 10 minutes at a time. (P5)]

  1. Days Per Week:____________

  1. IF 0 SKIP TO INTRODUCTION TO X7

  2. IF 1 – 7 CONTINUE TO X6

  1. DK or RF SKIP TO INTRODUCTION TO X7

X6. How much time did you usually spend walking on one of those days? (P6) [REMINDER: IF THEY ANSWER LESS THAN 10 MINUTES, REMIND THEM WE ARE ONLY INTERESTED IN ACTIVITIES DONE AT LEAST 10 MINUTES AT A TIME.]

  1. Hours Per Day:__________ SKIP TO INTRODUCTION TO X7

  2. Minutes Per Day:__________ SKIP TO INTRODUCTION TO X7 [REMINDER: IF THEY ANSWER LESS THAN 10 MINUTES, REMIND THEM WE ARE ONLY INTERESTED IN ACTIVITIES DONE AT LEAST 10 MINUTES AT A TIME.]

  3. DK or RF CONTINUE TO X6b

X6b. In the three months before you became pregnant, what is the total amount of time you spent walking in a typical week?

  1. Hours:__________

  2. Minutes:__________

  3. DK

  4. RF

Now think about the time you spent sitting on week days in the three months before you became pregnant. Include time spent at work, at home, while doing course work, and during leisure time. This may include time sitting at a desk, visiting friends, reading or sitting or lying down to watch television.

X7. In the three months before you became pregnant, in a typical week, how much time did you usually spend sitting on a week day? [PROBE: Include time spent lying down (awake) as well as sitting. (P7)]

  1. Hours Per Day:__________ SKIP TO NEXT SECTION

  2. Minutes Per Day:__________ SKIP TO NEXT SECTION

  3. DK RF CONTINUE TO X7b

X7b. What is the total amount of time you spent sitting on a typical Wednesday? PROBE: [Include time spent lying down (awake) as well as sitting.]

  1. Hours:__________

  2. Minutes:__________

  3. DK

  4. RF

Section Y: OBESITY

Now I have some questions about weight changes before [your pregnancy with [NOIB]; TAB: your pregnancy that ended on [DOIB/DOPT]]. {IF MOM’S RESPONSE SEEMS ILLOGICAL, VERIFY HER RESPONSE.) (IF MOM DOESN'T KNOW HEIGHT: Sometimes your height is on your driver's license or your identification card. Do you need a moment to check one of these for your height?) (IF MORE COMFORTABLE WITH METRIC: Do you know your height in centimeters?)

Y1. What is your height without shoes?



    1. Feet:__________

    2. Inches:__________ OR

    3. Centimeters:__________

    4. DK

    5. RF



Y2. How much did you weigh before [your pregnancy with [NOIB]; TAB: your pregnancy]?

  1. WEIGHT:__________

      1. Pounds

      2. Kilograms

  1. DK

  2. RF



Y3. Not including pregnancy, when you gain weight, where on your body do you mostly add the weight? [READ OPTIONS A-D]:



  1. Waist and/or upper body?

  2. Hips, bottom and/or upper thighs?

  3. Evenly over your body?

  4. Don’t gain weight?

  5. DK

  6. RF

Y4. Which describes the underlying shape of your body, regardless of weight gain or loss?

[READ OPTIONS A-C]:



  1. You carry most of your weight around your waist and/or upper body (apple shaped)?

  2. You carry most of your weight around your hips, bottom, or upper thighs (pear shaped)?

  3. You carry most of your weight evenly over your body?

  4. DK

  5. RF



Y5. What is the most you have ever weighed outside of pregnancy?



  1. WEIGHT:__________

  1. POUNDS

  2. KILOGRAMS

  1. DK

  2. RF



Y6. What was your age when you were that weight?



  1. AGE:__________

  2. DK

  3. RF


Y7. What is the least you have weighed outside of pregnancy in the last 5 years?



  1. WEIGHT:__________

  1. POUNDS

  2. KILOGRAMS

  1. DK

  2. RF



Y8. What was your age when you were that weight?



  1. AGE:__________

  2. DK

  3. RF

Y9. In the year before [your pregnancy with [NOIB]; TAB: your pregnancy], did your weight change by more than 20 pounds/9 kilograms?



  1. YES CONTINUE TO Y10

  2. NO SKIP TO Y12

  3. DK SKIP TO Y12

  4. RF SKIP TO Y12



Y10. How much did your weight change? [NOTE: REFERENCE WEIGHT = THEIR WEIGHT AT THE START OF THEIR PREGNANCY]



  1. AMOUNT:__________ DK RF

  1. POUNDS

  2. KILOGRAM



Y11. Was this change related to a pregnancy?



  1. YES

  2. NO

  3. DK

  4. RF



Y12. Have you ever had surgery to help you lose weight? This does not include cosmetic procedures such as liposuction.



  1. YES CONTINUE TO Y13

  2. NO SKIP TO Y14

  3. DK SKIP TO Y14

  4. RF SKIP TO Y14



Y13. What procedure did you have? SELECT ALL THAT APPLY



  1. Gastric bypass

  2. Belly band / lap band / gastric banding

  3. Gastric sleeve / sleeve gastrectomy

  4. OTHER (SPECIFY): _______

  5. DK

  6. RF



Y14. In the month before your pregnancy through the end of your third month of pregnancy, that is [B1] to [P4 (-1)], did you follow any of the following types of diet? [READ LIST. INDICATE ALL THAT APPLY]



  1. Vegetarian

  2. Vegan

  3. Low carbohydrate / low “carb”

  4. Low fat

  5. Gluten free

  6. Dairy free

  7. OTHER (SPECIFY):__________

  8. NONE OF THE ABOVE

  9. DK

  10. RF

Section Z: DENTAL PROCEDURES

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

  1. During the month before your pregnancy through the third month of your pregnancy, that is from [B1] to [P4 (-1)] did you go to the dentist or other dental specialist, such as a periodontist or oral surgeon?



    1. YES CONTINUE TO Z2

    2. NO SKIP TO NEXT SECTION

    3. DK SKIP TO NEXT SECTION

    4. RF SKIP TO NEXT SECTION



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



    1. NUMBER:__________ DK RF



  1. What dental procedures did you receive at that visit/those visits? IF DON’T KNOW GIVE OPTIONS. CAN REPORT MULTIPLE PROCEDURES. X-RAYS WILL BE REPORTED IN Z4. (NEXT QUESTION).



    1. Teeth cleaning and/or routine checkup

    2. Cavity filled or dental filling placed CONTINUE WITH Z4 – Z19, BUT SKIP Z20 AND GO TO Z21

    3. Root canal

    4. Teeth whitening

    5. Teeth removal (e.g. wisdom teeth)

    6. Place dental crown

    7. Dental bridge

    8. Oral surgery

    9. OTHER (SPECIFY):__________

    10. DK

    11. RF



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



    1. YES CONTINUE TO Z5

    2. NO SKIP TO Z6

    3. DK SKIP TO Z6

    4. RF SKIP TO Z6



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



    1. Yes for all X-rays

    2. Yes for some, but not all X-rays

    3. No for all X-rays

    4. DK

    5. RF



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



    1. YES

    2. NO

    3. DK

    4. RF



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



    1. YES

    2. NO

    3. DK

    4. RF



  1. Were you prescribed any medications for your dental visit/visits or at the visit/visits? (IF MOM PRESCRIBED DRUG BUT NEVER TOOK IT, SELECT "YES”.)



    1. YES CONTINUE TO Z9

    2. NO SKIP TO Z14

    3. DK SKIP TO Z14

    4. RF SKIP TO Z14



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

  1. Acetaminophen w/Codeine

  2. Amoxicillin

  3. Amoxil

  4. Clindamycin

  5. Chlorhexidine Gluconate

  6. Diazepam

  7. Doxycycline

  8. Erythromycin

  9. Fluoride Phosphate, Acidulated

  10. Hydrocodone/Ibuprofen

  11. Hydrocodone Bitartrate/ APAP

  12. Hydrocodone , product unknown

  13. Kenalog in Orabase

  14. Magic mouthwash

  15. Orabase

  16. Orafate Paste

  17. Oxycodone with Acetaminophen

  18. Penicillin

  19. Percocet

  20. Periostat

  21. Tylenol #1,#2,#3,#4

  22. Valium

  23. Vicodin

  24. Vicoprofen

  25. Pain Medication W/Codeine Unknown

  26. OTHER (SPECIFY):__________

  27. DK SKIP TO Z14

  28. RF SKIP TO Z14

ASK SERIES FOR EACH DRUG in Z9:

Z10. When did you start taking [ANSWER X9]? [CAN USE DK OR RF FOR MM OR DD OR YY]

    1. MM/DD/YYYY or

    2. MONTH OF PREGNANCY(B1, P1, P2, P3)

    3. DIDN’T TAKE IT (ONLY RECEIVED PRESCRIPTION; DIDN’T FILL IT)

    4. DK

    5. RF



  1. When did you use [ANSWER Z9] for the last time during this time period? [CAN USE DK OR RF FOR MM OR DD OR YY]



    1. MM/DD/YYYY or

    2. MONTH OF PREGNANCY(B1, P1, P2, P3) IF VALID RESPONSE TO Z10 and Z11, SKIP Z12

    3. DK

    4. RF

OR

  1. How long did you take it?



    1. AMOUNT:__________ DK RF

      1. Days

      2. Weeks

      3. Months



  1. How often did you use [ANSWER] during the month before your pregnancy through the end of your third month of pregnancy? You can say the number of times per day, per week, per month, or during the entire 4 month period.



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



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



    1. YES CONTINUE TO Z15

    2. NO SKIP TO X20 OR Z21A

    3. DK SKIP TO X20 OR Z21A

    4. RF SKIP TO X20 OR Z21A



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



  1. Acetaminophen

  2. Advil

  3. Anbesol Liquid /Gel

  4. Aspirin

  5. Bayer Aspirin

  6. Chloraseptic Liquid/Spray

  7. Ibuprofen

  8. Motrin

  9. Nuprin

  10. Ora-jel

  11. Tylenol

  12. Xylocaine

  13. OTHER (SPECIFY):__________

  14. DK SKIP TO Z20/Z21a

  15. RF SKIP TO Z20/Z21a



ASK SERIES BELOW FOR EACH DRUG:

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



    1. MM/DD/YYYY or

    2. MONTH OF PREGNANCY(B1, P1, P2, P3)

    3. DK

    4. RF



  1. When did you use [ANSWER Z15] for the last time during this time period? [CAN USE DK OR RF FOR MM OR DD OR YY]



    1. MM/DD/YYYY or

    2. MONTH OF PREGNANCY(B1, P1, P2, P3) IF VALID RESPONSE TO Z16 and Z17, SKIP Z18

    3. DK

    4. RF

OR

  1. How long did you take it?

    1. AMOUNT:__________ DK RF

      1. Days

      2. Weeks

      3. Months



  1. How often did you use [ANSWER X15] during the month before your pregnancy through the end of your third month of pregnancy? You can say the number of times per day, per week, per month, or during the entire 4 month period.



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



IF THEY REPORTED HAVING A CAVITY FILLED IN Z3 SKIP Z20 AND CONTINUE TO Z21a.



  1. IF THEY DID NOT REPORT HAVING A CAVITY FILLED IN Z3: Did you have any cavities filled or dental fillings placed during the visit/visits?



    1. YES CONTINUE TO Z21a

    2. NO SKIP TO NEXT SECTION

    3. DK SKIP TO NEXT SECTION

    4. RF SKIP TO NEXT SECTION

Z21a. During how many of the visits did you have a dental filling placed?

  1. NUMBER:__________ DK RF

Z21b. During the [1st, 2nd, etc.] visit in which you had a dental filling placed, how many dental fillings do you remember having placed? (IF MOM KNOWS SHE HAD AT LEAST ONE FILLING BUT DOESN'T KNOW HOW MANY, SELECT 1 AND DESCRIBE SITUATION IN COMMENTS)

    1. NUMBER:__________ DK RF

Z22. What was the date of the [1st, 2nd, etc.] visit when the filling(s) was/were placed? [ASK FOR EACH VISIT IF MULTIPLE VISITS]

  1. MM/DD/YYYY OR

  2. MONTH OF PREGNANCY(B1, P1, P2, P3)

  3. DK

  4. RF

Z23. Was the filling/Were the fillings silver in color, also called an amalgam filling, or tooth-colored, also called a composite resin filling? [ASK FOR EACH DATE REPORTED. ALLOW MULTIPLE RESPONSES IF MORE THAN ONE FILLING WAS PLACED DURING A SINGLE VISIT.]

  1. Amalgam / silver-colored

  2. Composite resin / tooth-colored

  3. DK

  4. RF

Section AA: SMOKING

The next questions are about cigarette use.

  1. At any time from 1 month before you became pregnant to the end of your third month of pregnancy, that is from [B1] to [P4 (-1)] did you smoke cigarettes? WE ARE ONLY INTERESTED IN TOBACCO CIGARETTES [PROBE: Even if you did not smoke the whole time, we are interested in whether you smoked any cigarettes at all during this time period.]



    1. YES CONTINUE TO AA2

    2. NO SKIP TO AA3

    3. DK SKIP TO AA3

    4. RF SKIP TO AA3



  1. During which months did you smoke? INDICATE ALL THAT APPLY



    1. B1

    2. P1

    3. P2

    4. P3

    5. DK

    6. RF

AA3. At any time from 1 month before you became pregnant to the end of your third month of pregnancy did you use electronic cigarettes, or any other electronic nicotine vaping devices? [PROBE: Some examples of electronic vaping devices include vape pens, mods, tank systems, e-hookahs, e-cigars, e-pipes, and ENDS. Even if you did not smoke the whole time, we are interested in whether you smoked any e-cigarettes at all during this time period.]

  1. YES CONTINUE TO AA4

  2. NO SKIP TO NEXT SECTION

  3. DK SKIP TO NEXT SECTION

  4. RF SKIP TO NEXT SECTION

AA4. How often did you use electronic cigarettes during the month before through the third month of pregnancy?

  1. Every Day

  2. Some Days

  3. Rarely

  4. DK

  5. RF

Section BB: MARIJUANA

The next questions are about marijuana cannabis products, sometimes called pot, weed, hashish, or concentrates. Some of the ways these products can be used are smoking (such as in joints, pipes, bongs, blunts, or hookahs), vaping (using vape pens, dab pens, tabletop vaporizers, or portable vaporizers), dabbing, eating or drinking, or applying as a lotion.


BB1. At any time from 1 month before you became pregnant to the end of your third month of pregnancy, that is from [B1] to [P4(-1)] did you use any form of marijuana? [PROBE: Even if you did not use any of these products the whole time, we are interested in whether you used any of them at all during this time period.]

a. YES CONTINUE TO BB2

b. NO SKIP TO NEXT SECTION

c. DK SKIP TO NEXT SECTION

d. RF SKIP TO NEXT SECTION

BB2. During the month before through your third month of pregnancy, in which of the following ways did you use marijuana or any cannabis product? [SELECT ALL THAT APPLY]

a. Smoking IF YES, ASK BB3

b. Vaping IF YES, ASK BB6

c. Dabbing IF YES, ASK BB7

d. Eating IF YES, ASK BB4

e. Drinking IF YES, ASK BB5

f. Putting drops, strips, lozenges, or sprays in your mouth or under your tongue IF YES, ASK BB8

g. Applying lotion, cream, or patches to your skin IF YES, ASK BB8

h. Taking pills IF YES, ASK BB8

i. Some other way? CONTINUE TO BB2a.

BB2a. How did you use it? CONTINUE TO BB8

j. DK

k. RF



BB3. On average, how often did you smoke marijuana during the month before through the third month of pregnancy? You can say the number of times per day, per week, per month, or during the entire 4 month period.

    1. Enter frequency:

    2. Select time period:

      1. PER DAY

      2. PER WEEK

      3. PER MONTH

      4. PER ENTIRE 4 MONTH PERIOD

BB4. On average, how often did you eat foods containing marijuana during the month before through the third month of pregnancy? You can say the number of times per day, per week, per month, or during the entire 4 month period.

  1. Enter frequency:

  2. Select time period:

  1. PER DAY

  2. PER WEEK

  3. PER MONTH

  4. PER ENTIRE 4 MONTH PERIOD

BB5. On average, how often did you drink something containing marijuana during the month before through the third month of pregnancy? You can say the number of times per day, per week, per month, or during the entire 4 month period.

  1. Enter frequency:

  2. Select time period:

  1. PER DAY

  2. PER WEEK

  3. PER MONTH

  4. PER ENTIRE 4 MONTH PERIOD

BB6. On average, how often did you vape marijuana during the month before through the third month of pregnancy? You can say the number of times per day, per week, per month, or during the entire 4 month period.

  1. Enter frequency:

  2. Select time period:

  1. PER DAY

  2. PER WEEK

  3. PER MONTH

  4. PER ENTIRE 4 MONTH PERIOD

BB7. On average, how often did you dab marijuana during the month before through the third month of pregnancy? You can say the number of times per day, per week, per month, or during the entire 4 month period.

  1. Enter frequency:

  2. Select time period:

  1. PER DAY

  2. PER WEEK

  3. PER MONTH

  4. PER ENTIRE 4 MONTH PERIOD

BB8. On average, how often did you use marijuana through [RESPONSE TO “OTHER”] during the month before through the third month of pregnancy? You can say the number of times per day, per week, per month, or during the entire 4 month period.

  1. Enter frequency:

  2. Select time period:

  1. PER DAY

  2. PER WEEK

  3. PER MONTH

  4. PER ENTIRE 4 MONTH PERIOD


BB9. Why did you use marijuana products during this 4 month time period? [READ ALL OPTIONS; SELECT ALL THAT APPLY]

a. To relieve nausea

b. To relieve vomiting

c. To relieve stress or anxiety

d. To relieve symptoms of a chronic condition

e. To relieve pain

f. For fun or to relax

g. Some other reason

i. SPECIFY:_________________________________________________

Section CC: ALCOHOL



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

  1. From one month before you became pregnant to the end of your third month of pregnancy, did you drink any wine, beer, mixed drinks or shots of liquor?



    1. YES CONTINUE TO CC2

    2. NO SKIP TO NEXT SECTION

    3. DK SKIP TO NEXT SECTION

    4. RF SKIP TO NEXT SECTION



  1. During the month before [your pregnancy with [NOIB]; the affected pregnancy] through the third month of pregnancy, which months did you drink any alcoholic beverages? INDICATE ALL THAT APPLY



    1. B1

    2. P1

    3. P2

    4. P3

    5. DK

    6. RF



  1. What was the greatest number of drinks you had on one occasion from the beginning of your pregnancy through the end of your third month of pregnancy? We define one drink as one beer, one glass of wine, one mixed drink, or one shot of liquor.



    1. NUMBER:__________ DK RF





Section DD: RESIDENCE HISTORY



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

  1. What is your current address? [REMEMBER TO ASK ABOUT AN APARTMENT NUMBER IF NONE GIVEN]

    1. ADDRESS:__________ DK RF



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



    1. YES SKIP TO NEXT SECTION

    2. NO CONTINUE TO QUESTION DD3

    3. DK SKIP TO NEXT SECTION

    4. RF SKIP TO NEXT SECTION

DD3. What was your address at the time [your pregnancy with [NOIB]; TAB: the pregnancy] began? This would be on or around [START DATE OF P1]. [REMEMBER TO ASK ABOUT AN APARTMENT NUMBER IF NONE GIVEN]



  1. ADDRESS:__________ SKIP TO NEXT SECTION

  2. DK SKIP TO NEXT SECTION

  3. RF SKIP TO NEXT SECTION

Section EE: MATERNAL OCCUPATION



The next set of questions asks about your work experiences – paid, volunteer, or military service. This includes part-time and full-time jobs that lasted one month or more, including jobs you worked at home, jobs on a farm, or jobs outside your home.

  1. From 1 month before you became pregnant to the end of your third month of pregnancy, that is from [B1] to [P4 (-1)] did you have a job?



    1. YES SKIP TO EE4

    2. NO CONTINUE TO EE2

    3. DK CONTINUE TO EE2

    4. RF CONTINUE TO EE2



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



    1. A homemaker/parent SKIP TO NEXT SECTION

    2. A student GO TO EE3

    3. Disabled SKIP TO NEXT SECTION

    4. Unemployed / in between jobs SKIP TO NEXT SECTION

    5. OTHER (SPECIFY):__________ SKIP TO NEXT SECTION

    6. DK or RF SKIP TO NEXT SECTION

  1. IF STUDENT: From 1 month before you became pregnant to the end of your third month of pregnancy, that is from [B1] to [P4(-1)] did you also have a paid or volunteer job while in school, including on-the-job training, such as an apprenticeship, internship, practicum or clinical experience?



    1. YES CONTINUE TO EE4

    2. NO SKIP TO NEXT SECTION

    3. DK SKIP TO NEXT SECTION

    4. RF SKIP TO NEXT SECTION



  1. Did you hold a job during that time in one of the following categories? If your job could fit into more than one category, please choose the ONE category that best describes how you spent most of your time at that job. If you had multiple jobs, please pick the best category for each job. [READ CHOICES. SELECT MULTIPLE IF MULTIPLE JOBS.]:


a. In the healthcare field, specifically as a healthcare professional providing direct patient care, or providing healthcare support such as diagnostic testing?

b. On a farm, ranch, orchard, or in a greenhouse?

c. As a janitor, housekeeper, maid, or other cleaning staff?

d. As a hairdresser, cosmetologist, or nail technician?

e. As a teacher or teaching assistant?

f. In a restaurant, café, or coffee shop?

g. In an office setting, performing primarily office, administrative, or computer work

h. As an electronic equipment operator in a call center, phone bank, or as a dispatcher?

i. NONE OF THE ABOVE

j. DK

k. RF


IF ANY YES, QUEUE REQUEST AT END OF INTERVIEW FOR ON-LINE FOLLOW-UP QUESTIONS

EE5. Now think about all the jobs, paid or volunteer, you held from [B1] to [P4 (-1)]. What kind of a company did you work for? Please be as specific as possible. (What did your company make or do?) [PROBE: LIST ALL EMPLOYERS, INCLUDING “SELF EMPLOYED”.]



  1. SPECIFY:__________________________________

  2. DK IF MOTHER RESPONDS DK, ENTER UNKNOWN IN RESPONSE BOX.

  3. RF

EE6. At the company that did [BB5 RESPONSE], what was your job title there? [ASK FOR EACH EMPLOYER]



  1. SPECIFY:__________________________________ DK RF



EE7. At the company that did [BB5 RESPONSE], describe what you did and how you did it. What were your main activities or duties? Anything else? [ASK FOR EACH EMPLOYER]



  1. SPECIFY:___________________________________

  2. DK

  3. RF

Section FF: RACE / ACCULTURATION / EDUCATION



Now I will be asking about your ethnic background.

  1. Were you born in the U.S.?

    1. YES SKIP TO FF4

    2. NO CONTINUE TO FF2

    3. DK SKIP TO FF4

    4. RF SKIP TO FF4







  1. Where were you born?



    1. COUNTRY:__________DK RF

OTHER (SPECIFY):__________



  1. How many years have you lived in the US?



    1. YEARS:__________ DK RF



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

  1. LANGUAGE:__________DK RF

  2. OTHER (SPECIFY):________



  1. Are you Hispanic or Latina?

    1. YES CONTINUE TO FF6

    2. NO SKIP TO FF7

    3. DK SKIP TO FF7

    4. RF SKIP TO FF7



  1. Which Hispanic or Spanish group do you consider yourself a member of? [PROBE: Mexican, Puerto Rican, Salvadoran, Honduran, Colombian, Peruvian, Guatemalan, Spanish, Central American, South American, etc.?]



    1. GROUP:__________ DK RF

    2. OTHER (SPECIFY):________


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



  1. American Indian or Alaska Native ASK FF9

  2. Asian CONTINUE TO FF8

  3. Black or African American SKIP TO FF10, unless (FF7a), (FF7b), or (FF7d) also selected

  4. Native Hawaiian or Other Pacific Islander CONTINUE TO FF8

  5. White SKIP TO FF10, unless (FF7a), (FF7b), or (FF7d) also selected

  6. DK SKIP TO FF10

  7. RF SKIP TO FF10



  1. IF FF7 = b OR d: What country? PROBE: Referring to Asian, Native Hawaiian or other Pacific Island countries



  1. COUNTRY:__________ DK RF

  2. OTHER (SPECIFY):_________



  1. IF FF7 = a: What tribe do you consider yourself a member of?



  1. TRIBE:__________ DK RF

  2. OTHER (SPECIFY):________



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



  1. No formal schooling

  2. 1-6 years

  3. 7-8 years

  4. 9-11 years

  5. 12 years, completed high school or equivalent

  6. 1-3 years college

  7. Completed technical college

  8. 4 years college or Bachelor’s degree

  9. Master’s degree

  10. Advanced degree (MD, PhD, JD)

  11. DK

  12. RF

IF THE FATHER IS UNKNOWN, SKIP TO NEXT SECTION

The next few questions are about [[NOIB]’s; TAB: the] biological or natural father.

  1. Was he born in the U.S.?

  1. YES SKIP TO FF14

  2. NO CONTINUE TO FF12

  3. DK SKIP TO FF14

  4. RF SKIP TO FF14



  1. Where was he born?

    1. COUNTRY:__________ DK RF

    2. OTHER (SPECIFY):_________



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

    1. YEARS:__________ DK RF



  1. Is the father Hispanic or Latino?

    1. Yes ASK FF15

    2. NO SKIP TO FF16

    3. DK SKIP TO FF16

    4. RF SKIP TO FF16



  1. Which Hispanic or Spanish group does he consider himself a member of? [PROBE: Mexican, Puerto Rican, Salvadoran, Honduran, Colombian, Peruvian, Guatemalan, Spanish, Central American, South American, etc.?]

    1. GROUP:__________ DK RF

    2. OTHER (SPECIFY):__________



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



    1. American Indian or Alaska Native ASK FF18

    2. Asian ASK FF17

    3. Black or African American SKIP TO FF19, UNLESS (FF16a), (FF16b), OR (FF16d) ALSO SELECTED

    4. Native Hawaiian or Other Pacific Islander ASK FF17

    5. White SKIP TO FF19, UNLESS (FF16a), (FF16b), OR (FF16d) ALSO SELECTED

    6. DK SKIP TO FF 19

    7. RF SKIP TO FF19



  1. IF FF16 = b or d: What country? [PROBE: Referring to Asian, Native Hawaiian or other Pacific Island countries.]



    1. COUNTRY:__________ DK RF

    2. OTHER (SPECIFY):__________



  1. IF FF16 = a: What tribe does he consider himself a member of?



    1. TRIBE:__________ DK RF

    2. OTHER (SPECIFY):__________



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



    1. No formal schooling

    2. 1-6 years

    3. 7-8 years

    4. 9-11 years

    5. 12 years, completed high school or equivalent

    6. 1-3 years college

    7. Completed technical college

    8. 4 years college or Bachelor’s degree

    9. Master’s degree

    10. Advanced degree (MD, PhD, JD)

    11. DK

    12. RF

Section GG: INSURANCE STATUS



The next questions are about health insurance. Include health insurance obtained through your job or that you bought directly, as well as government programs like Medicare and Medicaid that provide medical care or help pay medical bills. Please do not include private plans that only provide extra cash while hospitalized (e.g. Aflack).

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



    1. YES CONTINUE TO GG2

    2. NO SKIP TO GG3

    3. DK SKIP TO GG3

    4. RF SKIP TO GG3



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



    1. NAME:__________ DK RF



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



    1. YES, for the entire pregnancy CONTINUE TO GG4

    2. YES, for part of the pregnancy CONTINUE TO GG4

    3. NO SKIP TO NEXT SECTION

    4. DK SKIP TO NEXT SECTION

    5. RF SKIP TO NEXT SECTION



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


    1. NAME:__________ DK RF

Section HH: CLOSING



  1. [IF THE MOTHER REPORTED ONE OF THE OCCUPATIONAL CATEGORIES OF INTEREST]: We would like to get some additional information about your activities at the job you had during the month before your pregnancy through your third month of pregnancy. Would you be willing to let us send you an email with a link to an on-line survey with these additional questions once they become available?



    1. YES CONTINUE TO HH2

    2. NO SKIP TO HH3b

    3. DK SKIP TO HH3b



  1. What is your email address, so that we can send you a link to the questionnaire?

REMINDER: READ BACK EMAIL ADDRESS



    1. EMAIL ADDRESS 1:______________________________

    2. EMAIL ADDRESS 2:______________________________

    3. EMAIL ADDRESS 3:______________________________

    4. DK

HH3a. We may have other on-line surveys in the future on other topics. Would you be willing to let us send you an email telling you about them to see if you are interested in participating?

  1. YES SKIP TO HH6

  2. NO SKIP TO HH6

  3. DK SKIP TO HH6



HH3b. IF EE1 = NO OR DK: We may have other on-line surveys in the future on other topics. Would you be willing to let us send you an email telling you about them to see if you are interested in participating?

  1. YES SKIP TO HH5

  2. NO SKIP TO HH6

  3. DK SKIP TO HH6



HH4. IF MOTHER WAS NOT ASKED ABOUT EMAIL ADDRESS IN EE1-EE3 (DID NOT SELECT AN OCCUPATION OF INTEREST): We may have on-line surveys in the future to get additional information on certain topics. Would you be willing to let us send you an email telling you about them to see if you are interested in participating?

  1. YES CONTINUE TO HH5

  2. NO SKIP TO HH6

  3. DK SKIP TO HH6

HH5. What is your email address?

REMINDER: READ BACK EMAIL ADDRESS



  1. EMAIL ADDRESS 1:______________________________

  2. EMAIL ADDRESS 2:______________________________

  3. EMAIL ADDRESS 3:______________________________

  4. DK

HH6. In case we need to get in touch with you in the future, would you be willing to give us the name, address and phone number of someone who would always know where you are? This information will be kept separate from your questionnaire. It will be locked except when needed by the research team, and will be destroyed when the study is finished.



  1. YES CONTINUE TO HH7

  2. NO SKIP TO HH8

  3. DK SKIP TO HH8



HH7. Contact information

    • PREFIX: Ms, Mrs, Mr, Dr

    • FIRST NAME:_______________________

    • LAST NAME:________________________

    • RELATIONSHIP:______________________

    • HOME PHONE:______________________

    • WORK PHONE:______________________

    • STREET/APARTMENT:________________

    • CITY/STATE/ZIP:_____________________

    • COUNTRY:_______________

    • DK

    • RF



FOR HH8, INTERVIEWERS WILL NEED TO USE STATE AND INFANT STATUS TO DETERMINE WHICH SCRIPT TO USE:



HH8. FOR CENTERS THAT ARE COLLECTING BLOODSPOTS (STATE AR, IA, MA, NY, NC) AND A LIVEBORN INFANT: That completes the interview, but as you read in the advance packet, you may be asked to participate in other parts of the study. To thank you for your time, we will send you a $30 gift card. Along with the gift card, we will mail you two consent forms. One of the forms asks for your permission to request leftover newborn bloodspots that were already collected shortly after your baby’s birth by your state’s newborn screening program. This part of the study will help us to understand the role genetic and other biologic factors have in causing birth defects. The other form asks for your permission to request your infectious disease information that was already reported by your physician to your state’s health department. This information will be used to study how infectious diseases may play a role in why some babies have birth defects. If you choose to return the consent forms, we will send you a $10 gift card for each consent form returned as a token of appreciation for your continues interest in our study.



FOR CENTERS THAT ARE NOT COLLECTING BLOODSPOTS (STATE: CA, GA) OR FOR A NON-LIVEBORN INFANT: That completes the interview, but as you read in the advance packet, you may be asked to participate in other parts of the study. So that we may contact you in the future we would like to confirm your address. To thank you for your time, we will send you a $30 gift card. Along with the gift card, we will mail you a consent form. The consent form asks for your permission to request your infectious disease information that was already reported by your physician to your state’s health department. This information will be used to study how infectious diseases may play a role in why some babies have birth defects. If you choose to sign and send back the consent form, we will send you a $10 gift card as a token of appreciation for your continued interest in our study.

FOR STILLBIRTHS WITHOUT A BIRTH DEFECT (AR, MA CENTERS): That completes the interview, but as you read in the advance packet, you may be asked to participate in other parts of the study. So that we may contact you in the future we would like to confirm your address. To thank you for your time, we will send you a $30 gift card.



HH8b. IF ADDRESS PROVIDED IN RESIDENCE HISTORY DD3: To confirm, I have your address as [PULL STREET ADDRESS FROM DD3]. Is that the address where you receive mail?

  1. YES SKIP TO HH10

  2. NO CONTINUE TO HH9

  3. DK CONTINUE TO HH9

  4. RF SKIP TO HH10

HH9. ASK ONLY IF ADDRESS NOT PROVIDED IN RESIDENCE HISTORY DD3 OR ADDRESS ON FILE IS INCORRECT/DON’T KNOW: What is your current mailing address? REMEMBER TO ASK ABOUT APT NUMBER IF NONE IS GIVEN.

  • STREET/APT:_________________________ DK RF

  • CITY:___________________________

  • STATE:______________ ZIP:____________________________

FOR HH10, INTERVIEWERS WILL NEED TO USE STATE AND INFANT STATUS TO DETERMINE WHICH SCRIPT TO USE:

HH10. FOR CENTERS THAT ARE COLLECTING BLOODSPOTS (STATE: AR: AR, IA, MA, NY, NC) AND A LIVEBORN INFANT: In the introductory letter we sent you, there was a $20 gift card included as a token of appreciation for your interest. As I just mentioned, you will be sent a $30 gift card to thank you for your time to complete the interview, and you will have the opportunity to receive additional gift cards after you sign and return the consent forms to access your child’s newborn blood spots and your infectious disease information. We cannot promise you will get a gift card from your chosen store, but could you tell me which one of the following stores you would prefer? [READ LIST]



FOR CENTERS THAT ARE NOT COLLECTING BLOODSPOTS (STATE: CA, GA) OR A NON-LIVEBORN INFANT: In the introductory letter we sent you, there was a $20 gift card included as a token of appreciation for your interest. As I just mentioned, you will be sent a $30 gift card to thank you for your time to complete the interview, and you will have the opportunity to receive an additional gift card after you sign and return the consent form to access your infectious disease information. We cannot promise you will get a gift card from your chosen store, but could you tell me which one of the following stores you would prefer? [READ LIST]

FOR STILLBIRTHS WITHOUT A BIRTH DEFECT (AR, MA CENTERS)We cannot promise you will get a gift card from your chosen store, but could you tell me which one of the following stores you would prefer? [READ LIST]: In the introductory letter we sent you, there was a $20 gift card included as a token of appreciation for your interest. As I just mentioned, you will be sent a $30 gift card to thank you for your time to complete the interview.

  1. Amazon

  2. Target

  3. Wal-Mart

  4. CVS

HH11. We publish an electronic newsletter to update participants on the progress of the study. We post each new newsletter on the www.bdsteps.org website. Will you be able to access the newsletter on our website? IF ‘NO’, THEN ASK: We want to make sure families without access to the internet can also receive the newsletter. Would you like us to mail you a paper copy of the newsletter?

  1. YES to internet

  2. NO to internet; YES to newsletter

  3. NO to internet; NO to newsletter

  4. DK

  5. RF

FINAL REMARK

HH12. In closing, we would like to sincerely thank you for your time and efforts. Your contribution to this important study will help us greatly in our efforts to better understand the causes of birth defects. Thank you.

Section II: INTERVIEWER REMARKS



II1. The overall quality of this interview was:



          1. HIGH QUALITY

          2. GENERALLY RELIABLE

          3. QUESTIONABLE

          4. UNSATISFACTORY



II2. Did the father contribute to the mother’s answers? SKIP IF FATHER UNKNOWN



          1. YES

          2. NO

          3. DK



II3. Did some other person contribute to the mother’s answers?



          1. YES CONTINUE TO II4

          2. NO SKIP TO II5

          3. DK SKIP TO II5



II4. Who was it?



          1. SPECIFY:__________ DK



II5. IF II1 = C OR D: The main reason for questionable or unsatisfactory quality of information was because the respondent: INDICATE ALL THAT APPLY



          1. DID NOT KNOW ENOUGH INFORMATION REGARDING THE TOPIC

          2. DID NOT WANT TO BE MORE SPECIFIC

          3. SOUNDED BORED OR UNINTERESTED

          4. SOUNDED UPSET, DEPRESSED, OR ANGRY

          5. HAD POOR HEARING OR SPEECH

          6. SOUNDED CONFUSED OR DISTRACTED BY FREQUENT INTERRUPTIONS

          7. SOUNDED INHIBITED BY OTHERS AROUND HER

          8. SOUNDED EMBARRASSED BY THE SUBJECT MATTER

          9. SOUNDED EMOTIONALLY UNSTABLE

          10. SOUNDED PHYSICALLY ILL

          11. NOT COMFORTABLE WITH LANGUAGE OF THE QUESTIONNAIRE

          12. DOESN’T HAVE THE TIME

          13. FELT INTERVIEW TOO LONG

          14. OTHER (SPECIFY):__________



II6. Was the majority of the interview done in English or Spanish?



          1. ENGLISH

          2. SPANISH

          3. BOTH EQUALLY

II7. INTERVIEW IS COMPLETE. PLEASE CLICK THE FINISH BUTTON

Public reporting burden of this collection of information is estimated to average 55 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).


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