Study Start Blood Draw form 2007

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Study to Explore Early Development


Interviewer_______________ 			Study ID#_____________ 
	Date of Completion ___________ 
Time of Completion___________

Blood Draw Information Form 

1. Please tell me all vaccinations, medications, vitamins, and supplements, both prescription and over the counter, <you have> taken in the last month. 
[Interviewer: Check box for MOST RECENT time frame when medication was last taken.] 

If no medications, vitamins, or supplements given in last month, check here:  ____

Type of substance				Last 7 days		Last month	
1)_________________________	  		□ 		       □	 	 
2) _________________________	 	□		  	 □ 	        
3)_________________________			□	  		 □ 	        	 
4) _________________________		□	  	 	 □ 	        	 
5) _________________________		□	  	 	 □ 	        	 
6) _________________________		□	  		 □ 	        	  
7) _________________________		□		  	 □ 	        	  
8) _________________________		□	  		 □ 	        	 	 

2. List any cold, flu, fever, or other illness <you have> had in the last 2 weeks.  [Interviewer: Check box for MOST RECENT time frame when illness occurred.] 

If no illness in last 2 weeks, check here: _______ 
Illness			    		Last 2 days		   Last 2 weeks
1) _________________________		□ 	     	 	□ 	
2) _________________________		□ 	     	   	□
3) _________________________		□ 	     	   	□
4) _________________________		□ 	     	   	□

3. Have you or anyone else smoked cigarettes, cigars,   □ No
or pipes anywhere inside your home in the past week?   □ Yes, person giving blood smoked
								   □ Yes, someone else in home smoked