Clinic / Home Visit -Development Assessment (Child)

S tudy 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, <child first name> has 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 < child first name> has 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 child’s home □ Yes, person giving blood smoked

in the past week?

□ Yes, someone else in home smoked

Version 9-2015