**PRAMS Core English Questionnaire**

First, we would like to ask you a few questions about the time before
your new baby was born.

Please check the box next to the best answer.

1\. Before your new baby, did you ever have any other babies who were
born alive?

G No C\> **Go to Question 4**

G Yes

2\. Did the baby just before your new one weigh 5 pounds, 8 ounces ***or
less*** at birth?

G No

G Yes

3\. Was the baby just before your new one born ***more*** than 3 weeks
before its due date?

G No

G Yes

Next are some questions about the time just before and during your
pregnancy with your new baby. It may help to look at the calendar when
you answer these questions.

4\. How many weeks or months pregnant were you when you were ***sure***
you were pregnant? (For example, you had a pregnancy test or a doctor or
nurse said you were pregnant.)

\_\_\_\_ Weeks or \_\_\_\_ Months

G I don\'t remember

5\. Thinking back to ***just before*** you got pregnant, how did you
feel about becoming pregnant?

**Check the best answer.**

G I wanted to be pregnant sooner

G I wanted to be pregnant later

G I wanted to be pregnant then

G I didn\'t want to be pregnant then or at any time in the future

G I don\'t know

6\. ***Just before*** you got pregnant, did you have health insurance?

G No

G Yes

**Don\'t count Medicaid.**

7\. ***Just before*** you got pregnant, were you on Medicaid?

G No

G Yes

8\. When you got pregnant with your new baby, were you or your husband
or partner using any kind of birth control?

> Birth control means the pill, condoms, diaphragm, foam, rhythm,
> Norplant7, shots (Depo-Provera7), or ANY other way to keep from
> getting pregnant.

G No

G Yes C\> **Go to Question 10**

9\. Why were you or your husband or partner not using any birth control?

**Check all that apply.**

G I wanted to get pregnant

G I didn=t think I could get pregnant

G I had been having side effects from the birth control I used

G I didn=t want to use birth control

G I didn=t think I was going to have sex

G My husband or partner didn=t want to use birth control

G Other C\> Please tell us:
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

The next questions are about the prenatal care you got during your most
recent pregnancy. Prenatal care includes visits to a doctor, nurse, or
other health care worker before your baby was born to get check-ups and
advice about pregnancy. It may help to look at a calendar when you
answer these questions.

10\. How many weeks or months pregnant were you when you had your first
visit for prenatal care?

**Don=t count a visit that was only for a pregnancy test or only for WIC
(Women, Infants, and Children\'s Nutrition Program).**

\_\_\_\_ Weeks or \_\_\_\_ Months

G I did not go for prenatal care

11\. Did you get prenatal care as early in your pregnancy as you wanted?

G No

G Yes C\> **Go to Question 13**

G I did not want prenatal care C\> **Go to** **Question 13**

12\. Did any of these things keep you from getting prenatal care as
early as you wanted?

**Check all that apply.**

G I couldn=t get an appointment earlier in my pregnancy

G I didn=t have enough money or insurance to pay for my visits

G I didn=t know that I was pregnant

G I had no way to get to the clinic or doctor=s office

G I couldn=t find a doctor or a nurse who would take me as a patient

G I had no one to take care of my children

G I had too many other things going on

G Other C\> Please tell us:
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

If you did not go for prenatal care, go to Question 17 on Page 4.

13\. During each month of your pregnancy about how many visits for
prenatal care did you have? If you don\'t know exactly how many, please
give us your best guess. Don\'t count visits for WIC. It may help to use
the calendar.

**Month of pregnancy How many visits?**

First month \_\_\_\_\_\_\_

Second month \_\_\_\_\_\_\_

Third month \_\_\_\_\_\_\_

Fourth month \_\_\_\_\_\_\_

Fifth month \_\_\_\_\_\_\_

Sixth month \_\_\_\_\_\_\_

Seventh month \_\_\_\_\_\_\_

Eighth month \_\_\_\_\_\_\_

Ninth month \_\_\_\_\_\_\_

G I did not go for prenatal care C\> **Go to Question 17**

14\. Where did you go ***most of the time*** for your prenatal visits?
Don=t include visits for WIC.

**Check one answer.**

G Hospital clinic

G Health department clinic

G Private doctor=s office

G \[state-defined choice\]

G \[state-defined choice\]

G Other C\> Please tell us:
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

15\. How was your prenatal care paid for?

**Check all that apply.**

G Medicaid

G Personal income (cash, check, or credit card)

G Health insurance

G \[state-defined choice\]

G \[state-defined choice\]

G Other C\> Please tell us:
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

16\. During any of your prenatal care visits, did a doctor, nurse, or
other health care worker talk with you about any of the things listed
below? For each thing, please circle Y (Yes) if someone talked with you
about it or N (No) if no one talked with you about it.

**No Yes**

a\. What you should eat during your pregnancy N Y

b\. How smoking during pregnancy could affect your baby N Y

c\. Breast-feeding your baby N Y

d\. How drinking alcohol during pregnancy could affect your baby N Y

e\. Using a seat belt during your pregnancy N Y

f\. Birth control methods to use after your pregnancy N Y

g\. The kinds of medicines that were safe to take during your pregnancy
N Y

h\. How using illegal drugs could affect your baby N Y

i\. How your baby grows and develops during your pregnancy N Y

j\. What to do if your labor starts early N Y

k\. How to keep from getting HIV (the virus that causes AIDS) N Y

l\. Getting your blood tested for HIV (the virus that causes AIDS) N Y

m\. Physical abuse to women by their husbands or partners N Y

17\. During your pregnancy, were you on WIC?

G No

G Yes

18\. ***Just before*** you got pregnant, how much did you weigh?

\_\_\_\_\_ Pounds

G I don=t know

19\. How tall are you without shoes?

\_\_\_\_ Feet \_\_\_\_ Inches

20\. Have you ever heard or read that taking the vitamin folic acid can
help prevent some birth defects?

G No

G Yes

The next questions are about smoking cigarettes and drinking alcohol.

21\. Have you smoked at least 100 cigarettes in your entire life?

G No C\> **Go to Question 25**

G Yes

22\. In the ***3 months before*** you got pregnant, how many cigarettes
or packs of cigarettes did you smoke on an average day? (A pack has 20
cigarettes.)

\_\_\_\_\_ Cigarettes or \_\_\_\_ Packs

G Less than 1 cigarette a day

G I didn=t smoke

G I don=t know

23\. In the ***last 3 months*** of your pregnancy, how many cigarettes
or packs of cigarettes did you smoke on an average day? (A pack has 20
cigarettes.)

\_\_\_\_\_ Cigarettes or \_\_\_\_ Packs

G Less than 1 cigarette a day

G I didn=t smoke

G I don=t know

24\. How many cigarettes or packs of cigarettes do you smoke on an
average day ***now***?

\_\_\_\_\_ Cigarettes or \_\_\_\_ Packs

G Less than 1 cigarette a day

G I didn=t smoke

G I don=t know

25\. a. During the ***3 months before*** you got pregnant, how many
alcoholic drinks did you have in an average week? (A drink is: One glass
of wine. One wine cooler. One can or bottle of beer. One shot of liquor.
One mixed drink.)

G I didn=t drink then

G Less than 1 drink a week

G 1 to 3 drinks a week

G 4 to 6 drinks a week

G 7 to 13 drinks a week

G 14 or more drinks a week

G I don=t know

> b\. During the ***3 months before*** you got pregnant, how many times
> did you drink 5 or more alcoholic drinks at one sitting?

\_\_\_\_\_ Times

G I didn=t drink then

G I don=t know

26\. a. During the ***last 3 months*** of your pregnancy, how many
alcoholic drinks did you have in an average week?

G I didn=t drink then

G Less than 1 drink a week

G 1 to 3 drinks a week

G 4 to 6 drinks a week

G 7 to 13 drinks a week

G 14 or more drinks a week

G I don=t know

> b\. During the ***last 3 months*** of your pregnancy, how many times
> did you drink 5 or more alcoholic drinks at one sitting?

\_\_\_\_\_ Times

G I didn=t drink then

G I don=t know

The next questions are about times you may have had to stay in the
hospital while you were pregnant. Please DO NOT COUNT the time you went
to the hospital to have your baby.

27\. ***Not counting*** the time you went to the hospital to have your
baby, how many ***other*** times during your pregnancy did you go into a
hospital and stay ***at least one night?***

G None C\> **Go to Question 30**

G 1 time

G 2 times

G 3 times

G 4 times or more

28\. What problems caused you to stay in the hospital? **Check all of
the problems that you had.**

G Labor pains more than 3 weeks before my due date (premature labor)

G High blood pressure (preeclampsia or toxemia)

G Vaginal bleeding or placenta problems

G Nausea, vomiting, or dehydration

G Kidney or bladder infection

G High blood sugar (diabetes)

G Other C\> Please tell us:
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

29\. How many months pregnant were you the ***first*** time you had to
go into a hospital and stay at least one night?

\_\_\_\_\_ Months

Pregnancy can be a difficult time for some women. The next questions are
about some things that may have happened to you before and during your
most recent pregnancy.

30\. This question is about things that may have happened during the
***12 months before you delivered*** your new baby. This includes the
months before you got pregnant. **For each thing, circle Y (Yes) if it
happened to you or N (No) if it did not. It may help to use the
calendar.**

**No Yes**

a\. A close family member was very sick and had to go into the hospital
N Y

b\. You got separated or divorced from your husband or partner N Y

c\. You moved to a new address N Y

d\. You were homeless N Y

e\. Your husband or partner lost his job N Y

f\. You lost your job even though you wanted to go on working N Y

g\. You and your husband or partner argued more than usual N Y

h\. Your husband or partner said he did not want you to be pregnant N Y

i\. You had a lot of bills you couldn\'t pay N Y

j\. You were involved in a physical fight N Y

k\. You or your husband or partner went to jail N Y

l\. Someone very close to you had a bad problem with drinking or drugs N
Y

m\. Someone very close to you died N Y

The next questions are about physical abuse. Physical abuse means
pushing, hitting, slapping, kicking, or any other way of physically
hurting someone.

31\. During the ***12 months before you got pregnant*** with your new
baby, did any of these people physically abuse you? **Check all that
apply.**

G My husband or partner

G A family or household member ***other than*** my husband or partner

G A friend

G Someone else C\> Please tell us:
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

G No one physically abused me during the 12 months before I got pregnant

32\. ***During your most recent pregnancy***, did any of these people
physically abuse you? **Check all that apply.**

G My husband or partner

G A family or household member ***other than*** my husband or partner

G A friend

G Someone else C\> Please tell us:
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

G No one physically abused me during my pregnancy C\> **Go to Question
34**

33\. **During your most recent pregnancy**, would you say that you were
physically abused ***more*** often, ***less*** often, or ***about the
same*** compared with the ***12 months before*** you got pregnant?
**Check only one.**

G I was physically abused ***more often*** during my pregnancy

G I was physically abused ***less often*** during my pregnancy

G I was physically abused ***about the same*** during my pregnancy

G No one physically abused me during the ***12 months before*** I got
pregnant

The next questions are about your labor and delivery.

34\. When was your baby due?

\_\_\_\_ /\_\_\_\_ /\_\_\_\_

month day year

35\. When was your baby born?

\_\_\_\_ /\_\_\_\_ /\_\_\_\_

month day year

36\. When did you go into the hospital to have your baby?

\_\_\_\_ /\_\_\_\_ /\_\_\_\_

month day year

G I did not have my baby in a hospital

37\. When you had your baby, how many nights did you stay in the
hospital?

\_\_\_\_\_ Nights

G I did not stay overnight in the hospital

G I did not have my baby in a hospital

38\. When your baby was born, how many nights did he or she stay in the
hospital?

\_\_\_\_\_ Nights

G My baby did not stay overnight in the hospital

G My baby was not born in a hospital

39\. When your baby was born, was he or she put in an intensive care
unit?

G No

G Yes

G I don=t know

40\. How was your delivery paid for? **Check all that apply.**

G Medicaid

G Personal income (cash, check, or credit card)

G Health insurance

G \[state-defined choice\]

G \[state-defined choice\]

G Other C\> Please tell us:
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

41\. Is your baby alive now?

G No C\> When did your baby die? \_\_\_\_ /\_\_\_\_ /\_\_\_\_

month day year

G Yes C\> Is your baby living withyour now? G No

G Yes

If your baby is not alive or is not living with you now, go to Question
48 on Page 10.

42\. For how many weeks did you breast-feed your new baby?

\_\_\_\_\_ Weeks

G I didn=t breast-feed my baby C\> **Go to Question 44**

G I breast-fed less than 1 week C\> **Go to Question 44**

G I=m still breast-feeding

43\. How many weeks old was your baby the first time you fed him or her
anything besides breast milk? **Include formula, baby food, juice,
cow\'s milk, or anything else.**

\_\_\_\_\_ Weeks

G My baby was less than 1 week old

G I haven=t fed my baby anything besides breast milk

44\. About how many hours a day, on average, is your new baby in the
same room with someone who is smoking?

\_\_\_\_\_ Hours

G My baby is never in the same room with someone who is smoking

45\. How do you put your new baby down to sleep ***most*** of the time?
**Check one answer.**

G On his or her side

G On his or her back

G On his or her stomach

46\. How many times has your baby been to a doctor or nurse for
***routine*** well baby care? **Don=t count the times you took your baby
for care when he or she was sick. It may help to use the calendar.**

\_\_\_\_\_ Times

G My baby hasn=t been for routine well baby care C\> **Go to Question
48**

47\. When your baby goes for ***routine*** well baby care, where do you
take him or her? **Check all the places that you use.**

G Hospital clinic

G Health department clinic

G Private doctor=s office

G \[state-defined choice\]

G \[state-defined choice\]

G Other C\> Please tell us:
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

The next questions are about your family and the place where you live.

48\. Which rooms are in the house, apartment, or trailer where you live?
**Check all that you have.**

G Bedrooms C\> how many? \_\_\_\_\_

G Living room

G Separate dining room

G Kitchen

G Bathroom(s)

G Recreation room, den, or family room

G Finished basement

49\. How many people live in your house, apartment, or trailer? **Count
yourself.**

**How many?**

Babies, children, or teens aged 17 years or younger \_\_\_\_\_\_\_

Adults aged 18 years or older \_\_\_\_\_\_\_

50\. What were the sources of your family income during the past 12
months? **Check all that apply.**

G Money from a job or business

G Aid such as TANF (formerly AFDC), welfare, public assistance, general
assistance, food stamps, or SSI

G Unemployment benefits

G Child support or alimony

G Fees, rental income, commissions, interest, dividends

G Social security, workers= compensation, veteran benefits, or pensions

G Other C\> Please tell us:
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

51\. What is today=s date?

\_\_\_\_ /\_\_\_\_ /\_\_\_\_

month day year

52\. What is ***your*** date of birth?

\_\_\_\_ /\_\_\_\_ /\_\_\_\_

month day year