Document ID: EPA-HQ-ORD-2005-0010-0023
Agency: epa
Document Type: Supporting & Related Material
Title: 
Posted Date: 2005-09-28T04:00Z

NCS
Herald
Cohort
Study
Instrument
#
15
Female
Questionnaire
Pregnancy
Second
Trimester
Clinic
Visit
Eligibility:
All
pregnant
women
2nd
trimester
Mode
of
administration:
Interviewer,
clinic
visit
8/
4/
2005
Public
reporting
burden
for
this
collection
of
information
is
estimated
to
average
45
minutes
per
response,
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:
Dr.
Pauline
Mendola,
US
EPA,
MD­
58A,
Research
Triangle
Park,
NC
27711.
E­
mail:
mendola.
pauline@
epa.
gov.
Female
Pregnancy
2
Instrument
#
15)

1
PRELOADED
DATA:

Today's
date
Language
of
interview
(
English/
Spanish)

Respondent
Name
Respondent
Address
and
Phone
Spouse/
Partner's
Name
Spouse/
Partner's
Address
and
Phone
Biological
father's
name
Marital
status
Baby
due
date
OB/
GYN
name
Hospital
planning
to
deliver
Last
interview
date
Student
status
Employment
status
Smoking
status
Chemical
exposures
Medications
QUESTIONNAIRE:
Female
Pregnancy
2
Instrument
#
15)

2
Pregnancy
Status
(
Update
Revised
for
Pregnancy)

1.
What
is
your
due
date?

MM/
DD/
YYYY
DON'T
KNOW

What
was
the
first
day
of
your
last
menstrual
period?
MM/
DD/
YYYY
2.
[
IF
DELIVERY
HOSPITAL
PRELOADED
ASK]
Do
you
still
plan
on
having
your
baby
at
[
FILL
HOSPITAL
NAME]?

1
YES

GO
TO
NEXT
MODULE
2
NO
3.
Where
do
you
plan
to
deliver?

1
HOSPITAL
(
SPECIFY)
_______________________________
2
OTHER
(
SPECIFY)
_______________________________
3
DON'T
KNOW
4
REFUSED
Female
Pregnancy
2
Instrument
#
15)

3
Occupation
(
Update
Revised
for
Pregnancy)

1.
In
your
last
interview
on
[
FILL
DATE],
you
reported
that
you
were
(
FILL:
not
a/
a
full­
time/
a
parttime
student.
Is
this
still
correct?

1
YES

SKIP
TO
Q4
2
NO
2.
Are
you
now
a
student
full
or
part­
time?

1
YES,
FULL­
TIME
2
YES,
PART­
TIME
3
NO,
NOT
A
STUDENT

SKIP
TO
Q4
3.
What
type
of
school
are
you
currently
attending?

1
HIGH
SCHOOL
2
TECHNICAL
SCHOOL
3
COLLEGE
OR
UNIVERSITY
4
GRADUATE
SCHOOL
5
PROFESSIONAL
SCHOOL
(
FOR
EXAMPLE,
MEDICAL
SCHOOL)
6
OTHER
 
SPECIFY_________________

4.
On
your
last
interview
on
[
FILL
DATE],
you
reported
that
you
were
(
FILL
EMPLOYMENT).
Is
this
still
correct?

1
YES
2
NO

GO
TO
Q5
[
PROGRAMMING
INSTRUCTIONS]
Q4=
YES,
STILL
WORKING

SKIP
TO
Q5
Q4=
YES,
STILL
LOOKING
FOR
WORK

GO
TO
NEXT
MODULE
Q4=
YES,
STILL
NOT
WORKING

GO
TO
NEXT
MODULE
5.
Are
you
currently 

[
ONLY
DISPLAY
THE
OPTIONS
NOT
SELECTED
IN
PREVIOUS
INTERVIEW]
1
Working
at
a
job
or
business,

SKIP
TO
PARAGRAPH
BEFORE
Q7
2
Looking
for
work,
or

GO
TO
NEXT
MODULE
3
Not
working
at
a
job
or
business?

GO
TO
NEXT
MODULE
6.
Did
you
start
work
at
any
jobs
since
your
last
interview
on
[
FILL
DATE]?

1
YES
2
NO

SKIP
TO
Q15
Female
Pregnancy
2
Instrument
#
15)

4
Please
tell
me
about
the
jobs
you've
had
since
your
last
interview,
starting
with
the
(
FILL:
current/
most
recent)
one.

7.
On
what
date
did
you
start
this
job?

MM/
DD/
YYYY
8.
On
what
date
did
you
stop
working
at
this
job?

MM/
DD/
YYYY
1
=
STILL
EMPLOYED
9.
What
kind
of
business
or
industry
(
FILL:
is/
was)
this?
(
For
example:
TV
and
radio
management,
retail
shoe
store,
state
labor
department,
farm.)

_________________________________
ENTER
NAME
OF
BUSINESS,
JOB,
OR
INDUSTRY
10.
What
kind
of
work
(
FILL:
are/
were)
you
doing?
(
For
example:
farming,
mail
clerk,
computer
specialist.)

_________________________________
ENTER
NAME
OF
OCCUPATION
11.
How
many
hours
a
week
(
FILL:
do/
did)
you
usually
work
at
this
job?

____
HOURS
12.
(
FILL:
Do/
Did)
you
do
shift
work
for
this
job?

1
YES
2
NO

SKIP
TO
Q14
13.
(
FILL:
Does/
Did)
this
include
the
night
shift?

1
YES
2
NO
14.
Did
you
have
any
other
jobs
since
[
FILL
DATE]?

1
YES
[
REPEAT
Q7­
Q13
FOR
UP
TO
3
JOBS]
2
NO

GO
TO
Q15
15.
Did
you
stop
working
at
any
job,
even
temporarily,
because
of
your
pregnancy?

1
YES
2
NO

GO
TO
NEXT
MODULE
16.
Which
job
was
that?
[
DISPLAY
LIST
OF
ALL
JOBS
HELD]

17.
Did
you
stop
working
for
any
of
these
reasons?
(
CODE
ALL
THAT
APPLY)
Female
Pregnancy
2
Instrument
#
15)

5
1
doctor
recommended
it
2
didn't
feel
well
enough
3
decided
not
to
work
4
other
medical
reason
5
family
encouraged
you
to
quit
6
non­
family
encouraged
you
to
quit
7
some
other
reason
(
SPECIFY)
_____________________

{
END
OF
OCCUPATION
MODULE}
Female
Pregnancy
2
Instrument
#
15)

6
Chemical
Exposures
(
Update)

Now
I'm
going
to
ask
you
about
chemicals
you
may
have
used
at
work,
at
home,
or
for
any
hobbies.

1.
Last
time
you
said
you
were
{
FILL:
not
exposed
to
any
of
these
chemicals
/
exposed
to
[
DISPLAY
LIST
OF
EXPOSURES
REPORTED
IN
PREVIOUS
VISIT]}.
Is
this
still
correct?
(
HAND
SHOW
CARD
TO
RESPONDENT
AND
READ
THE
LETTER
CORRESPONDING
TO
EACH
PREVIOUS
EXPOSURE)

1
YES

IF
NO
PREVIOUS
EXPOSURES,
SKIP
TO
END
2
NO
2.
[
IF
Q1=
1,
ASK:]
Are
you
currently
also
exposed
to
any
of
the
following
chemicals?
[
IF
Q1=
2,
ASK:]
Which
of
the
following
chemicals
are
you
currently
exposed
to?

[
IF
Q1=
1,
DISPLAY
ONLY
THOSE
EXPOSURES
NOT
PREVIOUSLY
REPORTED.
IF
Q1=
2,
DISPLAY
ALL
EXPOSURES]

YES
NO

SKIP
TO
NEXT
EXPOSURE
3.
How
often
are
you
exposed
to
[
INSERT
EXPOSURE]
?
Would
you
say.
.
.

4.
Did
the
exposure
occur
while
you
were
at
work?

2.
Currently
Exposed
Yes
=
01
No
=
02
3.
Frequency
1
=
Daily
2
=
2­
3/
week
3
=
1/
week
4
=
1/
month
5
=
<
1/
month
4.
At
work
Yes
=
01
No
=
02
A.
Fuels,
solvents,
dry
cleaning
fluids,
degreasers,
or
adhesives
B.
Lead,
including
paints
with
lead
in
them
C.
Fumes
or
gases
(
e.
g.,
nitrous
oxide,
ethylene
oxide,
anesthetic
gases)
D.
Radiation
(
e.
g.,
fluoroscopy,
radioisotopes,
highintensity
microwaves,
x­
rays)
E.
Mercury
F.
Metal
fumes
or
particles
G.
Pesticides
that
you've
mixed
or
applied
H.
Paints,
strippers,
or
varnishes
I.
Hair
and
nail
products
(
e.
g,
hair
dye,
bleach,
hair
relaxer,
nail
polish
and
remover)
J.
Cleaning
products
(
e.
g.,
oven
cleaner,
disinfectant,
carpet
cleaner,
bleach)
K.
Carbon
black
from
copying
machines
L.
Coal
or
coal
products
from
hot
asphalt,
tar,
or
roofing
material
{
END
OF
CHEMICAL
EXPOSURES
MODULE}
Female
Pregnancy
2
Instrument
#
15)

7
Activity
(
Full,
revised
for
pregnancy)

Now
I
am
going
to
ask
you
some
questions
about
physical
activities
you
might
do
at
work,
at
home,
for
recreation,
and
about
activities
involving
child
or
adult
care.
I
want
you
to
tell
me
about
activities
you
did
in
the
past
month
that
caused
at
least
some
increase
in
breathing
and
heart
rate.

1.
In
the
past
month,
did
you 
2.
IF
YES:
On
average
over
the
past
month,
how
many
times
did
you
do
these
activities?
Would
you
say 
3.
Thinking
about
your
breathing
and
heart
rate,
how
hard
did
this
usually
feel
to
you?
Did
it
feel 
(
HAND
SHOW
CARD
TO
RESPONDENT)
A.
[
SKIP
IF
NOT
CURRENTLY
EMPLOYED]
participate
in
any
work
activities,
such
as
walking,
lifting,
or
carrying
objects
or
people,
that
caused
at
least
some
increase
in
breathing
and
heart
rate?
1
=
Daily,
2
=
2
to
3
times
per
week,
3
=
Once
a
week,
or
4
=
Once
a
month?
FH
SH
H
B.
participate
in
any
non­
work,
recreational
activity
or
exercise,
such
as
walking
for
exercise,
swimming,
or
dancing,
that
caused
at
least
some
increase
in
breathing
and
heart
rate?
1
=
Daily,
2
=
2
to
3
times
per
week,
3
=
Once
a
week,
or
4
=
Once
a
month?
FH
SH
H
C.
participate
in
any
outdoor
household
activities,
such
as
gardening,
mowing,
or
raking,
[
that
caused
at
least
some
increase
in
breathing
and
heart
rate]?
1
=
Daily,
2
=
2
to
3
times
per
week,
3
=
Once
a
week,
or
4
=
Once
a
month?
FH
SH
H
D.
participate
in
any
indoor
household
activities,
such
as
scrubbing
floors,
mopping,
laundry,
or
vacuuming,
[
that
caused
at
least
some
increase
in
breathing
and
heart
rate]?
1
=
Daily,
2
=
2
to
3
times
per
week,
3
=
Once
a
week,
or
4
=
Once
a
month?
FH
SH
H
E.
participate
in
any
child
or
adult
care
activities
that
caused
at
least
some
increase
in
breathing
and
heart
rate?
These
would
be
activities
such
as
playing
with
children,
pushing
a
stroller
or
wheelchair,
carrying,
or
lifting
a
child
or
adult.
1
=
Daily,
2
=
2
to
3
times
per
week,
3
=
Once
a
week,
or
4
=
Once
a
month?
FH
SH
H
F.
walk
for
transportation,
such
as
to
work
or
to
the
store,
and
that
walking
caused
at
least
some
increase
in
breathing
and
heart
rate?
1
=
Daily,
2
=
2
to
3
times
per
week,
3
=
Once
a
week,
or
4
=
Once
a
month?
FH
SH
H
G.
bike
for
transportation,
such
as
to
work
or
to
the
store,
and
that
biking
caused
at
least
some
increase
in
breathing
and
heart
rate?
1
=
Daily,
2
=
2
to
3
times
per
week,
3
=
Once
a
week,
or
4
=
Once
a
month?
FH
SH
H
FH
=
Fairly
hard
(
at
least
some
increase
in
breathing
and
heart
rate),
SH
=
Somewhat
hard
(
moderate
increase
in
breathing
and
heart
rate),
or
H
=
Hard
or
very
hard
(
large
increase
in
breathing
and
heart
rate)?

Now
think
about
the
activities
you
did
in
the
past
week 
Female
Pregnancy
2
Instrument
#
15)

8
1.
[
SKIP
IF
NOT
CURRENTLY
EMPLOYED]
In
the
past
week,
would
you
say
your
work
activities
were
usually 

1
Not
hard
=
did
not
feel
any
increase
in
breathing
or
heart
rate
2
Fairly
light
=
at
least
some
increase
in
breathing
and
heart
rate
3
Somewhat
hard
=
moderate
increase
in
breathing
and
heart
rate
4
Hard
or
very
hard
=
large
increase
in
breathing
and
heart
rate
2.
[
SKIP
IF
NOT
CURRENTLY
EMPLOYED]
In
the
past
week,
how
often
did
your
job
require
you
to
stand?

1
Very
often
2
Fairly
often
3
Sometimes
4
Almost
never
5
Never
3.
[
SKIP
IF
NOT
CURRENTLY
EMPLOYED]
Compared
to
other
weeks
in
this
pregnancy,
in
the
past
week
did
you
spend
more
time,
less
time,
or
about
the
same
amount
of
time
on
work
activities?

1
MORE
TIME
2
LESS
TIME
3
SAME
AMOUNT
OF
TIME
4.
Think
about
how
active
you
were
during
your
non­
working
and
recreational
hours
in
the
past
week.
Would
you
say
your
activities
were
usually 

1
not
hard
=
you
did
not
feel
any
increase
in
breathing
or
heart
rate
2
fairly
light
=
you
had
at
least
some
increase
in
breathing
and
heart
rate
3
somewhat
hard
=
you
had
a
moderate
increase
in
breathing
and
heart
rate
4
hard
or
very
hard
=
you
had
a
large
increase
in
breathing
and
heart
rate
5.
Compared
to
other
weeks
in
this
pregnancy,
in
the
past
week
did
you
spend
more
time,
less
time,
or
about
the
same
amount
of
time
on
non­
working
and
recreational
activities?

1
MORE
TIME
2
LESS
TIME
3
SAME
AMOUNT
OF
TIME
Now
I
will
ask
you
to
think
about
your
typical
daily
activities
during
the
past
month.

6.
Please
tell
me
which
of
these
four
sentences
best
describes
your
usual
daily
activities
over
the
past
month?
(
INTERVIEWER
PROBE:
Daily
activities
may
include
your
work,
housework,
errands,
and
anything
else
you
normally
do
throughout
a
typical
day.)

1
You
sit
during
the
day
and
do
not
walk
about
very
much
2
You
stand
or
walk
about
quite
a
lot
during
the
day,
but
do
not
have
to
carry
or
lift
things
very
often
3
You
lift
or
carry
light
loads,
or
have
to
climb
stairs
or
hills
often
4
You
do
heavy
work
or
carry
heavy
loads
Female
Pregnancy
2
Instrument
#
15)

9
7.
Over
the
past
month,
on
a
typical
day
how
much
time
altogether
did
you
spend
sitting
and
watching
TV
or
videos
or
using
a
computer
outside
of
work?
Would
you
say
.
.
.

0
Less
than
1
hour
1
1
hour
2
2
hours
3
3
hours
4
4
hours
5
5
hours
or
more
6
You
do
not
watch
TV
or
videos
or
use
a
computer
outside
of
work
8.
How
does
the
amount
of
activity
that
you
reported
for
the
past
month
compare
with
your
physical
activity
before
you
got
pregnant?
Over
the
past
month,
were
you
.
.
.

1
More
active
2
Less
active
3
About
the
same
{
END
OF
PREGNANCY
ACTIVITY
MODULE}
Female
Pregnancy
2
Instrument
#
15)

10
Diet
(
Update,
revised
for
pregnancy)

1.
On
average,
how
many
times
per
week
do
you
eat
meals
from
fast­
food
restaurants?

|___|___|
ENTER
NUMBER
ENTER
`
0'
IF
NEVER
ENTER
`
66'
IF
LESS
THAN
WEEKLY
2.
On
average,
how
many
times
per
week
do
you
eat
meals
that
were
prepared
in
a
restaurant,
other
than
fast­
food
restaurants?
Please
include
eat­
in
restaurants,
carry
out
restaurants
and
restaurants
that
deliver
food
to
your
house.
`
MEALS'
MEAN
MORE
THAN
A
BEVERAGE
OR
SNACK
FOOD
LIKE
CANDY
BARS
OR
BAG
OF
CHIPS
|___|___|
ENTER
NUMBER
ENTER
`
0'
IF
NEVER
ENTER
`
66'
IF
LESS
THAN
WEEKLY
3.
What
type
of
salt
do
you
usually
add
to
your
food
at
the
table?

0
I
do
not
add
salt
to
my
food
at
the
table

SKIP
TO
Q5
1
ordinary
salt
[
includes
regular
iodized
salt,
sea
salt
and
seasoning
salts
made
with
regular
salt]
2
lite
salt
3
salt
substitute
4.
How
often
do
you
add
ordinary
salt
to
your
food
at
the
table?

1
Rarely
2
Occasionally
3
Very
often
5.
During
your
pregnancy,
how
often
per
day
or
per
week
do
you
eat
dark
green
vegetables,
such
as
(
INTERVIEWER,
USE
SHOW
CARD)

|___|___|___|
ENTER
NUMBER
OF
TIMES
(
PER
DAY,
WEEK,
MONTH
OR
YEAR)
ENTER
`
0'
IF
NEVER
ENTER
UNIT
DAY
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
1
WEEK
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
..
2
MONTH
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
3
YEAR
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
4
6.
During
your
pregnancy,
how
often
per
day
or
per
week
do
you
eat
cooked
dried
beans
or
peas,
such
as
(
INTERVIEWER,
USE
SHOW
CARD)

|___|___|___|
ENTER
NUMBER
OF
TIMES
(
PER
DAY,
WEEK,
MONTH
OR
YEAR)
Female
Pregnancy
2
Instrument
#
15)

11
ENTER
`
0'
IF
NEVER
ENTER
UNIT
DAY
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.1
WEEK
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
2
MONTH
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
..
3
YEAR
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
..
4
7.
Do
you
ever
eat
poultry
such
as
chicken
and
turkey?
Please
include
foods
that
are
made
with
poultry
such
as
soups,
sandwiches,
stews
and
salads.
IF
EATEN
RARELY
OR
OCCASIONALLY,
ENTER
`
YES'

1
YES
2
NO

SKIP
TO
Q9
8.
When
you
eat
chicken
or
other
types
of
poultry,
how
often
do
you
eat
the
skin?

0
Never
1
Rarely
or
seldom
2
Sometimes
or
occasionally
3
Often
or
very
often
4
Always
9.
Do
you
ever
eat
meat
such
as
beef,
pork,
lamb
and
veal?
Please
include
foods
that
are
made
with
meat
such
as
soups,
stews,
sandwiches,
lunch
meats,
and
casseroles.
IF
EATEN
RARELY
OR
OCCASIONALLY,
ENTER
`
YES'

1
YES
2
NO

SKIP
TO
Q11
10.
When
you
eat
meat,
how
often
do
you
eat
the
visible
fat?
[
Visible
fat
is
the
fat
tissue
that
you
may
see
around
the
edge
of
a
piece
of
meat.]

0
Never
1
Rarely
or
seldom
2
Sometimes
or
occasionally
3
Often
or
very
often
4
Always
Now
I'm
going
to
ask
a
few
questions
about
milk
products.
Do
not
include
their
use
in
cooking.

11.
In
the
past
30
days,
how
often
did
you
have
milk
to
drink
or
on
your
cereal?
Please
include
chocolate
and
other
flavored
milks
as
well
as
hot
cocoa
made
with
milk.
Do
not
count
small
amounts
of
milk
added
to
coffee
or
tea.

0
Never

SKIP
TO
Q13
1
Rarely
 
less
than
once
a
week
2
Sometimes
 
once
a
week
or
more,
but
less
than
once
a
day
3
Often
 
once
a
day
or
more
12.
What
type
of
milk
was
it?
Was
it
usually
.
.
.
Female
Pregnancy
2
Instrument
#
15)

12
1
Whole
or
regular
2
2%
fat
milk
(
includes
"
low
fat
milk")
3
1%
fat
milk
4
Skim,
nonfat,
or
0.5%
fat
milk
(
includes
liquid
or
reconstituted
from
dry)
5
Evaporated
milk,
whole
milk
6
Evaporated
milk,
skim
milk
7
Buttermilk
8
Goat's
milk
9
Soy
or
imitation
milk
10
Another
type
(
Specify)
__________

The
next
questions
are
about
the
amount
of
food
you
eat.

13.
On
an
average
day,
how
many
helpings
of
the
following
kinds
of
foods
do
you
eat?

a.
Protein
foods,
such
as
meat,
fish,
seafood,
chicken,
turkey,
or
eggs.
Also
include
protein
foods,
such
as
peanut
butter
or
foods
that
are
made
from
dried
beans,
such
as
bean
soup,
baked
beans,
or
refried
beans,
meat
substitutes
and
soy
protein
foods
such
as
tofu
|___|___|
ENTER
NUMBER
OF
HELPINGS
OR
`
0'
IF
NEVER
OR
RARELY
EAT
THESE
FOODS
b.
Milk
or
dairy
foods
that
are
made
from
milk,
such
as
cheese,
cottage
cheese,
ice
cream,
milk
shakes,
or
yogurt
|___|___|
ENTER
NUMBER
OF
HELPINGS
OR
`
0'
IF
NEVER
OR
RARELY
EAT
THESE
FOODS
c.
Fruits
or
fruit
juices
|___|___|
ENTER
NUMBER
OF
HELPINGS
OR
`
0'
IF
NEVER
OR
RARELY
EAT
THESE
FOODS
d.
Vegetables,
including
vegetable
salads
|___|___|
ENTER
NUMBER
OF
HELPINGS
OR
`
0'
IF
NEVER
OR
RARELY
EAT
THESE
FOODS
e.
Breads
and
other
foods
that
are
made
from
grains,
such
as
cereals,
spaghetti,
pasta,
rice,
or
tortillas
|___|___|
ENTER
NUMBER
OF
HELPINGS
OR
`
0'
IF
NEVER
OR
RARELY
EAT
THESE
FOODS
The
next
questions
are
about
meals
provided
by
community
or
government
programs.

14.
Since
you
became
pregnant,
have
you
gone
to
a
community
program
or
volunteer
center
to
eat
prepared
meals?

1
YES
2
NO

SKIP
TO
END
Female
Pregnancy
2
Instrument
#
15)

13
15.
Since
you
became
pregnant,
how
many
days
per
week
did
you
go
to
a
community
program
or
volunteer
center
to
eat
prepared
meals?

|___|___|
ENTER
NUMBER
(
OF
DAYS
PER
WEEK)
ENTER
`
0'
IF
YOU
DID
NOT
GO
TO
PROGRAM
IN
PAST
MONTH
{
END
OF
DIET
MODULE}
Female
Pregnancy
2
Instrument
#
15)

14
Personal
Medical
History
(
update,
revised
for
pregnancy)

Now
I'd
like
to
ask
you
some
questions
about
your
general
health.

1.
Since
your
last
interview
on
[
FILL
DATE],
have
you
developed
any
of
the
following
health
problems?
(
CODE
ALL
THAT
APPLY)

[
CAPI:
ONLY
DISPLAY
ITEMS
=
NO
FOR
LAST
INTERVIEW]
1
High
blood
sugar
(
diabetes)
that
started
before
this
pregnancy
2
High
blood
sugar
(
diabetes)
that
started
during
this
pregnancy
3
Vaginal
bleeding
or
spotting
4
Kidney
or
bladder
(
urinary
tract)
infection
5
Severe
nausea,
vomiting,
or
dehydration
6
High
blood
pressure
or
hypertension
that
started
before
this
pregnancy
7
High
blood
pressure
or
hypertension
that
started
during
this
pregnancy
(
including
pregnancy­
induced
hypertension
[
PIH],
preeclampsia,
or
toxemia)
8
High
cholesterol
9
Anemia
(
poor
blood,
low
iron)
10
Heart
problems
11
Asthma
IF
Q1
=
11,
ASK
Q2­
4
ELSE,
SKIP
TO
Q5
2.
Did
a
doctor
or
other
medical
provider
ever
tell
you
that
you
had
asthma?

1
YES
2
NO

SKIP
TO
Q8
3.
In
the
past
6
months,
have
you
used
any
inhalers
or
taken
any
pills
for
asthma
or
wheezing
or
whistling
in
your
chest?

1
YES
2
NO
4.
Have
you
ever
gone
to
an
emergency
room
or
stayed
overnight
in
a
hospital
for
your
asthma?

1
YES
2
NO
5.
Some
women
experience
several
days
or
weeks
of
nausea
or
feeling
sick
to
their
stomach
when
they
are
pregnant
while
other
women
do
not.
Have
you
had
any
times
when
you
had
a
feeling
of
nausea
during
this
pregnancy?

1
YES
2
NO

SKIP
TO
Q9
6.
Did
your
nausea
cause
you
to:
[
read
choices
and
circle
all
that
apply]

1.
eat
less
food
than
you
usually
did
before
you
were
pregnant
2.
not
be
able
to
do
your
normal
daily
activities
3.
not
be
able
to
take
your
prenatal
vitamin
Female
Pregnancy
2
Instrument
#
15)

15
0.
none
of
the
above
7.
Have
you
vomited
during
this
pregnancy
because
of
nausea
related
to
being
pregnant?

1
YES
2
NO

SKIP
TO
Q9
8.
Have
you
vomited
more
than
4
times
in
a
week
for
at
least
one
week
during
this
pregnancy?

1
YES
2
NO
9.
Since
your
last
interview
on
[
FILL
DATE],
have
you
been
diagnosed
with
any
other
serious
illnesses
that
I
haven't
asked
about?

1
YES
2
NO

SKIP
TO
Q10
9a.
What
were
those
illnesses?
(
ENTER
VERBATIM)

_______________________

10.
Since
[
FILL
DATE],
have
you
been
hospitalized
for
any
reason?

1
YES
2
NO

GO
TO
NEXT
MODULE
10a.
Why
were
you
hospitalized?
(
ENTER
VERBATIM)

_______________________

{
END
OF
PERSONAL
MEDICAL
HISTORY
MODULE}
Female
Pregnancy
2
Instrument
#
15)

16
Medications
(
Update)

I'll
be
asking
you
about
prescription
and
non­
prescription
medications
you
are
currently
taking.
If
you
do
not
remember
the
specific
names
of
your
medications,
I
can
wait
for
you
to
gather
them.

1.
Are
you
currently
taking
any
new
prescription
medications
that
you
were
not
taking
when
we
last
interviewed
you
on
[
FILL
DATE]?

1
YES
2
NO

SKIP
TO
Q3
2.
Please
tell
me
what
prescription
medications
you
are
taking.
Are
you
currently
taking
any 

Medication
Type
IF
YES:
What
is
the
name
of
the
[
INSERT
MED
TYPE]
you
are
taking?
a.
Antibiotics?
1
YES
2
NO
b.
Allergy
medications,
antihistamines,
or
decongestants?
1
YES
2
NO
c.
Pain
Killers?
1
YES
2
NO
d.
Medications
for
depression?
1
YES
2
NO
e.
Medications
for
asthma?
1
YES
2
NO
f.
Other
prescription
medications?
1
YES
2
NO
3.
Do
you
currently
take
any
non­
prescription,
or
over­
the­
counter,
medications
on
a
regular
basis?

1
YES

IF
PREVIOUS
OTC
MEDS
REPORTED,
GO
TO
Q4.
IF
NOT,
GO
TO
Q5
2
NO

SKIP
TO
END
4.
[
CAPI
INSTRUCTION:
DISPLAY
PREVIOUS
OTC
MEDS
FROM
TABLE
BELOW
AND
FREQUENCY
REPORTED]
Last
time,
you
said
you
took
{
FILL
MED
NAME}
{
FILL
FREQUENCY}.
Has
this
changed?

4a.
Are
you
currently
taking
any
of
these
other
non­
prescription
medications
in
a
regular
basis?
[
CAPI
INSTRUCTION:
DISPLAY
OTC
MEDS
NOT
REPORTED
DURING
LAST
INTERVIEW]

5.
Please
tell
me
which
non­
prescription
medications
you
currently
take
on
a
regular
basis.
Do
you
take 
Female
Pregnancy
2
Instrument
#
15)

17
Medication
Type
IF
YES:
How
often
do
you
usually
take
this
medication?
a.
Tylenol
(
Acetominophen)?
1
YES
2
NO
1
=
Daily
2
=
2­
3/
week
3
=
1/
week
4
=
1/
month
5
=
<
1/
month
b.
Advil
or
Motrin
(
Ibuprofen)?
1
YES
2
NO
1
=
Daily
2
=
2­
3/
week
3
=
1/
week
4
=
1/
month
5
=
<
1/
month
c.
Cough
or
cold
medicine?
1
YES
2
NO
1
=
Daily
2
=
2­
3/
week
3
=
1/
week
4
=
1/
month
5
=
<
1/
month
d.
Allergy
medications,
antihistamines,
or
decongestants?
1
YES
2
NO
1
=
Daily
2
=
2­
3/
week
3
=
1/
week
4
=
1/
month
5
=
<
1/
month
e.
Aspirin?
1
YES
2
NO
1
=
Daily
2
=
2­
3/
week
3
=
1/
week
4
=
1/
month
5
=
<
1/
month
f.
Other
nonprescription
medications?
(
SPECIFY)
1
YES
2
NO
1
=
Daily
2
=
2­
3/
week
3
=
1/
week
4
=
1/
month
5
=
<
1/
month
{
END
OF
MEDICATIONS
MODULE}
Female
Pregnancy
2
Instrument
#
15)

18
Supplements,
Vitamins,
Etc.
(
update)

Now
I
will
ask
you
similar
questions
about
vitamins
and
supplements
you
are
taking.

1.
Are
you
currently
taking
any
multivitamins
such
as
One­
a­
Day,
Centrum,
or
prenatal
vitamins?

1
YES
2
NO

SKIP
TO
Q4
2.
How
often
do
you
take
any
multivitamins
or
prenatal
vitamins?

1
Every
day
2
4
 
6
days
per
week
3
1
 
3
days
per
week
4
1
 
3
days
per
month
3.
Do
your
multivitamins
usually
contain
minerals
such
as
iron,
zinc,
etc.?

1
YES
2
NO
4.
Are
you
currently
taking
any
vitamins,
minerals,
or
supplements
other
than
your
multivitamins?

1
YES
2
NO

GO
TO
NEXT
MODULE
5.
Do
you
take
any
of
the
following
supplements
that
are
not
part
of
a
multivitamin?
(
INTERVIEWER:
HAND
SHOW
CARD
TO
RESPONDENT.
CODE
ALL
THAT
APPLY)

1.
BETA­
CAROTENE
2.
VITAMIN
A
3.
VITAMIN
B­
6
OR
B­
COMPLEX
4.
VITAMIN
C
5.
VITAMIN
E
6.
CALCIUM
OR
CALCIUM­
CONTAINING
ANTACIDS
7.
VITAMIN
D,
INCLUDING
VITAMIN
D
TAKEN
AS
PART
OF
A
CALCIUM
SUPPLEMENT
8.
BREWER'S
YEAST
9.
COD
LIVER
OIL
10.
COENZYME
Q
11.
FISH
OIL
(
OMEGA
3
FATTY
ACIDS)
12.
FOLIC
ACID/
FOLATE
13.
GLUCOSAMINE
14.
HYDROXYTRYPTOPHAN
(
HTP)
15.
IRON
16.
NIACIN
17.
SELENIUM
18.
ZINC
Female
Pregnancy
2
Instrument
#
15)

19
6.
Please
tell
me
if
you
take
any
of
the
following
herbal
or
botanical
supplements
more
than
once
per
week.
Include
only
supplements
and
teas,
not
use
of
the
herb
in
food.
(
INTERVIEWER:
HAND
SHOW
CARD
TO
RESPONDENT.
CODE
ALL
THAT
APPLY)

1.
ALOE
VERA
2.
BILBERRY
3.
CAYENNE
4.
CRANBERRY
5.
DONG
KUAI
(
TANGKWEI)
6.
ECHINACEA
7.
EVENING
PRIMROSE
OIL
8.
FEVERFEW
9.
GARLIC
10.
GINGER
11.
GINKGO
BILOBA
12.
GINSENG
(
AMERICAN
OR
ASIAN)
13.
GOLDENSEAL
14.
GRAPESEED
EXTRACT
15.
KAVA
16.
MILK
THISTLE
17.
SIBERIAN
GINSENG
18.
ST.
JOHN'S
WORT
19.
VALERIAN
20.
OTHER
SPECIFY_____________________

{
END
OF
VITAMINS/
SUPPLEMENTS
MODULE}
Female
Pregnancy
2
Instrument
#
15)

20
Alcohol
(
update)

The
next
few
questions
are
about
alcohol
consumption.
A
"
drink"
is
a
can
or
bottle
of
beer,
a
glass
of
wine
or
a
wine
cooler,
a
shot
of
liquor,
or
a
mixed
drink
with
liquor
in
it.
We
are
not
asking
about
times
when
you
only
had
a
sip
or
two
from
a
drink.

1.
Since
your
last
interview
on
[
FILL
DATE],
have
you
had
any
alcoholic
drinks?

1
YES
2
NO

GO
TO
NEXT
MODULE
2.
Since
your
last
interview
on
[
FILL
DATE],
how
many
alcoholic
drinks
did
you
have
in
an
average
week?
Would
you
say 

1
Less
than
1
drink
a
week,
2
1
to
3
drinks
a
week,
3
4
to
6
drinks
a
week,
4
7
to
13
drinks
a
week,
or
5
14
drinks
or
more
a
week?

3.
Since
your
last
interview
on
[
FILL
DATE],
how
many
times
did
you
drink
5
alcoholic
drinks
or
more
in
one
sitting?
Would
you
say 

1
Never,
2
1
time,
3
2
or
3
times,
4
4
or
5
times,
or
5
6
or
more
times?

{
END
OF
ALCOHOL
MODULE}
Female
Pregnancy
2
Instrument
#
15)

21
Tobacco
(
update)

These
next
questions
are
about
your
use
of
tobacco
products.
This
includes
cigarettes,
chewing
tobacco,
snuff,
cigars,
and
pipe
tobacco.

1.
Since
your
last
interview
on
[
FILL
DATE],
have
you
used
snuff,
dip,
or
chewing
tobacco,
even
once?

1
YES
2
NO
2.
Since
your
last
interview,
have
you
smoked
a
cigar
or
tobacco
pipe,
even
once?

1
YES
2
NO

SKIP
TO
Q3
2a.
How
often
have
you
smoked
cigars
or
tobacco
pipes
since
your
last
interview?

_____
NUMBER
OF
TIMES
ENTER
UNIT
1
DAY
2
WEEK
3
MONTH
[
IF
SMOKER
FROM
PREVIOUS
INTERVIEW,
ASK
Q3­
Q4
]
[
IF
NON­
SMOKER
IN
PREVIOUS
INTERVIEW,
SKIP
TO
Q5
]
3.
Do
you
still
smoke
cigarettes?

1
YES

SKIP
TO
Q6
2
NO
4.
When
did
you
stop
smoking?

MM/
YYYY

SKIP
TO
Q7
5.
In
your
last
interview
you
reported
that
you
were
not
smoking
cigarettes.
Are
you
currently
smoking
cigarettes
now?

1
YES
2
NO

SKIP
TO
Q7
6.
How
many
cigarettes
do
you
smoke
on
an
average
day
now?
Would
you
say 

1
Less
than
1
cigarette
per
day,
2
1
to
5
cigarettes,
3
6
to
10
cigarettes,
4
11
to
20
cigarettes,
5
21
to
40
cigarettes,
or
6
41
cigarettes
or
more?

7.
In
your
last
interview
on
[
FILL
DATE],
you
reported
that
there
were
[
FILL
#]
cigarette
smokers
who
lived
in
your
home
not
including
yourself.
Is
this
still
correct?
Female
Pregnancy
2
Instrument
#
15)

22
1
YES

SKIP
TO
Q9
2
NO
8.
Not
including
yourself,
how
many
cigarette
smokers
live
in
your
home
now?

_____

9.
About
how
many
hours
per
day
are
you
in
the
same
room
with
someone
who
is
smoking
cigarettes,
cigars,
or
tobacco
pipes?

_____
Hours
999
Less
than
1
hour
a
day
{
END
OF
TOBACCO
MODULE}
Female
Pregnancy
2
Instrument
#
15)

23
Acceptability
(
To
be
administered
at
the
end
of
the
clinic
visit)

This
study
will
be
able
to
answer
health
questions
best
if
we
are
able
to
keep
people
involved
in
the
study.
To
do
this,
we
would
like
to
get
some
feedback
from
you
about
the
study
overall
and
this
visit
today
to
help
improve
the
study
in
the
future.

1.
Was
participating
in
the
visit
today
convenient
for
you?

1
YES
2
NO
2.
How
much
time
did
it
take
for
you
to
arrive
here
today?

_______
MINUTES
3.
How
did
you
arrive
at
the
clinic
today?

1
Your
own
vehicle
2
Public
transportation
3
Taxi
4
Some
other
ride
arrangement
4.
Did
you
have
to
take
time
off
from
work
to
come
to
the
clinic
today?

1
YES
2
NO
5.
Did
you
need
to
find
childcare
to
come
here
today?

1
YES
2
NO
6.
How
long
did
you
wait
to
be
seen
today?

_______
MINUTES
7.
Why
did
you
decide
to
participate
in
this
study?
(
CODE
ALL
THAT
APPLY)

1
THE
STUDY
WOULD
BENEFIT
MYSELF
OR
MY
CHILD
2
CONTRIBUTE
TO
IMPROVE
HEALTH
OF
CHILDREN
AND
PREGNANT
WOMEN
IN
THE
FUTURE
3
INTERESTING
PROJECT
TO
BE
INVOLVED
IN
4
CURIOSITY
5
DESIRE
TO
BELONG
TO
A
GROUP
OR
COMMUNITY
OF
SIMILAR
PEOPLE
6
DIDN'T
FEEL
COMFORTABLE
SAYING
NO
7
OTHER
REASON
(
SPECIFY)
___________________

8.
Is
there
anything
that
you
especially
like
about
participating
in
this
study?
(
ENTER
VERBATIM)

____________________________
Female
Pregnancy
2
Instrument
#
15)

24
9.
Is
there
anything
you
especially
dislike
about
participating
in
this
study?
(
ENTER
VERBATIM)

____________________________

10.
Finally,
do
you
have
any
recommendations
as
to
what
we
could
do
differently
in
the
overall
study
or
in
these
interviews?
(
ENTER
VERBATIM)

____________________________

{
END
OF
ACCEPTABILITY
MODULE}