Document ID: EPA-HQ-ORD-2005-0010-0014
Agency: epa
Document Type: Supporting & Related Material
Title: 
Posted Date: 2005-09-28T04:00Z

NCS
Herald
Cohort
Study
Instrument
#
6
Female
Questionnaire
Preconception
Second
Home
Visit
Eligibility:
All
women
enrolled
preconception,
not
yet
pregnant
Mode
of
administration:
Interviewer,
home
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
Preconception
2
(
Instrument
#
6)

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
Marital
status
Last
interview
date
Student
status
Employment
status
Flag
for
house
pets
reported
Smoking
status
Past
chemical
exposures
Past
prescription
medications
QUESTIONNAIRE:
Female
Preconception
2
(
Instrument
#
6)

2
Address
(
update)

1.
I'd
just
like
to
quickly
confirm
the
contact
information
we
have
on
file:
{
FILL
PRELOADED
ADDRESS
AND
PHONE
NUMBER}.
Is
this
still
correct?

1
YES
2
NO

Enter
correct
information
2.
Do
you
plan
to
move
from
this
address
before
{
FILL
END
DATE
OF
FOLLOW­
UP
PERIOD}?

1
YES
2
NO

GO
TO
NEXT
MODULE
3.
Where
do
you
plan
to
move?
(
Interviewer:
collect
complete
address
if
possible.
If
unknown,
collect
city
and
state.)

IF
MOVING
WITHIN
STUDY
AREA,
ADMINISTER
INSTRUMENT
#
29,
NEW
HOME
LOCATION
IF
MOVING
OUT
OF
STUDY
AREA,
INELIGIBLE.
SKIP
TO
END
{
END
OF
ADDRESS
MODULE}
Female
Preconception
2
(
Instrument
#
6)

3
Partner
(
update)

1.
When
we
last
interviewed
you,
you
said
you
were
[
FILL
MARITAL
STATUS
FROM
SCREENER].
Is
this
still
correct?

1
YES

SKIP
TO
Q5
2
NO
2.
What
is
your
current
marital
status?

1
Married
2
Widowed

GO
TO
NEXT
MODULE
3
Divorced

GO
TO
NEXT
MODULE
4
Separated

GO
TO
NEXT
MODULE
5
Living
with
a
partner
in
a
committed
relationship
6
In
a
committed
relationship,
but
not
living
together
7
Single,
never
married

GO
TO
NEXT
MODULE
3.
What
is
your
[
husband's/
partner's]
name?

COLLECT
HUSBAND/
PARTNER
NAME

IF
Q2=
6,
GO
TO
Q4.
ELSE,
GO
TO
NEXT
MODULE
REFUSED

GO
TO
NEXT
MODULE
4.
[
THIS
IS
ONLY
ASKED
IF
Q2=
6]
In
order
to
determine
if
your
partner
would
also
like
to
participate
in
the
study,
we
would
like
to
collect
some
contact
information.
What
is
your
partner's
address
and
telephone
number?

COLLECT
PARTNER
CONTACT
INFO

GO
TO
NEXT
MODULE
REFUSED

GO
TO
NEXT
MODULE
5.
I
would
like
to
verify
the
information
you
gave
me
the
last
time
we
interviewed
you.
I
have
your
[
husband's/
partner's]
name
as
[
PRELOAD
NAME].
Is
this
still
correct?

1
YES

GO
TO
NEXT
MODULE
2
NO
­
9
REFUSED
6.
Please
give
me
your
[
husband's/
partner's]
name
and
address.

COLLECT
INFORMATION
ON
NEW
PARTNER
REFUSED
{
END
OF
PARTNER
MODULE}
Female
Preconception
2
(
Instrument
#
6)

4
Pregnancy
Status
(
Update)

Now
I'd
like
to
ask
you
about
your
pregnancy
status
and
plans.

1.
Are
you
currently
pregnant?

1
YES
2
NO

SKIP
TO
Q5
3
DON'T
KNOW

SKIP
TO
Q5
2.
What
is
your
due
date?

MM/
DD/
YYYY
DON'T
KNOW

What
was
the
first
day
of
your
last
menstrual
period?
MM/
DD/
YYYY
3.
What
is
the
name
of
your
OB/
GYN
doctor?

1
NAME
(
SPECIFY)
_______________________________
2
DO
NOT
HAVE
A
DOCTOR
YET
3
REFUSED
4.
Where
do
you
plan
to
deliver?

1
HOSPITAL
(
SPECIFY)
_______________________________
2
OTHER
(
SPECIFY)
_______________________________
3
DON'T
KNOW
4
REFUSED
[
SWITCH
TO
PREGNANCY
VISIT
#
1
(
INSTRUMENT
#
11)]

5.
Which
of
the
following
statements
best
describes
your
current
feelings
about
becoming
pregnant?

1
I
am
trying
to
get
pregnant
now
2
I
don't
wish
to
get
pregnant
now,
but
I
would
like
to
get
pregnant
within
the
next
three
months
3
I
would
like
to
get
pregnant
sometime
in
the
future,
but
not
in
the
next
three
months
4
I
do
not
ever
wish
to
get
pregnant
6.
Do
you
currently
use
any
form
of
birth
control?
By
birth
control,
I
mean
anything
that
you
might
have
done
to
prevent
pregnancy.

1
YES
2
NO

GO
TO
NEXT
MODULE
7.
What
form(
s)
of
birth
control
do
you
use?
(
CODE
ALL
THAT
APPLY)

1
Birth
control
pills
2
IUD
3
Depo­
Provera/
Norplant
4
Condoms
5
Rhythm
Method
6
Diaphragm
7
Some
other
method
(
SPECIFY)
___________
Female
Preconception
2
(
Instrument
#
6)

5
{
END
OF
PREGNANCY
STATUS
MODULE}
Female
Preconception
2
(
Instrument
#
6)

6
Occupation
(
Update)

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

1
YES
2
NO

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

SKIP
TO
Q6
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,,

GO
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
[
FILL
DATE]?

1
YES
2
NO

GO
TO
NEXT
MODULE
Female
Preconception
2
(
Instrument
#
6)

7
Please
tell
me
about
the
jobs
you've
had
since
your
last
interview,
starting
with
the
(
FILL:
current/
most
recent/
next)
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
NEXT
MODULE
{
END
OF
OCCUPATION
MODULE}
Female
Preconception
2
(
Instrument
#
6)

8
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
Preconception
2
(
Instrument
#
6)

9
Activity
(
Full)

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)?
Female
Preconception
2
(
Instrument
#
6)

10
Now
think
about
the
activities
you
did
in
the
past
week 

4.
[
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
5.
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
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
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
for
the
past
12
months?
Over
the
past
month,
were
you
.
.
.

1
More
active
2
Less
active
3
About
the
same
Female
Preconception
2
(
Instrument
#
6)

11
9.
Compared
with
most
women
your
age,
would
you
say
that
you
are
.
.
.

1
More
active
2
Less
active
3
About
the
same
[
ASK
Q10
IF
WOMAN
AGE
>=
30]
10.
Compared
with
yourself
10
years
ago,
would
you
say
that
you
are
.
.
.

1
More
active
now
2
Less
active
now
3
About
the
same
{
END
OF
ACTIVITY
MODULE}
Female
Preconception
2
(
Instrument
#
6)

12
Diet
(
Full)

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
the
past
12
months,
how
often
per
day,
per
week,
per
month
or
per
year
did
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
the
past
12
months,
how
often
per
day,
per
week,
per
month
or
per
year
did
you
eat
cooked
dried
beans
or
peas,
such
as
(
INTERVIEWER,
USE
SHOW
CARD)

|___|___|___|
ENTER
NUMBER
OF
TIMES
(
PER
DAY,
WEEK,
MONTH
OR
YEAR)
Female
Preconception
2
(
Instrument
#
6)

13
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
Preconception
2
(
Instrument
#
6)

14
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)
__________

13.
The
next
question
is
about
regular
milk
use.
A
regular
milk
drinker
is
someone
who
uses
any
type
of
milk
at
least
5
times
a
week.
Using
this
definition,
which
statement
best
describes
you?

1
I've
been
a
regular
milk
drinker
for
most
or
all
of
my
life,
including
my
childhood
2
I've
never
been
a
regular
milk
drinker
3
My
milk
drinking
has
varied
over
my
life
 
sometimes
I've
been
a
regular
milk
drinker
and
sometimes
I
have
not
been
a
regular
milk
drinker
14.
Now,
I'm
going
to
ask
you
how
often
you
drank
milk
at
different
times
in
your
life.
How
often
did
you
drink
any
type
of
milk,
including
milk
added
to
cereal
when
you
were.
.
.

a.
a
child
between
the
ages
of
5
and
12
years
old?

0
Never
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
b.
a
teenager
between
the
ages
of
13
and
17
years
old?

0
Never
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
c.
a
young
adult
between
the
ages
of
18
and
35
years
old?

0
Never
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
The
next
questions
are
about
the
amount
of
food
you
eat.

15.
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
Female
Preconception
2
(
Instrument
#
6)

15
|___|___|
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.

16.
In
the
past
12
months,
did
you
go
to
a
community
program
or
volunteer
center
to
eat
prepared
meals?

1
YES
2
NO

SKIP
TO
END
17.
In
the
past
30
days,
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
Preconception
2
(
Instrument
#
6)

16
Personal
Medical
History
(
Update)

Now
I'd
like
to
ask
you
about
any
changes
to
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
pressure
or
hypertension
2
High
blood
sugar
or
diabetes
3
High
cholesterol
4
Anemia
(
poor
blood,
low
iron)
5
Heart
problems
6
Hayfever
or
allergy
7
Skin
allergy
or
eczema
8
Asthma
9
Kidney
or
bladder
(
urinary
tract)
infection
IF
Q1
=
8,
ASK
Q2­
4
ELSE,
SKIP
TO
Q5
2.
Did
a
doctor
or
other
medical
provider
tell
you
that
you
have
asthma?

1
YES
2
NO

SKIP
TO
Q5
3.
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.
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

GO
TO
NEXT
MODULE
5a.
What
were
those
illnesses?
(
ENTER
VERBATIM)

_______________________

6.
Since
[
FILL
DATE],
have
you
been
hospitalized
for
any
reason
1
YES
2
NO

GO
TO
NEXT
MODULE
Female
Preconception
2
(
Instrument
#
6)

17
6a.
Why
were
you
hospitalized?
(
ENTER
VERBATIM)

__________________________

{
END
OF
PERSONAL
MEDICAL
HISTORY
MODULE}
Female
Preconception
2
(
Instrument
#
6)

18
Dental
Health
(
Full)

1.
Have
you
ever
been
to
the
dentist
for
a
routine
cleaning?

1
YES
2
NO

SKIP
TO
Q3
2.
When
was
your
last
routine
cleaning?

MM/
YYYY
3.
Do
you
currently
have
any
of
the
following
dental
problems?

[
READ
EACH
CATEGORY]

IF
YES,
ASK:
When
was
the
last
time
you
saw
a
dentist
for
this
condition?

a.
Plaque
YES
NO
MM/
YYYY
0
=
NEVER
b.
Bleeding
gums
or
other
gum
disease
YES
NO
MM/
YYYY
0
=
NEVER
c.
Tooth
decay
YES
NO
MM/
YYYY
0
=
NEVER
d.
Tooth
ache
YES
NO
MM/
YYYY
0
=
NEVER
e.
Dentist­
diagnosed
gingivitis
YES
NO
MM/
YYYY
0
=
NEVER
f.
Dentist­
diagnosed
periodontitis
YES
NO
MM/
YYYY
0
=
NEVER
g.
Missing
or
broken
teeth?
YES
NO
MM/
YYYY
0
=
NEVER
g.
Any
other
dental
problems?
(
SPECIFY)
YES
NO
MM/
YYYY
0
=
NEVER
{
END
OF
DENTAL
HEALTH
MODULE}
Female
Preconception
2
(
Instrument
#
6)

19
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
Preconception
2
(
Instrument
#
6)

20
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
Preconception
2
(
Instrument
#
6)

21
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

SKIP
TO
NEXT
SECTION
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
Preconception
2
(
Instrument
#
6)

22
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
Preconception
2
(
Instrument
#
6)

23
Neighborhood
(
Full)

Now
I'd
like
to
ask
you
about
the
neighborhood
you
live
in.

1.
In
your
opinion,
is
your
neighborhood 

1
A
very
good
place
to
live
2
A
fairly
good
place
to
live
3
Not
a
very
good
place
to
live,
or
4
Not
at
all
a
good
place
to
live?

2.
How
often
do
people
in
your
neighborhood 

Never
Rarely
Sometimes
Often
Always
DK
a.
Visit
your
home?
0
1
2
3
4
­
1
b.
Argue
with
you?
0
1
2
3
4
­
1
c.
Look
after
your
children?
0
1
2
3
4
­
1
d.
Keep
to
themselves?
0
1
2
3
4
­
1
e.
Attend
religious
services?
0
1
2
3
4
­
1
3.
Is
your
neighborhood 

Not
at
all
Sometimes
Usually
a.
Lively?
0
1
2
b.
Polluted/
dirty?
0
1
2
c.
Friendly?
0
1
2
d.
Noisy?
0
1
2
e.
Clean?
0
1
2
f.
Attractive?
0
1
2
4.
Have
you
ever
asked
a
neighbor 
(
CODE
ALL
THAT
APPLY)

1.
To
help
with
minor
household
tasks
or
repairs?
2.
To
give
you
a
ride
somewhere?
3.
To
help
take
care
of
you
or
a
family
member
when
you
are
sick?
4.
To
borrow
money?
5.
To
borrow
other
items
such
as
food
or
tools?

5.
Do
you
feel
that
your
neighborhood
is 

1
Very
safe
2
Somewhat
safe
3
Somewhat
unsafe,
or
4
Very
unsafe?

6.
In
your
opinion,
does
your
neighborhood
have
problems
with 
(
CODE
ALL
THAT
APPLY)

a.
Property
crimes
such
as
break­
ins
or
burglaries?
b.
Personal
crimes
such
as
muggings
or
beatings?
c.
Violent
crimes?
d.
Drug
dealing?
Female
Preconception
2
(
Instrument
#
6)

24
7.
From
where
you
live,
is
it
relatively
easy
for
you
to
get
to 
(
CODE
ALL
THAT
APPLY)

1
stores
to
get
the
groceries
you
need?
2
public
parks
or
recreational
facilities?
3
doctor's
offices
or
clinics?
4
your
religious
institution?
5
your
children's
schools?
[
DISPLAY
ONLY
IF
R
HAS
CHILD]
6
daycare
programs?
[
DISPLAY
ONLY
IF
R
HAS
CHILD]

8.
Are
you
a
member
of
any
religious
faith?

1
YES
2
NO

GO
TO
NEXT
MODULE
9.
How
often
do
you
go
to
a
place
of
worship?

1
At
least
once
a
week
2
At
least
once
a
month
3
At
least
once
a
year
4
Or
not
at
all?

{
END
OF
NEIGHBORHOOD
MODULE}
Female
Preconception
2
(
Instrument
#
6)

25
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
Preconception
2
(
Instrument
#
6)

26
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?
Female
Preconception
2
(
Instrument
#
6)

27
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?

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
Preconception
2
(
Instrument
#
6)

28
Acceptability
(
To
be
administered
at
the
end
of
the
home
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

SKIP
TO
Q6
2
NO
2.
Did
you
have
to
take
time
off
from
work
to
have
this
interview
today?

1
YES
2
NO
3.
Did
you
need
to
find
childcare
to
have
this
interview
today?

1
YES
2
NO
4.
Were
there
any
other
major
obstacles
for
you
to
have
this
interview
today?

1
YES
2
NO

SKIP
Q6
5.
What
were
they?
(
ENTER
VERBATIM)

____________________________

6.
Is
there
anything
that
you
especially
like
about
participating
in
this
study?
(
ENTER
VERBATIM)

____________________________

7.
Is
there
anything
you
especially
dislike
about
participating
in
this
study?
(
ENTER
VERBATIM)

____________________________

8.
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}