ABC Maternal Baseline Questionnaire

ABC
Maternal Baseline Questionnaire
Participant ID
Initials
Instructions:
1. Please read the questionnaire instructions before answering the questions.
2. Please press firmly using a black ballpoint pen (provided). Never use pencil.
3. If it is necessary to make a correction, please draw a single line through the incorrect value and write
the correct value nearby. Please initial and date each correction. Never use an eraser or liquid paper.
4. Mark all choice boxes with an [x]
For example:
What is the baby’s sex?
Female
X Male
X
5. Do not leave blank boxes where a response is expected. For example, record ND (Not Done); UNK
(Unknown); or NA (Not applicable) in or near the boxes where the response would be expected.
6. Record the date in the following format: YYYY/MM/DD
2
0
Year
0
3
0
Month
3
1
1
Day
7. Print all text and numbers clearly in English. Print numbers inside the boxes and as simply as possible
without any loops or extra strokes.
Include an initial for the subject first, second/middle and surname. If the subject does not have a
second/middle name, please draw a straight line through the middle box as demonstrated in the example
below:
Initials
A
-
F
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ABC
Maternal Baseline Questionnaire
Participant ID
Initials
Baseline Visit Date
Year
Month
Day
DEMOGRAPHIC INFORMATION:
1. To which Nation do you identify yourself with?
Cayuga
Mohawk
Onondaga
Oneida
Seneca
Tuscarora
Other
2. What is your country of birth?
Canada
United States
Other (specify) _____________________
3. What is your place of birth?
Six Nations Reserve
Other
4. How long have you lived on the Six Nations Reserve?
Since Birth
OR
years
months
5. To which ethnicity does the biological father of your baby identify with?
Aboriginal
European
Mixed
Other
PAST PREGNANCY INFORMATION:
6. Do you have any other children, not including your unborn child?
No
Yes  a. How many other children do you have?
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Maternal Baseline Questionnaire
Participant ID
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7. Record the age and sex of your other children; provide other requested information.
Child #
Age
Sex
Premature*
C-section
* < 37 weeks
Birth Weight
Feeding
Breast milk
1.
Male
Female
Yes
No
Yes
No
Male
Female
Yes
No
Yes
No
Formula
lbs
oz
Combination of both
Breast milk
2.
lbs
oz
Formula
Combination of both
Breast milk
3.
4.
Male
Female
Yes
No
Yes
No
Male
Female
Yes
No
Yes
No
Formula
lbs
oz
Combination of both
Breast milk
lbs
oz
Formula
Combination of both
8. In the following section, please provide details about your past pregnancies.
a. Have you ever had stillbirth (20 weeks or later)?
No
Yes
 i. How many?
ii. At what gestational age was your most recent one?
weeks
b. Have you ever had miscarriage?
No
Yes
 i. How many?
ii. At what gestational age was your most recent one?
weeks
c. Have you ever had therapeutic abortion?
No
Yes
 i. How many?
ii. At what gestational age was your most recent one?
weeks
d. Have you ever had high blood pressure during pregnancy?
No
Yes
e. Have you ever had diabetes diagnosed during pregnancy?
No
Yes
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Maternal Baseline Questionnaire
Participant ID
Initials
CURRENT PREGNANCY:
9. What was:
a. The first date of your last menstrual period?
Year
Month
Year
Month
Day
b. Your expected delivery date?
Day
10. Have you had any ultrasounds during this pregnancy?
No
Yes  i. How many ultrasounds have you had?
ii. When was your most recent ultrasound?
11. What was your weight prior to becoming pregnant?
.
weeks
lbs
12. During this pregnancy, have you been diagnosed with:
a. High blood pressure?
No
Yes
b. High blood sugar?
No
Yes
i. Was this confirmed to be diabetes?
c. Please specify any other medical problems
No
Yes
_______________________________________
13. Has your doctor, midwife or nurse practitioner discussed what you plan to feed your baby (e.g: breast milk or
formula)?
No
Yes
14. What do you plan to feed your baby?
Breast milk
Formula
Combination of breast milk and formula
Undecided
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Maternal Baseline Questionnaire
Participant ID
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MEDICAL HISTORY:
15. Prior to this pregnancy, have you been diagnosed, by a doctor, as having any of the conditions listed below?
No
Yes
Age Diagnosed (If Yes)
High blood pressure (excluding pregnancy)
High blood cholesterol
Diabetes
Heart attack, stroke, angioplasty, coronary bypass
Heart valve problem
Blood clot to veins of lungs or legs
Current wheezing (in past 12 months)
Asthma
Eczema
Depression
Anxiety
Other
Specify _________________________
16. During the 12 months prior to your pregnancy, have you ever taken any of the following medications or had any
of the following treatments? Check all that apply.
No
Yes
Blood pressure pills
Lipid/cholesterol lowering pills
Insulin
Pills for diabetes
Prescribed diet for diabetes
Angioplasty or coronary bypass
Thyroid hormone
Antibiotics
Nicotine replacement therapy
Asthma medication (puffers)
Multivitamins
Specify_________________
Other
Specify_________________
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Maternal Baseline Questionnaire
Participant ID
Initials
17. During this pregnancy, have you ever taken any of the following medications or had any of the following
treatments? Check all that apply.
No
Yes
Blood pressure pills
Lipid/cholesterol lowering pills
Insulin
Pills for diabetes
Prescribed diet for diabetes
Angioplasty or coronary bypass
Thyroid hormone
Antibiotics
Nicotine replacement therapy
Asthma medication (puffers)
Multivitamins
Specify_________________
Other
Specify _________________
ALCHOHOL USE PRIOR TO PREGNANCY:
18. During the 12 months prior to pregnancy, how often did you drink beer, wine, liquor or any other alcoholic
beverage?
Never, or less than 1 drink a month
Once a month
Between 2 and 3 times a month
Once a week
Between 2 and 3 times a week
Between 4 and 6 times a week
Everyday
Greater than 5 drinks in a single day
ALCHOHOL USE DURING PREGNANCY:
19. During pregnancy, how often do you drink beer, wine, liquor or any other alcoholic beverage?
Never, or less than 1 drink a month
Once a month
Between 2 and 3 times a month
Once a week
Between 2 and 3 times a week
Between 4 and 6 times a week
Everyday
Greater than 5 drinks in a single day
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Maternal Baseline Questionnaire
Participant ID
Initials
TOBACCO USE:
20. Which best describes your history of smoking cigarettes?
Never
Former Smoker
a. When did you stop smoking (in months)?
Currently smokes cigarettes
a. How many cigarettes do you smoke (per day)?
b. How many years have you smoked?
21. Did you stop smoking since becoming pregnant?
N/A
No
Yes
a. When during pregnancy did you stop smoking?
weeks
22. Over the past 12 months what has been your typical exposure to other people's smoke?
Never
1 or more times per week
a. How many days/week?
b. How many hours/day?
23. Which best describes the biological father of your baby’s history of smoking cigarettes?
Never
Former Smoker
a. When did he stop smoking (in months)?
Currently smokes cigarettes
a. How many cigarettes did he smoke (per day)?
b. How many years has he smoked?
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ABC
Maternal Baseline Questionnaire
Participant ID
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DRUG USE:
24. Which of the following street drugs or medicines have you taken more than once in the past 12 months to get high,
to feel elated, to get a “buzz” or to change your mood? Please select all that apply.
Amphetamines
“Speed”
Crystal meth
“Crank”
“Rush”
Dexedrine
Ritalin
Diet pills
Snorting
IV
Freebase
Crack
“Speedball”
Heroin
Morphine
Dilaudid
Opium
Demerol
Methadone
Darvon
Codeine
Percodan
Vicodin
OxyContin
LSD (“acid”)
Mescaline
Peyote
Psilocybin
STP
“Mushrooms”
“Ecstasy”
MDA
MDMA
PCP
Ketamine
“Glue”
“Rush”
Ethyl chloride
THC
Nitrous oxide
Marijuana
Hashish
“Pot”
“Grass”
Amyl or butyl nitrate
“Reefer”
Quaalude
GHB
Seconal
Valium
Xanax
Librium
Ativan
Dalmane
Halcion
Barbiturates
Miltown
Roofinol
“Roofies”
Steroids
Nonprescription sleep or diet pills
Cough Medicine
Other Specify ________________________
25. From the above list, which drugs do you use most often?
1) _________________________________
2) _________________________________
3) _________________________________
4) _________________________________
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Maternal Baseline Questionnaire
Participant ID
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FAMILY MEDICAL HISTORY:
26. Has your mother had any of the following?
Unknown
No
Yes
No
Yes
Heart attack < 65 years of age
Toxemia or pre-ecampsia
Asthma diagnosed by doctor
Eczema
Diabetes
Stroke
Blood clot to veins of lungs or legs
27. Has your father ever had any of the following?
Unknown
Heart attack < 65 years of age
Asthma diagnosed by doctor
Eczema
Diabetes
Stroke
Blood clot to veins of lungs or legs
28. Has your biological full sister(s) ever had any of the following?
N/A
Unknown
No
Yes
Heart attack < 65 years of age
Toxemia or pre-ecampsia
Asthma diagnosed by doctor
Eczema
Diabetes
Stroke
Blood clot to veins of lungs or legs
29. Has your biological full brother(s) ever had any of the following?
N/A
Unknown
No
Yes
Heart attack < 65 years of age
Asthma diagnosed by doctor
Eczema
Diabetes
Stroke
Blood clot to veins of lungs or legs
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Maternal Baseline Questionnaire
Participant ID
Initials
30. In the past year, has the biological father of your baby taken any of the following medications or had any of the
following treatments? Select all that apply.
Unknown
No
Yes
Heart attack < 65 years of age
Asthma diagnosed by doctor
Eczema
Diabetes
Stroke
Blood clot to veins of lungs or legs
Blood pressure pills
Lipid/Cholesterol lowering pills
Insulin
Pills for diabetes
Prescribed diet for diabetes
Angioplasty or coronary bypass
Thyroid hormone
Antibiotics
PHYSICAL ACTIVITY -PRIOR TO PREGNANCY:
31. On an average day considering your work and leisure activities, how active have you been prior to this
pregnancy?
Mainly sedentary (using computer, answering phones)
Mainly walking on one level, or other mild exercise
Mainly walking, climbing stairs, walking uphill, or lifting heavy objects
Heavy physical labour or moderate/strenuous exercise
32. Prior to this pregnancy, how many minutes per day do you watch television, use the internet/email or computer
screens (ipad, kindle, etc.) or play video/computer games?
min/day
33. Prior to this pregnancy, how many minutes per day did you exercise so that you feel out of breath or sweat
(eg:waking or jogging)?
min/day
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ABC
Maternal Baseline Questionnaire
Participant ID
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PHYSICAL ACTIVITY -DURING PREGNANCY:
34. On an average day considering your work and leisure activities, how active are you during this pregnancy?
Mainly sedentary (using computer, answering phones)
Mainly walking on one level, or other mild exercise
Mainly walking, climbing stairs, walking uphill, or lifting heavy objects
Heavy physical labour or moderate/strenuous exercise
35. During this pregnancy, how many minutes per day do you watch television, use the internet/email or computer
screens (ipad, kindle, etc.) or play video/computer games?
min/day
36. During this pregnancy, how many minutes per day did you exercise so that you feel out of breath or sweat (eg:
walking or jogging)?
min/day
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ABC
Maternal Baseline Questionnaire
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EDUCATION:
37. What is the highest level of education obtained by yourself?
Did not complete High School
Completed High School (Secondary school)
Diploma from Trade, Technical, or Vocational school
Bachelor's degree or Teacher's College (B.A., B.Sc.)
Master's (M.A, M.Sc., M.Ed) or Doctorate (PhD)
Professional Degree (M.D, D.D.S, D.V.M)
38. What is the highest level of education obtained by the father of your baby?
Did not complete High School
Completed High School (Secondary school)
Diploma from Trade, Technical, or Vocational school
Bachelor's degree or Teacher's College (B.A., B.Sc.)
Master's (M.A, M.Sc., M.Ed) or Doctorate (PhD)
Professional Degree (M.D, D.D.S, D.V.M)
39. What is the highest level of education obtained by your father?
Did not complete High School
Completed High School (Secondary school)
Diploma from Trade, Technical, or Vocational school
Bachelor's degree or Teacher's College (B.A., B.Sc.)
Master's (M.A, M.Sc., M.Ed) or Doctorate (PhD)
Professional Degree (M.D, D.D.S, D.V.M)
40. What is the highest level of education obtained by your mother?
Did not complete High School
Completed High School (Secondary school)
Diploma from Trade, Technical, or Vocational school
Bachelor's degree or Teacher's College (B.A., B.Sc.)
Master's (M.A, M.Sc., M.Ed) or Doctorate (PhD)
Professional Degree (M.D, D.D.S, D.V.M)
41. What is your marital status?
Never married
Currently married
Common law/Living with partner
Widowed
Separated/Divorced
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Maternal Baseline Questionnaire
Participant ID
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42. Which of the following best describes your current employment status?
Employed (including self-employed)
a. What is the condition of your employment?
Full time
Part time
Unemployed
Retired
43. Which of the following best describes your baby's biological father's current employment status?
Employed (including self-employed)
a. What is the condition of your employment?
Full time
Part time
Unemployed
Retired
44. What is the best estimate of the total income of ALL household members, from ALL sources, in the past twelve
(12) months (before taxes)?
$0 - $14, 999
$15, 000 - $19, 999
$20, 000 - $29, 999
$30, 000 - $39, 999
$40, 000 - $49, 999
$50, 000 - $50, 999
$60, 000 - $80, 000
$80, 000 - $100, 000
$100, 000 +
45. Does the father of your baby share your home?
No
Yes
46. How many people currently share your home, including yourself?
47. How many of these are children are under the age of 18?
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ABC
Maternal Baseline Questionnaire
Participant ID
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STRESS:
48. To what extent do you agree or disagree with the following statements:
Strongly
Disagree
Disagree
Neutral
Agree
Strongly
Agree
At work I feel I have control over what
happens in most situations
I feel what happens in my life is often
determined by factors beyond my control
Over the next 5-10 years, I expect to have
more positive than negative experiences
I often feel like I am being treated unfairly
In the past 10 years my life has been full
of changes without my knowing what
will happen
I gave up trying to make big improvements
in my life a long time ago
PERSONAL MENTAL HEALTH:
49. In the past 30 days, how often do you feel:
None of the time
Some of the time
Most of the time All of the time
Nervous?
So nervous that nothing calms you down?
Hopeless?
Restless or fidgety?
So restless that you could not sit still?
Depressed?
That everything was an effort?
So sad that nothing could cheer you up?
Worthless?
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Maternal Baseline Questionnaire
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SOCIAL SUPPORT:
50. The following questions are related to your personal life situation, your children, your spouse or partner, and other
people you deal with. Please give a response that fits best with your typical experiences.
Definitely not enough
Not enough
Enough
Definitely enough
Do you feel there are enough people in your
environment who would help you with your
daily chores if you were sick (eg: cooking,
cleaning, grocery shopping, etc.)?
Do you feel there are enough people in your
environment who would look after your
children if you were called for an
emergency?
Do you feel there are enough people in your
environment who would lend you
something you need (eg: food, clothing,
money, etc.)?
Do you feel there are enough people in your
environment who would take you and your
child to the doctor in an emergency?
Do you feel there are enough people in your
environment to give you advice (eg: specific
suggestions on what to do when your child
has a health problem, or advice on your
household management or financial
matters)?
Do you feel there are enough people in your
environment to give you the information
you need (eg: people who can tell you about
all the people you can go to if your child
need a tutor, or who can tell you what the
options are foryour sick child: going to the
doctor or eating a particular type of food)?
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Maternal Baseline Questionnaire
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Definitely not enough
Not enough
Enough
Definitely enough
Do you feel that there are enough people in
your environment to talk to about things
that are very personal and private, like
difficulties in your relationship with your
husband,
family
matters,
physical
complaints, family planning etc.?
Do you feel there are enough people in your
environment who listen to you when you
want to talk about your sorrows, or about
your child's education or health?
Do you feel there are enough people in your
environment who can comfort you when
you feel unhappy about your daily life?
Do you feel there are enough people in your
environment who can show interest and
concern in your well being
(eg: when you are sick)?
Do you feel there are enough people in your
environment who can tell you that you did a
good job handling a problem (eg: your
child's difficult behavior, your child's health
problem, or a problem at work or in the
household)?
Do you feel there are enough people in your
environment who express their respect for
your personal qualities (eg: your personal
strength in facing difficulties, being
friendly, helping others with problems)?
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Maternal Baseline Questionnaire
Participant ID
Initials
VIEWS AROUND HEALTH OUTCOMES:
51. For the following statements, please rate how strongly you agree or disagree. See the box below for the values:
1 = Strongly disagree
2 = Disagree
3 = Neutral, neither agree nor disagree
4 = Agree
5 = Strongly agree
a. What I do right up to the time that my baby is born can affect my baby’s health.
1
2
3
4
5
b. My unborn child’s health can be seriously affected by my actions during pregnancy.
1
2
3
4
5
c. By attending prenatal classes taught by competent health professionals, I can greatly increase the odds of having
a health, normal baby.
1
2
3
4
5
d. No matter what I do when I am pregnant, the laws of nature determine whether or not my child will be healthy.
1
2
3
4
5
e. Even if I take excellent care of myself when I am pregnant, fate will determine whether my child will be normal
or abnormal.
1
2
3
4
5
f. Fate determines the health of my unborn child.
1
2
3
4
5
g. My baby will be born healthy only if I do everything my doctor/midwife/nurse tells me to do during pregnancy.
1
2
3
4
5
h. My baby’s health is in the hands of health professionals.
1
2
3
4
5
i. Only qualified health professionals can tell me what I should and should not do when I am pregnant.
1
2
3
4
5
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Maternal Baseline Questionnaire
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DIET:
52. How often do you eat foods from each of the following categories? For each food item, check how often you
consume the food (never, monthly, weekly or daily) and then record the actual number of times the item is consumed
during that time period.
< 1 per month or never
Monthly
Weekly
Daily
#times
Meat/Poultry
Fish
Eggs
Whole Grains
Refined/Milled Grains
Dairy products (not in tea/coffee)
Deep fried foods/snacks/fast food
Soy sauce, fish sauce
Salty foods/snacks
Pickled vegetables (brine)
Deserts/sweet snacks
Sugar/sweeteners
Tofu/soyabean curd
Legumes (eg: beans, lentils)
Nuts/seeds
Fruits
Fruit Juices
Leafy green vegetables
a. How are they usually eaten?
Raw
Cooked crisp
Cooked soft
Other vegetables (raw)
Other vegetables (cooked)
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