NCS
Herald
Cohort
Study
Instrument
#
3
Female
Questionnaire
Preconception
Initial
Visit
Eligibility:
All
women
enrolled
preconception
Mode
of
administration:
Interviewer,
home
visit
8/
4/
2005
Public
reporting
burden
for
this
collection
of
information
is
estimated
to
average
75
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
1
(
Instrument
#
3)

1
PRELOADED
DATA:
Today's
date
Language
of
interview
(
English/
Spanish)

Respondent
Name
Respondent
Address
and
Phone
Spouse/
Partner's
Name
(
Preload
from
screener)

Spouse/
Partner's
Address
and
Phone
(
Preload
from
screener)

Marital
status
(
Preload
from
screener)

QUESTIONNAIRE:
Female
Preconception
1
(
Instrument
#
3)

2
Household
Composition
(
Full)

The
first
questions
are
about
people
living
in
this
household.

1.
Including
yourself,
how
many
adults
ages
18
and
older
are
currently
living
in
this
household?
(
ENTER
NUMBER)

_____

2.
[
IF
Q1>
1]
Not
including
yourself,
who
are
the
other
adults
living
in
this
household?
(
PROMPT:
HOW
ARE
THEY
RELATED
TO
YOU?)
(
CODE
ALL
THAT
APPLY)

1
your
spouse
or
partner
2
your
parent(
s)
3
your
partner's
parent(
s)
4
your
adult
child
/
children
5
other
relation(
s)
of
yourself
6
other
relations
of
your
partner
7
roommate(
s)
8
boarder
or
renter
9
other
(
SPECIFY)
___________________

3.
How
many
children
aged
5
through
17
are
currently
living
in
this
household?
(
ENTER
NUMBER)

_____

4.
How
many
children
under
age
5
are
currently
living
in
this
household?
(
ENTER
NUMBER)

_____

5.
[
IF
Q
>
1]
Are
you
the
regular
caregiver
for
any
adults
or
children
who
live
in
this
household?

1
YES
2
NO

GO
TO
NEXT
MODULE
6.
How
many
adults
do
you
regularly
care
for?
(
ENTER
NUMBER)

_____

7.
[
IF
Q3+
Q4
>
1]
How
many
children
do
you
regularly
care
for?
(
ENTER
NUMBER)

_____

{
END
OF
HOUSEHOLD
COMPOSITION
MODULE}
Female
Preconception
1
(
Instrument
#
3)

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
1
(
Instrument
#
3)

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,
1ST
HOME
VISIT
(
INSTRUMENT
#
13)]

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)
___________

{
END
OF
PREGNANCY
STATUS
MODULE}
Female
Preconception
1
(
Instrument
#
3)

5
Occupation
(
Full)

Next,
I'm
going
to
ask
you
about
your
education
and
employment.

1.
Are
you
currently
a
full­
or
part­
time
student?

1
NO,
NOT
A
STUDENT

SKIP
TO
Q3
2
YES,
FULL­
TIME
STUDENT
3
YES,
PART­
TIME
STUDENT
2.
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)_________________

3.
Are
you
currently 

1
Working
at
a
job
or
business,

SKIP
TO
PARAGRAPH
BEFORE
Q5
2
Looking
for
work,
or
3
Not
working
at
a
job
or
business?

4.
Were
you
working
at
a
job
or
business
at
any
time
during
the
last
12
months?

1
YES
2
NO

GO
TO
NEXT
MODULE
Now,
I'd
like
to
ask
you
a
few
questions
about
jobs
you
held
in
the
last
year.
I
will
collect
information
on
your
last
3
jobs,
if
they
occurred
in
the
last
12
months.
Let's
start
with
your
(
FILL:
current/
most
recent/
next)
job.

5.
On
what
date
did
you
start
this
job?

MM/
DD/
YYYY
6.
[
SKIP
AND
PREFILL
WITH
`
1'
IF
CURRENT
JOB]
On
what
date
did
you
stop
working
at
this
job?

MM/
DD/
YYYY
1
=
STILL
EMPLOYED
7.
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
Female
Preconception
1
(
Instrument
#
3)

6
8.
What
kind
of
work
(
FILL:
are/
were)
you
doing?
(
For
example:
farming,
mail
clerk,
computer
specialist.)

_________________________________
ENTER
NAME
OF
OCCUPATION
9.
How
many
hours
a
week
(
FILL:
do/
did)
you
usually
work
at
this
job?

____
HOURS
10.
(
FILL:
Do/
Did)
you
do
shift
work
for
this
job?

1
YES
2
NO

SKIP
TO
Q12
11.
(
FILL:
Does/
Did)
this
include
the
night
shift?

1
YES
2
NO
12.
Did
you
have
any
other
jobs
in
the
last
12
months?

1
YES
[
REPEAT
Q5­
Q11
FOR
UP
TO
3
JOBS]
2
NO

GO
TO
NEXT
MODULE
{
END
OF
OCCUPATION
MODULE}
Female
Preconception
1
(
Instrument
#
3)

7
Chemical
Exposures
Module
Now
I'm
going
to
ask
you
about
chemicals
you
may
have
used
at
work,
at
home,
or
for
any
hobbies.

1.
Have
you
been
exposed
to
[
HAND
SHOW
CARD
TO
PARTICIPANT
FOR
EACH
EXPOSURE
FROM
TABLE
BELOW]
in
the
last
12
months?

If
Yes,
ASK:

2.
Are
you
currently
exposed
to
[
INSERT
EXPOSURE]
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?

1.
Exposed
in
last
12
months
Yes=
01
No
=
02
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
1
(
Instrument
#
3)

8
Home
Environment/
Conditions
(
Full)

The
next
series
of
questions
are
related
to
your
home
environment,
including
your
water
sources,
heating,
and
air
conditioning.

1.
How
long
have
you
lived
at
this
address:
{
FILL
PRELOAD
ADDRESS}?

______
YEARS
_______
MONTHS
2.
Which
water
source
is
used
more
than
half
the
time
for
cooking?

1
Tap
water
2
Bottled
water,
or
3
Water
from
some
other
source?
(
SPECIFY)
__________________

3.
Which
water
source
is
used
more
than
half
the
time
for
drinking?

1
Tap
water
2
Bottled
water,
or
3
Water
from
some
other
source?
(
SPECIFY)
__________________

4.
Do
you
use
any
of
the
following
to
treat
your
water
at
home?
(
CODE
ALL
THAT
APPLY)

1
A
water
softener?
2
Charcoal
filters?
3
Reverse
osmosis?
4
Distillation?
5
Something
else?
(
SPECIFY)_______________________

Heat
and
Air
Conditioning
1.
Which
fuels
are
used
for
heating
this
residence?
(
CODE
ALL
THAT
APPLY)

1
Gas:
from
underground
pipes
serving
the
neighborhood
2
Gas:
bottled,
tank,
or
LP
3
Electricity
4
Fuel
oil,
kerosene,
etc
5
Coal
or
coke
6
Wood
7
Solar
energy
8
Propane
9
Other
fuel
(
SPECIFY)
____________________

2.
Does
this
residence
have
a
central
heating
system
with
ducts
that
blow
air
into
most
rooms?

1
YES
2
NO
3.
During
which
month
do
you
usually
start
using
heating
devices?

_____
Female
Preconception
1
(
Instrument
#
3)

9
4.
During
which
month
do
you
usually
stop
using
heating
devices?

_____

5.
During
the
months
that
you
use
heating
devices,
do
you
use
portable
kerosene
heaters
in
this
residence?

1
YES
2
NO

SKIP
TO
Q7
6.
How
often
do
you
use
your
kerosene
heater
during
the
heating
season?

1
Less
than
one
day
a
month
2
One
to
three
days
per
month
3
One
or
two
days
a
week
4
3­
5
days
a
week
5
More
than
5
days
a
week
7.
During
the
heating
season,
is
a
portable
or
nonvented
gas
(
non­
kerosene)
heater
used
in
this
residence?

1
YES
2
NO

SKIP
TO
Q9
8.
How
often
do
you
use
a
portable
or
nonvented
gas
heater
during
the
heating
season?

1
Less
than
one
day
a
month
2
One
to
three
days
per
month
3
One
or
two
days
a
week
4
3­
5
days
a
week
5
More
than
5
days
a
week
9.
During
the
heating
season,
is
a
wood­
or
coal­
burning
stove
or
a
wood­
burning
fireplace
used
in
this
residence?

1
YES
2
NO

SKIP
TO
Q11
10.
How
often
do
you
use
a
wood­
or
coal­
burning
stove
or
a
wood­
burning
fireplace
during
the
heating
season?

1
Less
than
one
day
a
month
2
One
to
three
days
per
month
3
One
or
two
days
a
week
4
3­
5
days
a
week
5
More
than
5
days
a
week
11.
Is
air
conditioning
(
refrigeration)
used
to
cool
this
residence?

1
YES
2
NO

SKIP
TO
NEXT
SECTION
Female
Preconception
1
(
Instrument
#
3)

10
12.
Which
of
the
following
types
of
air
conditioning
units
do
you
use?
(
CODE
ALL
THAT
APPLY)

1
Central
unit/
units?
2
Window
or
wall
unit/
units?
3
Portable
unit/
units?

13.
During
which
month
do
you
usually
start
using
air
conditioning
to
cool
this
residence?

_____

14.
During
which
month
do
you
usually
stop
using
air
conditioning?

_____

Cooking
1.
Do
you
use
a
gas
stove
for
cooking?

1
YES
2
NO
2.
Do
you
use
a
gas
stove
for
any
other
purpose
than
cooking,
for
example,
drying
clothes
or
heating
a
room?

1
YES
2
NO
Pesticides
and
Lawn
Care
Now
I'm
going
to
ask
you
about
the
use
of
pesticides
and
lawn
treatments
in
and
around
your
home.

1.
In
the
past
6
months,
were
any
chemicals
used
inside
this
residence
for
the
control
of
termites,
insects,
rodents,
or
other
pests?

1
YES
2
NO

SKIP
TO
Q6
2.
In
the
past
6
months,
what
rooms
in
your
home
were
treated
with
products
for
the
control
of
termites,
insects,
rodents,
or
other
pests?
(
CODE
ALL
THAT
APPLY)

1
Living
room
2
Family
room
3
Dining
room
4
Kitchen
5
Bathroom(
s)
6
Bedroom(
s)
7
Other
rooms
Female
Preconception
1
(
Instrument
#
3)

11
3.
In
the
past
6
months,
how
many
times....

a.
did
a
professional
exterminator
apply
these
products
inside
this
residence?
_______

b.
did
you
apply
these
products
inside
this
residence?
_______

4.
In
what
month
were
they
last
used
inside
this
residence?

_____

5.
What
were
the
names
of
the
products
last
used
inside
this
residence?

_________________
_________________
_________________

6.
In
the
past
6
months,
were
any
chemicals
used
outside
this
residence
for
the
control
of
termites,
insects,
rodents,
or
other
pests?

1
YES
2
NO

SKIP
TO
Q10
7.
In
the
past
6
months,
how
many
times....

a.
did
a
professional
exterminator
apply
these
products
outside
this
residence?
_______

b.
did
you
apply
these
products
outside
this
residence?
_______

8.
In
what
month
were
they
last
used
outside
this
residence?

_____

9.
What
were
the
names
of
the
products
last
used
outside
this
residence?

_________________
_________________
_________________

10.
In
the
past
6
months,
have
you
had
any
regular
lawn
or
yard
treatments?

1
YES
2
NO

SKIP
TO
NEXT
SECTION
11.
Who
usually
applies
these
treatments?

1
You,
2
A
professional,
or
3
Someone
else?
Female
Preconception
1
(
Instrument
#
3)

12
The
next
few
questions
are
about
the
general
condition
of
your
home.

Renovations
and
Paint
1.
In
the
last
6
months,
which
of
the
following
renovations
have
been
performed
in
this
home?
(
CODE
ALL
THAT
APPLY)

1
Adding
a
room?
2
Putting
up
or
taking
down
a
wall?
3
Replacing
windows?
4
Refinishing
floors?
5
Exterior
painting?
6
Interior
painting
2.
Over
the
last
6
months,
how
would
you
rate
the
typical
condition
of
the
painted
surfaces
 
the
walls,
trim,
etc.
 
inside
this
residence?
Would
you
say 

1
Excellent,
2
Very
good,
3
Fair,
or
4
Poor?

Water
Damage
/
Mold
1.
Water
damage
includes
water
stains
on
the
ceiling
or
walls,
rotting
wood,
and
flaking
sheetrock
or
plaster.
This
damage
may
be
from
broken
pipes,
a
leaky
roof
or
floods.
Have
you
seen
any
water
damage
in
your
home?

1
YES
2
NO
2.
Have
you
seen
any
mold
or
mildew
on
walls
or
other
surfaces
other
than
food,
inside
your
home?

1
YES
2
NO

GO
TO
NEXT
MODULE
3.
In
which
rooms
have
you
seen
the
mold
or
mildew?
(
CODE
ALL
THAT
APPLY)

1
Kitchen
2
Living
room
3
Hall/
landing
4
Your
bedroom
5
Other
bedrooms
6
Bathroom/
toilet
{
END
OF
HOME
ENVIRONMENT
MODULE}
Female
Preconception
1
(
Instrument
#
3)

13
Pets
and
Pests
(
Full)

Now
I'm
going
to
ask
you
a
few
questions
about
pets
in
the
household.

1.
Do
you
have
house
pets
such
as
dogs,
cats,
gerbils,
hamsters,
rabbits,
guinea
pigs
or
birds?

1
YES
2
NO

SKIP
TO
Q6
2.
How
many
of
the
following
pets
do
you
have?
[
READ
EACH
TYPE
OF
PET.
IF
1
OR
MORE,
ASK:

3.
[
FILL:
Is
this
pet
/
How
many
of
these
pets
are]
kept
indoors?

Total
Number
Number
kept
indoors
1.
dogs
2.
cats
3.
gerbils,
hamsters
and
guinea
pigs
4.
rabbits
5.
birds
6.
Other
pets
(
specify)
____________

4.
Are
any
chemicals
used
on
the
pets
to
control
fleas
and
ticks?
(
e.
g.
treated
collars,
dips,
powders,
drops,
etc.)

1
YES
2
NO

SKIP
TO
Q6
5.
What
is
the
name
of
the
products
last
used
on
your
pets
to
control
fleas
or
ticks?

IF
RESPONDENT
DOES
NOT
KNOW,
ASK
TO
SEE
THE
CONTAINERS
_____________________
_____________________

6.
In
the
last
6
months,
have
you
seen
signs
of
mice,
rats,
or
other
rodents
in
your
home
(
not
including
pets)?

1
YES
2
NO
7.
In
the
last
6
months,
have
you
seen
cockroaches
in
your
home?

1
YES
2
NO
{
END
OF
PETS
AND
PESTS
MODULE}
Female
Preconception
1
(
Instrument
#
3)

14
Personal
and
Family
Medical
History
(
full)

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

1.
Are
you
allergic
to 
(
CODE
ALL
THAT
APPLY)

1
cats?
2
pollen?
3
dust?
4
insect
bites
or
stings?
5
any
foods?
(
SPECIFY)
___________________
6
anything
else?
(
SPECIFY)
__________________

2.
Have
you
ever
had
a
condition
called
"
hayfever"
or
an
allergy
that
makes
your
nose
runny
or
stuffy
or
your
eyes
itchy
when
you
do
not
have
a
cold?

1
YES
2
NO

SKIP
TO
Q4
3.
Did
a
doctor
or
other
medical
provider
ever
say
that
this
was
hayfever
or
allergy?

1
YES
2
NO
4.
Did
a
doctor
or
other
medical
provider
ever
tell
you
that
you
had
a
skin
allergy
or
eczema?

1
YES
2
NO
5.
Did
a
doctor
or
other
medical
provider
ever
tell
you
that
you
had
asthma?

1
YES
2
NO

SKIP
TO
Q8
6.
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
7.
Have
you
ever
gone
to
an
emergency
room
or
stayed
overnight
in
a
hospital
for
your
asthma?

1
YES
2
NO
8.
Do
you
have
any
of
the
following
health
problems?
(
CODE
ALL
THAT
APPLY)

1
High
blood
pressure
or
hypertension
2
High
blood
sugar
or
diabetes
3
High
cholesterol
4
Anemia
(
poor
blood,
low
iron)
5
Heart
problems
Female
Preconception
1
(
Instrument
#
3)

15
6
Kidney
or
bladder
(
urinary
tract)
infection
9.
Have
you
ever
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.
During
the
past
6
months,
have
you
been
hospitalized
for
any
reason?

1
YES
2
NO

SKIP
TO
Q11
10a.
Why
were
you
hospitalized?
(
ENTER
VERBATIM)

_______________________

11.
Have
any
of
your
blood
relatives
 
your
mother,
father,
sisters
or
brothers
 
ever
had 
(
CODE
ALL
THAT
APPLY)

1
High
blood
pressure
or
hypertension?
2
High
blood
sugar
or
diabetes?
3
High
cholesterol?
4
Heart
problems?

{
END
OF
PERSONAL
AND
FAMILY
MEDICAL
HISTORY
MODULE}
Female
Preconception
1
(
Instrument
#
3)

16
Medications
(
Full)

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
prescription
medications?

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
2
NO

GO
TO
NEXT
MODULE
4.
Please
tell
me
which
non­
prescription
medications
you
currently
take
on
a
regular
basis.
Do
you
take 

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
Female
Preconception
1
(
Instrument
#
3)

17
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
1
(
Instrument
#
3)

18
Supplements,
Vitamins,
Etc.
(
Full)

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
Q5
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.
How
long
have
you
been
taking
multivitamins?

1
Less
than
3
months
2
3
months
to
1
year
3
More
than
1
year
5.
Are
you
currently
taking
any
vitamins,
minerals,
or
supplements
other
than
your
multivitamins?

1
YES
2
NO

GO
TO
NEXT
MODULE
6.
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
Female
Preconception
1
(
Instrument
#
3)

19
16
NIACIN
17
SELENIUM
18
ZINC
7.
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
1
(
Instrument
#
3)

20
Health
Care
Access/
Insurance
(
Full)

The
next
few
questions
are
about
health
care
and
insurance.

1.
Are
you
covered
by
health
insurance
or
some
other
kind
of
health
care
plan?
Include
health
insurance
obtained
through
employment
or
purchased
directly
as
well
as
government
programs
like
Medicare
and
Medicaid
that
provide
medical
care
or
help
pay
medical
bills.

1
YES
2
NO

SKIP
TO
Q3
2.
What
kind
of
health
insurance
or
health
care
coverage
do
you
have?
Include
those
that
pay
for
only
one
type
of
service
(
nursing
home
care,
accidents,
or
dental
care).
Exclude
private
plans
that
only
provide
extra
cash
while
hospitalized.
(
INTERVIEWER:
USE
SHOW
CARD)

1
PRIVATE
HEALTH
INSURANCE
PLAN
FROM
EMPLOYER
OR
WORKPLACE
2
PRIVATE
HEALTH
INSURANCE
PLAN
PURCHASED
DIRECTLY
3
PRIVATE
HEALTH
INSURANCE
PLAN
THROUGH
A
STATE
OR
LOCAL
GOVERNMENT
PROGRAM
OR
COMMUNITY
PROGRAM
4
MEDICARE
5
MEDI­
GAP
6
MEDICAID
({
DISPLAY
STATE
PLAN
NAME})
7
CHIP
(
CHILDREN'S
HEALTH
INSURANCE
PROGRAM)
8
MILITARY
HEALTH
CARE/
VA
9
CHAMPUS/
TRICARE/
CHAMP­
VA
10
INDIAN
HEALTH
SERVICE
11
STATE­
SPONSORED
HEALTH
PLAN
({
DISPLAY
STATE
PLAN
NAME})
12
OTHER
GOVERNMENT
PROGRAM
13
SINGLE
SERVICE
PLAN
(
E.
G.,
DENTAL,
VISION,
PRESCRIPTIONS)

3.
What
kind
of
place
do
you
usually
go
to
most
often
when
you
are
sick
or
need
advice
about
your
health?

1
A
clinic
or
health
center,
2
A
doctor's
office
or
HMO,
3
A
hospital
emergency
room,
4
A
hospital
outpatient
department,
or
5
Some
other
place?
(
SPECIFY):
__________________
6
DOESN'T
GO
TO
ONE
PLACE
MOST
OFTEN
4.
About
how
long
has
it
been
since
you
last
saw
or
talked
to
a
doctor
or
other
health
care
professional
about
your
own
health?
Include
doctors
seen
while
a
patient
in
a
hospital.
Would
you
say 

0
Never,
1
6
months
or
less,
2
More
than
6
months,
but
not
more
than
1
year
ago,
3
More
than
1
year,
but
not
more
than
2
years
ago,
4
More
than
2
years,
but
not
more
than
5
years
ago,
or
5
More
than
5
years
ago?
{
END
OF
HEALTH
CARE
ACCESS/
INSURANCE
MODULE}
Female
Preconception
1
(
Instrument
#
3)

21
Reproductive
History
(
Full)

Now,
I
have
some
questions
about
your
reproductive
health
and
menstrual
history.
Please
remember
that
your
responses
will
be
kept
strictly
confidential.

Menstrual
History
1.
How
old
were
you
when
you
had
your
first
menstrual
period?

______
YEARS
OLD
2.
During
the
last
12
months,
what
was
the
average
number
of
days
between
the
first
day
of
bleeding
of
one
period
to
the
first
day
of
bleeding
of
your
next
period?

_____
DAYS
99
=
TOO
IRREGULAR
TO
KNOW
3.
During
the
last
12
months
{
FILL
IF
Q2=
99:
and
not
counting
any
previous
pregnancy},
did
you
ever
go
more
than
2
months
without
having
a
period?

1
YES
2
NO
Pregnancy
History
4.
How
many
times
have
you
ever
been
pregnant?
(
INT
PROBE:
No
matter
what
happened
with
the
pregnancy)

_____
[
IF
0,
GO
TO
NEXT
MODULE]

4a.
Did
any
of
these
pregnancies
result
in
a
live
birth?

1
YES
2
NO

GO
TO
NEXT
MODULE
5.
Did
any
of
your
babies
have
any
birth
defects
at
birth?

1
YES
2
NO
6.
Have
you
ever
had
a
baby
that
weighed
5
pounds,
8
ounces
(
2.5
kilos)
or
less
at
birth?

1
YES
2
NO
7.
Have
you
ever
had
baby
that
was
born
more
than
3
weeks
before
your
due
date?

1
YES
2
NO
{
END
OF
REPRO
HISTORY
MODULE}
Female
Preconception
1
(
Instrument
#
3)

22
Demographics
(
Income)

Household
income
is
often
used
in
scientific
studies
to
compare
groups
of
people
who
are
similar.
We
do
some
analysis
of
the
data
using
these
groups.
Please
remember
that
all
the
data
you
provide
is
held
in
strict
confidence.

1.
Do
you
or
your
household
receive
income
from ?
(
INTERVIEWER:
USE
SHOW
CARD.
CODE
ALL
THAT
APPLY)

1.
Wages
and
salaries?
2.
Self­
employment,
including
business
and
farm
income?
3.
Family
or
friends?
4.
Aid
such
as
Temporary
Assistance
for
Needy
Families
(
TANF),
welfare,
WIC,
public
assistance,
general
assistance,
food
stamps,
or
Supplemental
Security
Income?
5.
[
Do
you
or
your
household
receive
income
from]
Interest­
bearing
checking
accounts,
savings
accounts,
IRAs
or
certificates
of
deposit,
money
market
funds,
treasury
notes,
bonds,
or
other
investments
that
earned
interest?
6.
Dividends
received
from
stocks
or
mutual
funds,
or
net
rental
income
from
property,
royalties,
estates
or
trusts?
7.
Unemployment
benefits?
8.
Child
support
or
alimony?
9.
Social
security,
Railroad
Retirement,
workers'
compensation,
disability,
veteran
benefits,
or
pensions?
10.
Any
other
source?
(
SPECIFY)____________________

2.
Including
all
sources
of
income
just
mentioned,
approximately
what
is
the
gross
annual
income
for
all
members
in
this
household?
(
INTERVIEWER:
USE
SHOW
CARD)

1
Less
than
$
9,999,
2
$
10,000
­
$
19,999,
3
$
20,000
­
$
29,999,
4
$
30,000
­
$
39,999,
5
$
40,000
­
$
49,999,
6
$
50,000
­
$
74,999,
7
$
75,000
­
$
99,999,
or
8
$
100,000
or
more?

3.
How
many
adults
depend
on
this
income?

______

4.
How
many
children
depend
on
this
income?

______

5.
Do
you
own
this
house/
apartment,
or
is
it
being
rented
or
occupied
through
some
other
arrangement?

1
OWN
OR
BEING
BOUGHT
2
RENT
3
OTHER
ARRANGEMENT
(
SPECIFY)
___________________
Female
Preconception
1
(
Instrument
#
3)

23
6.
Do
you
{
FILL:
or
your
spouse/
partner}
have
any
money
in
savings
or
checking
accounts
or
other
investment
accounts?
(
INTERVIEWER:
IF
NECESSARY
READ:
Please
think
ONLY
about
these
types
of
savings
for
this
question.)

1
YES
2
NO
7.
Do
you
{
FILL:
or
your
spouse/
partner}
have
any
money
in
individual
retirement
accounts
such
as
IRAs
or
Keoghs?
(
INTERVIEWER:
IF
NECESSARY
READ:
Please
think
only
about
these
types
of
savings
for
this
question,
and
DO
NOT
REPORT
any
savings
already
reported.)

1
YES
2
NO
{
END
OF
DEMOGRAPHICS/
INCOME
MODULE}
Female
Preconception
1
(
Instrument
#
3)

24
Alcohol
(
Full)

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.
Have
you
had
any
alcoholic
drinks
in
the
past
2
years?

1
YES
2
NO

GO
TO
NEXT
MODULE
2.
Have
you
had
any
alcoholic
drinks
in
the
past
3
months?

1
YES
2
NO

GO
TO
NEXT
MODULE
3.
During
the
past
3
months,
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?

4.
During
the
past
3
months,
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?

5.
During
the
past
3
months,
what
one
type
of
alcohol
did
you
drink
most
often?

1
BEER
2
LIQUOR
3
WINE
4
OTHER
SPEFICY:_________________

{
END
OF
ALCOHOL
MODULE}
Female
Preconception
1
(
Instrument
#
3)

25
Tobacco
(
Full)

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

1.
During
the
past
30
days,
have
you
used
snuff,
dip,
or
chewing
tobacco,
even
once?

1
YES
2
NO
2.
During
the
past
30
days,
have
you
smoked
a
cigar
or
tobacco
pipe,
even
once?

1
YES
2
NO

SKIP
TO
Q3
2a.
How
often
do
you
smoke
cigars
or
tobacco
pipes?

_____
NUMBER
OF
TIMES
ENTER
UNIT
1
DAY
2
WEEK
3
MONTH
3.
Have
you
smoked
at
least
100
cigarettes
in
the
past
2
years?

1
YES
2
NO

SKIP
TO
Q7
4.
Do
you
currently
smoke
cigarettes?

1
YES

SKIP
TO
Q6
2
NO
5.
When
did
you
last
stop
smoking?

___
MONTH
___
YEAR
SKIP
TO
Q7
6.
How
many
cigarettes
do
you
smoke
on
an
average
day
now?
Would
you
say 
[
INTERVIEWER
PROBE:
ONE
PACK
IS
20
CIGARETTES]

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
1
(
Instrument
#
3)

26
7.
[
IF
PARTNER
EXISTS
ASK:]
Does
your
husband/
partner
currently
smoke
cigarettes?

1
YES
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
10.
Which
of
the
following
statements
describes
the
rules
about
smoking
inside
your
home
now?

1
No
one
is
allowed
to
smoke
anywhere
inside
my
home.
2
Smoking
is
allowed
in
some
rooms
or
at
some
times.
3
Smoking
is
permitted
anywhere
inside
my
home.

{
END
OF
TOBACCO
MODULE}
Female
Preconception
1
(
Instrument
#
3)

27
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
TO
Q6
5.
What
were
they?
(
ENTER
VERBATIM)

____________________________

6.
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)
___________________________

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

____________________________

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

____________________________
Female
Preconception
1
(
Instrument
#
3)

28
9.
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}
