I.

STUDY NUMBER ________________

II. TODAYS DATE __ __ / __ __ / __ __
III. RA INITIALS ___ ___ ___

EARLY PREGNANCY INTERVIEW

Okay, great. So, lets start the interview. Id like to begin by stressing that there are no right
or wrong answers, please just answer as best as you can.

IV. TIME START ___ ___ : ___ ___ (00:00-24:00)

V. Were you enrolled in Project Viva in an earlier pregnancy?
1 YES

2 NO

SECTION A. BASIC INFORMATION

This first section covers some basic information about you.

A1. What is your date of birth? __ __ / __ __ / __ __

M M/ D D/YY

A2. How tall are you?

__FEET __ __INCHES
OR __ __ __ CENTIMETERS

A3. HAND PARTICIPANT RESPONSE CARD 1

Please choose the highest level of school you have
completed from the list I am going to read to you.

1 Less than 12th grade

2 High school degree or a GED

3 Some college or an associates degree

4 4 years of college (BA, BS)

5 Graduate degree (Masters, Ph.D.)

Project Viva (EPI1)

VERSION 07/01/2001
1
A4. In what country were you born?

1 US (SKIP to A5)

2 OTHER, SPECIFY_____________

IF A4 CODED US, SKIP TO A5

a) HAND PARTICIPANT RESPONSE CARD 2

How old were you when you moved to the
United States (for at least 2 years)? Were you....

1 less than 5 years old

2 between 5 and 10 years old

3 between 11 and 17 years old

4 between 18 and 25 years old

5 more than 25 years old

A5. HAND PARTICIPANT RESPONSE CARD 3

Which of the following best describes your race or
ethnicity? You may choose more than one.

Hispanic or Latina

White or Caucasian

Black or African American

Asian or Pacific Islander

American Indian or Alaskan Native

Other, SPECIFY: ___________________

(IF OTHER, SKIP TO A6)
a) Is there a better or more specific way to describe
your race or ethnicity?
1 YES, SPECIFY_________________

2 NO

Project Viva (EPI1)

VERSION 07/01/2001
2
A6. How do you think other people would describe your
race or ethnicity? You may choose more than one.

Hispanic or Latina

White or Caucasian

Black or African American

Asian or Pacific Islander

American Indian or Alaskan Native

Other, SPECIFY:_______________

a) DELETED

Now Id like to ask about your marital status.

A7. HAND PARTICIPANT RESPONSE CARD 4

Choose the answer that best applies to you now from
the list I am going to read to you. Are you now....
1 Married

2 Not married, but living with a partner

3 Never married (SKIP TO A11)

4 Divorced (SKIP TO A11)

5 Separated (SKIP TO A11)

6 Widowed (SKIP TO A11)

Project Viva (EPI1)

VERSION 07/01/2001
3
A8. HAND PARTICIPANT RESPONSE CARD 5
Please choose the highest level of school your spouse or
partner has completed from the following list.

1 Less than 12th grade

2 High school degree or a GED

3 Some college or an associates degree

4 4 years of college (BA, BS)

5 Graduate degree (Masters, Ph.D.)

9 DONT KNOW

A9. In what country was your partner born?

1 US

2 OTHER, SPECIFY_____________

9 DK

A10. HAND PARTICIPANT RESPONSE CARD 6

Which of the following do you think best describes
your partners race or ethnicity? You may choose more
than one.
Hispanic or Latina/o

White or Caucasian

Black or African American

Asian or Pacific Islander

American Indian or Alaskan Native

Other, SPECIFY:_______________

DK
(IF CODED OTHER or DK,
SKIP TO A11)

Project Viva (EPI1)

VERSION 07/01/2001
4
 a) Is there a more specific way to describe your
partners race or ethnicity?
1 YES, SPECIFY ____________

2 NO

9 DK
IF NO PARTNER, START HERE
A11. In what country was your mother born?

1 US

2 OTHER,______________________
A12. In what country was your father born?

1 US

2 OTHER,______________________

A13. HAND PARTICIPANT RESPONSE CARD 5

Please choose the highest level of school that your
mother has completed from the following list.
1 Less than 12th grade

2 High school degree or a GED

3 Some college or an associates degree

4 4 years of college (BA, BS)

5 Graduate degree (Masters, Ph.D.)

9 DONT KNOW

Project Viva (EPI1)

VERSION 07/01/2001
5
A14. Please choose the highest level of school that your
father has completed from the following list.
1 Less than 12th grade

2 High school degree or a GED

3 Some college or an associates degree

4 4 years of college (BA, BS)

5 Graduate degree (Masters, Ph.D.)

9 DONT KNOW

SECTION B. MEDICAL HISTORY

These next few questions are about your medical history.
B1. Has a health professional
such as a doctor, physician assistant, or nurse practitioner ever
told you that you had..................
YES NO
*a) High blood pressure (hypertension) during a
time when you were not pregnant 1 2

*b) Type I, Juvenile-onset Diabetes 1 2

c) Type II, Adult-onset Diabetes 1 2

d) Thyroid disease 1 2

e) Asthma 1 2

*f) Hay Fever, seasonal allergies or allergic rhinitis 1 2

*g) Eczema (Atopic dermatitis) 1 2

B2. Have you ever received a blood transfusion?

(When someone elses blood is put into your
veins to replace blood you have lost from an accident or
surgery.)
1 YES

2 NO

9 DONT KNOW

Project Viva (EPI1)

VERSION 07/01/2001
6
B3. Not counting this pregnancy, how many times have
you been pregnant? Please include all of your
pregnancies regardless of outcome.

__ __ TIMES
(IF OO, SKIP TO SECTION C)
B4. During any of these past pregnancies, did a health
professional (such as a doctor, nurse practitioner,
physician assistant, or midwife) diagnose you with.....
YES NO
a) High Blood Pressure (hypertension)......
1 2

b) Pre-eclampsia (toxemia)........................... 1 2

c) Diabetes.......................................................
1 2

SECTION C. YOUR CURRENT PREGNANCY

Now well focus on your current pregnancy. Each of these questions will refer to during this
pregnancy. By during this pregnancy, I mean from the first day of your last menstrual period
on
__ __ / __ __ / __ __, until now.

C1. Have you felt nauseated (sick to your stomach) at all

during this pregnancy?

1 YES

2 NO (SKIP TO C3)
a) When did you start feeling nauseated?
__ __ / __ __ / __ __
M M/ D D/YY
b) Are you still feeling nauseated (at all)?
1 YES (SKIP TO C1c)

2 NO

9 DONT KNOW (SKIP TO C1c)

i. When did your nausea stop?
__ __ / __ __ / __ __
M M/ D D/YY

Project Viva (EPI1)

VERSION 07/01/2001
7
 c) During this pregnancy, have you felt (did you
feel) nauseated for seven consecutive days (in a
row)?
1 YES

2 NO

d) HAND PARTICIPANT RESPONSE CARD 7.

How many (total) times have you vomited (did
you vomit) during this pregnancy?
1 Never

2 1 to 2 times

3 3 to 10 times

4 11 to 20 times

5 More than 20 times

C2. During this pregnancy, have you changed your eating
or drinking habits because of feeling nauseated?
1 YES

2 NO

a) DELETED
C3. During this pregnancy, have you had any new
cravings for particular foods or beverages?
1 YES

2 NO (SKIP TO C4)
a) What (other) new cravings have you had?
i. _____________________
ii. _____________________
iii. _____________________

Project Viva (EPI1)

VERSION 07/01/2001
8
C4. During this pregnancy, have you had any new
aversions (strong dislikes) for particular foods or
beverages?
1 YES

2 NO (SKIP TO C5)

a) What (other) new aversions have you had?

i. _____________________
ii. _____________________
iii. _____________________

C5. Since you learned you were pregnant, have you been
eating a vegetarian diet? (a diet that excludes certain
animal products)

1 YES

2 NO (SKIP TO C6)

a) We know that there are different types of

vegetarian diets and we would like to know
about yours. Since you learned you were
pregnant, have you been eating.........(at all)
YES NO

i) Red meat 1 2

ii) Fish 1 2

iii) Poultry (like chicken or turkey) 1 2

iv) Eggs 1 2

v) Dairy Products (milk products) 1 2

b) DELETED

Project Viva (EPI1)

VERSION 07/01/2001
9
C6. These next few questions are about over-the-counter medicines, that is, medicines you can
buy without a prescription. (Remember, by during this pregnancy, I mean from the first
day of your last menstrual period on __ __ / __ __ / __ __ , until now.)

During this pregnancy, have you taken any................

a) Advil, Motrin, Nuprin, i. Have you taken at least

1 YES 1 YES
any other ibuprofen, or 10 total of these tablets
Alleve? 2 NO during this pregnancy? 2 NO

b) Tylenol or other i. Have you taken at least

1 YES 1 YES
acetaminophen, non- 10 total of these tablets
aspirin pain reliever? 2 NO during this pregnancy? 2 NO
c) Regular aspirin, such as 1 YES i. Have you taken at least 1 YES
Excedrin, Bayer, Anacin, 10 total of these tablets
Bufferin? 2 NO during this pregnancy? 2 NO
d) Other over-the-counter medicines, including herbal medicines, at 1 YES
least 10 times?
2 NO
(SKIP TO D1)
e) Which ones (over-the-counter/herbal medicines)
have you taken at least 10 times during this
pregnancy?
i. ______________________
ii. ______________________
iii. ______________________
iv. ______________________

Project Viva (EPI1)

VERSION 07/01/2001
10
 SECTION D. FATHERS DEMOGRAPHICS

This section is about the biological father of this baby, who may or may not be your current
spouse or partner. I understand that you may not know all of the answers to these questions,
but please answer as best you can.

D1. Was this baby conceived with donor sperm? (sperm

from a sperm bank or a friend for the specific purpose
of conceiving.)
1 YES

2 NO
D2. How old is the biological father of this baby?

__ __ YEARS OLD
9 DK

D3. How tall do you think he is? __ __ FEET __ __ INCHES

__ __ __ CENTIMETERS
9 DK

D4. How much do you think he weighs? __ __ __ LBS

(OR __ __ KGS)
9 DK

D5. Has the biological father of this baby ever had any of the following conditions
diagnosed by a health professional such as a doctor, physician assistant, or nurse
practitioner?
YES NO DK
a) High blood pressure (hypertension) 1 2 9

b) Type I, Juvenile-onset Diabetes 1 2 9

c) Type II, Adult-onset Diabetes 1 2 9

d) Thyroid disease 1 2 9

e) Asthma 1 2 9

f) Hay Fever, seasonal allergies or allergic rhinitis 1 2 9

g) Eczema (Atopic dermatitis) 1 2 9

Project Viva (EPI1)

VERSION 07/01/2001
11
 SECTION E. VITAMINS AND SUPPLEMENTS
This last section of the interview is about vitamins and supplements that you currently are
taking, or that you may have taken before you learned that you were pregnant.

E1. When did you first find out that you were pregnant?
__ __ / __ __ / __ __
M M/ D D/YY
JAN FEB MAR APR MAY JUN JUL AUG SEP OCT NOV DEC
Now, Id like you to think back to the time that began 3 months before that date that is,
__ __/ __ __ / __ __ (LEARNED- 3 mos)

From __ __ / __ __ / __ __ (LEARNED- 3 mos) until now, have you taken any.............

M/ D / Y

A B C D E F

ALL: On average,
how many tablets
YES/NO IF YES: When Are you IF NO: When did ALL: What have you taken
did you start still you stop taking brand and per wk during
taking them? taking them? type do/did this time period
them? you take? (DTTP)?
E2. Prenatal 1 YES >1 YR 1 YES __ __/__ __/__ __ __________ __ __/WK
BRAND
vitamins M D Y
2 NO __ __/__ __/__ __ 2 NO
__________
M D Y TYPE

E3. Multivitamins 1 YES >1 YR 1 YES __ __/__ __/__ __ __________ __ __/WK

BRAND
M D Y
2 NO __ __/__ __/__ __ 2 NO
__________
M D Y TYPE

IF E2 OR E3 CODED YES, READ INTRODUCTION BELOW. IF NO, SKIP TO E4.

For the next set of questions, please consider only the amount of the vitamin you take as a
separate pill or tablet. In other words, please dont include the amount you get from a
multivitamin or prenatal vitamin.

Project Viva (EPI1)

VERSION 07/01/2001
12
 From __ __ / __ __ / __ __ (LEARNED- 3 mos) until now, have you taken any.............
A B C D E F G
YES/NO IF YES: When Are IF NO: When ALL: What brand ALL: On

DELETED
did you start you did you stop and type do/did you average, how
taking them? still taking them? usually take? many tablets
taking have you taken
them? per wk DTTP?
E4 Antacid 1 YES >1 YR 1 YES __ __/__ __/__ __ 1 ANTACID,
REGULAR ___ ___ / WK
tablets with M D Y
2 NO __ __/__ __/__ __ 2 NO
M D Y 2 ANTACID, EXTRA
calcium on a
3 ANTACID,
regular basis or
ULTRA
another calcium
4 OTHER CALCIUM
supplement

From __ __ / __ __ / __ __ (LEARNED- 3 mos) until now, have you taken any.............

A B C D E F G
YES/NO IF YES: When Are you IF NO: When ALL: On average, how many

DELETED

DELETED
did you start still did you stop tablets have you taken per wk
taking them? taking taking them? DTTP?
them?
E5 Iron 1 YES >1 YR 1 YES __ __/__ __/__ __ ___ ___ / WK
2 NO 2 NO
__ __/__ __/__ __ M D Y
M D Y

From __ __ / __ __ / __ __ (LEARNED- 3 mos) until now, have you taken any.............

A B C D E F

YES/N IF YES: When Are IF NO: When ALL: What is the ALL: On average,
O did you start you did you stop dose/ strength of how many tablets
taking them? still taking them? each tablet? have you taken per
taking wk DTTP?
them?
E6 Vitamin A 1 YES >1 YR 1 YES __ __/__ __/__ __ __ __ , __ __ __IU
__ __/__ __/__ __ ___ ___ / WK
2 NO 2 NO M D Y
M D Y

E7 Vitamin B6 1 YES >1 YR 1 YES __ __/__ __/__ __ __ __ __ MG

__ __/__ __/__ __ ___ ___ / WK
2 NO 2 NO M D Y
M D Y

E8 Vitamin C 1 YES >1 YR 1 YES __ __/__ __/__ __ __,__ __ __ MG

__ __/__ __/__ __ ___ ___ / WK
2 NO 2 NO M D Y
M D Y
Project Viva (EPI1)
VERSION 07/01/2001
13
(ascorbic acid)
A B C D E F
YES/NO IF YES: When did Are you still IF NO: When did ALL: What is the ALL: On average, how
you start taking taking them? you stop taking dose/ strength of many tablets have you
them? them? each tablet? taken per wk DTTP?

E9 DELETED

E10 Vitamin E 1 YES >1 YR 1 YES

__ __/__ __/__ __
__ __/__ __/__ __ __ __ __ IU ___ ___ / WK
2 NO 2 NO M D Y
M D Y

E11 DELETED

E12 Folate, 1 YES >1 YR 1 YES

__ __/__ __/__ __ __,__ __ __ MCG
__ __/__ __/__ __ ___ ___ / WK
Folic Acid 2 NO 2 NO M D Y
M D Y

E13 Zinc 1 YES >1 YR 1 YES

__ __/__ __/__ __
__ __/__ __/__ __ __ __ __ MG
2 NO 2 NO ___ ___ / WK
M D Y
M D Y

E14 Metamucil or 1 YES >1 YR 1 YES __ __/__ __/__ __

__ __ TBS OR
other fiber __ __/__ __/__ __ M D Y
2 NO 2 NO ___ ___ / WK
__ __ PACKETS
M D Y
supplements

E15 Cod liver 1 YES >1 YR 1 YES __ __ TSP OR

__ __/__ __/__ __
oil 2 NO
__ __/__ __/__ __
2 NO __ __ CAPSULES ___ ___ / WK
M D Y
M D Y

E16 Fish Oil 1 YES >1 YR 1 YES

__ __/__ __/__ __ __ __ , __ __ __
(Omega 3 fatty __ __/__ __/__ __
2 NO 2 NO ___ ___ / WK
M D Y MG
M D Y
acids)

E17 Other 1 YES >1 YR 1 YES

vitamins or __ __/__ __/__ __ __ __/__ __/__ __ ________ (AMT)
2 NO 2 NO
M D Y ___ ___ / WK
supplements? M D Y ________ (UNIT)
____________

TIME STOP ___ ___ : ___ ___ (00:00-24:00)

Project Viva (EPI1)

VERSION 07/01/2001
14