Baseline Obstetric Data Form (BOF)

Baseline Obstetric Data Form (BOF)

Instructions for Completing Form

Participant Group: This form is completed for all participants enrolled in the MOTOR study.

Purpose: This form collects baseline medical. OB, smoking, alcohol and drug use history.

When completed: This form should be completed after enrollment, at the Baseline OB visit.

Who completes: Motor Staff trained by the Study Coordinator for data collection.

Other Documents: Other OB documents to be completed at this visit are the Baseline Demographic Form (BDF), the Baseline Obstetric Sample Collection Form (BSF), and the Maternal Blood Collection Form (MBF).

Form Instructions:

Header:

·  ID: Attach Participant ID label.

·  Name: Record the participant’s name (this is not data entered).

·  Staff ID: Record initials of staff collecting BOF data.

·  Date: Record date of BOF data collection

Special Instructions:

·  The information on this form is gathered from both medical records and participant interview.

·  Responses that are unknown or refused are coded “U”.

·  Form can be entered on paper for subsequent data entry, or entered interactively through the MOTOR DMS.

Instructions on How to Complete Form Items:

PHYSICAL EXAM:

Question 1. Pre-pregnancy Weight:

Enter the participant’s pre-pregnancy weight, either in kilograms or pounds in the appropriate space provided. If this information cannot be gathered from the participant’s medical records, enter the pre-pregnancy weight as reported by the participant.

Question 2: Weight measured today:

Measure and Record the participant’s weight today, in either kilograms or pounds in the appropriate space provided.

Question 3: Height measured today:

Measure and Record the participant’s height today, in centimeters or inches, in the appropriate space provided.

OB / Pregnancy HISTORY:

Question 4: Uterine Anomaly

Circle “Y” for “YES” if the participant reports or if medical records indicate a history of a uterine anomaly.

Question 5: Previous Pregnancies

Circle “Y” for YES if the participant reports previous pregnancies, “N” if not, “U” If unkown. IF “N” or “U” ship to question #6.

IF YES,

a) Record parity by recording the number of reported full-term births, preterm births (births less than

37 weeks), abortions, and the number of live births. If none, record “0”.

b)  If the number of Preterm births reported are >0, then record the participant reported gestational

age, birth weight, and delivery classification (see delivery codes). If more than 3 preterm births

are reported, record the 3 “worst” histories.

c)  Record the GA and circle the appropriate birth outcome for the most recent viable pregnancy,

defined as ≥ 20 weeks gestation.

Question 6 Cervix ever been treated?

Circle “Y” for “YES” if the participant reports or if medical records indicate that the participant’s cervix has ever been treated.

If YES, how?

If the participant’s cervix has been treated, specify treatment checking all that apply from the five options. If the participant’s cervix has been treated but the treatment is not listed, check “e” for “Other” and specify the treatment in the provided space. If the treatment is not known check “f” for unknown.

Question 7: Infertility treatment for this pregnancy?

Circle “Y” for “YES” if the participant reports or if medical records indicate infertility treatment for this pregnancy.

Question 8: Smoke cigarettes before pregnancy?

Circle “Y” for YES if the participant reports they smoked cigarettes before they found out they were pregnant, “N” if they did not, “U” if they refuse the question or do not know.

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Question 9: Smoked cigarettes at any time during this pregnancy?

Circle “Y” for YES if the participant reports that they have smoked cigarettes at any time during this pregnancy. Please note that smoking refers to tobacco cigarettes only (cigars and chewing tobacco are excluded.) “N” if they did not, “U” if they refuse the question or do not know.

If YES, Average number of cigarettes/day in the last week:

If the participant admits to smoking during the pregnancy, record the average number of cigarettes per day in the past week. If it is less than 1 per day, enter “0”.

Question 10: Alcoholic drinks at any time during this pregnancy?

Circle “Y” for “YES” if the participant reports having as little as one alcoholic drink during this pregnancy. “N” if they did not, “U” if they refuse the question or do not know.

If YES, Average number of drinks/week:

If the participant answers YES to Question 10, ask her to estimate the average number of alcoholic drinks consumed per week during this pregnancy. One drink of wine is defined as one 5 oz. glass. One drink of beer is defined as one 12 oz. glass, can or bottle. One drink of hard liquor is defined as any cocktail containing one shot, 1 ½ oz., of hard liquor. If the participant has drunk on average less than 1 drink per week, record “0”.

Question 11: Used “street drugs” at any time during this pregnancy?

Circle “Y” for “YES” if the participant reports having used “street drugs” at any point during this pregnancy. “N” if they did not, “U” if they refuse the question or do not know.

If YES, Cocaine or Crack used

If the participant answers YES to Question 11, ask them if this included Cocaine or Crack. Circle “Y” for “YES” if the participant reports having used Cocaine or Crack, “N” if they did not, “U” if they refuse the question or do not know.

BOF_QxQ / November 17, 2004 Page 2 of 3