Preconception Risk Factors Survey

Please answer the questions below and return this questionnaire in the enclosed postage paid envelope. All of the questions reference the time period of August 1, 2010 to February 29, 2012.

Your unique Study Number is: ***

If you are of child bearing potential and have concerns about medical history in relation to pregnancy, contact your primary care physician or gynecologist. If you have no medical provider, feel free to call XXX-XXX-XXXX with questions.

  1. Did you visit a healthcare provider (doctor, nurse, physician assistant) at one or more of the following sites between August 1, 2010 and February 29, 2012?

a.NorthShore Emergency Room at Evanston Hospital, Glenbrook Hospital, Highland Park Hospital or Skokie Hospital

b.NorthShore Medical Group office in Arlington Heights, Bannockburn, Buffalo Grove, Chicago, Deer Park, DesPlaines, Elmhurst, Evanston, Glenview, Gurnee, Harvey, Highland Park, Lake Bluff, Lincolnwood, Mount Prospect, Mundelein, Northbrook, Oak Lawn, Skokie or Vernon Hills

c.Other medical facility (Please specify)

d. Unsure or N/A

  1. Were you of child bearing potential between August 1, 2010 and February 29, 2012? (Was it possible for you to become pregnant?)

a. YesIF YES: Skip to Question 3

b. NoIF NO: Check all that apply

1)NO, because I did not have a sexual partner between August 1, 2010 and February 29, 2012

2)NO, because I had a surgical sterilization such as a tubal ligation, hysterectomy or ESSURE placement prior to February 29, 2012

3)NO, because I was using contraception such as birth control pills, Depo-Provera, IUD, NuvaRing, patch, condoms, Implanon, diaphragm between August 1, 2010 and February 29, 2012

The contraception I was using was prescribed at one of the NorthShore University HealthSystem sites listed in Question 1.

Yes / No / Unsure or N/A

4) NO, because I was pregnant during the August 1, 2010 to February 29, 2012 time period

5) NO, because of another reason (please list)

  1. Between August 1, 2010 and February 29, 2012 did you do any of the following?(Check all that apply)

a. Smoke tobacco

If you checked “Smoke tobacco”, approximately how many cigarettes did you smoke per week?

b. Drink alcoholic beverages

If you checked “Drink alcoholic beverages”, approximately how many drinks did you have per week?(12 oz beer, 5 oz wine or 1½ oz spirits is considered one drink.)

c. Take or use illegal drugs

d. Unsure or N/A

  1. Prior to February 29, 2012 had you been told that you had any of the following medical conditions?(Check all that apply)

a. Diabetes or high sugar levels

b. Hypertension or high blood pressure

c. Kidney problems

d. Anemia or low blood count

e. HIV or AIDS

f. Unsure or N/A

  1. Have you ever had an HIV test?

a. Yes

b. No

c.Unsure or N/A

  1. Were you on any of the following medications between August 1, 2010 and February 29, 2012? (Check all that apply)

a. ACE Inhibitor used to treat high blood pressure. (Some examples are Aceon, Altace, Accupril, benazepril, Capoten, captopril, enalapril, fosinopril, lisinopril, Lotensin, Monopril, Mavik, perindopril, Prinivil, quinapril, ramipril, trandolapril, Vasotec, Zestril)

Unsure or N/A

b.Benzodiazepines (Some examples are Alprazolam, Ativan, Centrax, chlordiazepoxide, Clonazepam, clorazepate, Dalmane, diazepam, Doral, estazolam, flurazepam, halazepam, Halcion, Klonopin, Librium, lorzepam, Midazolam, oxazepam, Paxipam, prazepam, ProSom, quazepam, Restoril, Serax, temazepam, Tranxene, triazolam, Valium, Versed, Xanax)

Unsure or N/A

c.Coumadin or Warfarin which are blood thinners.

Unsure or N/A

d. Anticonvulsants or seizure medications. (Some examples are Banzel, carbamazepine, clonazepan, Depakote, Dilantin, gabapentin, Keppra, Klononpin, lacosamide, Lamictal, lamotrigine, levetiracetam, Lyrica, Neurontin, oxcarbazepine, Phenobarbital, Phenytoin, pregabalin, rufinamide, Sabril, Tegretol, Topamax, topiramate, Trileptal, valproic acid, vigabtrin, Vimpat, Zonegran, zonisamide.)

Unsure or N/A

e.Tetracycline for infections or acne. (Some brand names are Sumycin, Achromycin V, Emtet-500, Actisite.)

Unsure or N/A

f.HMG Co-A Reductace Inhibitors used to lower cholesterol. (Some examples are Altocor, atorvastatin, Altoprev, Baycol, cerivastatin, Crestor, fluvastatin, Lescol, Lescol XL, Lipitor, Livalo, Lovastatin, pitavastatin, Pravachol, pravastatin, rosuvastatin, simvastatin, Zocor.)

Unsure or N/A

g.Lithium

Unsure or N/A

h.Triptan Medications which are used for migraine treatment. (Some examples are almotriptan, Axert, eletriptan, Frova, frovatriptan, Imitrex, Maxalt, rizatriptan, sumatriptan, Treximet.)

Unsure or N/A

i.Multivitamins

Unsure or N/A

j. Folate or folic acid

Unsure or N/A

k.Other Medications and/or Comments

  1. Between August 1, 2010 and February 29, 2012 did you receive treatment from NorthShoreUniversity HealthSystem for any of the following?

a. Gonorrhea

b. Chlamydia

c. Syphilis

d. Unsure or N/A

  1. If you were to be contacted and given information about improving your health prior to pregnancy, who would you prefer to contact you to provide information?(Check all that apply)

a. Your doctor

b. Directly from the hospital

c. Either

d. Other ______

  1. If you were to be contacted and given information about improving your health prior to pregnancy, which format would you prefer?(Check all that apply)

a. Telephone call

b. Secure, confidential email

c. USPS mail

d. Secure, confidential web portal, for example NorthShore Connect

e. Other ______

  1. Comments

Thank you for completing this survey and returning it in the enclosed postage paid envelope.

Page 1 of 3