Form 1f Survey

LIFE
$sitecode

User:

System Date:

Mode: Production

Site Name:

Women's Journal (FJL)
Version: 3.00; 08-15 -06
Week Beginning:

OMB# 0925-0543
Exp. 06/30/2010
Public reporting burden for this collection of information is estimated to average 2 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: NIH, Project Clearance Branch, 6705 Rockledge Drive, MSC 7974, Bethesda, MD 20892-7974, ATTN: PRA
(0925-0543).
Your journal collects information for each week of participation. Please answer the questions each day so that we will have
the very best information. When answering the questions, consider that each day ends at midnight. Please try to complete
the card about the same time each day. Please do not leave any spaces blank. Need help? Click the 'i' symbol for additional
instructions.

JOURNAL
QUESTIONS
1.
Menstruation:
bleeding or
spotting
0=None
1=Spotting
2=Light
3=Moderate
4=Heavy
2. Sexual
intercourse
frequency
Please fill in
number of times;
0=None
3. Did you do
anything to
prevent
pregnancy?
0=No
1=Yes
4. Pregnancy
test results
1=Pregnant
0=Not pregnant
X=Did not test
5. Multivitamin
taken
0=No
1=Yes, over-the-

Sun

Mon

Tue

Wed

Thu

Fri

Sat

counter
multivitamin
2=Yes,
prescription
multivitamin
6. Number of
aspirin (or other
pain relievers
taken)
Please fill in
number;
0=None
7. Overall
stress level
1=Almost no
stress
2=Relatively little
3=A moderate
amount
4=A lot of stress
8. Number of
cigarettes
smoked
Please fill in
number;
0=None
9. Number of
alcoholic drinks
consumed
Please fill in
number;
0=None
10. Number of
caffeinated
drinks
consumed
Please fill in
number;
0=None
11. Number of
4oz. servings of
fish or shellfish
eaten
Please fill in
number;
0=None
12. Took a hot
bath, whirlpool,
or sauna
0=No
1=Yes

This week, did you START taking any prescription
medication?
If yes, please list medication(s) STARTED:

0-No

1-Yes

This week, did you STOP taking any prescription
medication?
If yes, please list medication(s) STOPPED:

0-No

1-Yes

Comments:

Note: Please consult your health care provider before taking any over-the-counter or prescription medications during
pregnancy.