Form 1h Survey

LIFE
$sitecode

User:

System Date:

Mode: Production

Site Name:

Pregnancy Journal (PJL)
Version: 2.00; 05-29 -07
Segment:
Indicate Weeks:

OMB# 0925-0543
Exp. 06/30/2010
Public reporting burden for this collection of information is estimated to average 5 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 pregnancy journal collects information for each four -week time period during your pregnancy starting from the first day of
your 9 th week to delivery. Please answer the following journal questions every four weeks so that we will have the very best
information. Please try to complete the card at the end of each time period.
In the unlikely event that you experience a pregnancy loss, we ask that you please complete the Pregnancy Loss Information
Form. By collecting the information on these forms, we hope to learn more about the factors that affect a woman's ability to carry a
pregnancy to delivery and how pregnancy losses may be prevented in the future.
Consider that each four -week period ends on the date the nurse has indicated in your pregnancy calendar.
Journal start date:
Journal end date:

(mm/dd/yyyy)
(mm/dd/yyyy)

Health and Lifestyle
Comments
Bleeding or spotting
0=None
1=Spotting
2=Light
3=Moderate
4=Heavy
Lower belly cramping
0=No
1=Yes

Nausea or vomiting
0=None
1=Nausea
2=Vomiting
3=Nausea and vomiting
Regular multivitamin
use
0=No

1=Yes, prescription
prenatal vitamins
2=Yes, over-the-counter
multivitamins
Overall stress level
1=Almost no stress
2=Relatively little
3=A moderate amount
4=A lot of stress
Average number of
cigarettes smoked per
day
0=none
1=less than 10
2=10 to 20
3=more than 20
Average number of
alcoholic drinks
consumed per week
0=none
1=one
2=two
3=three or more
Number of 4 oz.
servings of fish or
shellfish eaten per
week
Please fill in number;
0=None
How much did you
weigh with clothes at
the end of this 4-week
period?
Please fill in your weight
in pounds. If you don't
know, leave blank.

(lbs)

Prenatal Care History
Comments
Has your health care
provider told you that
you have high blood
pressure?
0=No
1= Yes
9=Did not see a health
care provider
Has your health care
provider told you that
you have protein in
your urine?
0=No
1=Yes
9=Did not see a health
care provider
Has your health care
provider told you that
you have high blood
sugar?

0=No
1=Yes, high blood
sugar associated with
pregnancy
2=Yes, already known
to have diabetes
9=Did not see a health
care provider
Has your health care
provider identified
any other health
concerns relating to
your pregnancy?
0= No
1=Yes, please explain
in comments section
9=Did not see a health
care provider
Did you have a
sonogram
(ultrasound)?
If Yes, please fill in the
date of the sonogram.
If Not, leave blank.
What is your
estimated date of
delivery according to
the sonogram?
Please fill in the date.
If you don't know or did
not have a sonogram,
please leave blank.
Did you have a fetal
non-stress test?
0=No
1=Yes
9=Did not see a health
care provider
What was the result
of the fetal nonstress test?
0=Negative, baby was
fine
1=Positive, problems
were identified
Did you have a
Group B Strep
screening test?
0=No
1=Yes
9=Did not see a health
care provider
What was the result
of the Group B Strep
test?
0=Negative
1=Positive
Other comments:

(mm/dd/yyyy)

(mm/dd/yyyy)

Additional Selection Options for PJL
Indicate Weeks (key field):
Weeks 9 to 12
Weeks 13 to 16
Weeks 17 to 20
Weeks 21 to 24
Weeks 25 to 28
Weeks 29 to 32
Weeks 33 to 36
Weeks 37 to 40
Weeks 41 to 44