Form 1.1 Survey

ATTACHMENT 2 SCREENING TOOL OMB NUMBER: 0925-XXXX

EXPIRATION DATE: XX/XX/XXXX

STRESS AND CORTISOL MEASUREMENT SUBSTUDY SCREENING TOOL
INSTRUCTIONS: 1. Please complete this screening tool for all patients by reviewing their medical record. 2. For all patients who are eligible for this study, please call: Kaitlin Wolfe at (312) 503-5543 or page Kaitlin at (312) 695-4188.
Inclusion Criteria: (must answer YES to all)
							Yes	No
1. Maternal age >=18.0 Years.							□	□
2. Gestational age < 21 weeks based on clinical information and first ultrasound.							□	□
3. Singleton intrauterine pregnancy.							□	□
4. English speaking.							□	□
Exclusion Criteria: (must answer NO to all)
							Yes	No
1. Presence of known fetal congenital anomalies (lethal anomaly or anomalies that may lead to early delivery or increased risk of neonatal death).							□	□
2. Presence of known chromosomal abnormalities.							□	□
3. Progesterone treatment during the current pregnancy after 14 weeks.							□	□
4. Chronic corticosteroid (i.e. Prednisone or steroid) treatment during the current pregnancy (not including inhalers or topical)							□	□

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-XXXX). Do not return the completed form to this address.