Document LgNRR5n111rVEaz53LpRvna7w
AR226-1384
Revised 10-24-80
WORD PROCESSING WORK FORK
Tapet Day
Cy
10: DELOTEE RELATIONS DEPARDAENT
AR
_1
WORD PROCESSING CENTER - N-12533
nov: 7 sssracen Lion
Room:
aae
Tel:
38h
Date
Retain Diskette: Pern. [J Other Formac: beate (] Fioal Cop[y Spaciag:
Singte [] Dowie [J
asshom 0
Job TitleL: sgosrsg Ons Lutshorror eee r--------
Previous Author (if Applicable)
Special Instruction:
oeunr rTeqiuesatieidp.typTiincgaseiskeaetptacthheids. sheIeftyowuithdesyioruer wroervki.sion, please note and recurn to me
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iNnOdTicSaItGeN vUhNeTnILtaTpHeISmaWyORbKe1eraNsOedLObNyGER TO BE TYPED AGAIN.
signature
ype output requested: FinalCopy[J Drafe [] Correctio[ns] Call whenready [J
ype output requested: FinalCopy[] Drate [0 Corvectio[n]s Call hen ceaty OJ
ype output requested: Final Copy [] Drafe [1] Corrections [] Call hen resty
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ype output requested: FinalCopy [] Drate [] Correctio[n]s Call whenresty []
Type output requested: Final Copy[] Drate [] Correctio[n]s Call vhen Fr I
PLEASE WAKE ALL CORRECTIONS IN RED OR GREEN INK - ON ORIGINAL
EID106216
FOR WORD PROCESSING CENTER USE ONLY
-
Fetetae]|aes|Lo] rE| apes | tes| ems |os)
00012
PREGNANCY OUTCOME QUESTIONNAIRE
CONTAINS PERSONAL AND CONFIDENTIAL MEDICAL
INFORMATION
CASE +
EID106217
3
000146
`pewoaAPEIC
ost ___
hot is yhosur name: _TT
FIST -- WIDEeNeTrI
What is your social securitymmber? ____/__/_
What is your birth date? _ay _
`hat is your relationship to this study? (CIRCLE CORRECT ARSHER)
a. Female Washington Works erployee
b. Wifeof aWashiWonrksgemtplooynee
c. Male Washington Works eployee Sat isthelastgradeofschool youcompleted?
(CIRCLE CORRECT ANSWER)
Elen1e2r3t4a5r6y7:8
Secondary: 9 10 1 12
College: 13 14 15 16 17 18 19 20+
GoERAL MEDICAL ave youever
been
told by
adoctorthat youhad
anyofthefollowing
medical conditions?
[rsooeson]e| FFOoRnTHmItSscCmONoDITsION (LIST)
oo Suegamrad.iabeetnese enoo een.o|L o|o | T. |
yrotd comition. oo. a] | | |
o Enpeiulreoplsoyg,icafiltsc,onodritoiotnhse.r . + + I
o Kidney or bladder condition, - |_ | ||
o o
Livercondition. + +o oe| ||| aay ty ofcpanceer + ooo|_|| |
F o Heart condition. . . o-oo] 1h | |
SHRING
Yes mo
Have you ever Snoked CLJArett@s?...esuesssessssssssssnsssssseesses C11
Do yoAugenosvtmarotkeed:?...... [] Number years mwked?..... [yrs]
TowmanypJaamectaukdnasy?12(Cahne 1beoxcbe1lk2ow) 2o0rwre
o GDAeS?Pc.aw neevteeurncossleisainissTssneeB irsruesernrsea iseersenreeresseee rrp eeesreneersnJeernei e sezsmesieienee| C[T1]1 2
IIf yYoohuuowahak0ve1eHd,gowiewdvrmoeenaTnyouoyupupTcwiiRhpgEeeanEfrPyuel:tostnues&lcaaQnkassYite?ngs.ga.sev,eeeseeeueepesmeroseskseirnnseosgrr?oe.sos.re_er_sr_rryorrs.rere CI] 23
`
EID106218
000147
ccomaTian
`"paJvoebye,obueuvesrwiornkedeoorustcsosinddeeiotisfotn,sh?ehomeinanyof thefollowing industries,
YES wo fIrfoymeHso,vgievteodHatoes:
erientsorter + + vee eeneee|o]|
o Factory yorker, + ee eeneene1sl|
o Physician/dentist/chenist/pathologiat |__||
o Otherprofessionalworker + + + ov o| | |
o Chemicaloperator inafactory. + + + ovo] | |
Famer,fom hand,or fieldworker. . oo| | |
Maintenanceworkerorcraftmen . +. oo| | |
o Service vorker+/ooJoaoenniest|| or|.
o onstruction. ee eeneeeeann|s||
o Bainter. ooo enneeoeanne|es||
o Textileplant worker. oo ceo eeo| | |
Beautysalon haiorrbd eautricie an..s-|s__e| r|
Plant where dyesvere madeorused. + + + + |__| |
Surgicaloperating roam. + +o ooo oo] | |
Wereyouworkedaroundanestheticgases. .| | |
Dusty dob ee eeennnoceeenn|es||
o Here X-raysvereused. oo eo enns| | |
Vereradioactivematerialsvereused . + +| | |
o ere arugs/medicines vere made/packaged. |__||
Dry cleaning stop e ev nvveenne|s||
Wheresolventsvereused. . + veo ns| | |
heredegreasersvereused. + ++ oon] | |
Were itvasvery hot oo ouneea| nn||
Where itvasvery olde oo vee evans]||
Whereyouvorkedaroundeshastfumes . +o| | |
Whereplasticsveremade. + +booo e|||
o Where youhadtowear a respirator. + +o | | |
Where youworkedaroundfumes/gasvagor + +|__| |
Where youworkedaround mistsorsprays + +|__| |
Whereyouvorkedwith lead. 4 bees]||
Whereyouworkedwithothermetals. . . . | | |
g
Whyeouvrorkeed vith laboratory chemicals.|||
=
Sob imolvingheavy Lifting + vob oo] | |
:
ob involvingcontinualstanding. . +. oo] | |
Job involvingcontinualsitting + + + ooo | |
Laboratory/medical/dental technician. +. |_||
EIDioe21s
660148--
MENSTROL, HISTORY 2haceoenmeopxlftetftheeiwspqiiusecsattilooifnutsytarloreupeererahsbeooanulattlyh,.obuurtmeintstirsuvaelrpyeirm-ipoodrst.aYntofuomrauyfseteolgtehtat T2cocewoymopolludeSvtteeiprlielcythouaurvwiehnoegfnypyeooruirhodashdeyaatolutahrl.lf?irstpaeyrieosf?_Bo_myears
0,ADtidvyhoautrapgeeri4o1ddsy:ouah.avsteoypounartluarsatllpye?riof? years
4bc...ssstttooopppddfuuoeersttooomrseauodrtigaheteriryo?rne?ason?
e.stopfor some unknown reason?
Irvs,"Abo"uotnehpoewrmiaondytdoatyhsearfeitrshtedraeyfrOofymtohuernfeixrtstpdearyioodf? days
boamnttehio]wmthhaeenybedlaeeeydsidngoecsomypoluertpeelyriSotdOPlSa7s.t,.vtehsactsissss __GAYS
Bcelleows.is aSinLciestyoofu cwhearnege1s8 ytehaartsvoolmde,nhmaovmeetyionuesnnotioceat innyoti hfetihrc emefnoseltlrouwd ailng
chianynourgpeeriosds?
skippingperiods. + + + +oooo |
iGriernccerrgeeuaalssaeedrdpfFellrooiwwo..ds+.
+ +
1 +
+1+L+oo+o oo oeu ooeoon [[I1 ]|
`ionmceroetahseedrpkeinidnoofrccrhaamnpgien.g.+ +. + ++.+ [ ||
_
MARITAL HISTORY
Doyouthink youhave ever beenpregnant? a.yes b. no
IPYES,how manytineshave youbeenpregnant?__ tines
Are you now: ae..nmeavrerriehdaveb.beedinvomracrerdiedc. separated d. widowed
PRESENT PREVIOUS PREVIOUS
HUSBAND HUSBAND HUSBAND
What isyour husbbairnthdd'atse? (WAT+ +)+ / ' '
Inwhatyearvereyourmarvied?. . o.oo. 19 19 19
In whatyear vereyou vidowed/separated/divor.2. 19 19_ 19
Bowmany tines vere you Fregnant?. . + + + + -
Baveyoueverwantbeudttwoebreepmraeglneantt,o... oo ELHCETWILFLE1 i8
Didyoueveersee e adoectroirbnecrauasne yeo.u + + + CT C01. CID 3
Didyouryhouushbaadntdreovuebrlseegeetatdioncgtoprrebgencaanutsz.e . . . [1] CT1 CIT
.
EID106220
000149
PREGUINCY OUTOME 1 you have never been pregnant, stop bere.
Otherwise, please continue.
1. Bowmany live-born children have you had?
oa_T_Htmoenena __ livebom children. Their dates of birth (monthvyear) are
Listed below w_/_ W_/_
mf
6 _/
@_/_ &_/_ oe
_/_ OO _[_
ah_/[_ 0 _/_
2. were any of the Live-births born with birth defects or malformations?
&a_--_Yeosn.e `hmealdfaomtateoiosfn abirrethlis(tmeondtbiveyleoawr:) andtypeofdefecotr
a vate: __/__
(2) Date: __/__
Typapret, of body affected:
pTyapret,Of body affected: ----e--
3. wteoewkmsara- yfteprreaynoaunbceicesam3eipdryegonuanhta?ve that ended vith a miscarrioge less than 20
aT_oHc_accuNriortendea,dandthmeisncuamrbreiargoefs.weeTkhse pdraetgensan(tmwoentriev:year) that the miscarriages
w_/_ weeks
@ _/_ weeks
eo _/ weeks
w _/__ weeks
4. aofwtemranyyouprbeegcnaamnecipersegdniandty?ou have that ended in a stillbirth 20 weeks or more
&a_T_haMaohnead stillbirths. The
occurred andthe number of weeks
dates (month/year)
pregnant were:
that
the
stillbirths
Ww _/_ weeks
@ _/_ weeks
or _/ weeks
" _/_ weeks
5. Beocwtmiaoryn{panraboertigondpinedryfaoorumnheadvfceotrhimaetdeiecnadsledowritpehrsaotnahlreerasaonps)oe?ruintduicecd g
Bar TMoe nnead__ abortions. The dates (montanhd/umybeer oafwree)ks
&
a
pregnantare listed below:
w__w/e_e_ks
@ _we/ eks
_/
weeks
w _/
weeks
6. 7.
AAcceetyhoeurepraengyncmotndFiitgihotnsroowr.dias.ea_se_sntohatb.re_p_eyaetis:nyhoouwrmfaanniylmyo?ths?
month TN
a __ mo bo__yes IFYES,descthercoindibtioen:
6. irethereany conditionsor dicseeasesthatrepeatinyourhusband's family?
a __m b.__yes IP YES, destcheronidibtioen: --
000150
PLEASECOMPLETETHE TABLEBELOW. REPORT ON PREGNANCIESINTHEOFDER IN WHICHTHEY OCCURFED-
`Pregnancy `outcome: live-birth,
miscarriage,|
orabortion
28 P tr Sos t----Srs r + --e ----r r r r r r r -- = e 7 7 7 -- r r r r rc + e r + r p e r re C e er ] r L i r t] ] l <g gnancy
peci fy
Date of live-birth, | Illness miscarriage, arash oH r oae nbtohri /yteian orn|o1 YrESf|evWeOr?[YEs| Mo
outside| X-rays | cigarettes |o oYfeshe oMmeo?|| vteadkenW?| O|fsr per mos k4e:dt
s2 Pregnancy 3. 5c7 ss 2n0 2
Number of| alcoholic|
Type of birth`control
method
the 12
pmroanctthiscpedrdiurokinrog|!
Tmyepdeicoaftions/drugs
d`rpceiornnskwusemeekd| pdrieagphnraangcmy, (oPtihlel,r,UnDo,ne)| tparkeegnnadnucryin(gchoose from list in lower right of page
1 Tima JewFsem `@ antihistamines -- rT )iadas artificial sweetners
1 o diet drinks
1 --E--|| lo gmiauaiamenRneRastaion miscarriage | sitdmelewenn `@ other pain killers
[linenaiaations (specify which ane)
.
EID106222
000151
Por each
onita| 1 2
live born child, please complete the table below:
Doctor said
GBliorntnhpvdeaater)| pSoexr.e)| blaabtye,woars oeoartliyn,e
B(iprotuhnsw/eoirgh.t)|
3
4s
6
a
98
110 12
Birth
l(ienncghtehs)
I 1fany of youirnchyioulrdrfeanmivleyrehabvoernawsiitnhilaabriprrtohbldeenf?ectorother problem;does
a __M b__Yes IFES plese plete thetable below:
pee
a_i b__yes Have you ever been told that you had ahereditaryorgenetic problem?
IP YES, please describe the condition:
J Maeyour husband averbeen toldthat hehad a hereditary orgeneticprotien?
&
I -- 3 a __m
b.__yes 1p YES, please describe the condition:
2 0 QUESTIOnNAsIREg . Te HANKsYOU FOR YOUR COOPERATION.
.
EID106223
000152