Document NEpgR8ByKym7ZrMJbz7rexEQg

AR226-1384 Revised 10-24-80* IJ _W_O_RD__P_R_O_C_E_S_SI_N_G__W_O_R_K _F_O_R_M TO: EMPLOYEE RELATIONS DEPARTMENT WORD PROCESSING CENTER - N-12533 AD O D Q ' * *** Tape# /IP2.y __ /QffJj. FROM: Room: Tel: Date Retain Diskette: Perm. Other ______________________________ Format: Draft Q Final Copy 1 | Spacing: Single Q Double \ ) As Shown | j Job Title: ***^t $ wJuItA-^wAuthor _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ Previous Author (if Applicable) Special Instruction: Your requested typing is attached. If you desire revision, please note and return to me with this slip. Please keep this sheet with your work. ROTE: In order to keep our records current, please indicate when tape may be erased by returning this sheet to us with your signature. DO NOT SIGN UNTIL THIS WORK IS NO LONGER NEEDED. WHEN THE TAPE IS ERASED THE WORK WILL HAVE TO BE TYPED AGAIN. 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EID106216 Pages Scanned By \- 000X45 PREGNANCY OUTCOME QUESTIONNAIRE CONTAINS PERSONAL AND CONFIDENTIAL MEDICAL INFORMATION CASE # EID106217 * 000146 WEF000169 DEMOGRAPHIC CASE f What is jour n a m e : _______________________________________________________ LAST FIRST MIDDLE INITIAL ttiat is jour social security n u n ber? _______ /____ /__________ Vhat is your birth d a t e ? ___ _/ / __ month "3ay year What is jour relationship to this study? (CIRCLE CORRECT ANSWER) a. Female Washington works employee b. Wife of a Washington works employee c. Male Washington works enplcyee Vhat is the last grade of school jou completed? (CIRCLE CORRECT ANSWER) Elementary: 1 2 3 4 5 6 7 8 Secondary: 9 10 11 12 College: 13 14 15 16 17 18 19 20+ GENERAL MEDICAL Have you ever been told by a doctor that you had any of the following medical conditions? YES NO Anemia .................... Sugar diabetes ............. Thyroid condition........... Epilepsy, fits, or other neurological conditions. . . . Kidney or bladder condition. . Liver condition. ....... . . Any type of cancer......... Heart condition............. YEAR MEDICATIONS GIVEN FOR THIS CONDITION (LIST) WEF000170 SMOKING Have you ever smoked cigarettes?.................... Yes No m Age started? Do you now smoke: j Number years smoked?. I JS5--I Cigarettes? How many packs a day? (Check one box below) less than 1/2 ,1/2-1 1-2 2 or more r] Cigars?................. . How many cigars a day? ]c ][ r i Pipe? m How many pipefuls a day?....................I If you snake, do you inhale?................................. Jm If you have given up cigarette smoking, how old were you when you last gave up snaking?.._____yrs. m EID106218 000147 OCCUPATION Have sou ever worked outside of the hone in ary of the following industries, jobs, businesses, or conditions? If yes, give dates: YES NO from M o A r to Mo/Yr Clerical worker........................ Factory worker.......................... Xtiysician/dentist/chemist/pathologist . . . Other professional worker............... Chemical operator in a factory........... Farmer, farm hand, or field worker....... Maintenance worker or craftanan......... Service worker/janitor................... Construction........................... Painter ................................ Textile plant worker..................... Beauty salon hairdresser or beautician. . . Plant where dyes were made or used........ Surgical operating room ................. Where you worked around anesthetic gases. . Dusty job .............................. there X-rays were used............. . . . there radioactive materials ere used . . . there drugs/medicines were made/packaged. . Dry cleaning s h o p ...................... there solvents were used................. there degreasers were used. . . ......... there it was very h o t ................... there it was very cold................... there you worked around exhaust funes . . . there plastics were made................. there you had to wear a respirator........ there you worked around funes/gas vapor . . there you worked around mists or sprays . . there you worked with lead............... there you worked with other metals....... there you worked with laboratory chemicals. Job involving heavy lifting............. Job involving continual standing......... Job involving continual sitting ......... labaratory/medical/dental technician. . . . EID1062I9 000148 WEF000171 MENSTRUAL HISTORY The next few questions are about your menstrual periods. You may feel that >w> of this is a little personal, but it is very important for us to get a ccnplete picture of your health. How old were you when you had your first period? ___ years Are you still having periods at all? a. yes El no IF NO, At what age did you have your last period?____years Did your periods: a. stop naturally? b. stop due to surgery? c. stop due to radiation? d. stop for some other reason? e. stop for some unknown reason? IF YES, About how many days are there from the first day of one period to the first day of your next period?___days About how many days does your period last, that is until the bleeding completely stops?.......... ....days Below is a list of changes that women sometimes notice in their menstrual cycles. Since you were 18 years old, have you noticed any of the following changes in your periods? ______ skipping periods...... sans irregular periods . . . . increased flow....... decreased flow....... increased pain or cramping 9omeother kind of change. MARITAL HISTORY Do you think you have ever been pregnant? a. yes b. no IF YES, how many times have you been pregnant?___times Are you now: a. married b. divorced c. separated d. widowed e. never have been married PRESENT PREVIOUS PREVIOUS H05BAND HUSBAND HUSBAND ffcat is your husband's birth date? (mo/yr) . . . / In what year were your married?............... 19____ / 19 / 19 In that year were you widowed/separated/divor.?. 19__ 19 19 How many times were you pregnant?. . Have you ever wanted to be pregnant, but were unable to? m rj 1 I I l Did you ever see a doctor because you _____ had trouble getting pregnant?......... | | | r ~ r n m Did your husband ever see a doctor because _____ you had trouble getting pregnant?. . . . I | | EID106220 000149 WEF000172 pRBQNcy o o t o o oe If you have never been pregnant, stop here. Otherwise, please continue. 1. How nary live-born children have you had? a. ___None b. I have h a d ___live-bom children. Their dates of birth (month/year) are listed below: (1) / (4) / (7) / (10) / (2) / (5) / (8) / (11) / (3) / (6) / (9) / (12) / 2. Were any of the live-births b o m with birth defects or malformations? a. None h. Yes. The dates of birth (montVear) and type of defect or nalformation are listed below: (1) Date: (2) Date: Type# part of body affected: Type# part of body affected: 3. How nary pregnancies did you have that ended with a miscarriage less than 20 weeks after you became pregnant? a . __ None b. I have h a d ___miscarriages. The dates (month/year) that the miscarriages occurred, and the nunber of weeks pregnant were: (1) J __ 2( ) J __ (3) _ /_____ (4) weeks weeks weeks weeks 4. How many pregnancies did you have that ended in a stillbirth 20 weeks or more after you became pregnant? a. ___None b. I have had _stillbirths. The dates (month/year) that the stillbirths occurred and the number of weeks pregnant were: (1) _ /_____ (2) (3) (4) weeks weeks weeks weeks 5. How many pregnancies did you have that ended with a therapeutic or induced abortion (an abortion performed for medical or personal reasons)? a. None b. I have h a d __ _ abortions. The dates (month/year) and mnber of weeks pregnant are listed below: (1 ) / __ (2) _ / _ (3) / (4) / weeks weeks weeks weeks 6. Are you pregnant right now. a. ___no b. ____ yes: how many months?___month 7. Are there any conditions or diseases that repeat in your family? a . ___no b. ___ yes IF YES, describe the condition: EID106221 WEF000173 6. Are there any conditions or diseases that repeat in your husband's family? * ___ no b. ___ yes IF YES, describe the ondition: 000150 PLEASE COMPLETE THE TABLE BELOW. REPORT CN PREGNANCIES IN THE ORDER IN VEICH THEY OCCURRED Pceqnancv Pregnancy outcome: live-birth, stillbirths, miscarriage, or abortion (specify) 1 2 3 4 5 6 7 8 9 0 11 12 Date of live-birth, stillbirths, miscarriage, or abortion (month/year) _/ / _____ /_____ _____ /_____ _____ / _____ _____/_____ -- / -------- Illness with a cash or fever? YES iNO 1 1 11 I 1 1 l1 1 "1 1 1 1 1 i i1 1i1 11 Accidentsi Worked Number of injuries outside X-rays cigarettes or falls of home? taken? smoked YESI NO 1 1 1 ! 1l1i |1I ii YESI NO per day i1 11 1i i1 1 1 ( 11 11 1i 11 1 1 11 I1 1 1 i11iI tl 1t11I1 1_________ 11 1 11i 1 1 1I1 11 11 1 i 1 11i I ! _______ il_______ WEF000174 Pregnancy Nunber of alcoholic drinks censured per week Type of birth control method practiced during the 12 months prior t o pregnancy (Pill, IUD, diaphragm, other, none) Type of medications/drugs taken during pregnancy (choose from list in lower right of page 1 aspirin 2 anti-nausea pills cold pills 3 antihistamines 4 diet pills artificial sweetners 5 diet drinks 6 antibiotics sleeping pills 7 nerve medication 8 tranquilizers medicines to prevent 9 miscarriage 10 diuretics or water pill: tylenol 11 other pain killers 12 vitamins e other medications (specify which one) EID106222 000151 For each live bom child, please complete the table below: Child Birth date (Month/year) Sex (M or F) Doctor said baby was early, late, or on-time Birth weight (pounds/oz.) 1 2 3 4 5 6 7 8 9 10 11 12 Birth length (inches) If any of your children were b o m with a birth defect or other problem, does anyone else in your family have a similar problem? a. ___No b. ___ Yes IF YES, please complete the table below: Child Child's birthday (month/year) Child's problem Family member's problem 1 '/ 2/ Have you ever been told that you had a hereditary or genetic problem? a. ___rib b. ____yes IF YES, please describe the condition: WEF000175 Has your husband ever been told that he had a hereditary or genetic problem? a . ___ no b. ___ yes IF YES, please describe the condition: END OF QUESTIONNAIRE. THANK YOCJ FOR YOUR COOPERATION. PIEASE RETURN THIS QUESTIONNAIRE T O ______________ __ EID106223 000152