Start
sws_3_q2
PREGNANCY QUESTIONNAIRE SHORT VERSION
intro i

Name: (Forename, Surname)

Generic text
intro ii

Address:

Generic text
intro iii

Postcode:

Generic text
intro iv

Date of birth:

Date of birth
intro v

Interviewer:

Generic text
intro vi

Date of interview:

Generic date
intro vii(a)

May I just confirm your GP's name and address: GP's name:

Generic text
intro vii(b)

May I just confirm your GP's name and address: Surgery Address:

Generic text
1: DIETARY CHANGES & FOOD SUPPLEMENTS
s1 1

We asked you about your diet at our first visit before you became pregnant. In the time between that first visit in ... (month) ... (year) and your last menstrual period in ...(month) ...(year) were there major changes in any of the following?

First visit
Last menstrual period
0
No
1
Yes
If no go to 1.3.
qc_s1_1 == 0
Else
s1 2(a)

How often you were eating meat and meat dishes?

1
more
2
same
3
less
4
stopped completely
s1 2(b)

How often you were eating fruit and vegetables?

1
more
2
same
3
less
s1 2(c)

The amount of milk and other dairy products you were consuming

1
more
2
same
3
less
s1 2(d)

The amount of alcoholic drinks you were consuming.

1
more
2
same
3
less
4
stopped completely
s1 3

Since your last menstrual period, have you taken any pills, tonics or tablets to supplement your diet? (e.g. vitamins, minerals, iron tablets, folic acid, fish oils etc.)

0
No
1
Yes
If yes,
qc_s1_3 == 1
s1 3(i)
please state which:

(for number per day, record number of tablets/capsules/teaspoons per day, as appropriate)

Supplement Number per day How many days per week? Date started Date finished (if still taking please enter 88/88/88)
Generic dateHow manyGeneric dateDays in weekGeneric textGeneric dateGeneric textDays in weekGeneric dateHow manyGeneric textHow manyDays in weekGeneric dateGeneric dateGeneric dateHow manyGeneric dateGeneric textDays in weekGeneric textGeneric dateHow manyGeneric dateDays in week Generic dateHow manyGeneric dateDays in weekGeneric textGeneric dateGeneric textDays in weekGeneric dateHow manyGeneric textHow manyDays in weekGeneric dateGeneric dateGeneric dateHow manyGeneric dateGeneric textDays in weekGeneric textGeneric dateHow manyGeneric dateDays in week Generic dateHow manyGeneric dateDays in weekGeneric textGeneric dateGeneric textDays in weekGeneric dateHow manyGeneric textHow manyDays in weekGeneric dateGeneric dateGeneric dateHow manyGeneric dateGeneric textDays in weekGeneric textGeneric dateHow manyGeneric dateDays in week Generic dateHow manyGeneric dateDays in weekGeneric textGeneric dateGeneric textDays in weekGeneric dateHow manyGeneric textHow manyDays in weekGeneric dateGeneric dateGeneric dateHow manyGeneric dateGeneric textDays in weekGeneric textGeneric dateHow manyGeneric dateDays in week Generic dateHow manyGeneric dateDays in weekGeneric textGeneric dateGeneric textDays in weekGeneric dateHow manyGeneric textHow manyDays in weekGeneric dateGeneric dateGeneric dateHow manyGeneric dateGeneric textDays in weekGeneric textGeneric dateHow manyGeneric dateDays in week
1
2
3
4
5
6
7
8
9
10
APPETITE AND NAUSEA DURING PREGNANCY
s2 1

In the first three months of your pregnancy did you experience any nausea or sickness?

0
No
1
Yes
If yes,
qc_s2_1 == 1
s2 1(i)

was this:

1
Mild (nausea only)
2
Moderate (sometimes sick)
3
Severe (regularly sick, can't retain meals)
s2 2

In the first three months of your pregnancy, did you eat: ... than before you became pregnant.

1
More
2
The same
3
Less in amount
If more,
qc_s2_2 == 1
s2 3(i)

was this

1
Because you felt more hungry
2
To prevent you feeling sick
3
Because you felt it was best for the baby
9
(Not sure/other reason)
If less,
qc_s2_2 == 3
s2 3(ii)

was this

1
Because you felt less hungry
2
Because of nausea/sickness
3
Didn't want to put on too much weight
9
(Not sure/other reason)
3: SMOKING
I would like to ask you a few questions about your smoking habits.
s3 1

Did you smoke at the time of your last menstrual period?

0
No
1
Yes
If No to question 3.1 go to 3.3
qc_s3_1 == 0
Else
s3 2

How many per day (record maximum stated)?

How many
s3 3

Did you smoke when you were around 11 weeks pregnant?

0
No
1
Yes
If No to question 3.3 go to 3.5
qc_s3_3 == 0
Else
s3 4

How many per day (record maximum stated)?

How many
s3 5

Does anyone smoke regularly in the same room as you?

0
No
1
Yes
4: MEDICINES
I would like to ask you now about any medicines you may have taken.
s4 1
What, if any, medicines/inhalers/pills/tablets/indigestion remedies have you taken since your last menstrual period?

USE BLOCK CAPITALS & COPY NAMES DIRECTLY OFF BOTTLES IF POSSIBLE

-
Generic text
1
2
3
4
5
6
7
8
5: PREGNANCIES AND ILLNESSES
s5 1

Have you had any previous pregnancies of more than 28 weeks?

0
No
1
Yes
I would now like to ask you a few questions about any ILLNESSES you may have suffered from:
If 'no' to 5.1, go to 5.3
qc_s5_1 == 0
Else
s5 2(a)

During your previous pregnancies were you ever treated by a doctor for: High blood pressure (treatment includes admission/bed rest/induction)

0
No
1
Yes
s5 2(b)

During your previous pregnancies were you ever treated by a doctor for: Diabetes

0
No
1
Yes
s5 2(c)

During your previous pregnancies were you ever treated by a doctor for: Anaemia

0
No
1
Yes
s5 2(d)

Were you anaemic after the birth of any of your previous babies?

0
No
1
Yes
s5 3(a)

When not pregnant have you ever been treated by a doctor for: High blood pressure (don't include pill associated high BP)

0
No
1
Yes
s5 3(b)

When not pregnant have you ever been treated by a doctor for: Diabetes

0
No
1
Yes
s5 3(c)

When not pregnant have you ever been treated by a doctor for: Anaemia

0
No
1
Yes
s5 4

Either as a child or an adult, have you ever suffered from asthma?

0
No
1
Yes
If Yes
qc_s5_4 == 1
s5 4(a)

was this confirmed by a doctor?

0
No
1
Yes
s5 5

Have you had wheezing or whistling in the chest in the last 12 months?

0
No
1
Yes
If No to question 5.5 go to 5.7
qc_s5_5 == 0
Else
s5 6

How many attacks of wheezing have you had in the last 12 months?

0
None
1
1-3
2
4-12
3
More than 12
s5 7

Did you suffer from eczema in childhood?

0
No
1
Yes
s5 8

Have you had eczema affecting the creases of your elbows or knees in the last year?

0
No
1
Yes
s5 9

Have you ever had a problem with sneezing, or a runny, or blocked nose when you DID NOT have a cold or 'flu?

0
No
1
Yes
If No to question 5.9 go to section 6
qc_s5_9 == 0
Else
s5 10

Is the nose problem usually accompanied by itchy-watery eyes?

0
No
1
Yes
s5 11

In the last 12 months, have you had a problem with sneezing, or a runny, or blocked nose when you DID NOT have a cold or the 'flu?

0
No
1
Yes
If No to question 5.11 go to section 6
qc_s5_11 == 0
Else
s5 12

Have you used any medicines to treat hayfever, rhinitis or any other nasal problems, at any time in the last 12 months (including sprays, solutions, pills, capsules or tablets)?

0
No
1
Yes
6: BABY'S FATHER
Now I would like to ask some questions about the baby's natural father:
s6 1

Either as a child or an adult, has he ever suffered from asthma?

0
No
1
Yes
8
Don't talk about him
If Don't talk about him to question 6.1 go to section 8
qc_s6_1 == 8
Else
If Yes
qc_s6_1 == 1
s6 2(a)

was this confirmed by a doctor?

0
No
1
Yes
s6 3

Has he had wheezing or whistling in the chest in the last 12 months?

0
No
1
Yes
If No to question 6.3 go to 6.5
qc_s6_3 == 0
Else
s6 4

How many attacks of wheezing has he had in the last 12 months?

0
None
1
1-3
2
4-12
3
More than 12
s6 5

Did he suffer from eczema in childhood?

0
No
1
Yes
s6 6

Has he had eczema affecting the creases of his elbows or knees in the last year?

0
No
1
Yes
s6 7

Has he ever had a problem with sneezing, or a runny, or blocked nose when he DID NOT have a cold or 'flu?

0
No
1
Yes
If No to question 6.7 go to 6.11
qc_s6_7 == 0
Else
s6 8

Is the nose problem usually accompanied by itchy-watery eyes?

0
No
1
Yes
s6 9

In the last 12 months, has he had a problem with sneezing, or a runny, or blocked nose when he DID NOT have a cold or the 'flu?

0
No
1
Yes
If No to question 6.9 go to 6.11
qc_s6_9 == 0
Else
s6 10

Has he used any medicines to treat hayfever, rhinitis or any other nasal problems, at any time in the last 12 months (including sprays, solutions, pills, capsules or tablets)?

0
No
1
Yes
s6 11

Approximately what is his height? In feet and inches ... ft ... ins OR in centimetres ... cm

ft
ins in ft
cm
s6 12

Approximately what is his current weight? In stones and pounds ... st ... lb OR in kilograms ... kg

st
lb in st
kg
s6 13

What was his birth weight? In pounds and ounces ... lbs ... oz OR in grams ... grams

lbs
oz in lbs
grams
s6 14

What is his date of birth?

Date of birth
7: BABY'S FATHER'S OCCUPATION
s7 1

Was the baby's father in paid employment or self-employed in the week ending last Sunday?

0
No
1
Yes
If Yes to question 7.1 go to 7.2
qc_s7_1 == 1
s7 2

Was he working full time or part time?

0
Full time (more than 30 hours)
1
Part time (30 hours or fewer)
If No to question 7.1 or Part time (30 hours or fewer) to question 7.2 go to 7.3
qc_s7_1 == 0] || qc_s7_2 == 1
s7 3

Was he going to college full time?

0
No
1
Yes
if working part-time go to 7.6a
if not working go to 7.5
If yes,
qc_s7_3 == 1
s7 4

what is he studying?

Generic text
If working part time go to 7.7
If not working go to section 8
If not working or studying
qc_s7_1 == 0 && qc_s7_3 == 0
s7 5

was he

1
Unemployed ?
2
Permanently unable to work because of long term sickness or disability ?
3
looking after home or family?
4
other ? (specify)
Other
If not working or working part-time,
(qc_s7_1 == 0 || qc_s7_2 == 1) && qc_s7_3 == 0
s7 6(a)

what was his last full-time job? Job position

If only ever part-time give last part time job.

Generic text
s7 6(a)

what was his last full-time job?

If only ever part-time give last part time job.

1
Self-employed
2
manager
3
foreman
4
employee
s7 6(a)

what was his last full-time job? Industry

If only ever part-time give last part time job.

Generic text
Then if currently working part time go to 7.7, otherwise go to section 8
If working full-time,
qc_s7_2 == 0
s7 6(b)

what is his job? Job position

Probe industry & self-employed/manager/foreman/employee

Generic text
s7 6(b)

what is his job?

Probe industry & self-employed/manager/foreman/employee

1
Self-employed
2
manager
3
foreman
4
employee
s7 6(b)

what is his job? Industry

Probe industry & self-employed/manager/foreman/employee

Generic text
(Then go to section 8)
If working part-time now,
qc_s7_2 == 1
s7 7(i)

what is his current job? Job position

Generic text
s7 7(ii)

what is his current job?

1
Self-employed
2
manager
3
foreman
4
employee
s7 7(iii)

what is his current job? Industry

Generic text
s7 8

If working part time, how many hours per week does he work? ... hrs ... mins

Part-time work hours
mins
8: BODY MEASUREMENTS
s8 1

How much did you weigh 6-8 months ago, ie. before you became pregnant? ... st ... lbs ... kg

st
lbs in st
kg
s8 2

Head circumference ... cm

cm
9. FINAL CHECK FOR NURSES
s9 i

Have you left the Baby's Father's Birth Details Form?

0
No
1
Yes
THANK YOU VERY MUCH
End

sws_3_q2

s_intro_i
PREGNANCY QUESTIONNAIRE SHORT VERSION
intro i
Name: (Forename, Surname)
Generic text
intro ii
Address:
Generic text
intro iii
Postcode:
Generic text
intro iv
Date of birth:
Date of birth
intro v
Interviewer:
Generic text
intro vi
Date of interview:
Generic date
intro vii(a)
May I just confirm your GP's name and address: GP's name:
Generic text
intro vii(b)
May I just confirm your GP's name and address: Surgery Address:
Generic text

1: DIETARY CHANGES & FOOD SUPPLEMENTS

s1 1
We asked you about your diet at our first visit before you became pregnant. In the time between that first visit in ... (month) ... (year) and your last menstrual period in ...(month) ...(year) were there major changes in any of the following?
First visit
Last menstrual period
0
No
1
Yes
s1 2(a)
How often you were eating meat and meat dishes?
1
more
2
same
3
less
4
stopped completely
s1 2(b)
How often you were eating fruit and vegetables?
1
more
2
same
3
less
s1 2(c)
The amount of milk and other dairy products you were consuming
1
more
2
same
3
less
s1 2(d)
The amount of alcoholic drinks you were consuming.
1
more
2
same
3
less
4
stopped completely
s1 3
Since your last menstrual period, have you taken any pills, tonics or tablets to supplement your diet? (e.g. vitamins, minerals, iron tablets, folic acid, fish oils etc.)
0
No
1
Yes
s1 3(i)

please state which:

Supplement Number per day How many days per week? Date started Date finished (if still taking please enter 88/88/88)
Generic dateHow manyGeneric dateDays in weekGeneric textGeneric dateGeneric textDays in weekGeneric dateHow manyGeneric textHow manyDays in weekGeneric dateGeneric dateGeneric dateHow manyGeneric dateGeneric textDays in weekGeneric textGeneric dateHow manyGeneric dateDays in week Generic dateHow manyGeneric dateDays in weekGeneric textGeneric dateGeneric textDays in weekGeneric dateHow manyGeneric textHow manyDays in weekGeneric dateGeneric dateGeneric dateHow manyGeneric dateGeneric textDays in weekGeneric textGeneric dateHow manyGeneric dateDays in week Generic dateHow manyGeneric dateDays in weekGeneric textGeneric dateGeneric textDays in weekGeneric dateHow manyGeneric textHow manyDays in weekGeneric dateGeneric dateGeneric dateHow manyGeneric dateGeneric textDays in weekGeneric textGeneric dateHow manyGeneric dateDays in week Generic dateHow manyGeneric dateDays in weekGeneric textGeneric dateGeneric textDays in weekGeneric dateHow manyGeneric textHow manyDays in weekGeneric dateGeneric dateGeneric dateHow manyGeneric dateGeneric textDays in weekGeneric textGeneric dateHow manyGeneric dateDays in week Generic dateHow manyGeneric dateDays in weekGeneric textGeneric dateGeneric textDays in weekGeneric dateHow manyGeneric textHow manyDays in weekGeneric dateGeneric dateGeneric dateHow manyGeneric dateGeneric textDays in weekGeneric textGeneric dateHow manyGeneric dateDays in week
1
2
3
4
5
6
7
8
9
10
If yes,

APPETITE AND NAUSEA DURING PREGNANCY

s2 1
In the first three months of your pregnancy did you experience any nausea or sickness?
0
No
1
Yes
s2 1(i)
was this:
1
Mild (nausea only)
2
Moderate (sometimes sick)
3
Severe (regularly sick, can't retain meals)
If yes,
s2 2
In the first three months of your pregnancy, did you eat: ... than before you became pregnant.
1
More
2
The same
3
Less in amount
s2 3(i)
was this
1
Because you felt more hungry
2
To prevent you feeling sick
3
Because you felt it was best for the baby
9
(Not sure/other reason)
If more,
s2 3(ii)
was this
1
Because you felt less hungry
2
Because of nausea/sickness
3
Didn't want to put on too much weight
9
(Not sure/other reason)
If less,

3: SMOKING

s_s3q1
I would like to ask you a few questions about your smoking habits.
s3 1
Did you smoke at the time of your last menstrual period?
0
No
1
Yes
s3 2
How many per day (record maximum stated)?
How many
s3 3
Did you smoke when you were around 11 weeks pregnant?
0
No
1
Yes
s3 4
How many per day (record maximum stated)?
How many
s3 5
Does anyone smoke regularly in the same room as you?
0
No
1
Yes

4: MEDICINES

s_s4q1
I would like to ask you now about any medicines you may have taken.
s4 1

What, if any, medicines/inhalers/pills/tablets/indigestion remedies have you taken since your last menstrual period?

-
Generic text
1
2
3
4
5
6
7
8

5: PREGNANCIES AND ILLNESSES

s5 1
Have you had any previous pregnancies of more than 28 weeks?
0
No
1
Yes
s_s5q2
I would now like to ask you a few questions about any ILLNESSES you may have suffered from:
s5 2(a)
During your previous pregnancies were you ever treated by a doctor for: High blood pressure (treatment includes admission/bed rest/induction)
0
No
1
Yes
s5 2(b)
During your previous pregnancies were you ever treated by a doctor for: Diabetes
0
No
1
Yes
s5 2(c)
During your previous pregnancies were you ever treated by a doctor for: Anaemia
0
No
1
Yes
s5 2(d)
Were you anaemic after the birth of any of your previous babies?
0
No
1
Yes
s5 3(a)
When not pregnant have you ever been treated by a doctor for: High blood pressure (don't include pill associated high BP)
0
No
1
Yes
s5 3(b)
When not pregnant have you ever been treated by a doctor for: Diabetes
0
No
1
Yes
s5 3(c)
When not pregnant have you ever been treated by a doctor for: Anaemia
0
No
1
Yes
s5 4
Either as a child or an adult, have you ever suffered from asthma?
0
No
1
Yes
s5 4(a)
was this confirmed by a doctor?
0
No
1
Yes
If Yes
s5 5
Have you had wheezing or whistling in the chest in the last 12 months?
0
No
1
Yes
s5 6
How many attacks of wheezing have you had in the last 12 months?
0
None
1
1-3
2
4-12
3
More than 12
s5 7
Did you suffer from eczema in childhood?
0
No
1
Yes
s5 8
Have you had eczema affecting the creases of your elbows or knees in the last year?
0
No
1
Yes
s5 9
Have you ever had a problem with sneezing, or a runny, or blocked nose when you DID NOT have a cold or 'flu?
0
No
1
Yes
s5 10
Is the nose problem usually accompanied by itchy-watery eyes?
0
No
1
Yes
s5 11
In the last 12 months, have you had a problem with sneezing, or a runny, or blocked nose when you DID NOT have a cold or the 'flu?
0
No
1
Yes
s5 12
Have you used any medicines to treat hayfever, rhinitis or any other nasal problems, at any time in the last 12 months (including sprays, solutions, pills, capsules or tablets)?
0
No
1
Yes

6: BABY'S FATHER

s_s6q1
Now I would like to ask some questions about the baby's natural father:
s6 1
Either as a child or an adult, has he ever suffered from asthma?
0
No
1
Yes
8
Don't talk about him
s6 2(a)
was this confirmed by a doctor?
0
No
1
Yes
If Yes
s6 3
Has he had wheezing or whistling in the chest in the last 12 months?
0
No
1
Yes
s6 4
How many attacks of wheezing has he had in the last 12 months?
0
None
1
1-3
2
4-12
3
More than 12
s6 5
Did he suffer from eczema in childhood?
0
No
1
Yes
s6 6
Has he had eczema affecting the creases of his elbows or knees in the last year?
0
No
1
Yes
s6 7
Has he ever had a problem with sneezing, or a runny, or blocked nose when he DID NOT have a cold or 'flu?
0
No
1
Yes
s6 8
Is the nose problem usually accompanied by itchy-watery eyes?
0
No
1
Yes
s6 9
In the last 12 months, has he had a problem with sneezing, or a runny, or blocked nose when he DID NOT have a cold or the 'flu?
0
No
1
Yes
s6 10
Has he used any medicines to treat hayfever, rhinitis or any other nasal problems, at any time in the last 12 months (including sprays, solutions, pills, capsules or tablets)?
0
No
1
Yes
s6 11
Approximately what is his height? In feet and inches ... ft ... ins OR in centimetres ... cm
ft
ins in ft
cm
s6 12
Approximately what is his current weight? In stones and pounds ... st ... lb OR in kilograms ... kg
st
lb in st
kg
s6 13
What was his birth weight? In pounds and ounces ... lbs ... oz OR in grams ... grams
lbs
oz in lbs
grams
s6 14
What is his date of birth?
Date of birth

7: BABY'S FATHER'S OCCUPATION

s7 1
Was the baby's father in paid employment or self-employed in the week ending last Sunday?
0
No
1
Yes
s7 2
Was he working full time or part time?
0
Full time (more than 30 hours)
1
Part time (30 hours or fewer)
If Yes to question 7.1 go to 7.2
s7 3
Was he going to college full time?
0
No
1
Yes
If No to question 7.1 or Part time (30 hours or fewer) to question 7.2 go to 7.3
s_s7q3_i
if working part-time go to 7.6a
If No to question 7.1 or Part time (30 hours or fewer) to question 7.2 go to 7.3
s_s7q3_ii
if not working go to 7.5
If No to question 7.1 or Part time (30 hours or fewer) to question 7.2 go to 7.3
s7 4
what is he studying?
Generic text
If No to question 7.1 or Part time (30 hours or fewer) to question 7.2 go to 7.3
If yes,
s_s7q4_i
If working part time go to 7.7
If No to question 7.1 or Part time (30 hours or fewer) to question 7.2 go to 7.3
If yes,
s_s7q4_ii
If not working go to section 8
If No to question 7.1 or Part time (30 hours or fewer) to question 7.2 go to 7.3
If yes,
s7 5
was he
1
Unemployed ?
2
Permanently unable to work because of long term sickness or disability ?
3
looking after home or family?
4
other ? (specify)
Other
If not working or studying
s7 6(a)
what was his last full-time job? Job position
Generic text
If not working or working part-time,
s7 6(a)
what was his last full-time job?
1
Self-employed
2
manager
3
foreman
4
employee
If not working or working part-time,
s7 6(a)
what was his last full-time job? Industry
Generic text
If not working or working part-time,
s_s7q6a
Then if currently working part time go to 7.7, otherwise go to section 8
If not working or working part-time,
s7 6(b)
what is his job? Job position
Generic text
If working full-time,
s7 6(b)
what is his job?
1
Self-employed
2
manager
3
foreman
4
employee
If working full-time,
s7 6(b)
what is his job? Industry
Generic text
If working full-time,
s_s7q6b
(Then go to section 8)
If working full-time,
s7 7(i)
what is his current job? Job position
Generic text
If working part-time now,
s7 7(ii)
what is his current job?
1
Self-employed
2
manager
3
foreman
4
employee
If working part-time now,
s7 7(iii)
what is his current job? Industry
Generic text
If working part-time now,
s7 8
If working part time, how many hours per week does he work? ... hrs ... mins
Part-time work hours
mins
If working part-time now,

8: BODY MEASUREMENTS

s8 1
How much did you weigh 6-8 months ago, ie. before you became pregnant? ... st ... lbs ... kg
st
lbs in st
kg
s8 2
Head circumference ... cm
cm

9. FINAL CHECK FOR NURSES

s9 i
Have you left the Baby's Father's Birth Details Form?
0
No
1
Yes
s_outro_i
THANK YOU VERY MUCH
Name

19 Week Pregnancy Short Questionnaire