Start
sws_3_q2
PREGNANCY QUESTIONNAIRE SHORT VERSION

Name: (Forename, Surname)

Generic text

Address:

Generic text

Postcode:

Generic text

Date of birth:

Date of birth

Interviewer:

Generic text

Date of interview:

Generic date

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

Generic text

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

Generic text
1: DIETARY CHANGES & FOOD SUPPLEMENTS

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

How often you were eating meat and meat dishes?

1
more
2
same
3
less
4
stopped completely

How often you were eating fruit and vegetables?

1
more
2
same
3
less

The amount of milk and other dairy products you were consuming

1
more
2
same
3
less

The amount of alcoholic drinks you were consuming.

1
more
2
same
3
less
4
stopped completely

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
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
APPETITE AND NAUSEA DURING PREGNANCY

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

was this:

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

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

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

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.

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

How many per day (record maximum stated)?

How many

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

How many per day (record maximum stated)?

How many

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.
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

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

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

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

0
No
1
Yes

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

0
No
1
Yes

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

0
No
1
Yes

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

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

0
No
1
Yes

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

0
No
1
Yes

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

0
No
1
Yes
If Yes
qc_s5_4 == 1

was this confirmed by a doctor?

0
No
1
Yes

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

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

Did you suffer from eczema in childhood?

0
No
1
Yes

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

0
No
1
Yes

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

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

0
No
1
Yes

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

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:

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

was this confirmed by a doctor?

0
No
1
Yes

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

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

Did he suffer from eczema in childhood?

0
No
1
Yes

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

0
No
1
Yes

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

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

0
No
1
Yes

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

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

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

ft
ins in ft
cm

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

st
lb in st
kg

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

lbs
oz in lbs
grams

What is his date of birth?

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

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

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

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

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

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

what was his last full-time job? Job position

Generic text

what was his last full-time job?

1
Self-employed
2
manager
3
foreman
4
employee

what was his last full-time job? Industry

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

what is his job? Job position

Generic text

what is his job?

1
Self-employed
2
manager
3
foreman
4
employee

what is his job? Industry

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

what is his current job? Job position

Generic text

what is his current job?

1
Self-employed
2
manager
3
foreman
4
employee

what is his current job? Industry

Generic text

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

Part-time work hours
mins
8: BODY MEASUREMENTS

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

st
lbs in st
kg

Head circumference ... cm

cm
9. FINAL CHECK FOR NURSES

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

0
No
1
Yes
THANK YOU VERY MUCH
End

sws_3_q2

PREGNANCY QUESTIONNAIRE SHORT VERSION
Name: (Forename, Surname)
Generic text
Address:
Generic text
Postcode:
Generic text
Date of birth:
Date of birth
Interviewer:
Generic text
Date of interview:
Generic date
May I just confirm your GP's name and address: GP's name:
Generic text
May I just confirm your GP's name and address: Surgery Address:
Generic text

1: DIETARY CHANGES & FOOD SUPPLEMENTS

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
How often you were eating meat and meat dishes?
1
more
2
same
3
less
4
stopped completely
How often you were eating fruit and vegetables?
1
more
2
same
3
less
The amount of milk and other dairy products you were consuming
1
more
2
same
3
less
The amount of alcoholic drinks you were consuming.
1
more
2
same
3
less
4
stopped completely
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

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

APPETITE AND NAUSEA DURING PREGNANCY

In the first three months of your pregnancy did you experience any nausea or sickness?
0
No
1
Yes
was this:
1
Mild (nausea only)
2
Moderate (sometimes sick)
3
Severe (regularly sick, can't retain meals)
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
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)
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.
Did you smoke at the time of your last menstrual period?
0
No
1
Yes
How many per day (record maximum stated)?
How many
Did you smoke when you were around 11 weeks pregnant?
0
No
1
Yes
How many per day (record maximum stated)?
How many
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.

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

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:
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
During your previous pregnancies were you ever treated by a doctor for: Diabetes
0
No
1
Yes
During your previous pregnancies were you ever treated by a doctor for: Anaemia
0
No
1
Yes
Were you anaemic after the birth of any of your previous babies?
0
No
1
Yes
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
When not pregnant have you ever been treated by a doctor for: Diabetes
0
No
1
Yes
When not pregnant have you ever been treated by a doctor for: Anaemia
0
No
1
Yes
Either as a child or an adult, have you ever suffered from asthma?
0
No
1
Yes
was this confirmed by a doctor?
0
No
1
Yes
Have you had wheezing or whistling in the chest in the last 12 months?
0
No
1
Yes
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
Did you suffer from eczema in childhood?
0
No
1
Yes
Have you had eczema affecting the creases of your elbows or knees in the last year?
0
No
1
Yes
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
Is the nose problem usually accompanied by itchy-watery eyes?
0
No
1
Yes
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
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:
Either as a child or an adult, has he ever suffered from asthma?
0
No
1
Yes
8
Don't talk about him
was this confirmed by a doctor?
0
No
1
Yes
Has he had wheezing or whistling in the chest in the last 12 months?
0
No
1
Yes
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
Did he suffer from eczema in childhood?
0
No
1
Yes
Has he had eczema affecting the creases of his elbows or knees in the last year?
0
No
1
Yes
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
Is the nose problem usually accompanied by itchy-watery eyes?
0
No
1
Yes
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
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
Approximately what is his height? In feet and inches ... ft ... ins OR in centimetres ... cm
ft
ins in ft
cm
Approximately what is his current weight? In stones and pounds ... st ... lb OR in kilograms ... kg
st
lb in st
kg
What was his birth weight? In pounds and ounces ... lbs ... oz OR in grams ... grams
lbs
oz in lbs
grams
What is his date of birth?
Date of birth

7: BABY'S FATHER'S OCCUPATION

Was the baby's father in paid employment or self-employed in the week ending last Sunday?
0
No
1
Yes
Was he working full time or part time?
0
Full time (more than 30 hours)
1
Part time (30 hours or fewer)
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
what is he studying?
Generic text
If working part time go to 7.7
If not working go to section 8
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
what was his last full-time job? Job position
Generic text
what was his last full-time job?
1
Self-employed
2
manager
3
foreman
4
employee
what was his last full-time job? Industry
Generic text
Then if currently working part time go to 7.7, otherwise go to section 8
what is his job? Job position
Generic text
what is his job?
1
Self-employed
2
manager
3
foreman
4
employee
what is his job? Industry
Generic text
(Then go to section 8)
what is his current job? Job position
Generic text
what is his current job?
1
Self-employed
2
manager
3
foreman
4
employee
what is his current job? Industry
Generic text
If working part time, how many hours per week does he work? ... hrs ... mins
Part-time work hours
mins

8: BODY MEASUREMENTS

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

9. FINAL CHECK FOR NURSES

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

19 Week Pregnancy Short Questionnaire