Start
sws_8_visit
SOUTHAMPTON WOMEN’S SURVEY - BLOOD AND URINE QUESTIONNAIRE

FIRST name ONLY:

Generic text

Date of birth:

Date of birth

Nurse:

Generic text

Date of blood sample:

Generic date

What was the date of the first day of your last menstrual period?

Generic date
Have you taken any medication (prescribed or from the chemist) in the last 7 days?
-

0 - No

1 - Yes

Painkillers
Antibiotics
Blood pressure tablets
Steroids: tablets, inhalers or creams
Epilepsy tablets
Cough/cold remedies

Hormones: Within the last month have you taken the oral contraceptive pill or are you using another hormonal contraceptive?

0
No
1
Yes

Hormones: Within the last nine months have you been given the Depot or Noristerat injection?

0
No
1
Yes

Hormones: Within the last month have you been on hormone replacement therapy (HRT) or received hormonal treatment for infertility or menstrual problems? e.g. Clomid

0
No
1
Yes
If yes to any of the hormone questions above,
qc_7_i == 1 || qc_7_ii == 1 || qc_7_iii == 1

what is the woman using? Enter current/most recent in first box and give the code number from the prompt card if possible otherwise give the name(s) or as close to it/them as possible

101
Oral contraceptives Combined pills: BiNovum
102
Oral contraceptives Combined pills: Brevinor
103
Oral contraceptives Combined pills: Cilest
104
Oral contraceptives Combined pills: Eugynon 30
105
Oral contraceptives Combined pills: Femodene (including ED)
106
Oral contraceptives Combined pills: Loestrin 20
107
Oral contraceptives Combined pills: Loestrin 30
108
Oral contraceptives Combined pills: Logynon (including ED)
109
Oral contraceptives Combined pills: Marvelon
110
Oral contraceptives Combined pills: Mercilon
111
Oral contraceptives Combined pills: Microgynon 30 (including ED)
112
Oral contraceptives Combined pills: Minulet
113
Oral contraceptives Combined pills: Norimin
114
Oral contraceptives Combined pills: Norinyl-1
115
Oral contraceptives Combined pills: Ovran
116
Oral contraceptives Combined pills: Ovran 30
117
Oral contraceptives Combined pills: Ovranette
118
Oral contraceptives Combined pills: Ovysmen
119
Oral contraceptives Combined pills: Synphase
120
Oral contraceptives Combined pills: Tri-Minulet
121
Oral contraceptives Combined pills: Triadene
122
Oral contraceptives Combined pills: Trinordiol
123
Oral contraceptives Combined pills: TriNovum
201
Progestogen only pills: Femulen
202
Progestogen only pills: Micornor
203
Progestogen only pills: Microval
204
Progestogen only pills: Neogest
205
Progestogen only pills: Norgeston
206
Progestogen only pills: Noriday
301
Other hormonal contraceptives: Depot
302
Other hormonal contraceptives: Implanon
303
Other hormonal contraceptives: Mirena
304
Other hormonal contraceptives: Noristerat
305
Other hormonal contraceptives: Norplant
401
Other hormonal treatments: Clomid
402
Other hormonal treatments: Other infertility treatment
403
Other hormonal treatments: Any form of hormone replacement therapy
Generic text
Generic text 2
FOOD SUPPLEMENTS

During the past seven days 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_9 == 1
please state which:

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

Supplement Number per day How many days in the last 7?
How manyHow manyDays in 7 daysHow manyHow manyDays in 7 daysDays in 7 daysHow manyHow many How manyHow manyDays in 7 daysHow manyHow manyDays in 7 daysDays in 7 daysHow manyHow many How manyHow manyDays in 7 daysHow manyHow manyDays in 7 daysDays in 7 daysHow manyHow many
1
2
3
4
5

Have you given a food supplement questionnaire to the woman?

0
No
1
Yes

Have you sent back your food diary?

0
No
1
Yes

Have you sent back your birth details?

0
No
1
Yes
Have you CONSENTED this woman?

Blood sample provided

0
No
1
Yes

Time blood sample taken (24 hr clock)

Generic time

Time finished last meal or snack (24hr clock)

Generic time
Have you CONSENTED this woman?

Urine sample provided

0
No
1
Yes

Time of urine sample (24 hr clock)

Generic time

When did you last pass urine (prior to passing this sample) Time (24 hr clock)

Generic time
End

sws_8_visit

SOUTHAMPTON WOMEN’S SURVEY - BLOOD AND URINE QUESTIONNAIRE
FIRST name ONLY:
Generic text
Date of birth:
Date of birth
Nurse:
Generic text
Date of blood sample:
Generic date
What was the date of the first day of your last menstrual period?
Generic date

Have you taken any medication (prescribed or from the chemist) in the last 7 days?

-

0 - No

1 - Yes

Painkillers
Antibiotics
Blood pressure tablets
Steroids: tablets, inhalers or creams
Epilepsy tablets
Cough/cold remedies
Hormones: Within the last month have you taken the oral contraceptive pill or are you using another hormonal contraceptive?
0
No
1
Yes
Hormones: Within the last nine months have you been given the Depot or Noristerat injection?
0
No
1
Yes
Hormones: Within the last month have you been on hormone replacement therapy (HRT) or received hormonal treatment for infertility or menstrual problems? e.g. Clomid
0
No
1
Yes
what is the woman using? Enter current/most recent in first box and give the code number from the prompt card if possible otherwise give the name(s) or as close to it/them as possible
101
Oral contraceptives Combined pills: BiNovum
102
Oral contraceptives Combined pills: Brevinor
103
Oral contraceptives Combined pills: Cilest
104
Oral contraceptives Combined pills: Eugynon 30
105
Oral contraceptives Combined pills: Femodene (including ED)
106
Oral contraceptives Combined pills: Loestrin 20
107
Oral contraceptives Combined pills: Loestrin 30
108
Oral contraceptives Combined pills: Logynon (including ED)
109
Oral contraceptives Combined pills: Marvelon
110
Oral contraceptives Combined pills: Mercilon
111
Oral contraceptives Combined pills: Microgynon 30 (including ED)
112
Oral contraceptives Combined pills: Minulet
113
Oral contraceptives Combined pills: Norimin
114
Oral contraceptives Combined pills: Norinyl-1
115
Oral contraceptives Combined pills: Ovran
116
Oral contraceptives Combined pills: Ovran 30
117
Oral contraceptives Combined pills: Ovranette
118
Oral contraceptives Combined pills: Ovysmen
119
Oral contraceptives Combined pills: Synphase
120
Oral contraceptives Combined pills: Tri-Minulet
121
Oral contraceptives Combined pills: Triadene
122
Oral contraceptives Combined pills: Trinordiol
123
Oral contraceptives Combined pills: TriNovum
201
Progestogen only pills: Femulen
202
Progestogen only pills: Micornor
203
Progestogen only pills: Microval
204
Progestogen only pills: Neogest
205
Progestogen only pills: Norgeston
206
Progestogen only pills: Noriday
301
Other hormonal contraceptives: Depot
302
Other hormonal contraceptives: Implanon
303
Other hormonal contraceptives: Mirena
304
Other hormonal contraceptives: Noristerat
305
Other hormonal contraceptives: Norplant
401
Other hormonal treatments: Clomid
402
Other hormonal treatments: Other infertility treatment
403
Other hormonal treatments: Any form of hormone replacement therapy
Generic text
Generic text 2
FOOD SUPPLEMENTS
During the past seven days 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 in the last 7?
How manyHow manyDays in 7 daysHow manyHow manyDays in 7 daysDays in 7 daysHow manyHow many How manyHow manyDays in 7 daysHow manyHow manyDays in 7 daysDays in 7 daysHow manyHow many How manyHow manyDays in 7 daysHow manyHow manyDays in 7 daysDays in 7 daysHow manyHow many
1
2
3
4
5
Have you given a food supplement questionnaire to the woman?
0
No
1
Yes
Have you sent back your food diary?
0
No
1
Yes
Have you sent back your birth details?
0
No
1
Yes
Have you CONSENTED this woman?
Blood sample provided
0
No
1
Yes
Time blood sample taken (24 hr clock)
Generic time
Time finished last meal or snack (24hr clock)
Generic time
Have you CONSENTED this woman?
Urine sample provided
0
No
1
Yes
Time of urine sample (24 hr clock)
Generic time
When did you last pass urine (prior to passing this sample) Time (24 hr clock)
Generic time
Name

Initial Blood and Urine Questionnaire