Questionnaires

Early Pregnancy Study (EPS)

For more information about Early Preganancy Study questionnaires, contact Allen J. Wilcox, M.D., Ph.D.

Screening Questionnaire (http://www.niehs.nih.gov/research/atniehs/labs/epi/studies/eps/EarlyPreg_screen)   (560K)
The questionnaire determines eligibility to participate in the study.

Procedural Manual (http://www.niehs.nih.gov/research/atniehs/labs/epi/studies/eps/EarlyPreg_procedural_man.pdf)   (707K)
The manual contains important information for participants such as the purpose of study, procedures for collection of specimens and how to fill out the daily record card.

Intake (http://www.niehs.nih.gov/research/atniehs/labs/epi/studies/eps/EarlyPreg)   (801K)
The questionnaire covers pregnancy and menstrual/contraceptive history and intake of medications, tobacco and beverages.

Eight Week Pregnancy (http://www.niehs.nih.gov/research/atniehs/labs/epi/studies/eps/EarlyPreg_8wk.pdf)   (766K)

Three Month (http://www.niehs.nih.gov/research/atniehs/labs/epi/studies/eps/EarlyPreg_3mo.pdf)   (781K)

Six Month (http://www.niehs.nih.gov/research/atniehs/labs/epi/studies/eps/EarlyPreg_6mo.pdf)   (747K)
This questionnaire is taken throughout pregnancy to determine medication, tobacco and beverage intake history.

Pregnancy Follow-up (http://www.niehs.nih.gov/research/atniehs/labs/epi/studies/eps/EarlyPreg_pregnancy followup.pdf)   (136K)
This questionnaire notes the pregnancy outcome/due date, birthweight and gender.

First Year Follow-up (http://www.niehs.nih.gov/research/atniehs/labs/epi/studies/eps/EarlyPreg_1yr_followup)   (140K)
This pregnancy history questionnaire is taken in the six-month period following discontinuation of specimen collection.

Husband (http://www.niehs.nih.gov/research/atniehs/labs/epi/studies/eps/EarlyPreg_husband.pdf)   (1.3M)
This questionnaire determines the medication, tobacco and beverage intake of husband.

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