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Your Environment. Your Health.

Questionnaires

Early Pregnancy Study (EPS

Early Pregnancy Study (EPS)

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

 

Screening Questionnaire(626KB)  

The questionnaire determines eligibility to participate in the study.

 

Procedural Manual(782KB)  

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(1MB)  

The questionnaire covers pregnancy and menstrual/contraceptive history and intake of medications, tobacco and beverages.

 

Eight Week Pregnancy(945KB)

 

Three Month(872KB)

 

Six Month(838KB)  

This questionnaire is taken throughout pregnancy to determine medication, tobacco and beverage intake history.

 

Pregnancy Follow-up(152KB)  

This questionnaire notes the pregnancy outcome/due date, birthweight and gender.

 

First Year Follow-up(155KB)  

This pregnancy history questionnaire is taken in the six-month period following discontinuation of specimen collection.

 

Husband(1MB)  

This questionnaire determines the medication, tobacco and beverage intake of husband.

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