ABC Maternal Baseline Questionnaire Participant ID Initials Instructions: 1. Please read the questionnaire instructions before answering the questions. 2. Please press firmly using a black ballpoint pen (provided). Never use pencil. 3. If it is necessary to make a correction, please draw a single line through the incorrect value and write the correct value nearby. Please initial and date each correction. Never use an eraser or liquid paper. 4. Mark all choice boxes with an [x] For example: What is the baby’s sex? Female X Male X 5. Do not leave blank boxes where a response is expected. For example, record ND (Not Done); UNK (Unknown); or NA (Not applicable) in or near the boxes where the response would be expected. 6. Record the date in the following format: YYYY/MM/DD 2 0 Year 0 3 0 Month 3 1 1 Day 7. Print all text and numbers clearly in English. Print numbers inside the boxes and as simply as possible without any loops or extra strokes. Include an initial for the subject first, second/middle and surname. If the subject does not have a second/middle name, please draw a straight line through the middle box as demonstrated in the example below: Initials A - F 1 of 18 Version 7. July 16 ABC Maternal Baseline Questionnaire Participant ID Initials Baseline Visit Date Year Month Day DEMOGRAPHIC INFORMATION: 1. To which Nation do you identify yourself with? Cayuga Mohawk Onondaga Oneida Seneca Tuscarora Other 2. What is your country of birth? Canada United States Other (specify) _____________________ 3. What is your place of birth? Six Nations Reserve Other 4. How long have you lived on the Six Nations Reserve? Since Birth OR years months 5. To which ethnicity does the biological father of your baby identify with? Aboriginal European Mixed Other PAST PREGNANCY INFORMATION: 6. Do you have any other children, not including your unborn child? No Yes  a. How many other children do you have? 2 of 18 Version 7. July 16 ABC Maternal Baseline Questionnaire Participant ID Initials 7. Record the age and sex of your other children; provide other requested information. Child # Age Sex Premature* C-section * < 37 weeks Birth Weight Feeding Breast milk 1. Male Female Yes No Yes No Male Female Yes No Yes No Formula lbs oz Combination of both Breast milk 2. lbs oz Formula Combination of both Breast milk 3. 4. Male Female Yes No Yes No Male Female Yes No Yes No Formula lbs oz Combination of both Breast milk lbs oz Formula Combination of both 8. In the following section, please provide details about your past pregnancies. a. Have you ever had stillbirth (20 weeks or later)? No Yes  i. How many? ii. At what gestational age was your most recent one? weeks b. Have you ever had miscarriage? No Yes  i. How many? ii. At what gestational age was your most recent one? weeks c. Have you ever had therapeutic abortion? No Yes  i. How many? ii. At what gestational age was your most recent one? weeks d. Have you ever had high blood pressure during pregnancy? No Yes e. Have you ever had diabetes diagnosed during pregnancy? No Yes 3 of 18 Version 7. July 16 ABC Maternal Baseline Questionnaire Participant ID Initials CURRENT PREGNANCY: 9. What was: a. The first date of your last menstrual period? Year Month Year Month Day b. Your expected delivery date? Day 10. Have you had any ultrasounds during this pregnancy? No Yes  i. How many ultrasounds have you had? ii. When was your most recent ultrasound? 11. What was your weight prior to becoming pregnant? . weeks lbs 12. During this pregnancy, have you been diagnosed with: a. High blood pressure? No Yes b. High blood sugar? No Yes i. Was this confirmed to be diabetes? c. Please specify any other medical problems No Yes _______________________________________ 13. Has your doctor, midwife or nurse practitioner discussed what you plan to feed your baby (e.g: breast milk or formula)? No Yes 14. What do you plan to feed your baby? Breast milk Formula Combination of breast milk and formula Undecided 4 of 18 Version 7. July 16 ABC Maternal Baseline Questionnaire Participant ID Initials MEDICAL HISTORY: 15. Prior to this pregnancy, have you been diagnosed, by a doctor, as having any of the conditions listed below? No Yes Age Diagnosed (If Yes) High blood pressure (excluding pregnancy) High blood cholesterol Diabetes Heart attack, stroke, angioplasty, coronary bypass Heart valve problem Blood clot to veins of lungs or legs Current wheezing (in past 12 months) Asthma Eczema Depression Anxiety Other Specify _________________________ 16. During the 12 months prior to your pregnancy, have you ever taken any of the following medications or had any of the following treatments? Check all that apply. No Yes Blood pressure pills Lipid/cholesterol lowering pills Insulin Pills for diabetes Prescribed diet for diabetes Angioplasty or coronary bypass Thyroid hormone Antibiotics Nicotine replacement therapy Asthma medication (puffers) Multivitamins Specify_________________ Other Specify_________________ 5 of 18 Version 7. July 16 ABC Maternal Baseline Questionnaire Participant ID Initials 17. During this pregnancy, have you ever taken any of the following medications or had any of the following treatments? Check all that apply. No Yes Blood pressure pills Lipid/cholesterol lowering pills Insulin Pills for diabetes Prescribed diet for diabetes Angioplasty or coronary bypass Thyroid hormone Antibiotics Nicotine replacement therapy Asthma medication (puffers) Multivitamins Specify_________________ Other Specify _________________ ALCHOHOL USE PRIOR TO PREGNANCY: 18. During the 12 months prior to pregnancy, how often did you drink beer, wine, liquor or any other alcoholic beverage? Never, or less than 1 drink a month Once a month Between 2 and 3 times a month Once a week Between 2 and 3 times a week Between 4 and 6 times a week Everyday Greater than 5 drinks in a single day ALCHOHOL USE DURING PREGNANCY: 19. During pregnancy, how often do you drink beer, wine, liquor or any other alcoholic beverage? Never, or less than 1 drink a month Once a month Between 2 and 3 times a month Once a week Between 2 and 3 times a week Between 4 and 6 times a week Everyday Greater than 5 drinks in a single day 6 of 18 Version 7. July 16 ABC Maternal Baseline Questionnaire Participant ID Initials TOBACCO USE: 20. Which best describes your history of smoking cigarettes? Never Former Smoker a. When did you stop smoking (in months)? Currently smokes cigarettes a. How many cigarettes do you smoke (per day)? b. How many years have you smoked? 21. Did you stop smoking since becoming pregnant? N/A No Yes a. When during pregnancy did you stop smoking? weeks 22. Over the past 12 months what has been your typical exposure to other people's smoke? Never 1 or more times per week a. How many days/week? b. How many hours/day? 23. Which best describes the biological father of your baby’s history of smoking cigarettes? Never Former Smoker a. When did he stop smoking (in months)? Currently smokes cigarettes a. How many cigarettes did he smoke (per day)? b. How many years has he smoked? 7 of 18 Version 7. July 16 ABC Maternal Baseline Questionnaire Participant ID Initials DRUG USE: 24. Which of the following street drugs or medicines have you taken more than once in the past 12 months to get high, to feel elated, to get a “buzz” or to change your mood? Please select all that apply. Amphetamines “Speed” Crystal meth “Crank” “Rush” Dexedrine Ritalin Diet pills Snorting IV Freebase Crack “Speedball” Heroin Morphine Dilaudid Opium Demerol Methadone Darvon Codeine Percodan Vicodin OxyContin LSD (“acid”) Mescaline Peyote Psilocybin STP “Mushrooms” “Ecstasy” MDA MDMA PCP Ketamine “Glue” “Rush” Ethyl chloride THC Nitrous oxide Marijuana Hashish “Pot” “Grass” Amyl or butyl nitrate “Reefer” Quaalude GHB Seconal Valium Xanax Librium Ativan Dalmane Halcion Barbiturates Miltown Roofinol “Roofies” Steroids Nonprescription sleep or diet pills Cough Medicine Other Specify ________________________ 25. From the above list, which drugs do you use most often? 1) _________________________________ 2) _________________________________ 3) _________________________________ 4) _________________________________ 8 of 18 Version 7. July 16 ABC Maternal Baseline Questionnaire Participant ID Initials FAMILY MEDICAL HISTORY: 26. Has your mother had any of the following? Unknown No Yes No Yes Heart attack < 65 years of age Toxemia or pre-ecampsia Asthma diagnosed by doctor Eczema Diabetes Stroke Blood clot to veins of lungs or legs 27. Has your father ever had any of the following? Unknown Heart attack < 65 years of age Asthma diagnosed by doctor Eczema Diabetes Stroke Blood clot to veins of lungs or legs 28. Has your biological full sister(s) ever had any of the following? N/A Unknown No Yes Heart attack < 65 years of age Toxemia or pre-ecampsia Asthma diagnosed by doctor Eczema Diabetes Stroke Blood clot to veins of lungs or legs 29. Has your biological full brother(s) ever had any of the following? N/A Unknown No Yes Heart attack < 65 years of age Asthma diagnosed by doctor Eczema Diabetes Stroke Blood clot to veins of lungs or legs 9 of 18 Version 7. July 16 ABC Maternal Baseline Questionnaire Participant ID Initials 30. In the past year, has the biological father of your baby taken any of the following medications or had any of the following treatments? Select all that apply. Unknown No Yes Heart attack < 65 years of age Asthma diagnosed by doctor Eczema Diabetes Stroke Blood clot to veins of lungs or legs Blood pressure pills Lipid/Cholesterol lowering pills Insulin Pills for diabetes Prescribed diet for diabetes Angioplasty or coronary bypass Thyroid hormone Antibiotics PHYSICAL ACTIVITY -PRIOR TO PREGNANCY: 31. On an average day considering your work and leisure activities, how active have you been prior to this pregnancy? Mainly sedentary (using computer, answering phones) Mainly walking on one level, or other mild exercise Mainly walking, climbing stairs, walking uphill, or lifting heavy objects Heavy physical labour or moderate/strenuous exercise 32. Prior to this pregnancy, how many minutes per day do you watch television, use the internet/email or computer screens (ipad, kindle, etc.) or play video/computer games? min/day 33. Prior to this pregnancy, how many minutes per day did you exercise so that you feel out of breath or sweat (eg:waking or jogging)? min/day 10 of 18 Version 7. July 16 ABC Maternal Baseline Questionnaire Participant ID Initials PHYSICAL ACTIVITY -DURING PREGNANCY: 34. On an average day considering your work and leisure activities, how active are you during this pregnancy? Mainly sedentary (using computer, answering phones) Mainly walking on one level, or other mild exercise Mainly walking, climbing stairs, walking uphill, or lifting heavy objects Heavy physical labour or moderate/strenuous exercise 35. During this pregnancy, how many minutes per day do you watch television, use the internet/email or computer screens (ipad, kindle, etc.) or play video/computer games? min/day 36. During this pregnancy, how many minutes per day did you exercise so that you feel out of breath or sweat (eg: walking or jogging)? min/day 11 of 18 Version 7. July 16 ABC Maternal Baseline Questionnaire Participant ID Initials EDUCATION: 37. What is the highest level of education obtained by yourself? Did not complete High School Completed High School (Secondary school) Diploma from Trade, Technical, or Vocational school Bachelor's degree or Teacher's College (B.A., B.Sc.) Master's (M.A, M.Sc., M.Ed) or Doctorate (PhD) Professional Degree (M.D, D.D.S, D.V.M) 38. What is the highest level of education obtained by the father of your baby? Did not complete High School Completed High School (Secondary school) Diploma from Trade, Technical, or Vocational school Bachelor's degree or Teacher's College (B.A., B.Sc.) Master's (M.A, M.Sc., M.Ed) or Doctorate (PhD) Professional Degree (M.D, D.D.S, D.V.M) 39. What is the highest level of education obtained by your father? Did not complete High School Completed High School (Secondary school) Diploma from Trade, Technical, or Vocational school Bachelor's degree or Teacher's College (B.A., B.Sc.) Master's (M.A, M.Sc., M.Ed) or Doctorate (PhD) Professional Degree (M.D, D.D.S, D.V.M) 40. What is the highest level of education obtained by your mother? Did not complete High School Completed High School (Secondary school) Diploma from Trade, Technical, or Vocational school Bachelor's degree or Teacher's College (B.A., B.Sc.) Master's (M.A, M.Sc., M.Ed) or Doctorate (PhD) Professional Degree (M.D, D.D.S, D.V.M) 41. What is your marital status? Never married Currently married Common law/Living with partner Widowed Separated/Divorced 12 of 18 Version 7. July 16 ABC Maternal Baseline Questionnaire Participant ID Initials 42. Which of the following best describes your current employment status? Employed (including self-employed) a. What is the condition of your employment? Full time Part time Unemployed Retired 43. Which of the following best describes your baby's biological father's current employment status? Employed (including self-employed) a. What is the condition of your employment? Full time Part time Unemployed Retired 44. What is the best estimate of the total income of ALL household members, from ALL sources, in the past twelve (12) months (before taxes)? $0 - $14, 999 $15, 000 - $19, 999 $20, 000 - $29, 999 $30, 000 - $39, 999 $40, 000 - $49, 999 $50, 000 - $50, 999 $60, 000 - $80, 000 $80, 000 - $100, 000 $100, 000 + 45. Does the father of your baby share your home? No Yes 46. How many people currently share your home, including yourself? 47. How many of these are children are under the age of 18? 13 of 18 Version 7. July 16 ABC Maternal Baseline Questionnaire Participant ID Initials STRESS: 48. To what extent do you agree or disagree with the following statements: Strongly Disagree Disagree Neutral Agree Strongly Agree At work I feel I have control over what happens in most situations I feel what happens in my life is often determined by factors beyond my control Over the next 5-10 years, I expect to have more positive than negative experiences I often feel like I am being treated unfairly In the past 10 years my life has been full of changes without my knowing what will happen I gave up trying to make big improvements in my life a long time ago PERSONAL MENTAL HEALTH: 49. In the past 30 days, how often do you feel: None of the time Some of the time Most of the time All of the time Nervous? So nervous that nothing calms you down? Hopeless? Restless or fidgety? So restless that you could not sit still? Depressed? That everything was an effort? So sad that nothing could cheer you up? Worthless? 14 of 18 Version 7. July 16 ABC Maternal Baseline Questionnaire Participant ID Initials SOCIAL SUPPORT: 50. The following questions are related to your personal life situation, your children, your spouse or partner, and other people you deal with. Please give a response that fits best with your typical experiences. Definitely not enough Not enough Enough Definitely enough Do you feel there are enough people in your environment who would help you with your daily chores if you were sick (eg: cooking, cleaning, grocery shopping, etc.)? Do you feel there are enough people in your environment who would look after your children if you were called for an emergency? Do you feel there are enough people in your environment who would lend you something you need (eg: food, clothing, money, etc.)? Do you feel there are enough people in your environment who would take you and your child to the doctor in an emergency? Do you feel there are enough people in your environment to give you advice (eg: specific suggestions on what to do when your child has a health problem, or advice on your household management or financial matters)? Do you feel there are enough people in your environment to give you the information you need (eg: people who can tell you about all the people you can go to if your child need a tutor, or who can tell you what the options are foryour sick child: going to the doctor or eating a particular type of food)? 15 of 18 Version 7. July 16 ABC Maternal Baseline Questionnaire Participant ID Initials Definitely not enough Not enough Enough Definitely enough Do you feel that there are enough people in your environment to talk to about things that are very personal and private, like difficulties in your relationship with your husband, family matters, physical complaints, family planning etc.? Do you feel there are enough people in your environment who listen to you when you want to talk about your sorrows, or about your child's education or health? Do you feel there are enough people in your environment who can comfort you when you feel unhappy about your daily life? Do you feel there are enough people in your environment who can show interest and concern in your well being (eg: when you are sick)? Do you feel there are enough people in your environment who can tell you that you did a good job handling a problem (eg: your child's difficult behavior, your child's health problem, or a problem at work or in the household)? Do you feel there are enough people in your environment who express their respect for your personal qualities (eg: your personal strength in facing difficulties, being friendly, helping others with problems)? 16 of 18 Version 7. July 16 ABC Maternal Baseline Questionnaire Participant ID Initials VIEWS AROUND HEALTH OUTCOMES: 51. For the following statements, please rate how strongly you agree or disagree. See the box below for the values: 1 = Strongly disagree 2 = Disagree 3 = Neutral, neither agree nor disagree 4 = Agree 5 = Strongly agree a. What I do right up to the time that my baby is born can affect my baby’s health. 1 2 3 4 5 b. My unborn child’s health can be seriously affected by my actions during pregnancy. 1 2 3 4 5 c. By attending prenatal classes taught by competent health professionals, I can greatly increase the odds of having a health, normal baby. 1 2 3 4 5 d. No matter what I do when I am pregnant, the laws of nature determine whether or not my child will be healthy. 1 2 3 4 5 e. Even if I take excellent care of myself when I am pregnant, fate will determine whether my child will be normal or abnormal. 1 2 3 4 5 f. Fate determines the health of my unborn child. 1 2 3 4 5 g. My baby will be born healthy only if I do everything my doctor/midwife/nurse tells me to do during pregnancy. 1 2 3 4 5 h. My baby’s health is in the hands of health professionals. 1 2 3 4 5 i. Only qualified health professionals can tell me what I should and should not do when I am pregnant. 1 2 3 4 5 17 of 18 Version 7. July 16 ABC Maternal Baseline Questionnaire Participant ID Initials DIET: 52. How often do you eat foods from each of the following categories? For each food item, check how often you consume the food (never, monthly, weekly or daily) and then record the actual number of times the item is consumed during that time period. < 1 per month or never Monthly Weekly Daily #times Meat/Poultry Fish Eggs Whole Grains Refined/Milled Grains Dairy products (not in tea/coffee) Deep fried foods/snacks/fast food Soy sauce, fish sauce Salty foods/snacks Pickled vegetables (brine) Deserts/sweet snacks Sugar/sweeteners Tofu/soyabean curd Legumes (eg: beans, lentils) Nuts/seeds Fruits Fruit Juices Leafy green vegetables a. How are they usually eaten? Raw Cooked crisp Cooked soft Other vegetables (raw) Other vegetables (cooked) 18 of 18 Version 7. July 16