Column A	Column B
Family Background
1. Do you consider yourself African-American?	Yes No
2. Were you born in the United States?	Yes No
3. Are you younger than 18 or older than 35?	Yes No
4. Is your annual income less than $8,000 for a family of two, or less than $10,000 for a family of three?	Yes No
5. Are you a single parent?	Yes No
6. Do you have preschool children at home?	Yes No
7. Do you have more than two children at home?	Yes No
8. Do one or more elderly relatives live with you?	Yes No
Gynecological, Obstetrical, and Medical History Factors
Before this pregnancy, have you had…
9. ---more than one spontaneous abortion?	Yes No
10. ---more than one induced abortion?	Yes No
11. ---any preterm births (<37 weeks' gestation)?	Yes No
Were any of your previous newborns…
12. ---born dead (stillborns)?	Yes No
13. ---less than 5½ pounds at birth?	Yes No
14. ---dead within one month after birth?	Yes No
15. Do you have a history of infertility treatments?	Yes No
16. Did your mother take DES (diethylstilbesterol) when she was pregnant with you?	Yes No
17. Is this your first pregnancy?	Yes No
18. Have you given birth four or more times before?	Yes No
19. Did you have any preexisting medical conditions?	Yes No
Current Obstetrical Factors
20. Have you had any vaginal bleeding after 12 weeks?	Yes No
21. Do you have any placental complications?	Yes No
22. Have you been told you have an incompetent cervix?	Yes No
23. Do you have premature rupture of membranes?	Yes No
24. Have you had one or more vaginal infections?	Yes No
25. Are you pregnant with more than one baby (multiples)?	Yes No
Nutritional Historical Factors
26. Are you less than five feet tall?	Yes No
27. Can you pinch less than one inch of fat on your arm?	Yes No
28. Are you underweight for your height?	Yes No
29. Have you recently been dieting to lose weight?	Yes No
30. Have you recently had a major illness or surgery?	Yes No
Home and Work Environment Factors
31. Do you climb stairs at home?		Yes No
32. Do you do much lifting at home?		Yes No
33. Do you do much carrying at home?		Yes No
34. Do you do much standing at home?		Yes No
35. Is your home environment noisy?		Yes No
36. Do you spend much time driving (carpool, groceries, errands)?		Yes No
37. Is your job high-stress or physically demanding?		Yes No
38. Do you stand while commuting to and from work?		Yes No
39. Do you stand most of the time at work?		Yes No
40. Do you do much lifting at work?		Yes No
41. Does your job require much physical exertion?		Yes No
42. Do you have irregular work hours?		Yes No
43. Does your job involve shift work?		Yes No
44. Do you work more than 8 hours per day?		Yes No
45. Do you work more than 40 hours per week?		Yes No
46. Do you become fatigued at work?		Yes No
47. Is your work environment noisy?		Yes No
48. Are you under a lot of stress at work?		Yes No
49. Do you drive at work or commute to work?		Yes No
Lifestyle Factors
50. Do you drink alcohol?		Yes No
51. Do you smoke cigarettes?		Yes No
52. Do you drink more than 2 cups of coffee per day?		Yes No
If you participate in recreational exercise,
53. ---do you exercise on your back or until fatigued?		Yes No
54. ---do you exercise until you perspire?		Yes No
Nutritional Factors in the Current Pregnancy
Have you been told that you have…
55. ---to eat more frequently (don't skip meals)?		Yes No
56. ---not gained enough weight before 20 weeks?		Yes No
57. ---not gained enough weight after 20 weeks?		Yes No
58. ---iron-deficiency anemia?		Yes No
59. ---an inadequate iron intake?		Yes No
60. ---an inadequate calcium intake?		Yes No