Inova BabyNET 2010 28 Week Survey: Pam Survey

Inova BabyNET 2010 28 Week Survey: Pam

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28 Week Prenatal Survey

Congratulations, you are in your last trimester of pregnancy! Thank you for taking a minute to answer these quick questions once you are at least 28 weeks pregnant. Please answer yes to any question that applies to your CURRENT pregnancy.

1.	What is your name?*

2.	Do you know the signs and symptoms of preterm labor and what to do if you think you might be having preterm labor?*
	No
	Yes

Please call your healthcare provider immediately or go to the hospital if you think you are having preterm labor. Some signs are:

* Contractions (your abdomen tightens like a fist) every 10 minutes or more often

* Change in vaginal discharge (leaking fluid or bleeding from your vagina)

* Pelvic pressure�the feeling that your baby is pushing down

* Low, dull backache

* Cramps that feel like your period

* Abdominal cramps with or without diarrhea

3.	What is your due date?*
	mm/dd/yyyy

4.	Are you currently having a multiple birth (twins, triplets or more)?*
	No
	Yes

5.	Have you been tested for diabetes during this pregnancy?*
	No
	Yes

6.	Are you currently being treated for diabetes during this pregnancy?*
	Yes No

7.	Have you experienced any recent hard falls or injuries?*
	No
	Yes

8.	Have you had a lot of swelling in your face or hands?*
	No
	Yes

9.	Have you had any recent high blood pressure?* More than one high reading
	No
	Yes

10.	Have you had any recent abdominal cramping, discomfort or pain?* This can include contractions, menstrual-like cramping or lower back pain.
	No
	Yes, please describe

11.	Have you had any problems with urination (like urgency, burning, pain or increased frequency)?*
	No
	Yes

12.	Have you had any recent vaginal infections?*
	No
	Yes

13.	Have you had any recent vaginal bleeding?* After the first trimester (after 12 weeks).
	No
	Yes

14.	Have you been told you have placenta previa with this pregnancy?*
	No
	Yes

15.	Have you been treated for premature labor at any point in this pregnancy?*
	No
	Yes, please describe

16.	Have you had any recent hospitalizations?*
	No
	Yes, please describe

17.	Have you taken any over-the-counter medication in any form?* Do not include recreational drugs. Remember, many medications are not safe during pregnancy. Please consult with your doctore before taking medications like ibuprofen and asprin.
	No
	Yes

18.	Have you recently had tobacco in any form?*
	No
	Yes

19.	How much alcohol are you currently consuming?* A single beverage would be a glass of wine, a beer or half a mixed-drink.
	None
	1 per week
	2-3 per week
	4-5 per week
	more than 6 per week

20.	Have you recently had any recreational drugs in any form?*
	No
	Yes

21.	Has your doctor recommended that you currently stay on any form of bedrest?*
	No
	Yes, please describe