Westside Health Authority's             
Every Block A Village Online
        

 
                        Home                            About EBV                              Site Map Summary Report & Strategy Guide
 

EBVOnline Maternal & Child Health Questionnaire

This Questionnaire may take up to 20 minutes to complete.
Use the tab key to move from field to field.
When you are finished be sure to press the "Submit" button at the end of the form.
Thanks!

Please tell us your name: Thanks!
For future comparison of your knowledge, please give us your birth date
(Month, Day & Year: For example: June 11, 1950)
Do you live in Beat 1524 of Austin, IL (Between Division & Ohio and Central & Laramie)?
I do live in Beat 1524  or  I do not live here but would like to answer the questionnaire.

animrnbw.gif (4513 bytes)

I would like to ask you some questions about health,
particularly health among pregnant women and their babies.

Question #1
There are conditions that can help a new baby grow healthy and there are other conditions that can harm a newborn baby. Please check whether the following conditions can: harm the baby, help the baby grow healthy, or neither (has no effect on the baby).

Can Hurt
Can Help
Has no effect

Can Hurt
Can Help
Has no effect
Can Hurt
Can Help
Has no effect
Can Hurt
Can Help
Has no effect

Can Hurt
Can Help
Has no effect
Can Hurt
Can Help
Has no effect
Can Hurt
Can Help
Has no effect
Can Hurt
Can Help
Has no effect
Can Hurt
Can Help
Has no effect
Can Hurt
Can Help
Has no effect
Can Hurt
Can Help
Has no effect
Can Hurt
Can Help
Has no effect
Can Hurt
Can Help
Has no effect
Can Hurt
Can Help
Has no effect
Question #2
A woman is thinking about having a baby.

before getting pregnant
beginning of the pregnancy (first three months)
middle of the pregnancy (fourth to sixth month)
near the end of the pregnancy (seventh to ninth month)

Question #3
What is the best amount of weight gain during pregnancy for most women?
under 10 pounds
around 20 pounds
as many pounds as possible

Question #4
What is an "OK" amount of alcohol for a woman early in her pregnancy?
3 or more drinks a day
1 or 2 drinks a day
none

Question #5
If a woman continues doing her usual activities during pregnancy (for example: walking, preparing meals, doing chores):
Check all that apply:
does not harm the baby
may lead to a low birth weight baby
may lead to a baby who is born too early
may lead to a baby with birth defects
may lead to bleeding during the pregnancy

Question #6
Infection during pregnancy including sexually transmitted diseases (STD's):
Check all that apply:
does not harm the baby
may lead to a low birth weight baby
may lead to a baby who is born too early
may lead to a baby with birth defects
may lead to bleeding during the pregnancy

Question #7
Smoking cigarettes during pregnancy:
Check all that apply:
does not harm the baby
may lead to a low birth weight baby
may lead to a baby who is born too early
may lead to a baby with birth defects
may lead to bleeding during the pregnancy

Question #8
Using drugs or alcohol during pregnancy:
Check all that apply:
does not harm the baby
may lead to a low birth weight baby
may lead to a baby who is born too early
may lead to a baby with birth defects
may lead to bleeding during the pregnancy

Question #9
Use of prescription and over-the-counter medications during pregnancy are:
always safe
usually safe but should be checked by a doctor or pharmacist
always dangerous

Question #10
Sometimes a baby is born too soon and is premature. What do you think is the likelihood of survival for a premature baby born after only 24 weeks of pregnancy (the earliest time a baby can survive outside the womb with a modern intensive care unit in the hospital)?
20% likelihood
40% likelihood
60% likelihood
80% likelihood
100% likelihood

Question #11
Often there are problems for premature babies after birth and after they leave the hospital. What do you think are some of the problems?

Question #12
Suppose a pregnant woman from your block tells you she really wants to stop smoking cigarettes. She asks for your help. What would you do or suggest?

Question #13
A woman from your block tells you that she is concerned about starting a good diet during her pregnancy. What would you do or suggest?

Question #14
If a woman from your block who is pregnant tells you that she has not seen a doctor for prenatal care. What would you do or suggest?

Question #15
One day as you meet one of your neighbors on your block and both of you stop to talk for a while. She tells you that her boyfriend it hitting her and the children. She says she would like to know where she could go for help. What would you suggest or do?

Thank you for completing this questionnaire!

This page has been accessed Hit Counter times since February 1, 1999.
Updated: Monday, March 05, 2007 Margaret Z. Cassey, MPH, RN, C.

 

Please report any outdated information or give us your suggestions

This page was created through a 1998 U. S. Department of Commerce Technology Opportunity Program Grant

Partners included West Suburban Hospital Medical Center Westside Health Authority,
 
Loyola University Chicago & West Suburban College of Nursing (of Oak Park & Chicago, IL). 

Address all inquiries to Christopher Masi, MD, Project Director (netmasi@aol.com).
 

1998-2009 All rights Reserved.