Generated Narrative: Questionnaire Questionnaire-patients-fetal-death LinkID Text Cardinality Type Description & Constraints QuestionnairePatientsFetalDeathWorksheet This Questionnaire represents the [Patient's Worksheet for the Report of Fetal Death](https://www.cdc.gov/nchs/data/dvs/fetal-death-mother-worksheet-english-2019-508.pdf). Questionnaire http://hl7.org/fhir/us/bfdr/Questionnaire/Questionnaire-patients-fetal-death#2.0.0 #xD; intro We are truly sorry about the loss you have experienced. We understand that this is a difficult time for you and your loved ones. We need to ask you a few questions to assist in the completion of the official report of fetal death. State laws provide protection against the unauthorized release of identifying information from the report of fetal death to ensure confidentiality of the parents. This information may also help researchers understand some of the factors that are related to miscarriage and stillbirth. Your assistance in providing complete and accurate information is very important. We appreciate your help, especially during this very difficult time. 0..1 display #xD; child-name 1. Would you like to name the child? This is entirely optional. 0..1 group #xD; child-first-name First 0..1 string #xD; child-middle-name Middle 0..1 string #xD; child-last-name Last 0..1 string #xD; child-suffix Suffix (Jr., III, etc.) 0..1 string #xD; mother-current-legal-name 2. What is your current legal name? 0..1 group #xD; mother-first-name First 0..1 string #xD; mother-middle-name Middle 0..1 string #xD; mother-last-name Last 0..1 string #xD; mother-suffix Suffix (Jr., III, etc.) 0..1 string #xD; mother-address 3. Where do you usually live - that is - where is your household/residence located? 0..1 group #xD; mother-nbr-street Complete number and street (do not enter rural route numbers) 0..1 string #xD; mother-apt-nbr Apartment Number 0..1 string #xD; mother-city City, Town, or Location 0..1 string #xD; mother-county County 0..1 string #xD; mother-state State (or U.S. Territory, Canadian Province) 0..1 choice Value Set: Value Set - States, Territories and Provinces Vital Records #xD; mother-zip Zip Code 0..1 string #xD; mother-country If not in the United States, country 0..1 choice Value Set: Value Set - Residence Country Vital Records #xD; inside-city-limits 4. Is this household inside city limits (inside the incorporated limits of the city, town, or location where you live)? 0..1 choice Value Set: Value Set - Yes No Unknown Vital Records #xD; mother-mail 5. What is your mailing address 0..1 group #xD; mother-mail-same Same as residence [Go to next question] 0..1 boolean #xD; mother-mail-nbr-street Complete number and street 0..1 string Enable When: mother-mail-same = #xD; mother-mail-apt-nbr Apartment Number 0..1 string Enable When: mother-mail-same = #xD; mother-mail-po-box P.O. Box 0..1 string Enable When: mother-mail-same = #xD; mother-mail-city City, Town, or Location 0..1 string Enable When: mother-mail-same = #xD; mother-mail-state State (or U.S. Territory, Canadian Province) 0..1 choice Enable When: mother-mail-same = Value Set: Value Set - States, Territories and Provinces Vital Records #xD; mother-mail-zip Zip Code 0..1 string Enable When: mother-mail-same = #xD; mother-mail-country If not in the United States, country 0..1 choice Enable When: mother-mail-same = Value Set: Value Set - Residence Country Vital Records #xD; mother-dob 6. What is your date of birth? 0..1 date #xD; mother-birthplace 7. In what State, U.S. territory, or foreign country were you born? Please specify one of the following: 0..1 group #xD; mother-birthplace-state State 0..1 choice Value Set: Value Set - US States Vital Records #xD; mother-birthplace-territory or U.S. territory, i.e., Puerto Rico, U.S. Virgin Islands, Guam, American Samoa or Norther Marianas 0..1 choice Value Set: Value Set - US Territories Vital Records #xD; mother-birthplace-country or Foreign country 0..1 choice Value Set: Value Set - Birthplace Country Vital Records #xD; mother-education 8. What is the highest level of schooling that you have completed at the time of delivery? (Check the box that best describes your education. If you are currently enrolled, check the box that indicates the previous grade or highest degree received). 0..1 choice Value Set: Value Set - Education Level Vital Records #xD; mother-ethnicity 9. Are you Spanish/Hispanic/Latina? (if so, please answer 9a-9d) 0..1 boolean #xD; mother-ethnicity-mexican Are you Mexican, Mexican-American? 0..1 boolean Enable When: mother-ethnicity = #xD; mother-ethnicity-puerto-rican Are you Puerto Rican? 0..1 boolean Enable When: mother-ethnicity = #xD; mother-ethnicity-cuban Are you Cuban? 0..1 boolean Enable When: mother-ethnicity = #xD; mother-ethnicity-other Are you of other Spanish/Hispanic/Latina (e.g., Spaniard, Salvadoran, Dominican, Columbian). 0..1 boolean Enable When: mother-ethnicity = #xD; mother-ethnicity-other-literal (specify) 0..1 string Enable When: mother-ethnicity-other = #xD; mother-race 10. What is your race? (Please check one or more races to indicate what you consider yourself to be). 0..1 group #xD; mother-race-white White 0..1 boolean #xD; mother-race-black-or-aa Black or African American 0..1 boolean #xD; mother-race-aian American Indian or Alaskan Native 0..1 boolean #xD; mother-race-aian-tribe (name of enrolled or principal tribe) 0..1 string Enable When: mother-race-aian = #xD; mother-race-asian-indian Asian Indian 0..1 boolean #xD; mother-race-chinese Chinese 0..1 boolean #xD; mother-race-filipino Filipino 0..1 boolean #xD; mother-race-japanese Japanese 0..1 boolean #xD; mother-race-korean Korean 0..1 boolean #xD; mother-race-vietnamese Vietnamese 0..1 boolean #xD; mother-race-other-asian Other Asian 0..1 boolean #xD; mother-race-other-asian-literal (specify) 0..1 string Enable When: mother-race-other-asian = #xD; mother-race-native-hawaiian Native Hawaiian 0..1 boolean #xD; mother-race-guamanian-or-chamorro Guamanian or Chamorro 0..1 boolean #xD; mother-race-samoan Samoan 0..1 boolean #xD; mother-race-other-pacific-islander Other Pacific Islander 0..1 boolean #xD; mother-race-other-pacific-islander-specify (specify) 0..1 string Enable When: mother-race-other-pacific-islander = #xD; mother-race-other Other (specify) 0..1 boolean #xD; mother-race-other-specify (specify) 0..1 string Enable When: mother-race-other = #xD; father-current-legal-name 11. What is the current legal name of your baby's father? 0..1 group #xD; father-first-name First 0..1 string #xD; father-middle-name Middle 0..1 string #xD; father-last-name Last 0..1 string #xD; father-suffix Suffix (Jr., III, etc.) 0..1 string #xD; father-dob 12. What is the father's date of birth? 0..1 date #xD; father-birthplace 13. In what State, U.S. territory, or foreign country was the father born? Please specify one of the following: 0..1 group #xD; father-birthplace-state State 0..1 choice Value Set: Value Set - US States Vital Records #xD; father-birthplace-territory or U.S. territory, i.e., Puerto Rico, U.S. Virgin Islands, Guam, American Samoa or Norther Marianas 0..1 choice Value Set: Value Set - US Territories Vital Records #xD; father-birthplace-country or Foreign country 0..1 choice Value Set: Value Set - Birthplace Country Vital Records #xD; receive-wic 14. Did you receive WIC (Women, Infants and Children) food for yourself during this pregnancy? 0..1 choice Value Set: Value Set - Yes No Unknown Vital Records #xD; mothers-height 15. What is your height? 0..1 group #xD; mothers-height-feet Feet 0..1 quantity #xD; mothers-height-inches Inches 0..1 quantity #xD; mothers-prepregnancy-weight 16. lbs 0..1 quantity #xD; mothers-smoking 17. How many cigarettes OR packs of cigarettes did you smoke on an average day during each of the following time periods? If you NEVER smoked, enter zero for each time period. 0..1 group #xD; mothers-smoking-3-months-prior Three months before pregnancy 0..1 group #xD; mothers-smoking-3-months-prior-cig # of cigarettes* 0..1 integer #xD; mothers-smoking-3-months-prior-pck # of packs 0..1 integer #xD; mothers-smoking-trimester-1 First three months of pregnancy 0..1 group #xD; mothers-smoking-trimester-1-cig # of cigarettes* 0..1 integer #xD; mothers-smoking-trimester-1-pck # of packs 0..1 integer #xD; mothers-smoking-trimester-2 Second three months of pregnancy 0..1 group #xD; mothers-smoking-trimester-2-cig # of cigarettes* 0..1 integer #xD; mothers-smoking-trimester-2-pck # of packs 0..1 integer #xD; mothers-smoking-trimester-3 Third trimester of pregnancy 0..1 group #xD; mothers-smoking-trimester-3-cig # of cigarettes* 0..1 integer #xD; mothers-smoking-trimester-3-pck # of packs 0..1 integer #xD; cigarette-note *refers to tobacco products only, NOT e-cigarettes. 0..1 display #xD; outro Thank you for completing this worksheet at this very difficult time. The information you have provided is very important; it will be used by researchers to better understand factors related to miscarriage and stillbirth and lead to improved prevention strategies for the future. 0..1 display #xD; Documentation for this format
Questionnaire - Patient's Worksheet for the Report of Fetal Death
This Questionnaire represents the [Patient's Worksheet for the Report of Fetal Death](https://www.cdc.gov/nchs/data/dvs/fetal-death-mother-worksheet-english-2019-508.pdf).
We are truly sorry about the loss you have experienced. We understand that this is a difficult time for you and your loved ones. We need to ask you a few questions to assist in the completion of the official report of fetal death. State laws provide protection against the unauthorized release of identifying information from the report of fetal death to ensure confidentiality of the parents. This information may also help researchers understand some of the factors that are related to miscarriage and stillbirth. Your assistance in providing complete and accurate information is very important. We appreciate your help, especially during this very difficult time.
Would you like to name the child? This is entirely optional.
Where do you usually live - that is - where is your household/residence located?
Complete number and street (do not enter rural route numbers)
State (or U.S. Territory, Canadian Province)
Is this household inside city limits (inside the incorporated limits of the city, town, or location where you live)?
In what State, U.S. territory, or foreign country were you born? Please specify one of the following:
or U.S. territory, i.e., Puerto Rico, U.S. Virgin Islands, Guam, American Samoa or Norther Marianas
What is the highest level of schooling that you have completed at the time of delivery? (Check the box that best describes your education. If you are currently enrolled, check the box that indicates the previous grade or highest degree received).
Are you Spanish/Hispanic/Latina? (if so, please answer 9a-9d)
Are you of other Spanish/Hispanic/Latina (e.g., Spaniard, Salvadoran, Dominican, Columbian).
What is your race? (Please check one or more races to indicate what you consider yourself to be).
What is the current legal name of your baby's father?
In what State, U.S. territory, or foreign country was the father born? Please specify one of the following:
Did you receive WIC (Women, Infants and Children) food for yourself during this pregnancy?
How many cigarettes OR packs of cigarettes did you smoke on an average day during each of the following time periods? If you NEVER smoked, enter zero for each time period.
*refers to tobacco products only, NOT e-cigarettes.
Thank you for completing this worksheet at this very difficult time. The information you have provided is very important; it will be used by researchers to better understand factors related to miscarriage and stillbirth and lead to improved prevention strategies for the future.