Generated Narrative: QuestionnaireResponse QuestionnaireResponse-patients-fetal-death-carmen-lee LinkID Text Definition Answer QuestionnaireResponse-patients-fetal-death-carmen-lee Questionnaire:Questionnaire - Patient's Worksheet for the Report of Fetal Death #xD; mother-current-legal-name What is your current legal name? #xD; mother-first-name First Carmen #xD; mother-middle-name Middle Teresa #xD; mother-last-name Last Lee #xD; mother-address Where do you usually live - that is - where is your household/residence located? #xD; mother-nbr-street Complete number and street (do not enter rural route numbers) 3670 Miller Road #xD; mother-city City, Town, or Location #xD; mother-state State (or U.S. Territory, Canadian Province) MI #xD; mother-zip Zip Code 48103 #xD; inside-city-limits Is this household inside city limits (inside the incorporated limits of the city, town, or location where you live)? v2 Y/N Indicator N: No #xD; mother-mail What is your mailing address #xD; mother-mail-same Same as residence [Go to next question] true #xD; mother-dob What is your date of birth? 1986-02-15 #xD; mother-birthplace In what State, U.S. territory, or foreign country were you born? Please specify one of the following: #xD; mother-birthplace-territory or U.S. territory, i.e., Puerto Rico, U.S. Virgin Islands, Guam, American Samoa or Norther Marianas PR #xD; mother-education 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). Education Level SEC: Some secondary or high school education #xD; mother-ethnicity true #xD; mother-ethnicity-mexican true #xD; mother-ethnicity-puerto-rican true #xD; mother-ethnicity-cuban true #xD; mother-ethnicity-other false #xD; mother-race #xD; mother-race-black-or-aa true #xD; father-current-legal-name What is the current legal name of your baby's father? #xD; father-first-name First Tom #xD; father-middle-name Middle Yan #xD; father-last-name Last Lee #xD; father-dob What is the father's date of birth? 1984-02-27 #xD; father-birthplace In what State, U.S. territory, or foreign country was the father born? Please specify one of the following: #xD; father-birthplace-state State NY #xD; receive-wic Did you receive WIC (Women, Infants and Children) food for yourself during this pregnancy? v2 Y/N Indicator N: No #xD; mothers-height What is your height? #xD; mothers-height-inches Inches 65 [in_i] (Details: UCUM code[in_i] = '[in_i]') #xD; mothers-prepregnancy-weight lbs 180 [lb_av] (Details: UCUM code[lb_av] = '[lb_av]') #xD; mothers-smoking 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. #xD; mothers-smoking-3-months-prior Three months before pregnancy #xD; mothers-smoking-3-months-prior-cig # of cigarettes* 0 #xD; mothers-smoking-3-months-prior-pck # of packs 0 #xD; mothers-smoking-trimester-1 First three months of pregnancy #xD; mothers-smoking-trimester-1-cig # of cigarettes* 0 #xD; mothers-smoking-trimester-1-pck # of packs 0 #xD; mothers-smoking-trimester-2 Second three months of pregnancy #xD; mothers-smoking-trimester-2-cig # of cigarettes* 0 #xD; mothers-smoking-trimester-2-pck # of packs 0 #xD; mothers-smoking-trimester-3 Third trimester of pregnancy #xD; mothers-smoking-trimester-3-cig # of cigarettes* 0 #xD; mothers-smoking-trimester-3-pck # of packs 0 #xD; Documentation for this format
Patient - Decedent Fetus (Fetus Not Named)
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).
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.