Generated Narrative: Questionnaire Questionnaire-patients-fetal-death version: versionId: id (PrimitiveType/Questionnaire.meta.versionId): native = id -> 12; Last updated: 2021-07-09 07:23:29+0000 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 https://profiles.ihe.net/QRPH/bfdr/Questionnaire/Questionnaire-patients-fetal-death#1.1.0 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 child-name 1. Would you like to name the child? This is entirely optional. 0..1 group child-first-name First 0..1 string child-middle-name Middle 0..1 string child-last-name Last 0..1 string child-suffix Suffix (Jr., III, etc.) 0..1 string mother-current-legal-name 2. What is your current legal name? 0..1 group mother-first-name First 0..1 string mother-middle-name Middle 0..1 string mother-last-name Last 0..1 string mother-suffix Suffix (Jr., III, etc.) 0..1 string mother-address 3. Where do you usually live - that is - where is your household/residence located? 0..1 group mother-nbr-street Complete number and street (do not enter rural route numbers) 0..1 string mother-apt-nbr Apartment Number 0..1 string mother-city City, Town, or Location 0..1 string mother-county County 0..1 string mother-state State (or U.S. Territory, Canadian Province) 0..1 string mother-zip Zip Code 0..1 string mother-country If not in the United States, country 0..1 string 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: Yes No Unknown (YNU) mother-mail 5. What is your mailing address 0..1 group mother-mail-same Same as residence [Go to next question] 0..1 boolean mother-mail-nbr-street Complete number and street 0..1 string Enable When: mother-mail-same = mother-mail-apt-nbr Apartment Number 0..1 string Enable When: mother-mail-same = mother-mail-po-box P.O. Box 0..1 string Enable When: mother-mail-same = mother-mail-city City, Town, or Location 0..1 string Enable When: mother-mail-same = mother-mail-state State (or U.S. Territory, Canadian Province) 0..1 string Enable When: mother-mail-same = mother-mail-zip Zip Code 0..1 string Enable When: mother-mail-same = mother-mail-country If not in the United States, country 0..1 string Enable When: mother-mail-same = mother-dob 6. What is your date of birth? 0..1 date mother-birthplace 7. In what State, U.S. territory, or foreign country were you born? Please specify one of the following: 0..1 group mother-birthplace-state State 0..1 string mother-birthplace-territory or U.S. territory, i.e., Puerto Rico, U.S. Virgin Islands, Guam, American Samoa or Norther Marianas 0..1 string mother-birthplace-country or Foreign country 0..1 string 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: Vital Records Education Level (NCHS) mother-ethnicity 9. Are you Spanish/Hispanic/Latina? If not Spanish/Hispanic/Latina, check the “No” box. If Spanish/Hispanic/Latina, check the appropriate box. 0..1 group mother-shl Are you Spanish/Hispanic/Latina 0..* choice Value Set: OMB Ethnicity Categories mother-detailed-shl If Spanish/Hispanic/Latina, check the appropriate box. 0..1 choice Enable When: mother-shl = Value Set: Detailed ethnicity mother-race 10. What is your race? (Please check one or more races to indicate what you consider yourself to be). 0..1 group mother-race-category Race categories 0..* choice Value Set: OMB Race Categories mother-detailed-race Extended race codes 0..* choice Value Set: Detailed Race father-current-legal-name 11. What is the current legal name of your baby's father? 0..1 group father-first-name First 0..1 string father-middle-name Middle 0..1 string father-last-name Last 0..1 string father-suffix Suffix (Jr., III, etc.) 0..1 string father-dob 12. What is the father's date of birth? 0..1 date 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 father-birthplace-state State 0..1 string father-birthplace-territory or U.S. territory, i.e., Puerto Rico, U.S. Virgin Islands, Guam, American Samoa or Norther Marianas 0..1 string father-birthplace-country or Foreign country 0..1 string receive-wic 14. Did you receive WIC (Women, Infants and Children) food for yourself during this pregnancy? 0..1 choice Value Set: Yes No Unknown (YNU) mothers-height 15. What is your height? 0..1 group mothers-height-feet Feet 0..1 quantity mothers-height-inches Inches 0..1 quantity mothers-prepregnancy-weight 16. lbs 0..1 quantity 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 mothers-smoking-3-months-prior Three months before pregnancy 0..1 group mothers-smoking-3-months-prior-cig # of cigarettes* 0..1 integer mothers-smoking-3-months-prior-pck # of packs 0..1 integer mothers-smoking-trimester-1 First three months of pregnancy 0..1 group mothers-smoking-trimester-1-cig # of cigarettes* 0..1 integer mothers-smoking-trimester-1-pck # of packs 0..1 integer mothers-smoking-trimester-2 Second three months of pregnancy 0..1 group mothers-smoking-trimester-2-cig # of cigarettes* 0..1 integer mothers-smoking-trimester-2-pck # of packs 0..1 integer mothers-smoking-trimester-3 Third trimester of pregnancy 0..1 group mothers-smoking-trimester-3-cig # of cigarettes* 0..1 integer mothers-smoking-trimester-3-pck # of packs 0..1 integer cigarette-note *refers to tobacco products only, NOT e-cigarettes. 0..1 display 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 Documentation for this format
Questionnaire - Patient's Worksheet for the Report of Fetal Death
IHE Quality, Research and Public Health Committee
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 not Spanish/Hispanic/Latina, check the “No” box. If Spanish/Hispanic/Latina, check the appropriate box.
If Spanish/Hispanic/Latina, check the appropriate box.
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.