Generated Narrative: QuestionnaireResponse QuestionnaireResponse-patients-fetal-death-carmen-lee version: versionId: id (PrimitiveType/QuestionnaireResponse.meta.versionId): element = id -> versionId=id[10]; Last updated: 2021-07-09 07:16:14+0000 LinkID Text Definition Answer QuestionnaireResponse-patients-fetal-death-carmen-lee Questionnaire:Questionnaire - Patient's Worksheet for the Report of Fetal Death mother-current-legal-name What is your current legal name? mother-first-name First Carmen mother-middle-name Middle Teresa mother-last-name Last Lee mother-address Where do you usually live - that is - where is your household/residence located? mother-nbr-street Complete number and street (do not enter rural route numbers) 3670 Miller Road mother-city City, Town, or Location mother-state State (or U.S. Territory, Canadian Province) MI mother-zip Zip Code 48103 inside-city-limits Is this household inside city limits (inside the incorporated limits of the city, town, or location where you live)? expandedYes-NoIndicator N: No mother-mail What is your mailing address mother-mail-same Same as residence [Go to next question] true mother-dob What is your date of birth? 1986-02-15 mother-birthplace In what State, U.S. territory, or foreign country were you born? Please specify one of the following: mother-birthplace-territory or U.S. territory, i.e., Puerto Rico, U.S. Virgin Islands, Guam, American Samoa or Norther Marianas PR 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). unknown PHC1449: 9th through 12th grade; no diploma mother-ethnicity Are you Spanish/Hispanic/Latina? If not Spanish/Hispanic/Latina, check the “No” box. If Spanish/Hispanic/Latina, check the appropriate box. mother-shl Are you Spanish/Hispanic/Latina Race & Ethnicity - CDC 2135-2: Hispanic or Latino mother-race What is your race? (Please check one or more races to indicate what you consider yourself to be). mother-race-category Race categories Race & Ethnicity - CDC 2054-5: Black or African American father-current-legal-name What is the current legal name of your baby's father? father-first-name First Tom father-middle-name Middle Yan father-last-name Last Lee father-dob What is the father's date of birth? 1984-02-27 father-birthplace In what State, U.S. territory, or foreign country was the father born? Please specify one of the following: father-birthplace-state State NY receive-wic Did you receive WIC (Women, Infants and Children) food for yourself during this pregnancy? expandedYes-NoIndicator N: No mothers-height What is your height? mothers-height-inches Inches 65 [in_i] (Details: UCUM code[in_i] = '[in_i]') mothers-prepregnancy-weight lbs 180 [lb_av] (Details: UCUM code[lb_av] = '[lb_av]') 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. mothers-smoking-3-months-prior Three months before pregnancy mothers-smoking-3-months-prior-cig # of cigarettes* 0 mothers-smoking-3-months-prior-pck # of packs 0 mothers-smoking-trimester-1 First three months of pregnancy mothers-smoking-trimester-1-cig # of cigarettes* 0 mothers-smoking-trimester-1-pck # of packs 0 mothers-smoking-trimester-2 Second three months of pregnancy mothers-smoking-trimester-2-cig # of cigarettes* 0 mothers-smoking-trimester-2-pck # of packs 0 mothers-smoking-trimester-3 Third trimester of pregnancy mothers-smoking-trimester-3-cig # of cigarettes* 0 mothers-smoking-trimester-3-pck # of packs 0 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).
Are you Spanish/Hispanic/Latina? If not Spanish/Hispanic/Latina, check the “No” 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.