Pregnancy and Wellness Survey (PAWS)

Are you at least 18 years of age or older?

Yes

No

Are you currently pregnant?

Yes

No

Currently, how many weeks pregnant are you? (Example: 13 weeks, 4 days)

Please record your weight in pounds at each specified time point below. If you have not reached a trimester yet, please record Not Applicable (NA), or leave blank. If you are at the beginning or middle of a trimester, simply enter your current weight in that trimester.

How tall are you without shoes, in feet and inches?

Are you currently pregnant with more than one child?

Yes

No

Is this your first pregnancy ever? (Note: if previous pregnancies ended due to miscarriage or stillbirth please select no)

Yes

No

How many previous pregnancies have you had? (Note: include miscarriage and stillbirth)

1

2

3

4

5 or more

How many previous live births have you had?

1

2

3

4

5 or more

In any of your previous pregnancies, did you ever have a baby by cesarean delivery or c-section (when a doctor cuts through the mother's belly to bring out the baby)?

Yes

No

In any of your previous pregnancies, did you experience any of the following complications? Check all that apply.

Stillbirth

Pre-eclampsia

Spontaneous abortion (miscarriage)

Fetal anomalies

Preterm Labor

Preterm Delivery

None

Other (please list) ______

How many children under the age of 18 are currently living with you in your household?

None

1

2

3 or more

Have you been clinically diagnosed with and currently suffering from any of the following physical and/or mental health disorders? Check all that apply.

Asthma

High blood pressure

Diabetes (before pregnancy)

Gestational diabetes (diabetes that started during pregnancy)

Anemia (poor blood, low iron)

Heart problems

Epilepsy (seizures)

Thyroid problems

Depression

Anxiety

Bipolar Disorder

None

Other (please list) ______

What type of diabetes do you have?

Type I

Type II

In any of your previous pregnancies, were you told that you had gestational diabetes (diabetes that started during pregnancy)?

Yes

No

Not applicable

Are you currently taking medication for your condition(s)?

Yes

No

Which conditions are you taking medications for? Check all that apply.

Asthma

High blood pressure

Diabetes (before pregnancy)

Gestational diabetes (diabetes that started during pregnancy)

Anemia (poor blood, low iron)

Heart problems

Epilepsy (seizures)

Thyroid Problems

Depression

Anxiety

Bipolar Disorder

Other (please list) ______

Are you currently receiving counseling or therapy for depression?

Yes

No

Are you current receiving counseling or therapy for Anxiety?

Yes

No

At any time during your current pregnancy, did you ask for help for depressionfrom a doctor, nurse, or other health care worker?

Yes

No

At any time during your current pregnancy, did you ask for help for anxiety from a doctor, nurse, or other health care worker?

Yes

No

The next questions are about smoking cigarettes and consuming alcohol around the time of your most recent pregnancy (before and during).

In the 3 months before your current pregnancy did you smoke cigarettes? If yes, how many cigarettes did you smoke on an average day? (A pack has 20 cigarettes).

Yes, 41 cigarettes or more

Yes, 21 to 40 cigarettes

Yes, 11 to 20 cigarettes

Yes, 6 to 10 cigarettes

Yes, 1 to 5 cigarettes

Yes, Less than 1 cigarette

No, I didn't smoke then

How many cigarettes do you smoke on an average day now? (A pack has 20 cigarettes).

41 cigarettes or more

21 to 40 cigarettes

11 to 20 cigarettes

6 to 10 cigarettes

Less than 1 cigarette

I don't smoke now

Which of the following statements best describes the rules about smoking inside your home now? Check one answer

No one is allowed to smoke anywhere inside my home

Smoking is allowed in some rooms or at some times

Smoking is permitted anywhere inside my home

During the 3 months before your current pregnancy, how many alcoholic drinks did you have in an average week?

14 drinks or more a week

7 to 13 drinks a week

4 to 6 drinks a week

1 to 3 drinks a week

Less than 1 drink a week

None

How many alcoholic drinks do you currently have in an average week?

14 drinks or more a week

7 to 13 drinks a week

4 to 6 drinks a week

1 to 3 drinks a week

Less than 1 drink a week

None

During your current pregnancy, did a doctor, nurse, or other health worker talk with you about any of the things listed below? Please count only discussions, not reading materials or videos. Check all that apply.

Foods that are good to eat during pregnancy

Exercise during pregnancy

Programs or resources to help me gain the right amount of weight during pregnancy

Programs or resources to help me lose weight after pregnancy

None of the above

Did your doctor recommend exercise during your current pregnancy?

Yes

No

What type(s) of exercise did your doctor recommend during your currentpregnancy? Check all that apply.

Aerobic/cardio

Strength training

Swimming

Walking

Biking

Jogging/running

Yoga

Other, please list: ______

Did not specify

How often did your doctor recommend exercise during your currentpregnancy?

30-60 min/week

61-90 min/week

91-120 min/week

121-150 min/week

More than 150 min/week

Did not specify

At what intensity did your doctor recommend when exercising during your current pregnancy?

Light (i.e., no sweating, no noticeable change in breathing patterns)

Moderate (i.e., breathing quickens but not out of breath, light sweat, you can carry on a conversation but not sing)

Vigorous (i.e., challenging, breathing is deep and rapid, sweat accumulates after a few minutes of activity, cannot comfortably carry on a conversation)

Did not specify

Did you want information about exercise, nutrition, or weight management duringyour current pregnancy?

Yes

No

What kind of information would you have wanted to have about exercise, nutrition, or weight management during your current pregnancy? Check all that apply.

Brochure or printed material

Health counseling session

Online resources

Community resources

Other, please specify: ______

Pregnancy can be a difficult time for some women. These next questions are about things that may have happened before and during you most recent pregnancy. As you are pregnant or have recently had a baby, we would like to know how you are feeling. Please check the answer that comes closes to how you have felt IN THE PAST 7 DAYS, not just how you feel today.

I have been able to laugh and see the funny side of things

As much as I always could

Not quite so much now

Definitely not so much now

Not at all

I have looked forward with enjoyment to things

As much as I ever did

Rather less than I used to

Definitely less than I used to

Hardly at all

I have blamed myself unnecessarily when things went wrong

Yes, most of the time

Yes, some of the time

Not very often

No, never

I have been anxious or worried for no good reason

No, not at all

Hardly ever

Yes, sometimes

Yes, very often

I have felt scared or panicky for no very good reason

Yes, quite a lot

Yes, sometimes

No, not much

No, not at all

Things have been getting on top of me

Yes, most of the time I haven't been able to cope at all

Yes, sometimes I haven't been coping as well as usual

No, most of the time I have coped quite well

No, I have been coping as well as ever

I have been so unhappy that I have had difficulty sleeping

Yes, most of the time

Yes, sometimes

Not very often

No, not at all

I have felt sad or miserable

Yes, most of the time

Yes, quite often

Not very often

No, not at all

I have been so unhappy that I have been crying

Yes, most of the time

Yes, quite often

Only occasionally

No, never

The thought of harming myself has occurred to me

Yes, quite often

Sometimes

Hardly ever

Never

Did any of the following things happen to youwithin the past 12 months. Note: you may or may not have been pregnant at the time. Please select all that apply.

A close family member was very sick and had to go to the hospital

I got separated or divorced from my husband or partner

I moved to a new address

I was homeless

My husband or partner lost his job

I lost my job even though I wanted to go on working

I argued with my husband or partner more than usual

My husband or partner said he didn't want me to be pregnant

I had a lot of bills I couldn't pay

I was in a physical fight

My husband or partner or I went to jail

Someone vey close to me had a problem with drinking or drugs

Someone very close to me died

I got married

I got a major job promotion

Other, please specify: ______

None

Is this stressful event ongoing?

Yes, for the past 0-3 months

Yes, for the past 4-6 months

Yes, for the past 7-9 months

Yes, for the past 9 months or longer

No

Were you pregnant at the time of this stressful event?

Yes

No

How far along in your pregnancy were you at the time of this stressful event?

A number of statements which people have used to describe themselves are given below. Read each statement and then select the appropriate response to the right of the statement to indicate how you feelRIGHT NOW, at this moment. There are no right or wrong answers. Do not spend too much time on any one statement but give the answer which seems to describe your present feelings best.

Not at all / Somewhat / Moderately so / Very much so
I feel calm /  /  /  / 
I am tense /  /  /  / 
I feel upset /  /  /  / 
I am relaxed /  /  /  / 
I feel content /  /  /  / 
I am worried /  /  /  / 

The next questions are related to your stress levels during your current pregnancy.

Please rate on a scale of 1-5 (1=not stressed; 5=severely stressed) your average level of stress during your current pregnancy?

1-Not stressed

2-Low stressed

3-Moderately stressed

4-High stressed

5-Severely stressed

What tends to stress you out the most? Select all that apply.

Work

Family conflict

Taking care of children

Taking care of family members

Romantic relationship

Financial burden

School

Not enough time

Unsafe environment

Pregnancy

Social pressure

Other, please specify: ______

What about pregnancy is the most stressful? Check all that apply.

Fear of birth outcome

Not knowing how to care for myself or baby during pregnancy

Fear of first time parenting

Trouble sleeping

Discomforts of pregnancy (nausea, bodily pain)

Concern for health of baby

Fear of labor

Other, please specify: ______

What do you typically do to manage your stress during your current pregnancy? Check all that apply.

Read

Journal

Arts and crafts

Exercise

Eat

Don't eat

Meditate

Vacation

Take medications

Counseling

Nothing

I don't have stress

Other, please specify: ______

If you currently have children, in general, how well do you feel you are coping with the day to day demands of parenthood?

Very well

Somewhat well

Not very well

Not well at all

Do not have children

During your current pregnancy, did your husband or partner push, hit, slap, kick, choke, or physically hurt you in any other way?

Yes

No

The next questions ask you about your feelings and thoughts during the last month. In each case, you will be asked to indicate by choosing how often you felt or thought a certain way.In the last month, how often have you....

Never / Almost never / Sometimes / Fairly often / Very often
been upset because of something that happened unexpectedly? /  /  /  /  / 
felt that you were unable to control the important things in your life? /  /  /  /  / 
felt nervous and "stressed"? /  /  /  /  / 
felt confident about your ability to handle your personal problems? /  /  /  /  / 
felt that things were going your way? /  /  /  /  / 
found that you could not cope with all the things that you had to do? /  /  /  /  / 
been able to control irritations in your life? /  /  /  /  / 
felt that you were on top of things? /  /  /  /  / 
angered because of things that were outside of your control? /  /  /  /  / 
felt difficulties were piling up so high that you could not overcome them? /  /  /  /  / 

People sometimes look to others for companionship, assistance, or other types of support. How often is each of the following kinds of support available to you if you need it?

None of the time / A little of the time / Some of the time / Most of the time / All of the time
Someone to help you if you were confined to bed /  /  /  /  / 
Someone to take you to the doctor if you needed it /  /  /  /  / 
Someone to prepare your meals if you were unable to do it yourself /  /  /  /  / 
Someone to help with daily chores if you were sick /  /  /  /  / 
Someone to have a good time with /  /  /  /  / 
Someone to turn to for suggestions about how to deal with a personal problem /  /  /  /  / 
Someone who understands your problems /  /  /  /  / 
Someone to love you and make you feel wanted /  /  /  /  / 

The next questions are about weight gain during your current pregnancy.

During any of your prenatal care visits, did a doctor, nurse, or other health care worker talk with you about how much weight you should gainduring your currentpregnancy?

Yes

No

How much weight did your doctor, nurse, or other health care worker tell you to gain during your currentpregnancy?

5-10 lbs

11-20 lbs

15-25 lbs

25-35 lbs

None

I was told to lose weight

I don't remember

Other, please specify: ______

Are you aware of how much weight to gain during your pregnancy? If yes, please enter the number of pounds (lbs) you believe you should gain during your pregnancy.

Yes, please specify: ______

No

Exercise (or physical activity) includes activities such as walking briskly, jogging, bicycling, swimming, or any other activity in which the exertion is as least as intense as these activities. For exercise to beregular, it must add up to atotalof 30 min or more per day and be done at least 5 days per week. For example, you could take one 30-minute walk or take three 10-min walks for a daily total of 30 minutes.The next questions are about your exercise habits during your current pregnancy.

Are you currently participating in regular exercise?

Yes

No

What kind of exercise do you participate in during your currentpregnancy? Check all that apply.

Aerobic/cardio

Strength training

Swimming

Walking

Biking

Jogging/running

Yoga

Other, please specify: ______

None

How many days per week do you typically exercise during your currentpregnancy?

1

2

3

4

5

6

7

None

What are your reasons for exercising during your currentpregnancy? Check all that apply.

To manage pregnancy weight gain

Increase physical strength

To manage stress levels

Increase energy

To keep a healthy pregnancy

General health

I don't exercise

Other, please specify: ______

What kind of diet best describes how your are eating during your currentpregnancy?

Similar to Paleo (caveman diet, high protein, high fiber, high fat; no grains, dairy, or refined sugar)

Low carb/high protein (30-50% of calories from protein; limit bread, pasta, rice, potatoes, sugar)

Vegetarian/vegan (plant based diet)

Gluten free (eliminating gluten-the protein found in wheat, barley, rye, and other grains)

Similar to Weight watchers (foods are assigned ‘points’ based on nutritional content)

Calorie counting (decreasing the amount of calories you eat by reading food labels)

Balanced diet (similar do the Dietary Guidelines for Americans by the USDA)

Other, please specify: ______

Below is a collection of statements about your everyday experience. Using thescale below, please indicate how frequently or infrequently you currently have eachexperience. Please answer according to whatreally reflectsyour experience rather thanwhat you think your experience should be. Please treat each item separately from everyother item.

Almost always / Very frequently / Somewhat frequently / Somewhat infrequently / Very infrequently / Almost never
I could be experiencing some emotion and not be conscious of it until some time later. /  /  /  /  /  / 
I break or spill things because of carelessness, not paying attention, or thinking of something else. /  /  /  /  /  / 
I find it difficult to stay focused on what’s happening in the present. /  /  /  /  /  / 
I tend to walk quickly to get where I’m going without paying attention to what I experience along the way. /  /  /  /  /  / 
I tend not to notice feelings of physical tension or discomfort until they really grab my attention. /  /  /  /  /  / 
I forget a person's name almost as soon as I've been told it for the first time. /  /  /  /  /  / 
It seems I am "running on automatic," without much awareness of what I'm doing. /  /  /  /  /  / 
I rush through activities without being really attentive to them. /  /  /  /  /  / 
I get so focused on the goal I want to achieve that I lose touch with what I'm doing right now to get there. /  /  /  /  /  / 
I do jobs or tasks automatically, without being aware of what I'm doing. /  /  /  /  /  / 
I find myself listening to someone with one ear, doing something else at the same time. /  /  /  /  /  / 
I drive places on "automatic pilot" and then wonder why I went there. /  /  /  /  /  / 
I find myself preoccupied with the future or the past. /  /  /  /  /  / 
I find myself doing things without paying attention. /  /  /  /  /  / 
I snack without being aware that I am eating. /  /  /  /  /  / 

What is your date of birth? Please enter in as MM/DD/YYYY, example: 01/30/1990

Please choose the race that you most identify with

Caucasian

African American

Asian or Pacific Islander

American Indian

2 or more races

Other, please specify: ______

Are you of Hispanic/Latino origin?

Yes

No

What is your marital status?

Single (never married)