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 soI 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 oftenbeen 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 timeSomeone 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 neverI 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)