Block B
|
|
|
|
|
|
Cuando quedó embarazada, ¿lo estaba buscando? |
Planned to get pregnant: |
When did you get pregnant, were looking forward in getting pregnant? |
Were you willing to get pregnant? |
Were you hoping to get pregnant? |
Sí ( ) |
Yes ( ) |
Yes ( ) |
Yes ( ) |
Yes ( ) |
No ( ) |
No ( ) |
No ( ) |
No ( ) |
No ( ) |
No se lo había planteado ( ) |
I did not plan ( ) |
I did not imagine ( ) |
|
|
No se/No respondeo ( ) |
I do not know ( ) |
I do not know ( ) |
|
|
|
|
|
|
|
Uso previo de anticonceptivos hormonales (indique fecha inicio y final): |
Previous use of hormonal contraception? |
Previous use of hormonal contraceptives (indicate the initial date and end): dd/mm/yyyy dd/mm/yyyy |
Were you taking hormonal contraceptives when you got pregnant? |
Were you taking hormonal contraceptive ("the pill", " injectable") when you got pregnant? |
__/__/__ dm a |
Initial: _/_/_ |
|
If yes, did you quit taking before getting pregnant? |
If yes, did you quit taking hormonal contraceptives before getting pregnant? |
__/__/__ dm a |
End:_ /_/_ |
|
Did you stop before ( ) |
Did you stop before ( ) |
|
|
|
Did you get pregnant taking hormonal contraceptives ( ) |
Did you get pregnant by taking hormonal contraceptives ( ) |
|
|
|
If you got pregnant taking hormonal contraceptives, how long?_ months |
If you got pregnant by taking hormonal contraceptives, how long?_ months |
|
Block C
|
|
|
|
|
|
Pruebas médicas de radiaciones ionizantes em la etapa periconcep-cional y embarazo: |
Did you perform any medical examinations with exposure to ionizing radiation in pre-conception and at pregnancy? |
Did you perform any medical examinations of ionizing radiation on the peri- conceptional and at pregnancy? |
Did you perform any exams with exposure to ionizing radiation until two months before or during the pregnancy? |
Did you perform any exams with exposure to ionizing radiation ("X-Ray") until two months before or during the pregnancy? |
Sí ( ) |
Yes ( ) |
Yes ( ) |
Yes ( ) |
Yes ( ) |
No ( ) |
No ( ) |
No ( ) |
No ( ) |
No ( ) |
|
I do not know ( ) |
|
|
If yes, was the examination performed two months before the pregnancy? ( ) |
|
|
|
|
|
Block D
|
|
|
|
|
|
¿Ha tomado alguna medicación de forma esporádica o habitual? (desde um mes antes del embarazo o lactancia) |
Did you take some medication on time or daily in the pre-conception or during the pregnancy? |
Do you take any sporadic or usual medicine? (Since one month before the pregnancy or lactation) |
Did you take some sporadic or usual medication between the period of one month before the pregnancy or during breastfeed- ing? |
Did you take some sporadic or usual medication between the period of one month before the pregnancy until delivery or during breastfeeding? |
|
|
|
Yes ( ) |
Yes ( ) |
|
|
|
No ( ) |
No ( ) |
|
|
|
|
|
Questions contained in the table (below the question cited above): |
- Drug or product |
- Drug or product |
- Drug or product |
- Drug or product |
Fármaco o produto |
-Reason |
-Reason |
-Reason |
-Reason |
-Motivo |
- Dosage |
- Dosage |
- Dosage |
- Dosage |
- Posología |
- Initial Date |
- Initial Date |
- End date or current date |
- the period of use: |
- Fecha inicio |
- End Date |
- End date or current date |
|
1 month before the pregnancy ( ) |
- Fecha final o actual |
|
|
|
1st T( ) 2nd T ( )3rd T ( ) |
|
|
|
|
Breastfeeding ( ) |
|
|
|
|
|
Block E
|
|
|
|
|
|
Riesgos ambientales asociados a las ocupaciones de los que viven en casa: _________________ |
Are there environmental risks associated to the occupation of the household: ___ |
Are there environmental risks associated to those occupation live in the house:__ |
Do you or someone who lives with you work with other toxic products? |
Do you or someone who lives with you work with other toxic products? |
¿Le preocupa alguna exposición a tóxicos medioambientales em el trabajo? |
Is there a concern about the exposure to environmental toxic at work? |
How concerned are you with some exposure to environmental toxic at work? |
Yes ( ) |
Yes ( ) |
No ( ) |
No ( ) |
Exposed (mother, father, other residents) and products. |
Table: Exposed (mother, father, other residents) and products. |
Sí ( ) |
Yes ( ) |
Yes ( ) |
|
|
No ( ) |
No ( ) |
No ( ) |
|
|
No lo sé ( ) |
I do not know ( ) |
I do not know ( ) |
|
|