Life Style # Question Response Action Purpose Main Panel 4a. Past Smoking Text box, Z9, Numeric to be asked if not on PNSS In the 3 months before you were pregnant, how __ Cigarettes/day WIC during pregnancy. If many cigarettes did you smoke on an average on WIC during the most day? (1 pack = 20 cigarettes) current pregnancy, bring the answer forward from the last pregnancy assessment. 4b. In the last 3 months of your pregnancy, how many Text box, Z9, Numeric PNSS cigarettes did you smoke on an average day? (1 __ Cigarettes/day pack = 20 cigarettes) Current Smoking Text box, Z9, Numeric Display Currently smokes PNSS, Risk 371 4c. How many cigarettes do you smoke on an average __ Cigarettes/day <value of day now? BloodWork.PackPerDayCd> pack(s)/day if smoking information (packs/day) was recorded on the blood screen today. 4d. Does anyone else living in your household smoke Radio buttons: PNSS, Risk 904 inside the home? Yes/No 4e. Past Alcohol Use Text box, Z9, Numeric Needs to be asked if not on PNSS In the 3 months before you were pregnant, how ___ Drinks/wk during pregnancy. If on many alcoholic drinks (beer, wine or liquor) did you during pregnancy, bring have in an average week? forward the answer. 4f. In the last 3 months of your pregnancy, how many Text box, Z9, Numeric PNSS alcoholic (beer, wine or liquor) did you have in an ___ Drinks/wk average week? 4g. Current Alcohol Use buttons: Note: auto-assign routine PNSS, Risk 372 Do you currently drink alcohol? If yes, how much Yes, No use and heavy drinking and how often? If yes, Drinks/wk is a required (>5/wk) based on number of 372a - Alcohol use Binge drinking drinks/wk (current) – Text box, Z9, Numeric ___ Drinks/wk
Life Style # Question Response Action Purpose Main Panel 4a. Past Smoking In the 3 months before you were pregnant, how many cigarettes did you smoke on an average day? (1 pack = 20 cigarettes) Text box, Z9, Numeric __ Cigarettes/day to be asked if not on WIC during pregnancy. If on WIC during the most current pregnancy, bring the answer forward from the last pregnancy assessment. PNSS 4b. In the last 3 months of your pregnancy, how many cigarettes did you smoke on an average day? (1 pack = 20 cigarettes) Text box, Z9, Numeric __ Cigarettes/day PNSS 4c. Current Smoking How many cigarettes do you smoke on an average day now? Text box, Z9, Numeric __ Cigarettes/day Display Currently smokes <value of BloodWork.PackPerDayCd> pack(s)/day if smoking information (packs/day) was recorded on the blood screen today. PNSS, Risk 371 4d. Does anyone else living in your household smoke inside the home? Radio buttons: Yes/No PNSS, Risk 904 4e. Past Alcohol Use In the 3 months before you were pregnant, how many alcoholic drinks (beer, wine or liquor) did you have in an average week? Text box, Z9, Numeric ___ Drinks/wk Needs to be asked if not on during pregnancy. If on during pregnancy, bring forward the answer. PNSS 4f. In the last 3 months of your pregnancy, how many alcoholic (beer, wine or liquor) did you have in an average week? Text box, Z9, Numeric ___ Drinks/wk PNSS 4g. Current Alcohol Use Do you currently drink alcohol? If yes, how much and how often? 372a - Alcohol use – Binge drinking buttons: Yes, No If yes, Drinks/wk is a required Text box, Z9, Numeric ___ Drinks/wk Note: auto-assign routine use and heavy drinking (>5/wk) based on number of drinks/wk (current) PNSS, Risk 372