Influence of Maternal Prenatal Vitamin D Status on Infant Oral Health

<strong>Prenatal</strong> Nutritional Deficiency and Early Childhood Caries in an Urban Aboriginal
Population – QUESTIONNAIRE
Code: __ __ __ __ __ __ __
Date: ___________________(dd/mm/yy)
Interviewer: _______________________
Primary clinic site where prenatal care is being provided:
Mount Carmel Clinic Health Action Centre Women’s Hospital
Has informed consent form been explained and signed? Yes No
Has blood sample been obtained? Yes No By whom? ___________________
Participant Pr<strong>of</strong>ile:
Date <strong>of</strong> Birth:__________________(dd/mm/yy) Province <strong>of</strong> birth: _________________________
Where were you born? _____________________________________________________
Current Address: _______________________________________Phone: ____________________
Do you live in Winnipeg? Yes No
Which Aboriginal category below would best describe your heritage?
<strong>Status</strong> Indian Non <strong>Status</strong> Indian Metis Inuit Other___________________
Pregnancy & Health Pr<strong>of</strong>ile:
Is this your first pregnancy? Yes No
If no, how many children have you had and when did you last have a baby? ___________________
________________________________________________________________________________
Did you give any <strong>of</strong> your babies vitamin D drops (e.g. D-Vi-Sol)? Yes No
Expected due date: ___________________________(dd/mm/yy)
How would you rate your health during this pregnancy? Good Average Poor
If you rate your health as poor explain: ________________________________________________
Are you worried about your health during this pregnancy? Yes No
If yes, explain: ___________________________________________________________________
Do you think prenatal care is important? Yes No Unsure
If no, explain: ____________________________________________________________________
Do you regularly come to this medical clinic? Yes
No
How do you get to your doctor’s <strong>of</strong>fice for prenatal care? Walk Drive Bus Taxi Friend
Did your doctor recommend that you take vitamins during this pregnancy (Materna, multivitamins)?
Yes No
If yes, are you taking them? Yes No
If no, why? ______________________________________________________________________
Questionnaire Version 8 – May, 2002 Page 1<strong>of</strong> 7