Appendix A. Online Risk Assessment Tool - AHRQ National ...

Sexual and reproductive health (continued)# Question Prereq Sub-Question Options Script(s)A premature orpreterm baby(born at least 3Prior premature6 Have you ever had: "Yes" to 4 weeks early)? Yesbirth6 Have you ever had: "Yes" to 4 A premature or preterm baby (born at least 3 weeks early)?No6 Have you ever had: "Yes" to 4 A premature or preterm baby (born at least 3 weeks early)?Don't6 Have you ever had:"Yes"to 46 Have you ever had: "Yes" to 4 A baby with a birth defect?No6 Have you ever had: "Yes" to 4 A baby with a birth defect?Don't6 Have you ever had:"Yes"to 46 Have you ever had: "Yes" to 4 A baby that had to stay in an intensive care nursery (NICU)?No6 Have you ever had:"Yes"to 4Prior prematureknow birthA baby with abirth defect? Yes Birth defectknow Birth defectA baby that hadto stay in anintensive carenursery (NICU)? Yes NICUVaginalbleeding late inpregnancy?6 Have you ever had: "Yes" to 4 Vaginal bleeding late in pregnancy?No6 Have you ever had:"Yes"to 4A problem withyour uterus(womb)?6 Have you ever had: "Yes" to 4 A problem with your uterus (womb)?No6 Have you ever had: "Yes" to 4 A problem with your uterus (womb)?Don't7YesYesknowHave you ever gottenpregnant less than 3months after the end ofanother pregnancy? "Yes" to 4 Yes7 Have you ever gotten pregnant less than 3 months after the end of another pregnancy? "Yes" to 4No7 Have you ever gotten pregnant less than 3 months after the end of another pregnancy? "Yes" to 4Don't8When you were bornvery early or very small?8 When you were born very early or very small?No8 When you were born very early or very small?Don’t9When your mother wasborn, was she born veryearly or very small?9 When your mother was born, was she born very early or very small?NoknowYesknowYesVaginalbleedingUterineanomaliesUterineanomaliesShort timebetweenpregnanciesShort timebetweenpregnanciesBorn low birthweight orpretermBorn low birthweight orpretermMother born lowbirth weight orpretermProgrammingNotesMother born lowbirth weight orDon't know preterm9 When your mother was born, was she born very early or very small?Source: Adapted from Jack BW, Culpepper L, Babcock J, Kogan MD, Weismiller D. Addressing Preconception Risks Identifiedat the Time of a Negative Pregnancy Test. A Randomized Trial. J Fam Pract. 1998;47(1):33-38. References: Norton M. Newevidence on birth spacing: Promising findings for improving newborn, infant, child, and maternal health. International Journal ofGynecology and Obstetrics (2005) 89, S1—S6. Zhu BP. Effect of interpregnancy interval on birth outcomes: Findings from threerecent US studies. International Journal of Gynecology and Obstetrics. 2005. 89:S25—S33. Zhu BP, Rolfs RT, Nangle BE,Horan, JM. Effect of the interval between pregnancies on perinatal outcomes. NEJM. 2005; 340(8):589-594. Reviewed by DeanV. Coonrod, MD; Karla Damus, RN, MSPH, PhD.5