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

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Chronic medical and meds# Question Prereq Options Script(s) Programming Notes1Do you have any chronic healthconditions, like diabetes, asthmaor HIV? Yes Tb high riskPlug in "because youhave been diagnosedwith a chronic healthcondition"1 Do you have any chronic health conditions, like diabetes, asthma or HIV?No2Have you been told by a doctorthat you have any of these healthissues? Check all that apply: Diabetes DiabetesPre-Diabetes2 Have you been told by a doctor that you have any of these health issues? Check all that apply:Pre-Diabetes2 Have you been told by a doctor that you have any of these health issues? Check all that apply:2 Have you been told by a doctor that you have any of these health issues? Check all that apply:2 Have you been told by a doctor that you have any of these health issues? Check all that apply:2 Have you been told by a doctor that you have any of these health issues? Check all that apply:2 Have you been told by a doctor that you have any of these health issues? Check all that apply:2 Have you been told by a doctor that you have any of these health issues? Check all that apply:2 Have you been told by a doctor that you have any of these health issues? Check all that apply:Lupus2 Have you been told by a doctor that you have any of these health issues? Check all that apply:2 Have you been told by a doctor that you have any of these health issues? Check all that apply:GestationalDiabetes(diabetes duringpregnancy)ThyroidDisease(Overactive)ThyroidDisease(Underactive)Phenylketonuria(PKU)Hypertension(high bloodpressure)RheumatoidArthritisGestationalDiabetes(diabetesduringpregnancy)ThyroidDiseaseoveractiveThyroidDiseaseunderactivePKUHypertensionRheumatoidArthritisSLEKidneyChronic RenalProblems DiseaseCardiovascularDisease (heartdisease) Cardiovascular2 Have you been told by a doctor that you have any of these health issues? Check all that apply:2 Have you been told by a doctor that you have any of these health issues? Check all that apply:2 Have you been told by a doctor that you have any of these health issues? Check all that apply:2 Have you been told by a doctor that you have any of these health issues? Check all that apply:Blood Clots ThrombophiliaAsthma AsthmaSeizures(Epilepsy) SeizuresNone of theabove3 Do you have a disability? YesWomen withDiabilities3 Do you have a disability?No4 Have you ever had cancer? Yes Cancer4 Have you ever had cancer?No5Do you take any medicinesprescribed by a doctor? Yes Prescriptions Continue to 3Skip to 45 Do you take any medicines prescribed by a doctor?No6
6 Do you take any prescriptions for the following health issues? Check all that apply: "Yes" to 56 Do you take any prescriptions for the following health issues? Check all that apply: "Yes" to 56 Do you take any prescriptions for the following health issues? Check all that apply: "Yes" to 56 Do you take any prescriptions for the following health issues? Check all that apply: "Yes" to 56 Do you take any prescriptions for the following health issues? Check all that apply: "Yes" to 56 Do you take any prescriptions for the following health issues? Check all that apply: "Yes" to 56 Do you take any prescriptions for the following health issues? Check all that apply: "Yes" to 56 Do you take any prescriptions for the following health issues? Check all that apply: "Yes" to 56 Do you take any prescriptions for the following health issues? Check all that apply: "Yes" to 56 Do you take any prescriptions for the following health issues? Check all that apply: "Yes" to 5Chronic medical and meds (continued)# Question Prereq Options Script(s) Programming Notes6Do you take any prescriptions forthe following health issues?Check all that apply: "Yes" to 5 Diabetes PrescriptionsPlug condition intoscript6 Do you take any prescriptions for the following health issues? Check all that apply: "Yes" to 5Seizures(Epilepsy) PrescriptionsPlug condition intoscriptHypertension(high bloodpressure) PrescriptionsPlug condition intoscriptThyroidDisease PrescriptionsPlug condition intoscriptLupus PrescriptionsPlug condition intoscriptRheumatoidArthritisPrescriptionsPlug condition intoscriptAsthma PrescriptionsPlug condition intoscriptKidneyProblems PrescriptionsPlug condition intoscriptCardiovascularDisease (heartdisease) PrescriptionsPlug condition intoscriptBlood Clots PrescriptionsPlug condition intoscriptChronic Pain PrescriptionsPlug condition intoscriptFor anotherhealth issue PrescriptionsPlug condition intoscriptDo you take any "over the7 counter" medications? Yes OTC's7 Do you take any "over the counter" medications?NoHave you ever taken herbs (likechamomile or ginseng), herbalteas, home remedies, or weightloss products for your health?HerbalSupplementsand weightloss products8YesNo8 Have you ever taken herbs (like chamomile or ginseng), herbal teas, home remedies, or weight loss products for your health?Source: Adapted from Jack BW, Culpepper L, Babcock J, Kogan MD, Weismiller D. Addressing Preconception <strong>Risk</strong>s Identifiedat the Time of a Negative Pregnancy Test. A Randomized Trial. J Fam Pract. 1998;47(1)33-38. Reviewed by Anne L. Dunlop,MD, MPH; Benjamin D. Solomon, MD; Cynthia S. Shellhaas, MD, MPH; Joseph N.Bottalico, DO; Melissa A. McDiarmid, MD,MPH; Mona R. Prasad, DO, MPH; Paula M. Gardiner, MD, MPH; Catherine Ruhl, CNM, MS.7
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Page 3 and 4: 2 Do you use birth control on a reg
Page 5: Sexual and reproductive health (con
Page 9 and 10: Family and genetic history (continu
Page 11 and 12: Psychiatric (continued)# Question P
Page 13 and 14: Immunizations (continued)# Question
Page 15 and 16: Infectious disease (continued)# Que
Page 17 and 18: Infectious disease (continued)# Que
Page 19 and 20: Nutrition and activity# Question Pr
Page 21 and 22: Environmental exposures# Question P

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