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

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Family and genetic historyAdd "or your partner" if chose "Male" or "Both" to Question 3 in Health1 Have you or your partner ever had any of the following conditions? Check all that apply:PromotionAdd "or your partner" if chose "Male" or "Both" to Question 3 in Health1 Have you or your partner ever had any of the following conditions? Check all that apply:PromotionAdd "or your partner" if chose "Male" or "Both" to Question 3 in Health1 Have you or your partner ever had any of the following conditions? Check all that apply:PromotionAdd "or your partner" if chose "Male" or "Both" to Question 3 in Health1 Have you or your partner ever had any of the following conditions? Check all that apply:PromotionAdd "or your partner" if chose "Male" or "Both" to Question 3 in Health1 Have you or your partner ever had any of the following conditions? Check all that apply:PromotionAdd "or your partner" if chose "Male" or "Both" to Question 3 in Health1 Have you or your partner ever had any of the following conditions? Check all that apply:Promotion# Question Prereq Options Script(s)Add "or yourpartner" if chose"Male" or "Both"Have you or your partner ever had to Question 3 inany of the following conditions? HealthChromosomal1 Check all that apply:Promotion disorders Personal History1 Have you or your partner ever had any of the following conditions? Check all that apply:Add "or your partner" if chose "Male" or "Both" to Question 3 in HealthPromotionDeafness Personal HistoryFacial Clefts(Cleft Palate) Personal HistorySickle Celldisease or trait Personal HistoryThalassemia Personal HistoryDevelopmentalDelay/MentalRetardation Personal HistoryBlood Clots Personal HistoryCancer Personal HistoryClotting1 Have you or your partner ever had any of the following conditions? Check all that apply:1 Have you or your partner ever had any of the following conditions? Check all that apply:1 Have you or your partner ever had any of the following conditions? Check all that apply:1 Have you or your partner ever had any of the following conditions? Check all that apply:1 Have you or your partner ever had any of the following conditions? Check all that apply:1 Have you or your partner ever had any of the following conditions? Check all that apply:1 Have you or your partner ever had any of the following conditions? Check all that apply:1 Have you or your partner ever had any of the following conditions? Check all that apply:2Has anyone in your family or yourpartner’s family ever had(including parents, grandparents,siblings, aunts, uncles, cousins)and of the following?:2 Has anyone in your family or your partner’s family ever had (including parents, grandparents, siblings, aunts, uncles, cousins) and of the following?:2 Has anyone in your family or your partner’s family ever had (including parents, grandparents, siblings, aunts, uncles, cousins) and of the following?:2 Has anyone in your family or your partner’s family ever had (including parents, grandparents, siblings, aunts, uncles, cousins) and of the following?:2 Has anyone in your family or your partner’s family ever had (including parents, grandparents, siblings, aunts, uncles, cousins) and of the following?:2 Has anyone in your family or your partner’s family ever had (including parents, grandparents, siblings, aunts, uncles, cousins) and of the following?:2 Has anyone in your family or your partner’s family ever had (including parents, grandparents, siblings, aunts, uncles, cousins) and of the following?:2 Has anyone in your family or your partner’s family ever had (including parents, grandparents, siblings, aunts, uncles, cousins) and of the following?:Add "or your partner" if chose "Male" or "Both" to Question 3 in HealthPromotionAdd "or your partner" if chose "Male" or "Both" to Question 3 in HealthPromotionAdd "or your partner" if chose "Male" or "Both" to Question 3 in Health HeartPromotionAdd "or your partner" if chose "Male" or "Both" to Question 3 in HealthPromotionAdd "or your partner" if chose "Male" or "Both" to Question 3 in HealthPromotionAdd "or your partner" if chose "Male" or "Both" to Question 3 in Health OtherPromotionAdd "or your partner" if chose "Male" or "Both" to Question 3 in HealthPromotionAdd "or your partner" if chose "Male" or "Both" to Question 3 in HealthPromotionAdd "or yourpartner's family"if chose "Male"or "Both" toQuestion 3 inHealthPromotionAdd "or your partner's family" if chose "Male" or "Both" to Question 3 in Health DeafnessPromotionAdd "or your partner's family" if chose "Male" or "Both" to Question 3 in HealthPromotionAdd "or your partner's family" if chose "Male" or "Both" to Question 3 in HealthPromotionAdd "or your partner's family" if chose "Male" or "Both" to Question 3 in HealthPromotionThalassemiaAdd "or your partner's family" if chose "Male" or "Both" to Question 3 in HealthPromotionAdd "or your partner's family" if chose "Male" or "Both" to Question 3 in Health BloodPromotionAdd "or your partner's family" if chose "Male" or "Both" to Question 3 in Health CancerPromotiondisordersNeural TubeDefects (SpinaBifida)Personal HistoryPersonal HistoryDisease Personal HistoryVision loss,inherited fromfamily member Personal HistoryFamily history ofother congenitalmalformations orbirth defectsPersonal HistoryPersonal HistoryDon't knowabout genetichistoryDon’t knowNone of theaboveChromosomaldisorders Family HistoryFamily HistoryFacial Clefts(Cleft Palate) Family HistorySickle CellDisease or trait Family HistoryFamily HistoryDevelopmentalDelay/MentalRetardation Family HistoryClots Family HistoryFamily HistoryProgrammingNotes8
Family and genetic history (continued)# Question Prereq Options Script(s)Add "or yourpartner's family"Has anyone in your family or your if chose "Male"partner’s family ever hador "Both" to(including parents, grandparents, Question 3 insiblings, aunts, uncles, cousins) HealthClotting2 and of the following?:Promotion disorders Family HistoryNeural TubeDefects (ex:2 Has anyone in your family or your partner’s family ever had (including parents, grandparents, siblings, aunts, uncles, cousins) and of the following?:Add "or your partner's family" if chose "Male" or "Both" to Question 3 in HealthPromotionSpina Bifida) Family History2 Has anyone in your family or your partner’s family ever had (including parents, grandparents, siblings, aunts, uncles, cousins) and of the following?:2 Has anyone in your family or your partner’s family ever had (including parents, grandparents, siblings, aunts, uncles, cousins) and of the following?:2 Has anyone in your family or your partner’s family ever had (including parents, grandparents, siblings, aunts, uncles, cousins) and of the following?:2 Has anyone in your family or your partner’s family ever had (including parents, grandparents, siblings, aunts, uncles, cousins) and of the following?:2 Has anyone in your family or your partner’s family ever had (including parents, grandparents, siblings, aunts, uncles, cousins) and of the following?:2 Has anyone in your family or your partner’s family ever had (including parents, grandparents, siblings, aunts, uncles, cousins) and of the following?:2 Has anyone in your family or your partner’s family ever had (including parents, grandparents, siblings, aunts, uncles, cousins) and of the following?:2 Has anyone in your family or your partner’s family ever had (including parents, grandparents, siblings, aunts, uncles, cousins) and of the following?:2 Has anyone in your family or your partner’s family ever had (including parents, grandparents, siblings, aunts, uncles, cousins) and of the following?:3Add "or your partner's family" if chose "Male" or "Both" to Question 3 in Health HeartPromotionAdd "or your partner's family" if chose "Male" or "Both" to Question 3 in HealthPromotionAdd "or your partner's family" if chose "Male" or "Both" to Question 3 in HealthPromotionAdd "or your partner's family" if chose "Male" or "Both" to Question 3 in HealthPromotionAdd "or your partner's family" if chose "Male" or "Both" to Question 3 in HealthPromotionAdd "or your partner's family" if chose "Male" or "Both" to Question 3 in Health CysticPromotionAdd "or your partner's family" if chose "Male" or "Both" to Question 3 in HealthPromotionAdd "or your partner's family" if chose "Male" or "Both" to Question 3 in HealthPromotionAdd "or your partner's family" if chose "Male" or "Both" to Question 3 in HealthPromotionDisease Family HistoryVision loss,inherited fromfamily member Family HistorySudden InfantDeath Syndrome(SIDS)Family HistoryEarly infantdeathFamily HistoryMuscularDystrophy Family HistoryFibrosis Family HistoryFamily history ofother congenitalmalformations orbirth defects Family HistoryDon’t knowNone of theaboveDon't knowabout genetichistoryWhat is your blood ancestors’ethnic/racial/geographicbackground? Please check all thatapply: White Ethnicity-Based3 What is your blood ancestors’ ethnic/racial/geographic background? Please check all that apply: 3European3 What is your blood ancestors’ ethnic/racial/geographic background? Please check all that apply: 33 What is your blood ancestors’ ethnic/racial/geographic background? Please check all that apply: 3French-Canadian3 What is your blood ancestors’ ethnic/racial/geographic background? Please check all that apply: 3Cajun3 What is your blood ancestors’ ethnic/racial/geographic background? Please check all that apply: 3African3 What is your blood ancestors’ ethnic/racial/geographic background? Please check all that apply: 3Mediterranean3 What is your blood ancestors’ ethnic/racial/geographic background? Please check all that apply: 3Asian3 What is your blood ancestors’ ethnic/racial/geographic background? Please check all that apply: 3Ethnicity-BasedAshkenaziJewishEthnicity-BasedEthnicity-BasedEthnicity-BasedEthnicity-BasedEthnicity-BasedEthnicity-BasedNone of theaboveProgrammingNotesAdapted from Jack BW, Culpepper L, Babcock J, Kogan MD, Weismiller D. Addressing Preconception <strong>Risk</strong>s Identified at theTime of a Negative Pregnancy Test. A Randomized Trial. J. Fam Pract. 1998;47(1)33-38. Reviewed by Benjamin D. Solomon,MD; W. Gregory Feero, MD, PhD; Karla Damus, RN, MSPH, PhD.9
Page 1 and 2: Appendix A: Online Risk Assessment
Page 3 and 4: 2 Do you use birth control on a reg
Page 5 and 6: Sexual and reproductive health (con
Page 7: 6 Do you take any prescriptions for
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

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

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