Rate Your Prematurity Risks

The following questionnaire includes the 60 proven risks associated with preterm delivery, birth before 37 completed weeks' gestation. This questionnaire is a starting point for your personal assessment of your characteristics and factors in your daily life. The answers will pinpoint the risks currently present in your life--risks that you should reduce to improve your chances of having a healthy pregnancy.

Family Background
1. Do you consider yourself African-American?
2. Were you born in the United States?
3. Are you younger than 18 or older than 35?
4. Is your annual income less than $8,000 for a family of two, or less than $10,000 for a family of three?
5. Are you a single parent?
6. Do you have preschool children at home?
7. Do you have more than two children at home?
8. Do one or more elderly relatives live with you?
Gynecological, Obstetrical, and Medical History Factors Before this pregnancy, have you had...
9. ...more than one spontaneous abortion?
10. ...more than one induced abortion?
11. ...any preterm births (<37 weeks' gestation)?
Were any of your previous newborns...
12. ...born dead (stillborns)?
13. ...less than 5.5 pounds at birth?
14. ...dead within one month after birth?
15. Do you have a history of infertility treatments?
16. Did your mother take DES (diethylstilbesterol) when she was pregnant with you?
17. Is this your first pregnancy?
18. Have you given birth four or more times before?
19. Did you have any preexisting medical conditions?
Current Obstetrical Factors
20. Have you had any vaginal bleeding after 12 weeks?
21. Do you have any placental complications?
22. Have you been told you have an incompetent cervix?
23. Do you have premature rupture of membranes?
24. Have you had one or more vaginal infections?
25. Are you pregnant with more than one baby (multiples)?
Nutritional Historical Factors
26. Are you less than five feet tall?
27. Can you pinch less than one inch of fat on your arm?
28. Are you underweight for your height?
29. Have you recently been dieting to lose weight?
30. Have you recently had a major illness or surgery?
Home and Work Environment Factors
31. Do you climb stairs at home?
32. Do you do much lifting at home?
33. Do you do much carrying at home?
34. Do you do much standing at home?
35. Is your home environment noisy?
36. Do you spend much time driving (carpool, groceries, errands)?
37. Is your job high-stress or physically demanding?
38. Do you stand while commuting to and from work?
39. Do you stand most of the time at work?
40. Do you do much lifting at work?
41. Does your job require much physical exertion?
42. Do you have irregular work hours?
43. Does your job involve shift work?
44. Do you work more than 8 hours per day?
45. Do you work more than 40 hours per week?
46. Do you become fatigued at work?
47. Is your work environment noisy?
48. Are you under a lot of stress at work?
49. Do you drive at work or commute to work?
Lifestyle Factors
50. Do you drink alcohol?
51. Do you smoke cigarettes?
52. Do you drink more than 2 cups of coffee per day?
If you participate in recreational exercise,
53. ...do you exercise on your back or until fatigued?
54. ...do you exercise until you perspire?
Nutritional Factors in the Current Pregnancy Have you been told that you have...
55. ...to eat more frequently (don't skip meals)?
56. ...not gained enough weight before 20 weeks?
57. ...not gained enough weight after 20 weeks?
58. ...iron-deficiency anemia?
59. ...an inadequate iron intake?
60. ...an inadequate calcium intake?