Liverpool Baby Breathing Study

Questionnaire 1 

The following questionnaire asks questions about your baby and what has been happening to him or her over the last three months. It should take no longer than 10 minutes to complete. All future questionnaires should take no more than 5 minutes to complete. 

This study aims to find out more about the respiratory symptoms, such as wheezing, coughs and colds, that your baby experiences, and how they affect you and your family. 

Our study will help us understand what makes these symptoms more or less likely to occur and how they change over time. 

It is important that every question is answered, even if your baby has been perfectly well, with no problems at all.  

 

Thank you!

What is your new baby's first name?*

What is your new baby's last name?*

How many weeks pregnant were you when you gave birth?*

Did you smoke at any time during your pregnancy?*

Did any member of your household smoke, anywhere or at any time during your pregnancy?*

Where did these people smoke?*

Tick all that apply

Did you breast feed your new baby at any time?*

This includes expressed breast milk or bottle feeding at the same time

Who has asthma, hay fever or eczema?*

Tick all that apply

Which illness do you (the baby's mother) have?*

Tick all that apply

Which illness does your baby's father have?*

Tick all that apply

Which illness does your eldest child have?*

Tick all that apply

Which illness does your second eldest child have?*

Tick all that apply

Which illness does your third eldest child have?*

Tick all that apply

Which illness does your fourth eldest child have?*

Tick all that apply

Which illness does this other person have?*

Tick all that apply

Does any member in your household smoke, anywhere?*

Please select yes, even if they smoke outside

Where do these people smoke?

Tick all that apply

Who does your baby share a bedroom with?*

Please tick all that apply

My new baby has been wheezing (whistling noise coming from the chest):*

My new baby has had a rattly chest (noise that you can hear and feel as a vibration, when placing your hands over your baby's chest):*

How many colds (runny nose, and high temperature) has your new baby had in the last three months?*

What is your first name?*

What is your last name?*

What is your year of birth?

What is your new baby's father's first name?

What is your new baby's father's last name?

What is your postcode?*

What is your main e-mail address?

What is your main telephone number?