Facial Palsy and Pregnancy * 1. Did you have a pregnancy during which you developed facial palsy? Yes No * 2. How many successful pregnancies did you have prior to the pregnancy related to facial palsy? 0, this was my first pregnancy 1 2 3 and more * 3. Have you ever had facial palsy before developing it during pregnancy, and if so, was it on the same side? Yes, and it was on the same side Yes, but it was not on the same side No * 4. At what point in your pregnancy did you develop facial palsy? First trimester Second trimester Third trimester Postpatrum * 5. What were your symptoms just prior to/at the time of onset? Check ALL that apply. Facial weakness and/or paralysis Difficulty with taste Difficulty with eating/drinking/brushing teeth Difficulty with blinking and eye closure Eye dryness and excessive tearing Eyelid and/or eyebrow drooping Eye twitching Pain or ringing in ears Jaw pain Other (please specify) * 6. How severe was your paralysis? Incomplete (some movement) Complete (no movement) * 7. Is your paralysis unilateral (one side) or bilateral (both sides)? Unilateral Bilateral * 8. How long after the onset of facial palsy did you receive medical intervention? 0-3 weeks 3-6 weeks After 6 weeks I did not receive medical intervention * 9. Were you treated with steroids? Yes No * 10. Were you treated with antiviral medication? Yes No * 11. Did you have elevated sugar levels during any of the following periods: During pregnancy At the time of onset Not at all * 12. Did you have gestational diabetes during any of the following periods: During pregnancy At the time of onset Not at all * 13. Did you have swelling/fluid retention during any of the following periods: During pregnancy At the time of onset Not at all * 14. Did you have preeclampsia during any of the following periods: During pregnancy At the time of onset Not at all * 15. Did you have depression during any of the following periods: During pregnancy At the time of onset Not at all * 16. Did you have hypocalcemia (low calcium level in blood) during any of the following periods: During pregnancy At the time of onset Not at all * 17. What was your age at the start of pregnancy? 17-25 26-33 34-40 40 and above * 18. What was your height at the start of pregnancy? 4'11" and below 5' to 5'5" 5'6" to 6' 6' and above * 19. What was your weight at the start of pregnancy? Under 130 lbs 130-150 151-171 172-192 Over 192 * 20. How much weight did you gain in the first trimester of pregnancy? 0-2 lbs 3-5 lbs 6 lbs and above I don't know/remember I lost weight * 21. How much weight did you gain in the second trimester of pregnancy? 0-2 lbs 3-5 lbs 6 lbs and above I don't know/remember I lost weight * 22. How much weight did you gain in the third trimester of pregnancy? 0-2 lbs 3-5 lbs 6 lbs and above I don't know/remember I lost weight * 23. Have you ever had fertility issues that were managed with fertility treatment? Yes, but I didn't receive fertility treatment Yes, and I did receive fertility treatment I had neither fertility issues nor fertility treatment. * 24. Did you have high blood pressure during any of the following periods: During pregnancy At the time of onset Not at all * 25. When did you fully recover? During pregnancy After delivery I have not yet recovered. * 26. Has any blood relative ever had facial palsy from unknown causes? Yes No * 27. Are there any other medical conditions that you were diagnosed with during your pregnancy? Done
