Facial Palsy and Pregnancy * 1. Did you have swelling/fluid retention during any of the following periods: During pregnancy At the time of onset Not at all * 2. Did you have gestational diabetes during any of the following periods: During pregnancy At the time of onset Not at all * 3. Did you have elevated sugar levels during any of the following periods: During pregnancy At the time of onset Not at all * 4. Did you have high blood pressure during any of the following periods: During pregnancy At the time of onset Not at all * 5. Did you have a pregnancy during which you developed facial palsy? Yes No * 6. 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 * 7. 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 * 8. At what point in your pregnancy did you develop facial palsy? First trimester Second trimester Third trimester Postpatrum * 9. 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) * 10. How severe was your paralysis? Incomplete (some movement) Complete (no movement) * 11. Is your paralysis unilateral (one side) or bilateral (both sides)? Unilateral Bilateral * 12. 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 * 13. Were you treated with steroids? Yes No * 14. Were you treated with antiviral medication? Yes No * 15. 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. * 16. What was your age, height, and weight at the start of your pregnancy? Age: Height: Weight: * 17. How much weight did you gain during your pregnancy? First trimester Second trimester Third trimester * 18. When did you fully recover? During pregnancy After delivery I have not yet recovered. * 19. Has any blood relative ever had facial palsy from unknown causes? Yes No * 20. Are there any other medical conditions that you were diagnosed with during your pregnancy? Done
