Appendix S.2 PRENATAL MR Form

S TUDY ID Number:

caddre

prenatal Chart

Abstraction Form

(11/14/2005)

A. IDENTIFYING INFORMATION  No Info
Mother’s name (Last, First, Middle)			2. Study ID#
3. Maiden Name	4. AKA
5. Mother’s Medical Record Number	6. SSN		7. Mother’s DOB
8. Street Address	9. City		10. State	11. Zip Code _ _ _ _ _ - _ _ _ _
12. Provider/Clinic Name
13. Clinic Street Address	14. City		15. State	16. Zip Code _ _ _ _ _ - _ _ _ _
17. Provider/Clinic Name
18. Clinic Street Address	19. City		20. State	21. Zip Code _ _ _ _ _ - _ _ _ _
22. Provider/Clinic Name
23. Clinic Street Address	24. City		25. State	26. Zip Code _ _ _ _ _ - _ _ _ _
27. Delivery Hospital
28. Delivery Hospital Address	29. City		30. State	31. Zip code _ _ _ _ _ - _ _ _ _
32. Date Abstracted __ __/__ __/__ __ __ __		33. Abstractor
34. Start Time :		35. Stop Time :
36. Start Time :		37. Stop Time :
38. Start Time :		39. Stop Time :
40. Start Time :		41. Stop Time :
Comments:

MATERNAL Address History
9. Date _ _ /_ _/_ _ _ _	10. Mother’s Street Address
11. City		12. State	13. Zip Code
14. Date _ _ /_ _/_ _ _ _	15. Mother’s Street Address
16. City		17. State	18. Zip Code
19. Date _ _ /_ _/_ _ _ _	20. Mother’s Street Address
21. City		22. State	23. Zip Code
24. Date _ _ /_ _/_ _ _ _	25. Mother’s Street Address
26. City		27. State	28. Zip Code
29. Date _ _ /_ _/_ _ _ _	30. Mother’s Street Address
31. City		32. State	33. Zip Code
34. Date _ _ /_ _/_ _ _ _	35. Mother’s Street Address
36. City		37. State	38. Zip Code
39. Date _ _ /_ _/_ _ _ _	40. Mother’s Street Address
41. City		42. State	43. Zip Code
COMMENTS:

B. MENSTRUAL HISTORY, CONCEPTION, INFERTILITY, PRENATAL CARE  No Info

1. Date of first PNV

__ __/__ __/__ __ __ __ 99. unknown

2. Date of last PNV

__ __/__ __/__ __ __ __ 99. unknown

3. Total # Visits

99. unknown

4. LMP Date

__ __/__ __/__ __ __ __ 99. unknown

5. LMP date certain?

1.  Yes 2.  No

9.  Unknown

6. EDC-LMP

99. unknown

7. EDC-US

99. unknown

8. Number of months current pregnancy attempted

________ months

77.  Unplanned 99. unknown

9. Contraceptives in use at time of conception?

1.  None/rhythm 2.  Barrier/chemical

3.  Hormonal 4.  IUD

9.  Unknown

10. Date contraceptives stopped:

__ __/__ __/__ __ __ __

99. unknown

11. Conception

1.  Spontaneous

2.  Assisted ___________

3.  Delayed

9.  Unknown

12. Menstrual History

Age of onset ____

99. unknown

13. Menstrual cycles

1.  Regular 2.  Irregular

9.  Unknown

14. Intercycle Interval

____days

99. unknown

15. Duration

____days

99. unknown

16. Infertility Diagnosis	Index Preg	Past History/Not including index pregnancy
Tubal Factor
Ovulatory Dysfunction
Diminished ovarian reserve
Endometriosis
Uterine factor
Male Factor
Unexplained cause
Other (Specify):
Unknown/No Info

17. Infertility Treatment (INDEX pregnancy) check all that apply:

 IUI (intrauterine insemination)

 CI or ICI (cervical insemination)

 IVF (in vitro fertilization)

 GIFT(gamete intrafallopian transfer)

 ZIFT (zygote intrafallopian transfer)

 TET (tubal embryo transfer)

 Egg Donor

 Egg Recipient

 Gestational surrogate

 Frozen embryo transfer (FET/CET)

 ICSI (intracytoplasmic sperm injection)

 Open fallopian tubes

 Rejoin fallopian tubes

 Treatment of uterine fibroids

 Removal of endometriosis

 Infertility treatment not specified/unknown

INFERTILITY (past or index pregnancy) NO INFO

18. Infertility

Medication	F	M	Medication	F	M	Medication	M	F
Baby aspirin			Fertinex			Pergonal
Bromocriptin			Follistim			Pregnyl
Clomid			Gonal-F			Profasi
Clomiphene citrate			Heparin			Prometrium
Crinone			Lupron			Provera
Danazol			Metrodin			Repronex
Danocrine			Lutrepulse			Serophene
Dostinex			Novarel			Steroid tx (Specify)
Factrel			Parlodel			Synarel

Medications

M=Mother

F=Father

Comments:

C. PREGNANCY HISTORY  No Info

1. Gravida

2. Para

3. Stillbirths/SAB

4. TAB

5. Preterm (<37 wks)

Term (>37 wks)

**Use the following codes to complete the table below**

Sex

Plurality

Zygosity

Outcome

1. Male 2. Female 3. Ambiguous 9. Unknown

11. Singleton 20. Twin NOS * 21. Twin A 22. Twin B *NOS = not otherwise stated

1. monozygotic (mz) 2. Dizygotic (dz) 9. Unknown Trimesters 1) weeks 1-12 2) weeks 13-26 3) weeks 27-40 +

1. SAB (<20 wks) 2. TAB 3. Live Birth 4. Stillbirth < 20 weeks 5. Neonatal death (0-28 days) 6. Postneonatal death (28 days -1 year) 7 Death (>1 year) 8 Death (NOS) * If death occurred code and write reason in outcome box 9. Ectopic pregnancy 10. Molar pregnancy 88 Other specify 99. Unknown

Prenatal & Delivery Problems /Complications

No complications noted Abruptio placentae Birth defect Cephalopelvic disproportion Cesarean section delivery Chorioamnionitis Deep vein thrombosis Eclampsia Fetal reduction Gestational Diabetes HELLP Hyperemesis Intrauterine growth restriction/retardation (IUGR)

Macrosomia Placenta previa Postpartum depression Postpartum hemmorhage Pregnancy induced hypertension/ preeclampsia/gestational hypertension Premature rupture of membranes (PROM) Preterm labor Pulmonary edema Pulmonary embolus (PE) Uterine rupture Vaginal bleeding 88. Other: specify 99. Unknown/Not Documented

PregNo.

Baby No.

Delivery Mo.

Delivery Yr.

Wt gm lb oz

GA (wks)

Sex

Plurality

Zygosity

Outcome

Prenatal & Delivery Problems / Complications

Comments:

D. MATERNAL BASELINE MEASUREMENTS (WEIGHT, HEIGHT, AND BLOOD PRESSURE)  No Info
	Date	GA	Measurement			Date	GA	Measurement
1. Pre-pregnancy weight	__ __/__ __/__ __ __ __ 99. unknown		lb __ __ __ . __ __	kg __ __ . __	5. Pre-pregnancy maternal height			ft		in	cms
			99. unknown					99. unknown
2. First PNV weight	__ __/__ __/__ __ __ __ 99. unknown	99.□ unk	lb __ __ __ . __ __	kg __ __ . __	6. First PNV BP	__ __/__ __/__ __ __ __ 99. unknown	99. □ unk	/ sys/dias 99. unknown
			99. unknown
3. Last PNV weight	__ __/__ __/__ __ __ __ 99. unknown	99.□ unk	lb __ __ __ . __ __	kg __ __ . __	7. Second PNV BP	__ __/__ __/__ __ __ __ 99. unknown	99. □ unk	/ sys/dias 99. unknown
			99. unknown
4.Admission weight	__ __/__ __/__ __ __ __ 99. unknown	99. □ unk	lb __ __ __ . __ __	kg __ __ . __	8. .  20 weeks PNV BP	__ __/__ __/__ __ __ __ 99. unknown	99. □ unk	/ sys/dias 99. unknown
			99. unknown
Comments:

E. BLOOD TYPE AND SCREENINGS  No Info
1. Blood type and Rh + / - 99. unknown	2. Antibody screen 1.  Neg 2.  Pos________ 99. unknown	3. RPR/VDRL 1.  NR 2.  React 99. unknown			4. HbsAG 1.  Neg 2.  Pos 99. unknown	5. Rubella Titer 1.  Im 2.  Non-im 99. unknown	6. HIV  Done 1.  Neg 2.  Pos 99. unknown
7. Hgb electrophoresis Date 1.  Neg  __ __/__ __/__ __ __ __ 2.  Pos ____________ 99. unknown				8. Triple Marker Date 1.  NL __ __/__ __/__ __ __ __ 2.  ABNL ____________ 99. unknown Numeric results: AFP: _______ Declined Unconjugated estriol:_______ Hcg: _______
9. MSAFP Date  NL __ __/__ __/__ __ __ __  ABNL ____________ 99. unknown MS-AFP Accession number:				10. Progesterone level Date  NL __ __/__ __/__ __ __ __  ABNL ____________ 99. unknown
11. Chorionic Villi Date Sampling 1.  NL  __ __/__ __/__ __ __ __ 2.  ABNL ____________ 99. unknown				12. Amniocentesis Date karyotype ____________  __ __/__ __/__ __ __ __ 99. unknown
13. Amnio gram stain Date 1.  Neg  __ __/__ __/__ __ __ __ 2.  Pos ____________ 99. unknown			14. Amnio lung maturity Date LS______ PG_______ FSI_______ __ __/__ __/__ __ __ __
15. C-reactive protein lab values First PNV value ______ unknown date __ __/__ __/__ __ __ __ unknown Delivery admission value ______ unknown date __ __/__ __/__ __ __ __ unknown Closest to delivery value ______ unknown date __ __/__ __/__ __ __ __ unknown __ First postpartum value ______ unknown date __ __/__ __/__ __ __ __ unknown
Comments:

F. ULTRASOUND REPORTS  No Info
Date of scan __ __/__ __/__ __ __ __ 99.  unknown	#fetuses	EGA-dates	EGA-US	Reason (check all that apply) 1.  Confirm dates 2.  Fetal growth 3.  Placenta 4.  BPP 5.  Decreased fetal movement 6.  Amniotic fluid volume 7.  Malformation 8.  Other: (Specify) _________________ 99.  unknown	Results: 1.  Normal 2.  Abnormal _________________ 99. unknown
Comments
Date of scan __ __/__ __/__ __ __ __ 99.  unknown	#fetuses	EGA-dates	EGA-US	Reason (check all that apply) 1.  Confirm dates 2.  Fetal growth 3.  Placenta 4.  BPP 5.  Decreased fetal movement 6.  Amniotic fluid volume 7.  Malformation 8.  Other: (Specify) _________________ 99.  unknown	Results: 1.  Normal 2.  Abnormal _________________ 99. unknown
Comments
3. Date of scan __ __/__ __/__ __ __ __ 99.  unknown	#fetuses	EGA-dates	EGA-US	Reason (check all that apply) 1.  Confirm dates 2.  Fetal growth 3.  Placenta 4.  BPP 5.  Decreased fetal movement 6.  Amniotic fluid volume 7.  Malformation 8.  Other: (Specify) _________________ 99.  unknown	Results: 1.  Normal 2.  Abnormal _________________ 99. unknown
Comments

F. ULTRASOUND REPORTS (cont’d)
4. Date of scan __ __/__ __/__ __ __ __ 99.  unknown	#fetuses	EGA-dates	EGA-US		Reason (check all that apply) 1.  Confirm dates 2.  Fetal growth 3.  Placenta 4.  BPP 5.  Decreased fetal movement 6.  Amniotic fluid volume 7.  Malformation 8.  Other: (Specify) _________________ 99.  unknown		Results: 1.  Normal 2.  Abnormal _________________ 99. unknown
Comments
5. Date of scan __ __/__ __/__ __ __ __ 99.  unknown	#fetuses	EGA-dates	EGA-US	Reason (check all that apply) 1.  Confirm dates 2.  Fetal growth 3.  Placenta 4.  BPP 5.  Decreased fetal movement 6.  Amniotic fluid volume 7.  Malformation 8.  Other: (Specify) _________________ 99.  unknown		Results: 1.  Normal 2.  Abnormal _________________ 99. unknown
Comments
6. Date of scan __ __/__ __/__ __ __ __ 99.  unknown	#fetuses	EGA-dates	EGA-US	Reason (check all that apply) 1.  Confirm dates 2.  Fetal growth 3.  Placenta 4.  BPP 5.  Decreased fetal movement 6.  Amniotic fluid volume 7.  Malformation 8.  Other: (Specify) _________________ 99.  unknown		Results: 1.  Normal 2.  Abnormal _________________ 99. unknown
Comments
Comments:

G. Substance Abuse  No Info
	3 mos prior to conception through conception	Trimester 1 Weeks 1-12	Trimester 2 13-26	Trimester 3 27-40 +	Date stopped
a. Drugs/Subs.
a1. Marijuana	Yes No Not Stated	Yes No Not Stated	Yes No Not Stated	Yes No Not Stated	­__ __/__ __/__ __ __ __ 99.  unknown
a2. Cocaine	Yes No Not Stated	Yes No Not Stated	Yes No Not Stated	Yes No Not Stated	­__ __/__ __/__ __ __ __ 99.  unknown
a3. Ecstasy, speed, methamphetamines	Yes No Not Stated	Yes No Not Stated	Yes No Not Stated	Yes No Not Stated	­__ __/__ __/__ __ __ __ 99.  unknown
a3. Other(specify): _______	Yes No Not Stated	Yes No Not Stated	Yes No Not Stated	Yes No Not Stated	­__ __/__ __/__ __ __ __ 99.  unknown
b. Tobacco	__ __ cigs/day __ __ packs/day __ __ packs/wk No Unknown	__ __ cigs/day __ __ packs/day __ __ packs/wk No Unknown	__ __ cigs/day __ __ packs/day __ __ packs/wk No Unknown	__ __ cigs/day __ __ packs/day __ __ packs/wk No Unknown	­__ __/__ __/__ __ __ __ 99.  unknown
c. Alcohol	__ __ drinks/day __ __ drinks/week or  heavy  moderate/ social  occasional  rarely/ minimal No Unknown	__ __ drinks/day __ __ drinks/week or  heavy  moderate/ social  occasional  rarely/ minimal No Unknown	__ __ drinks/day __ __ drinks/week or  heavy  moderate/ social  occasional  rarely/ minimal No Unknown	__ __ drinks/day __ __ drinks/week or  heavy  moderate/ social  occasional  rarely/ minimal No Unknown	­__ __/__ __/__ __ __ __ 99.  unknown
Comments:

H. MATERNAL INFECTIONS ANYTIME DURING CURRENT PREGNANCY  No Info Dx: Use codes from Infection List (Appendix ) If cultures were performed, note in Section I. If “yes” is indicated for medications, please fill out Section R.
a. Dx	Date diagnosed __ __/__ __/__ __ __ __ 9.  unknown		GA	Tri	Certainty of Dx 1.  Lab 2.  Clinical 3.  Suspect 9.  unknown	Duration __ __ __ days 9.  unk		Highest temp oC______ oF______ 1.  No temp 999.  unk	Cultures 1.  Yes 2.  No 9.  Unknown	Medication given 1.  Yes 2.  No 9.  Unknown
b. Dx	Date diagnosed __ __/__ __/__ __ __ __ 9.  unknown		GA	Tri	Certainty of Dx 1.  Lab 2.  Clinical 3.  Suspect 9.  unknown	Duration __ __ __ days 9.  unk		Highest temp oC______ oF______ 1.  No temp 999.  unk	Cultures 1.  Yes 2.  No 9.  Unknown	Medication given 1.  Yes 2.  No 9.  Unknown
c. Dx	Date diagnosed __ __/__ __/__ __ __ __ 9.  unknown		GA	Tri	Certainty of Dx 1.  Lab 2.  Clinical 3.  Suspect 9.  unknown	Duration __ __ __ days 9.  unk		Highest temp oC______ oF______ 1.  No temp 999.  unk	Cultures 1.  Yes 2.  No 9.  Unknown	Medication given 1.  Yes 2.  No 9.  Unknown
d. Dx	Date diagnosed __ __/__ __/__ __ __ __ 9.  unknown		GA	Tri	Certainty of Dx 1.  Lab 2.  Clinical 3.  Suspect 9.  unknown	Duration __ __ __ days 9.  unk		Highest temp oC______ oF______ 1.  No temp 999.  unk	Cultures 1.  Yes 2.  No 9.  Unknown	Medication given 1.  Yes 2.  No 9.  Unknown
e. Dx	Date diagnosed __ __/__ __/__ __ __ __ 9.  unknown		GA	Tri	Certainty of Dx 1.  Lab 2.  Clinical 3.  Suspect 9.  unknown	Duration __ __ __ days 9.  unk		Highest temp oC______ oF______ 1.  No temp 999.  unk	Cultures 1.  Yes 2.  No 9.  Unknown	Medication given 1.  Yes 2.  No 9.  Unknown
f. Dx	Date diagnosed __ __/__ __/__ __ __ __ 9.  unknown		GA	Tri	Certainty of Dx 1.  Lab 2.  Clinical 3.  Suspect 9.  unknown	Duration __ __ __ days 9.  unk		Highest temp oC______ oF______ 1.  No temp 999.  unk	Cultures 1.  Yes 2.  No 9.  Unknown	Medication given 1.  Yes 2.  No 9.  Unknown
	Fever >37.7C or 100F  No Info
	5 highest fevers	Date					Time
1.	oC______ oF______ 99.  unknown	__ __/__ __/__ __ __ __					99.  unknown
2.	oC______ oF______ 99.  unknown	__ __/__ __/__ __ __ __					99.  unknown
Fever >37.7C or 100F(cont’d)
3.	oC______ oF______ 99.  unknown	__ __/__ __/__ __ __ __					99.  unknown
4.	oC______ oF______ 99.  unknown	__ __/__ __/__ __ __ __					99.  unknown
5.	oC______ oF______ 99.  unknown	__ __/__ __/__ __ __ __					99.  unknown
Comments:

I. CULTURES ANYTIME DURING CURRENT PREGNANCY (RECORD ALL CULTURES OBTAINED)- Indicate the number of the event from section H. If the culture does not correspond to an event in section H, then enter ‘0’.  No Info
Source: 1= amniotic fluid, 2= placenta, 3= cervix, 4= vagina, 5=urine, 6=blood, 7= sputum, 8= stool, 88= other, (specify), 99= unknown
Refer	Date cultured	Source	Results	Description (organisms, etc)
	__ __/__ __/__ __ __ __ 99.  unknown		1.  No growth 3.  NL Flora 2.  Light growth 4. Positive 5.  Growth noted, not specified 99.  unknown
	__ __/__ __/__ __ __ __ 99.  unknown		1.  No growth 3.  NL Flora 2.  Light growth 4. Positive 5.  Growth noted, not specified 99.  unknown
	__ __/__ __/__ __ __ __ 99.  unknown		1.  No growth 3.  NL Flora 2.  Light growth 4. Positive 5.  Growth noted, not specified 99.  unknown
	__ __/__ __/__ __ __ __		1.  No growth 3.  NL Flora 2.  Light growth 4. Positive 5.  Growth noted, not specified 99.  unknown
	__ __/__ __/__ __ __ __ 99.  unknown		1.  No growth 3.  NL Flora 2.  Light growth 4. Positive 5.  Growth noted, not specified 99.  unknown
	__ __/__ __/__ __ __ __ 99.  unknown		1.  No growth 3.  NL Flora 2.  Light growth 4. Positive 5.  Growth noted, not specified 99.  unknown
	__ __/__ __/__ __ __ __ 99.  unknown		1.  No growth 3.  NL Flora 2.  Light growth 4. Positive 5.  Growth noted, not specified 99.  unknown
	__ __/__ __/__ __ __ __ 99.  unknown		1.  No growth 3.  NL Flora 2.  Light growth 4. Positive 5.  Growth noted, not specified 99.  unknown
	__ __/__ __/__ __ __ __ 99.  unknown		1.  No growth 3.  NL Flora 2.  Light growth 4. Positive 5.  Growth noted, not specified 99.  unknown
	__ __/__ __/__ __ __ __ 99.  unknown		1.  No growth 3.  NL Flora 2.  Light growth 4. Positive 5.  Growth noted, not specified 99.  unknown
Comments:

J. OTHER ABNORMAL REPORTS  No Info

Refer

Test Date

Test Name/Description

Results

Comments

__ __/__ __/__ __ __ __

1.  Normal 2.  Abnormal:______________ 9.  unknown

__ __/__ __/__ __ __ __

1.  Normal 2.  Abnormal:______________ 9.  unknown

__ __/__ __/__ __ __ __

1.  Normal 2.  Abnormal:______________ 9.  unknown

Comments

K. INJECTIONS/VACCINATIONS DURING CURRENT PREGNANCY  No Info

Injection/vaccination

Rhogam (or other RH(D)) immunoglobulin

Date First__ __/__ __/__ __ __ __ 99.  Unknown Second__ __/__ __/__ __ __ __ 99.  Unknown

Dose First________ 99.  No Info Second_____ 99.  Unknown

Manufacturer First________ 99.  No Info Second______ 99.  Unknown

Product Name First________ 99.  No Info Second_______ 99.  Unknown

Lot #

Influenza vaccine

Date __ __/__ __/__ __ __ __ 99.  Unknown

Manufacturer 99.  Unknown

Lot # 99.  Unknown

Other (specify)_________

Date __ __/__ __/__ __ __ __ 99.  Unknown

Manufacturer 99.  Unknown

Lot # 99.  Unknown

Comments:

L.VAGINAL BLEEDING ANYTIME DURING CURRENT PREGNANCY  No Info
Dx: 1=Placenta previa, 2= Placental abruption, 3= Trauma, 4= Effaced/dilated, 5= Uterine rupture, 6= Implantation bleeding, 7= Placenta accreta 8=Other, (specify), 9= Unknown If “yes” is indicated for medications, please fill out Section R.
Date occurred __ __/__ __/__ __ __ __ 99.  unknown	GA	Tri	Dx	Duration ___ ___ days 99.  Unk	Pain 1.  Yes 2.No (stated) 3. Suspect 9.  Unknown	Cramping 1.  Yes 2.No (stated) 3. Suspect 9.  Unknown	Medication given 1.  Yes 2.  No 9.  Unknown
Date occurred __ __/__ __/__ __ __ __ 99.  unknown	GA	Tri	Dx	Duration ___ ___ days 99.  Unk	Pain 1.  Yes 2.No (stated) 3. Suspect 9.  Unknown	Cramping 1.  Yes 2.No (stated) 3. Suspect 9.  Unknown	Medication given 1.  Yes 2.  No 9.  Unknown
Date occurred __ __/__ __/__ __ __ __ 99.  unknown	GA	Tri	Dx	Duration ___ ___ days 99.  Unk	Pain 1.  Yes 2.No (stated) 3. Suspect 9.  Unknown	Cramping 1.  Yes 2.No (stated) 3. Suspect 9.  Unknown	Medication given 1.  Yes 2.  No 9.  Unknown
Comments:

M. PRETERM LABOR If “yes” is indicated for medications, please fill out Section R.  No Info
a. Date reported __ __/__ __/__ __ __ __ 99.  unknown	GA	Onset of s/s per patient 1.  No s/s 2.  <12h 3.  12-24h 4.  >24h 99.  unknown	Signs/symptoms  Uterine contractions  Cramping (per pt)  Cervical change  PROM  Other, (specify) 99.  unknown	Treatments  Meds (fill out sect. Q)  Bed rest  IV Hydration  Other, (specify)______ 99.  unknown
b. Date reported __ __/__ __/__ __ __ __ 99.  unknown	GA	Onset of s/s per patient 1.  No s/s 2.  <12h 3.  12-24h 4.  >24h 99.  unknown	Signs/symptoms  Uterine contractions  Cramping (per pt)  Cervical change  PROM  Other, (specify) 99.  unknown	Treatments  Meds (fill out sect. Q)  Bed rest  IV Hydration  Other, (specify)______ 99.  unknown
c. Date reported __ __/__ __/__ __ __ __ 99.  unknown	GA	Onset of s/s per patient 1.  No s/s 2.  <12h 3.  12-24h 4.  >24h 99.  unknown	Signs/symptoms  Uterine contractions  Cramping (per pt)  Cervical change  PROM  Other, (specify) 99.  unknown	Treatments  Meds (fill out sect. Q)  Bed rest  IV Hydration  Other, (specify)______ 99.  unknown
d. Date reported __ __/__ __/__ __ __ __ 99.  unknown	GA	Onset of s/s per patient 1.  No s/s 2.  <12h 3.  12-24h 4.  >24h 99.  unknown	Signs/symptoms  Uterine contractions  Cramping (per pt)  Cervical change  PROM  Other, (specify) 99.  unknown	Treatments  Meds (fill out sect. Q)  Bed rest  IV Hydration  Other, (specify)______ 99.  unknown
e. Date reported __ __/__ __/__ __ __ __ 99.  unknown	GA	Onset of s/s per patient 1.  No s/s 2.  <12h 3.  12-24h 4.  >24h 99.  unknown	Signs/symptoms  Uterine contractions  Cramping (per pt)  Cervical change  PROM  Other, (specify) 99.  unknown	Treatments  Meds (fill out sect. Q)  Bed rest  IV Hydration  Other, (specify)______ 99.  unknown
Comments:

N. OTHER CONDITIONS OR TRAUMA ANYTIME DURING CURRENT PREGNANCY  No Info
Dx: 1= Decreased fetal movement 2= Trauma/injury 3= Oligohydramnios 4= Polyhydramnios 5= IUGR 6= Macrosomia 7= loss of conciousness 8= Spontaneous reduction 88= other, (specify) 99= unknown If “yes” is indicated for medications, please fill out Section R.
a. Date diagnosed __ __/__ __/__ __ __ __ 99.  unknown	GA	Tri	Dx	Description	Medication given  Yes  No 9.  Unknown
b. Date diagnosed __ __/__ __/__ __ __ __ 99.  unknown	GA	Tri	Dx	Description	Medication given Yes No 9.  Unknown
c. Date diagnosed __ __/__ __/__ __ __ __ 99.  unknown	GA	Tri	Dx	Description	Medication given 1.  Yes 2.  No 9.  Unknown
d. Date diagnosed __ __/__ __/__ __ __ __ 99.  unknown	GA	Tri	Dx	Description	Medication given 1.  Yes 2.  No 9.  Unknown
Comments:

O. HOSPITAL ADMISSIONS/VISITS THIS PREGNANCY (INPATIENT AND OUTPATIENT) For Medical History Code use Appendix If “yes” is indicated for medications, please fill out Section R.  No Info
Treated in/as 1.  ER 2.  Outpatient 3.  Inpatient 9.  Unknown	Hospital/facility				Admit date __ __/__ __/__ __ __ __			GA			Discharge date __ __/__ __/__ __ __ __
Procedures:  X-rays, including dental  Mammogram  CT/CAT scans  MRI/magnetic resonance  Radionuclide study or scan  Radiation treatments or scan  Surgery 88.  Other: (Specify) 99.  unknown	Dx1	ICD9	Dx2	ICD9		Dx3	ICD9		Treatment: 1.  Surgery 2.  Medications 8.  Other, (specify): ________________ 99.  unknown
		Problem		Problem			Problem
		Medical History Code		Medical History Code			Medical History Code
2. Treated in/as 1.  ER 2.  Outpatient 3.  Inpatient 9.  Unknown	Hospital/facility			Admit date __ __/__ __/__ __ __ __				GA		Discharge date __ __/__ __/__ __ __ __
Procedures:  X-rays, including dental  Mammogram  CT/CAT scans  MRI/magnetic resonance  Radionuclide study or scan  Radiation treatments or scan  Surgery 88.  Other: (Specify) 99.  unknown	Dx1	ICD9	Dx2	ICD9		Dx3	ICD9		Treatment: 1.  Surgery 2.  Medications 8.  Other, (specify): ________________ 99.  unknown
		Problem		Problem			Problem
		Medical History Code		Medical History Code			Medical History Code
3. Treated in/as 1.  ER 2.  Outpatient 3.  Inpatient 9.  Unknown	Hospital/facility			Admit date __ __/__ __/__ __ __ __				GA			Discharge date __ __/__ __/__ __ __ __
Procedures:  X-rays, including dental  Mammogram  CT/CAT scans  MRI/magnetic resonance  Radionuclide study or scan  Radiation treatments or scan  Surgery 88.  Other: (Specify) 99.  unknown	Dx1	ICD9	Dx2	ICD9		Dx3	ICD9		Treatment: 1.  Surgery 2.  Medications 8.  Other, (specify): ________________ 99.  unknown
		Problem		Problem			Problem
		Medical History Code		Medical History Code			Medical History Code
4. Treated in/as 1.  ER 2.  Outpatient 3.  Inpatient 9.  Unknown	Hospital/facility			Admit date __ __/__ __/__ __ __ __				GA			Discharge date __ __/__ __/__ __ __ __
Procedures:  X-rays, including dental  Mammogram  CT/CAT scans  MRI/magnetic resonance  Radionuclide study or scan  Radiation treatments or scan  Surgery 88.  Other: (Specify) 99.  unknown	Dx1	ICD9	Dx2	ICD9		Dx3	ICD9		Treatment: 1.  Surgery 2.  Medications 8.  Other, (specify): ________________ 99.  unknown
		Problem		Problem			Problem
		Medical History Code		Medical History Code			Medical History Code
Comments:

P. PRENATAL PROCEDURES  No Info
Procedure
Fetal echocardiogram	Date: __ __/__ __/__ __ __ __	1.  normal 2.  abnormal 99.  unknown
External version	# attempts:	1.  successful 2.  unsuccessful 99.  unknown
Fetal reduction	Date: __ __/__ __/__ __ __ __	 # fetuses originally ______  # fetuses remaining _______
Cerclage	Date placed : __ __/__ __/__ __ __ __ Date removed: __ __/__ __/__ __ __ __
Fetal Transfusion	Date: __ __/__ __/__ __ __ __	Reason:
Fetal Surgery	Date: __ __/__ __/__ __ __ __	Type/Description
Nonstress test (NST)	Date: __ __/__ __/__ __ __ __ Date: __ __/__ __/__ __ __ __	Findings: 1) 2)
Contraction stress test (CST)	Date: __ __/__ __/__ __ __ __	Findings:
Other (specify) ______________	Date: __ __/__ __/__ __ __ __
Comments:

Q. MEDICAL HISTORY  No Info Medical History: Use codes from Medical History List (Appendix ) If “yes” is indicated for medications, please fill out Section R.
No.	Medical Condition Code (and specify)	Precision Code	Time Period Condition Active (CHECK ALL THAT APPLY)	Date/Age at First Diagnosis	Medication Given
1		1. Suspected 2. Definite 9  Unknown	1  Active before index pregnancy 2  Active during 1st trimester (1-13 weeks GA) 3  Active during 2nd trimester (14- 26 weeks GA) 4  Active during 3rd trimester (27-40+ weeks GA) 5  Active during index pregnancy, trimester unknown 9 Not stated/unknown	Date: __ __/__ __/__ __ __ __ Age: __ __ 9. unknown	1.  Yes 2.  No 9.  Unk
2		1. Suspected 2. Definite 9  Unknown	1  Active before index pregnancy 2  Active during 1st trimester (1-13 weeks GA) 3  Active during 2nd trimester (14- 26 weeks GA) 4  Active during 3rd trimester (27-40+ weeks GA) 5  Active during index pregnancy, trimester unknown 9 Not stated/unknown	Date: __ __/__ __/__ __ __ __ Age: __ __ 9. unknown	1.  Yes 2.  No 9.  Unk
3		1. Suspected 2. Definite 9  Unknown	1  Active before index pregnancy 2  Active during 1st trimester (1-13 weeks GA) 3  Active during 2nd trimester (14- 26 weeks GA) 4  Active during 3rd trimester (27-40+ weeks GA) 5  Active during index pregnancy, trimester unknown 9 Not stated/unknown	Date: __ __/__ __/__ __ __ __ Age: __ __ 9. unknown	1.  Yes 2.  No 9.  Unk
4		1. Suspected 2. Definite 9  Unknown	1  Active before index pregnancy 2  Active during 1st trimester (1-13 weeks GA) 3  Active during 2nd trimester (14- 26 weeks GA) 4  Active during 3rd trimester (27-40+ weeks GA) 5  Active during index pregnancy, trimester unknown 9 Not stated/unknown	Date: __ __/__ __/__ __ __ __ Age: __ __ 9. unknown	1.  Yes 2.  No 9.  Unk
5		1. Suspected 2. Definite 9  Unknown	1  Active before index pregnancy 2  Active during 1st trimester (1-13 weeks GA) 3  Active during 2nd trimester (14- 26 weeks GA) 4  Active during 3rd trimester (27-40+ weeks GA) 5  Active during index pregnancy, trimester unknown 9 Not stated/unknown	Date: __ __/__ __/__ __ __ __ Age: __ __ 9. unknown	1.  Yes 2.  No 9.  Unk
6		1. Suspected 2. Definite 9  Unknown	1  Active before index pregnancy 2  Active during 1st trimester (1-13 weeks GA) 3  Active during 2nd trimester (14- 26 weeks GA) 4  Active during 3rd trimester (27-40+ weeks GA) 5  Active during index pregnancy, trimester unknown 9 Not stated/unknown	Date: __ __/__ __/__ __ __ __ Age: __ __ 9. unknown	1.  Yes 2.  No 9.  Unk
7.		1. Suspected 2. Definite 9  Unknown	1  Active before index pregnancy 2  Active during 1st trimester (1-13 weeks GA) 3  Active during 2nd trimester (14- 26 weeks GA) 4  Active during 3rd trimester (27-40+ weeks GA) 5  Active during index pregnancy, trimester unknown 9 Not stated/unknown	Date: __ __/__ __/__ __ __ __ Age: __ __ 9. unknown	1.  Yes 2.  No 9.  Unk
8.		1. Suspected 2. Definite 9  Unknown	1  Active before index pregnancy 2  Active during 1st trimester (1-13 weeks GA) 3  Active during 2nd trimester (14- 26 weeks GA) 4  Active during 3rd trimester (27-40+ weeks GA) 5  Active during index pregnancy, trimester unknown 9 Not stated/unknown	Date: __ __/__ __/__ __ __ __ Age: __ __ 9. unknown	1.  Yes 2.  No 9.  Unk
COMMENTS:

R. ALL MEDICATIONS (INCLUDING ALL ANTI-INFECTIVES ,STEROIDS, HORMONES, AND OTHER MEDICATIONS) GIVEN DURING PREGNANCY- Indicate the number of the event from the corresponding section. If the medication does not correspond to a section above, enter ‘0’  No Info different amts?
Drug codes: 9= steroids (lung maturity) 10= antidiabetics, 11= steroids (other), 12= hormones, 13= thyroid, 14= antibiotics, 15= antifungals, 16= antivirals, 17= anesthetics, 18= anticonvulsants, 19= analgesics/hypnotics/sedatives/antipsychotics, 20 = antihypertensives/diuretics, 21= cardiovascular, 22= narcotic antagonists, 23= ergotrate, 24=antidepressants, 25= prenatal vitamins, 26= asthma, 27= preterm labor prevention,88= other (specify), 99= unknown Exclusions: laxatives, enemas, disinfectants, topical agents, cough medicine, non-prenatal vitamins, antacids, stool softeners, benadryl, tylenol, methergine Reason: 3 = lung maturity, 4= cervical ripening, 5= maternal disease, 6= prophylaxis 7= maternal fever 8= positive culture, 9= pain relief, 10= hyperemesis, 11= PIH, 88= other (specify), 99= unknown
Refer	Code	Drug name	Reason	Start Date	Duration (in days)	Dose		Unit		Freq	Entire pregnancy
				__ __/__ __/ __ __ __ __ 99. Unknown		 variable		1.  gm 2.  mg 3.  mcg 4.  mU 5. . cc/ml 8. . other		1. QD 2. BID 3. TID 4. QID 5. PRN 6. Every ___ hrs 7. Per week 8. Total dose 9. No Info	
				__ __/__ __/ __ __ __ __ 99. Unknown		 variable		1.  gm 2.  mg 3.  mcg 4.  mU 5. . cc/ml 8. . other		1. QD 2. BID 3. TID 4. QID 5. PRN 6. Every ___ hrs 7. Per week 8. Total dose 9. No Info	
				__ __/__ __/ __ __ __ __ 99. Unknown		 variable		1.  gm 2.  mg 3.  mcg 4.  mU 5. . cc/ml 8. . other		1. QD 2. BID 3. TID 4. QID 5. PRN 6. Every ___ hrs 7. Per week 8. Total dose 9. No Info	
				__ __/__ __/ __ __ __ __ 99. Unknown		 variable		1.  gm 2.  mg 3.  mcg 4.  mU 5. . cc/ml 8. . other		1. QD 2. BID 3. TID 4. QID 5. PRN 6. Every ___ hrs 7. Per week 8. Total dose 9. No Info	
R. ALL MEDICATIONS (INCLUDING ALL ANTI-INFECTIVES ,STEROIDS, HORMONES, AND OTHER MEDICATIONS) GIVEN DURING PREGNANCY (cont’d) Indicate the number of the event from the corresponding section. If the medication does not correspond to a section above, enter ‘0’ Drug codes: 9= steroids (lung maturity) 10= antidiabetics, 11= steroids (other), 12= hormones, 13= thyroid, 14= antibiotics, 15= antifungals, 16= antivirals, 17= anesthetics, 18= anticonvulsants, 19= analgesics/hypnotics/sedatives/antipsychotics, 20 = antihypertensives/diuretics, 21= cardiovascular, 22= narcotic antagonists, 23= ergotrate, 24=antidepressants, 25= prenatal vitamins, 26= asthma, 27= preterm labor prevention,88= other (specify), 99= unknown Exclusions: laxatives, enemas, disinfectants, topical agents, cough medicine, non-prenatal vitamins, antacids, stool softeners, benadryl, tylenol, methergine Reason: 3 = lung maturity, 4= cervical ripening, 5= maternal disease, 6= prophylaxis 7= maternal fever 8= positive culture, 9= pain relief, 10= hyperemesis, 11= PIH, 88= other (specify), 99= unknown
Refer	Code	Drug name	Reason	Start Date	Duration (in days)		Dose		Unit	Freq	Entire preg.
				__ __/__ __/ __ __ __ __ 99. Unknown			 variable		1.  gm 2.  mg 3.  mcg 4.  mU 5. . cc/ml 8. . other	1. QD 2. BID 3. TID 4. QID 5. PRN 6. Every ___ hrs 7. Per week 8. Total dose 9. No Info	
				__ __/__ __/ __ __ __ __ 99. Unknown			 variable		1.  gm 2.  mg 3.  mcg 4.  mU 5. . cc/ml 8. . other	1. QD 2. BID 3. TID 4. QID 5. PRN 6. Every ___ hrs 7. Per week 8. Total dose 9. No Info	
				__ __/__ __/ __ __ __ __ 99. Unknown			 variable		1.  gm 2.  mg 3.  mcg 4.  mU 5. . cc/ml 8. . other	1. QD 2. BID 3. TID 4. QID 5. PRN 6. Every ___ hrs 7. Per week 8. Total dose 9. No Info	
				__ __/__ __/ __ __ __ __ 99. Unknown			 variable		1.  gm 2.  mg 3.  mcg 4.  mU 5. . cc/ml 8. . other	1. QD 2. BID 3. TID 4. QID 5. PRN 6. Every ___ hrs 7. Per week 8. Total dose 9. No Info	
R. ALL MEDICATIONS (INCLUDING ALL ANTI-INFECTIVES ,STEROIDS, HORMONES, AND OTHER MEDICATIONS) GIVEN DURING PREGNANCY (cont’d) Indicate the number of the event from the corresponding section. If the medication does not correspond to a section above, enter ‘0’ Drug codes: 9= steroids (lung maturity) 10= antidiabetics, 11= steroids (other), 12= hormones, 13= thyroid, 14= antibiotics, 15= antifungals, 16= antivirals, 17= anesthetics, 18= anticonvulsants, 19= analgesics/hypnotics/sedatives/antipsychotics, 20 = antihypertensives/diuretics, 21= cardiovascular, 22= narcotic antagonists, 23= ergotrate, 24=antidepressants, 25= prenatal vitamins, 26= asthma, 27= preterm labor prevention,88= other (specify), 99= unknown Exclusions: laxatives, enemas, disinfectants, topical agents, cough medicine, non-prenatal vitamins, antacids, stool softeners, benadryl, tylenol, methergine Reason: 3 = lung maturity, 4= cervical ripening, 5= maternal disease, 6= prophylaxis 7= maternal fever 8= positive culture, 9= pain relief, 10= hyperemesis, 11= PIH, 88= other (specify), 99= unknown
Refer	Code	Drug name	Reason	Start Date	Duration (in days)		Dose		Unit	Freq	Entire preg.
				__ __/__ __/ __ __ __ __ 99. Unknown			 variable		1.  gm 2.  mg 3.  mcg 4.  mU 5. . cc/ml 8. . other	1. QD 2. BID 3. TID 4. QID 5. PRN 6. Every ___ hrs 7. Per week 8. Total dose 9. No Info	
				__ __/__ __/ __ __ __ __ 99. Unknown			 variable		1.  gm 2.  mg 3.  mcg 4.  mU 5. . cc/ml 8. . other	1. QD 2. BID 3. TID 4. QID 5. PRN 6. Every ___ hrs 7. Per week 8. Total dose 9. No Info	
				__ __/__ __/ __ __ __ __ 99. Unknown			 variable		1.  gm 2.  mg 3.  mcg 4.  mU 5. . cc/ml 8. . other	1. QD 2. BID 3. TID 4. QID 5. PRN 6. Every ___ hrs 7. Per week 8. Total dose 9. No Info	
				__ __/__ __/ __ __ __ __ 99. Unknown			 variable		1.  gm 2.  mg 3.  mcg 4.  mU 5. . cc/ml 8. . other	1. QD 2. BID 3. TID 4. QID 5. PRN 6. Every ___ hrs 7. Per week 8. Total dose 9. No Info	
R. ALL MEDICATIONS (INCLUDING ALL ANTI-INFECTIVES ,STEROIDS, HORMONES, AND OTHER MEDICATIONS) GIVEN DURING PREGNANCY (cont’d) Indicate the number of the event from the corresponding section. If the medication does not correspond to a section above, enter ‘0’ Drug codes: 9= steroids (lung maturity) 10= antidiabetics, 11= steroids (other), 12= hormones, 13= thyroid, 14= antibiotics, 15= antifungals, 16= antivirals, 17= anesthetics, 18= anticonvulsants, 19= analgesics/hypnotics/sedatives/antipsychotics, 20 = antihypertensives/diuretics, 21= cardiovascular, 22= narcotic antagonists, 23= ergotrate, 24=antidepressants, 25= prenatal vitamins, 26= asthma, 27= preterm labor prevention,88= other (specify), 99= unknown Exclusions: laxatives, enemas, disinfectants, topical agents, cough medicine, non-prenatal vitamins, antacids, stool softeners, benadryl, tylenol, methergine Reason: 3 = lung maturity, 4= cervical ripening, 5= maternal disease, 6= prophylaxis 7= maternal fever 8= positive culture, 9= pain relief, 10= hyperemesis, 11= PIH, 88= other (specify), 99= unknown
Refer	Code	Drug name	Reason	Start Date	Duration (in days)		Dose		Unit	Freq	Entire preg.
				__ __/__ __/ __ __ __ __ 99. Unknown			 variable		1.  gm 2.  mg 3.  mcg 4.  mU 5. . cc/ml 8. . other	1. QD 2. BID 3. TID 4. QID 5. PRN 6. Every ___ hrs 7. Per week 8. Total dose 9. No Info	
				__ __/__ __/ __ __ __ __ 99. Unknown			 variable		1.  gm 2.  mg 3.  mcg 4.  mU 5. . cc/ml 8. . other	1. QD 2. BID 3. TID 4. QID 5. PRN 6. Every ___ hrs 7. Per week 8. Total dose 9. No Info	
				__ __/__ __/ __ __ __ __ 99. Unknown			 variable		1.  gm 2.  mg 3.  mcg 4.  mU 5. . cc/ml 8. . other	1. QD 2. BID 3. TID 4. QID 5. PRN 6. Every ___ hrs 7. Per week 8. Total dose 9. No Info	
Comments:

Appendix S2

Page 27 of 27