Appendix S.5 Pediatric MR Form

11

Study ID Number

caddre

pediatric Chart

Abstraction Form

A.

(11/16/2005)

A. identifying Information
1. Name (Last, First, Middle)				2. AKA
3. Date of Birth _ _ /_ _/_ _ _ _		Child’s SSN			5. Father’s Name (Last, First)
6. Mother’s Name (Last, First)		7. Maiden Name			8. Mother’s SSN
Child’s Address History
9. Date _ _ /_ _/_ _ _ _	10. Child’s Street Address
11. City			12. State			13. Zip Code
14. Date _ _ /_ _/_ _ _ _	15. Child’s Street Address
16. City			17. State			18. Zip Code
19. Date _ _ /_ _/_ _ _ _	20. Child’s Street Address
21. City			22. State			23. Zip Code
24. Date _ _ /_ _/_ _ _ _	25. Child’s Street Address
26. City			27. State			28. Zip Code
29. Date _ _ /_ _/_ _ _ _	30. Child’s Street Address
31. City			32. State			33. Zip Code
34. Date _ _ /_ _/_ _ _ _	35. Child’s Street Address
36. City			37. State			38. Zip Code
39. Date _ _ /_ _/_ _ _ _	40. Child’s Street Address
41. City			42. State			43. Zip Code

Clinic Information
44. Clinic Name	45. Child’s Medical Record #
46. Clinic Street Address	47. City	48. State	49. Zip Code
50. Provider’s Name (Last, First, Degree)	51. Comments

Date Abstracted __ __/__ __/__ __ __ __	53. Abstractor
54. Start Time __ __ : __ __	Stop Time __ __ : __ __

56. Clinic Name	57. Child’s Medical Record #
58. Clinic Street Address	59. City	60. State	61. Zip Code
62. Provider’s Name (Last, First, Degree)	63. Comments
Date Abstracted __ __/__ __/__ __ __ __	65. Abstractor
66. Start Time __ __ : __ __	Stop Time __ __ : __ __

68. Clinic Name	69. Child’s Medical Record #
70. Clinic Street Address	71. City	72. State	73. Zip Code
74. Provider’s Name (Last, First, Degree)	75. Comments
Date Abstracted __ __/__ __/__ __ __ __	77. Abstractor
78. Start Time __ __ : __ __	Stop Time __ __ : __ __

B.Growth and Anthropometric Measurements
1. Date of Exam _ _/_ _/_ _ _ _	Weight 1 Lbs ______________ 2  Kg ________ 3  %ile	Height/Length 1 in _______________ 2  cm _______________ 3  %ile	Head Circumference 1 in ___________________ 2 cm ____________________ 3  %ile	Birth Measurements
Comments/Referrals:
2. Date of Exam _ _/_ _/_ _ _ _	Weight 1 Lbs ______________ 2  Kg ________ 3  %ile	Height/Length 1 in _______________ 2  cm _______________ 3  %ile	Head Circumference 1 in ___________________ 2 cm ____________________ 3  %ile	Type of Exam 1  Well Care 2  Acute 3  Chronic 4  Dev/Psy 5  Other (specify) ________________________
Comments/Referrals:
3. Date of Exam _ _/_ _/_ _ _ _	Weight 1 Lbs ______________ 2  Kg ________ 3  %ile	Height/Length 1 in _______________ 2  cm _______________ 3  %ile	Head Circumference 1 in ___________________ 2 cm ____________________ 3  %ile	Type of Exam 1  Well Care 2  Acute 3  Chronic 4  Dev/Psy 5  Other (specify) ________________________
Comments/Referrals:
4. Date of Exam _ _/_ _/_ _ _ _	Weight 1 Lbs ______________ 2  Kg ________ 3  %ile	Height/Length 1 in _______________ 2  cm _______________ 3  %ile	Head Circumference 1 in ___________________ 2 cm ____________________ 3  %ile	Type of Exam 1  Well Care 2  Acute 3  Chronic 4  Dev/Psy 5  Other (specify) ________________________
Comments/Referrals:
5. Date of Exam _ _/_ _/_ _ _ _	Weight 1 Lbs ______________ 2  Kg ________ 3  %ile	Height/Length 1 in _______________ 2  cm _______________ 3  %ile	Head Circumference 1 in ___________________ 2 cm ____________________ 3  %ile	Type of Exam 1  Well Care 2  Acute 3  Chronic 4  Dev/Psy 5  Other (specify) ________________________
Comments/Referrals:
6. Date of Exam _ _/_ _/_ _ _ _	Weight 1 Lbs ______________ 2  Kg ________ 3  %ile	Height/Length 1 in _______________ 2  cm _______________ 3  %ile	Head Circumference 1 in ___________________ 2 cm ____________________ 3  %ile	Type of Exam 1  Well Care 2  Acute 3  Chronic 4  Dev/Psy 5  Other (specify) ________________________
Comments/Referrals:
7. Date of Exam _ _/_ _/_ _ _ _	Weight 1 Lbs ______________ 2  Kg ________ 3  %ile	Height/Length 1 in _______________ 2  cm _______________ 3  %ile	Head Circumference 1 in ___________________ 2 cm ____________________ 3  %ile	Type of Exam 1  Well Care 2  Acute 3  Chronic 4  Dev/Psy 5  Other (specify) ________________________
Comments/Referrals:
B. Growth and Anthropometric Measurements (cont’d)
8. Date of Exam _ _/_ _/_ _ _ _	Weight 1 Lbs ______________ 2  Kg ________ 3  %ile	Height/Length 1 in _______________ 2  cm _______________ 3  %ile	Head Circumference 1 in ___________________ 2 cm ____________________ 3  %ile	Type of Exam 1  Well Care 2  Acute 3  Chronic 4  Dev/Psy 5  Other (specify) ________________________
Comments/Referrals:
9. Date of Exam _ _/_ _/_ _ _ _	Weight 1 Lbs ______________ 2  Kg ________ 3  %ile	Height/Length 1 in _______________ 2  cm _______________ 3  %ile	Head Circumference 1 in ___________________ 2 cm ____________________ 3  %ile	Type of Exam 1  Well Care 2  Acute 3  Chronic 4  Dev/Psy 5  Other (specify) ________________________
Comments/Referrals:
10. Date of Exam _ _/_ _/_ _ _ _	Weight 1 Lbs ______________ 2  Kg ________ 3  %ile	Height/Length 1 in _______________ 2  cm _______________ 3  %ile	Head Circumference 1 in ___________________ 2 cm ____________________ 3  %ile	Type of Exam 1  Well Care 2  Acute 3  Chronic 4  Dev/Psy 5  Other (specify) ________________________
Comments/Referrals:
11. Date of Exam _ _/_ _/_ _ _ _	Weight 1 Lbs ______________ 2  Kg ________ 3  %ile	Height/Length 1 in _______________ 2  cm _______________ 3  %ile	Head Circumference 1 in ___________________ 2 cm ____________________ 3  %ile	Type of Exam 1  Well Care 2  Acute 3  Chronic 4  Dev/Psy 5  Other (specify) ________________________
Comments/Referrals:
12. Date of Exam _ _/_ _/_ _ _ _	Weight 1 Lbs ______________ 2  Kg ________ 3  %ile	Height/Length 1 in _______________ 2  cm _______________ 3  %ile	Head Circumference 1 in ___________________ 2 cm ____________________ 3  %ile	Type of Exam 1  Well Care 2  Acute 3  Chronic 4  Dev/Psy 5  Other (specify) ________________________
Comments/Referrals:
13. Date of Exam _ _/_ _/_ _ _ _	Weight 1 Lbs ______________ 2  Kg ________ 3  %ile	Height/Length 1 in _______________ 2  cm _______________ 3  %ile	Head Circumference 1 in ___________________ 2 cm ____________________ 3  %ile	Type of Exam 1  Well Care 2  Acute 3  Chronic 4  Dev/Psy 5  Other (specify) ________________________
Comments/Referrals:
14. Date of Exam _ _/_ _/_ _ _ _	Weight 1 Lbs ______________ 2  Kg ________ 3  %ile	Height/Length 1 in _______________ 2  cm _______________ 3  %ile	Head Circumference 1 in ___________________ 2 cm ____________________ 3  %ile	Type of Exam 1  Well Care 2  Acute 3  Chronic 4  Dev/Psy 5  Other (specify) ________________________
Comments/Referrals:
B. Growth and Anthropometric Measurements (cont’d)
15. Date of Exam _ _/_ _/_ _ _ _	Weight 1 Lbs ______________ 2  Kg ________ 3  %ile	Height/Length 1 in _______________ 2  cm _______________ 3  %ile	Head Circumference 1 in ___________________ 2 cm ____________________ 3  %ile	Type of Exam 1  Well Care 2  Acute 3  Chronic 4  Dev/Psy 5  Other (specify) ________________________
Comments/Referrals:
16. Date of Exam _ _/_ _/_ _ _ _	Weight 1 Lbs ______________ 2  Kg ________ 3  %ile	Height/Length 1 in _______________ 2  cm _______________ 3  %ile	Head Circumference 1 in ___________________ 2 cm ____________________ 3  %ile	Type of Exam 1  Well Care 2  Acute 3  Chronic 4  Dev/Psy 5  Other (specify) ________________________
Comments/Referrals:
17. Date of Exam _ _/_ _/_ _ _ _	Weight 1 Lbs ______________ 2  Kg ________ 3  %ile	Height/Length 1 in _______________ 2  cm _______________ 3  %ile	Head Circumference 1 in ___________________ 2 cm ____________________ 3  %ile	Type of Exam 1  Well Care 2  Acute 3  Chronic 4  Dev/Psy 5  Other (specify) ________________________
Comments/Referrals:
18. Date of Exam _ _/_ _/_ _ _ _	Weight 1 Lbs ______________ 2  Kg ________ 3  %ile	Height/Length 1 in _______________ 2  cm _______________ 3  %ile	Head Circumference 1 in ___________________ 2 cm ____________________ 3  %ile	Type of Exam 1  Well Care 2  Acute 3  Chronic 4  Dev/Psy 5  Other (specify) ________________________
Comments/Referrals:
19. Date of Exam _ _/_ _/_ _ _ _	Weight 1 Lbs ______________ 2  Kg ________ 3  %ile	Height/Length 1 in _______________ 2  cm _______________ 3  %ile	Head Circumference 1 in ___________________ 2 cm ____________________ 3  %ile	Type of Exam 1  Well Care 2  Acute 3  Chronic 4  Dev/Psy 5  Other (specify) ________________________
Comments/Referrals:
20. Date of Exam _ _/_ _/_ _ _ _	Weight 1 Lbs ______________ 2  Kg ________ 3  %ile	Height/Length 1 in _______________ 2  cm _______________ 3  %ile	Head Circumference 1 in ___________________ 2 cm ____________________ 3  %ile	Type of Exam 1  Well Care 2  Acute 3  Chronic 4  Dev/Psy 5  Other (specify) ________________________
Comments/Referrals:
21. Date of Exam _ _/_ _/_ _ _ _	Weight 1 Lbs ______________ 2  Kg ________ 3  %ile	Height/Length 1 in _______________ 2  cm _______________ 3  %ile	Head Circumference 1 in ___________________ 2 cm ____________________ 3  %ile	Type of Exam 1  Well Care 2  Acute 3  Chronic 4  Dev/Psy 5  Other (specify) ________________________
Comments/Referrals:

B. Growth and Anthropometric Measurements (cont’d)
22. Date of Exam _ _/_ _/_ _ _ _	Weight 1 Lbs ______________ 2  Kg ________ 3  %ile	Height/Length 1 in _______________ 2  cm _______________ 3  %ile	Head Circumference 1 in ___________________ 2 cm ____________________ 3  %ile	Type of Exam 1  Well Care 2  Acute 3  Chronic 4  Dev/Psy 5  Other (specify) ________________________
Comments/Referrals:
23. Date of Exam _ _/_ _/_ _ _ _	Weight 1 Lbs ______________ 2  Kg ________ 3  %ile	Height/Length 1 in _______________ 2  cm _______________ 3  %ile	Head Circumference 1 in ___________________ 2 cm ____________________ 3  %ile	Type of Exam 1  Well Care 2  Acute 3  Chronic 4  Dev/Psy 5  Other (specify) ________________________
Comments/Referrals:
24. Date of Exam _ _/_ _/_ _ _ _	Weight 1 Lbs ______________ 2  Kg ________ 3  %ile	Height/Length 1 in _______________ 2  cm _______________ 3  %ile	Head Circumference 1 in ___________________ 2 cm ____________________ 3  %ile	Type of Exam 1  Well Care 2  Acute 3  Chronic 4  Dev/Psy 5  Other (specify) ________________________
Comments/Referrals:
25. Date of Exam _ _/_ _/_ _ _ _	Weight 1 Lbs ______________ 2  Kg ________ 3  %ile	Height/Length 1 in _______________ 2  cm _______________ 3  %ile	Head Circumference 1 in ___________________ 2 cm ____________________ 3  %ile	Type of Exam 1  Well Care 2  Acute 3  Chronic 4  Dev/Psy 5  Other (specify) ________________________
Comments/Referrals:
26. Date of Exam _ _/_ _/_ _ _ _	Weight 1 Lbs ______________ 2  Kg ________ 3  %ile	Height/Length 1 in _______________ 2  cm _______________ 3  %ile	Head Circumference 1 in ___________________ 2 cm ____________________ 3  %ile	Type of Exam 1  Well Care 2  Acute 3  Chronic 4  Dev/Psy 5  Other (specify) ________________________
Comments/Referrals:
27. Date of Exam _ _/_ _/_ _ _ _	Weight 1 Lbs ______________ 2  Kg ________ 3  %ile	Height/Length 1 in _______________ 2  cm _______________ 3  %ile	Head Circumference 1 in ___________________ 2 cm ____________________ 3  %ile	Type of Exam 1  Well Care 2  Acute 3  Chronic 4  Dev/Psy 5  Other (specify) ________________________
Comments/Referrals:
28. Date of Exam _ _/_ _/_ _ _ _	Weight 1 Lbs ______________ 2  Kg ________ 3  %ile	Height/Length 1 in _______________ 2  cm _______________ 3  %ile	Head Circumference 1 in ___________________ 2 cm ____________________ 3  %ile	Type of Exam 1  Well Care 2  Acute 3  Chronic 4  Dev/Psy 5  Other (specify) ________________________
Comments/Referrals:

C. Medical History  NO INFO

Medical Problem Codes: See Medical Problem List

Precision Codes: 1= Possible, 2= Probable, 3= R/O, 4= Definite, 9= Unknown Specialty Codes: 1=Pediatrician, 2=Physician Asst., 3=Nurse, 4=Family Physician, 5=Developmental Pediatrician, 6=Geneticist, 7= Neurologist, 8=Immunologist, 9=Gastroenterologist, 10=MD, Not specified, 88=Other (specify), 99=Unknown If ‘yes’ is indicated for Medications Given then fill out Section I.

No.

Problem Code

Precision Code

Specialty Code

Date Diagnosed

Meds Given

Referral Given

1.

_ _/_ _/_ _ _ _ 9  Unknown

1  Yes 2  No 9  Unknown

1  Yes 2  No 9  Unknown

2.

_ _/_ _/_ _ _ _ 9  Unknown

1  Yes 2  No 9  Unknown

1  Yes 2  No 9  Unknown

3.

_ _/_ _/_ _ _ _ 9  Unknown

1  Yes 2  No 9  Unknown

1  Yes 2  No 9  Unknown

4.

_ _/_ _/_ _ _ _ 9  Unknown

1  Yes 2  No 9  Unknown

1  Yes 2  No 9  Unknown

5.

_ _/_ _/_ _ _ _ 9  Unknown

1  Yes 2  No 9  Unknown

1  Yes 2  No 9  Unknown

6.

_ _/_ _/_ _ _ _ 9  Unknown

1  Yes 2  No 9  Unknown

1  Yes 2  No 9  Unknown

7.

_ _/_ _/_ _ _ _ 9  Unknown

1  Yes 2  No 9  Unknown

1  Yes 2  No 9  Unknown

8.

_ _/_ _/_ _ _ _ 9  Unknown

1  Yes 2  No 9  Unknown

1  Yes 2  No 9  Unknown

9.

_ _/_ _/_ _ _ _ 9  Unknown

1  Yes 2  No 9  Unknown

1  Yes 2  No 9  Unknown

10.

_ _/_ _/_ _ _ _ 9  Unknown

1  Yes 2  No 9  Unknown

1  Yes 2  No 9  Unknown

Comments

D. INFECTION HISTORY  NO INFO

Infection Codes: see infection code sheet If ‘yes’ is indicated for Medications then fill out Section I. If ‘yes’ is indicated for Fever then fill out Section H. If a culture was performed then fill out Section E. If child was hospitalized then fill out Section F.

No.

Infection Code

Date Diagnosed

Certainty of Dx

Duration

Highest Temp

Cultures

Medication

1.

_ _/_ _/_ _ _ _ 9  Unknown

1.  Lab 2.  Clinical 3.  Suspect 9.  Unknown

__ __ __ days 9  Unknown

oC______ oF______ 1.  No temp 999.  Unknown

1  Yes 2  No 9  Unk

1  Yes 2  No 9  Unk

2.

_ _/_ _/_ _ _ _ 9  Unknown

1.  Lab 2.  Clinical 3.  Suspect 9.  Unknown

__ __ __ days 9  Unknown

oC______ oF______ 1.  No temp 999.  Unknown

1  Yes 2  No 9  Unk

1  Yes 2  No 9  Unk

3.

_ _/_ _/_ _ _ _ 9  Unknown

1.  Lab 2.  Clinical 3.  Suspect 9.  Unknown

__ __ __ days 9  Unknown

oC______ oF______ 1.  No temp 999.  Unknown

1  Yes 2  No 9  Unk

1  Yes 2  No 9  Unk

4.

_ _/_ _/_ _ _ _ 9  Unknown

1.  Lab 2.  Clinical 3.  Suspect 9.  Unknown

__ __ __ days 9  Unknown

oC______ oF______ 1.  No temp 999.  Unknown

1  Yes 2  No 9  Unk

1  Yes 2  No 9  Unk

5.

_ _/_ _/_ _ _ _ 9  Unknown

1.  Lab 2.  Clinical 3.  Suspect 9.  Unknown

__ __ __ days 9  Unknown

oC______ oF______ 1.  No temp 999.  Unknown

1  Yes 2  No 9  Unk

1  Yes 2  No 9  Unk

6.

_ _/_ _/_ _ _ _ 9  Unknown

1.  Lab 2.  Clinical 3.  Suspect 9.  Unknown

__ __ __ days 9  Unknown

oC______ oF______ 1.  No temp 999.  Unknown

1  Yes 2  No 9  Unk

1  Yes 2  No 9  Unk

7.

_ _/_ _/_ _ _ _ 9  Unknown

1.  Lab 2.  Clinical 3.  Suspect 9.  Unknown

__ __ __ days 9  Unknown

oC______ oF______ 1.  No temp 999.  Unknown

1  Yes 2  No 9  Unk

1  Yes 2  No 9  Unk

Comments

E. CULTURES  NO INFO
Source: 1 = urine, 2 = blood, 3 = sputum, 4 = stool, 5 = cerebral spinal fluid, 8= other, 9= unknown Refer: Use event number from Section E for Refer number (i.e. E1).
No.	Refer	Date Cultured	Source	Results	Description (organisms, etc.)
1.		__ __/__ __/__ __ __ __ 9  Unknown		1.  No growth 3.  NL Flora 2.  Light growth 4. Positive 5.  Growth noted, not specified 99.  Unknown
2.		__ __/__ __/__ __ __ __ 9  Unknown		1.  No growth 3.  NL Flora 2.  Light growth 4. Positive 5.  Growth noted, not specified 99.  Unknown
3.		__ __/__ __/__ __ __ __ 9  Unknown		1.  No growth 3.  NL Flora 2.  Light growth 4. Positive 5.  Growth noted, not specified 99.  Unknown
4.		__ __/__ __/__ __ __ __ 9  Unknown		1.  No growth 3.  NL Flora 2.  Light growth 4. Positive 5.  Growth noted, not specified 99.  Unknown
5.		__ __/__ __/__ __ __ __ 9  Unknown		1.  No growth 3.  NL Flora 2.  Light growth 4. Positive 5.  Growth noted, not specified 99.  Unknown
6.		__ __/__ __/__ __ __ __ 9  Unknown		1.  No growth 3.  NL Flora 2.  Light growth 4. Positive 5.  Growth noted, not specified 99.  Unknown
7.		__ __/__ __/__ __ __ __ 9  Unknown		1.  No growth 3.  NL Flora 2.  Light growth 4. Positive 5.  Growth noted, not specified 99.  Unknown
8.		__ __/__ __/__ __ __ __ 9  Unknown		1.  No growth 3.  NL Flora 2.  Light growth 4. Positive 5.  Growth noted, not specified 99.  Unknown
9.		__ __/__ __/__ __ __ __ 9  Unknown		1.  No growth 3.  NL Flora 2.  Light growth 4. Positive 5.  Growth noted, not specified 99.  Unknown
10.		__ __/__ __/__ __ __ __ 9  Unknown		1.  No growth 3.  NL Flora 2.  Light growth 4. Positive 5.  Growth noted, not specified 99.  Unknown
11.		__ __/__ __/__ __ __ __ 9  Unknown		1.  No growth 3.  NL Flora 2.  Light growth 4. Positive 5.  Growth noted, not specified 99.  Unknown
12.		__ __/__ __/__ __ __ __ 9  Unknown		1.  No growth 3.  NL Flora 2.  Light growth 4. Positive 5.  Growth noted, not specified 99.  Unknown
13.		__ __/__ __/__ __ __ __ 9  Unknown		1.  No growth 3.  NL Flora 2.  Light growth 4. Positive 5.  Growth noted, not specified 99.  Unknown
14.		__ __/__ __/__ __ __ __ 9  Unknown		1.  No growth 3.  NL Flora 2.  Light growth 4. Positive 5.  Growth noted, not specified 99.  Unknown
Comments

F. Hospitalizations  NO INFO

Problem/Infection Code: See Appendix A for list of codes. * If ‘yes’ is checked for Culture, Fever, or Medications, then complete the respective sections (E, H, I).

Hospital/Facility Name

Type of Visit 1  ER Observe 3  ER Admit 2  ER Only 4  Elective 8  Other (specify) ________________________________

Admit Date _ _/_ _/_ _ _ _

Discharge Date _ _/_ _/_ _ _ _

Dx1

ICD9 or CPT Code

Dx2

ICD9 or CPT Code

Dx3

ICD9 or CPT Code

Dx4

ICD9 or CPT Code

Dx5

ICD9 or CPT Code

Dx6

ICD9 or CPT Code

Name

Name

Name

Name

Name

Name

Problem/Infxn Code

Problem/Infxn Code

Problem/Infxn Code

Problem/Infxn Code

Problem/Infxn Code

Problem/Infxn Code

Cultures 1  Yes 2  No 9  Unknown

Fever 1  Yes 2  No 9  Unknown

Medications Given 1  Yes 2  No 9  Unknown

Injury 1  Yes (specify below) 2  No 9  Unknown

Surgery 1  Yes (specify below) 2  No 9  Unknown

Injury Comments:

Surgery Details 1  Radiology 2  Other Procedure(s) (specify below) Comments:

Hospital/Facility Name

Type of Visit 1  ER Observe 3  ER Admit 2  ER Only 4  Elective 8  Other (specify) ________________________________

Admit Date _ _/_ _/_ _ _ _

Discharge Date _ _/_ _/_ _ _ _

Dx1

ICD9 or CPT Code

Dx2

ICD9 or CPT Code

Dx3

ICD9 or CPT Code

Dx4

ICD9 or CPT Code

Dx5

ICD9 or CPT Code

Dx6

ICD9 or CPT Code

Name

Name

Name

Name

Name

Name

Problem/Infxn Code

Problem/Infxn Code

Problem/Infxn Code

Problem/Infxn Code

Problem/Infxn Code

Problem/Infxn Code

Cultures 1  Yes 2  No 9  Unknown

Fever 1  Yes 2  No 9  Unknown

Medications Given 1  Yes 2  No 9  Unknown

Injury 1  Yes (specify below) 2  No 9  Unknown

Surgery 1  Yes (specify below) 2  No 9  Unknown

Injury Comments:

Surgery Details 1  Radiology 2  Other Procedure(s) (specify below) Comments:

G. Immunizations
Vaccine codes								Manufacturer codes
1. DtaP 2. Hib 3. HepA 4. HepB 5. MMR 6. Polio IPV				7. Varicella Zoster 8. PCV 9. PPV 88. Other (specify) 99. Unknown				1. AVP (Aventis Pasteur) 2. CHI (Chiron) 3. CONN (Connetics) 4. GSK (GlaxoSmithKline) 5. LED (Lederle)		6. MER (Merck) 7. SKB (SmithKlineBeecham) 8. WYE (Wyeth Ayerst) 88. Other (specify) 99. Unknown
Vaccine Information								Adverse Reaction Information
No.	Date	Vaccine Code	Manufacturer Code		Lot Number	Dose	Adverse Reaction	Date & Type of Contact	Describe Reaction (check all that apply)		Medications Given For Reaction*
1.	_ _/_ _/_ _ _ _						1 Yes 2  No 9  Unknown	_ _/_ _/_ _ _ _ 1 Phone/E-mail 2 Visit	1 Rash 3 Seizures 2 Fever 8 Other (specify) ___________________________		1  Yes 2  No 9  Unknown
2.	_ _/_ _/_ _ _ _						1 Yes 2  No 9  Unknown	_ _/_ _/_ _ _ _ 1 Phone/E-mail 2 Visit	1 Rash 3 Seizures 2 Fever 8 Other (specify) ___________________________		1  Yes 2  No 9  Unknown
3.	_ _/_ _/_ _ _ _						1 Yes 2  No 9  Unknown	_ _/_ _/_ _ _ _ 1 Phone/E-mail 2 Visit	1 Rash 3 Seizures 2 Fever 8 Other (specify) ___________________________		1  Yes 2  No 9  Unknown
4.	_ _/_ _/_ _ _ _						1 Yes 2  No 9  Unknown	_ _/_ _/_ _ _ _ 1 Phone/E-mail 2 Visit	1 Rash 3 Seizures 2 Fever 8 Other (specify) ___________________________		1  Yes 2  No 9  Unknown
5.	_ _/_ _/_ _ _ _						1 Yes 2  No 9  Unknown	_ _/_ _/_ _ _ _ 1 Phone/E-mail 2 Visit	1 Rash 3 Seizures 2 Fever 8 Other (specify) ___________________________		1  Yes 2  No 9  Unknown
6.	_ _/_ _/_ _ _ _						1 Yes 2  No 9  Unknown	_ _/_ _/_ _ _ _ 1 Phone/E-mail 2 Visit	1 Rash 3 Seizures 2 Fever 8 Other (specify) ___________________________		1  Yes 2  No 9  Unknown
7.	_ _/_ _/_ _ _ _						1 Yes 2  No 9  Unknown	_ _/_ _/_ _ _ _ 1 Phone/E-mail 2 Visit	1 Rash 3 Seizures 2 Fever 8 Other (specify) ___________________________		1  Yes 2  No 9  Unknown

H. Fever  NO INFO
Children < 8 weeks of age: Axillary Temps: Record temperatures > 36.9oC (98.4oF) Rectal Temps: Record temperatures > 38.0oC (100.4oF) Children > 8 weeks of age: Oral Temps: Record temperatures > 38.6oC (101.5oF) Axillary Temps: Record temperatures > 38.1oC (100.5oF) Rectal Temps: Record temperatures > 39.2oC (102.5oF) Indicate the event number from the appropriate Section for Refer No. (i.e. I3). If ‘yes’ is indicated for Medications Given, please fill out Section I.
1	Refer No. ___________ 9  NA	Date _ _/_ _/_ _ _ _	Duration ______ hours ______ days 9  Unk	Highest temp _________ 1  oC 2  oF	Mode 1  Oral 2  Axillary 3  Rectal 9  Unknown	Medication Given 1  Yes 2  No 9  Unknown	Comments
2	Refer No. ___________ 9  NA	Date _ _/_ _/_ _ _ _	Duration ______ hours ______ days 9  Unk	Highest temp _________ 1  oC 2  oF	Mode 1  Oral 2  Axillary 3  Rectal 9  Unknown	Medication Given 1  Yes 2  No 9  Unknown	Comments
3	Refer No. ___________ 9  NA	Date _ _/_ _/_ _ _ _	Duration ______ hours ______ days 9  Unk	Highest temp _________ 1  oC 2  oF	Mode 1  Oral 2  Axillary 3  Rectal 9  Unknown	Medication Given 1  Yes 2  No 9  Unknown	Comments
4	Refer No. ___________ 9  NA	Date _ _/_ _/_ _ _ _	Duration ______ hours ______ days 9  Unk	Highest temp _________ 1  oC 2  oF	Mode 1  Oral 2  Axillary 3  Rectal 9  Unknown	Medication Given 1  Yes 2  No 9  Unknown	Comments
5	Refer No. ___________ 9  NA	Date _ _/_ _/_ _ _ _	Duration ______ hours ______ days 9  Unk	Highest temp _________ 1  oC 2  oF	Mode 1  Oral 2  Axillary 3  Rectal 9  Unknown	Medication Given 1  Yes 2  No 9  Unknown	Comments
6	Refer No. ___________ 9  NA	Date _ _/_ _/_ _ _ _	Duration ______ hours ______ days 9  Unk	Highest temp _________ 1  oC 2  oF	Mode 1  Oral 2  Axillary 3  Rectal 9  Unknown	Medication Given 1  Yes 2  No 9  Unknown	Comments
7	Refer No. ___________ 9  NA	Date _ _/_ _/_ _ _ _	Duration ______ hours ______ days 9  Unk	Highest temp _________ 1  oC 2  oF	Mode 1  Oral 2  Axillary 3  Rectal 9  Unknown	Medication Given 1  Yes 2  No 9  Unknown	Comments
Comments

I. MEDICATIONS  NO INFO
Refer No.: Please indicate the event number from the appropriate section for Refer No., otherwise enter the reason from medical chart. 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 Reason: Specify
	Refer No.	Code	Drug Name	Reason	Start Date/Time	Duration (in days)	Dose	Unit	Frequency
1					_ _ /_ _ /_ _ _ _ 9  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
2					_ _ /_ _ /_ _ _ _ 9  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
3					_ _ /_ _ /_ _ _ _ 9  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
4					_ _ /_ _ /_ _ _ _ 9  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
5					_ _ /_ _ /_ _ _ _ 9  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
6					_ _ /_ _ /_ _ _ _ 9  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
7					_ _ /_ _ /_ _ _ _ 9  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
8					_ _ /_ _ /_ _ _ _ 9  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

J. cranial studies (EEG, MRI and CT Scan)  NO INFO
Please abstract all ultrasounds, unless the findings are clearly the same. Code: 1 = EEG, 2 = Cranial MRI, 3 = CT scan, 8 = Other (specify in comments)
1. Date __ __/__ __/__ __ __ ___			Code	Results 1 Normal 3 Equivocal 2 Abnormal 9 Unknown				Final Impression	Comments
2. Date __ __/__ __/__ __ __ ___			Code	Results 1 Normal 3 Equivocal 2 Abnormal 9 Unknown				Final Impression	Comments
3. Date __ __/__ __/__ __ __ ___			Code	Results 1 Normal 3 Equivocal 2 Abnormal 9 Unknown				Final Impression	Comments
Cranial Ultrasounds
Please abstract all ultrasounds, unless the findings are clearly the same.
1. Date _ _/_ _/_ _ _ _		Results 1 Normal 2 Abnormal		Hemisphere: 1 = Right, 2 = Left, 3 = Bilateral, 9 = NK Location: 1 = Anterior/Frontal, 2 = Posterior/Occipital, 3 = Parietal, 4 = Temporal, 9 = NK Size: 1 = Small/Mild, 2 = Medium/Moderate, 3 = Large/Severe, 9 = NK
	Findings (1= No, 2= Definite, 3=Suspect)			H	L	S	Description/Comments
	Ventriculomegaly
	Echodensity/echogenicity
	Echolucency
	IVH grade _____
	Germinal matrix bleed (Grade I IVH)
	Other bleed
	PVL/cavitation/white matter necrosis
	Malformation
	Subarachnoid hemorrhage/blood
	Other findings, specify.
2. Date _ _/_ _/_ _ _ _		Results 1 Normal 2 Abnormal		Hemisphere: 1 = Right, 2 = Left, 3 = Bilateral, 9 = NK Location: 1 = Anterior/Frontal, 2 = Posterior/Occipital, 3 = Parietal, 4 = Temporal, 9 = NK Size: 1 = Small/Mild, 2 = Medium/Moderate, 3 = Large/Severe, 9 = NK
	Findings (1= No, 2= Definite, 3=Suspect)			H	L	S	Description/Comments
	Ventriculomegaly
	Echodensity/echogenicity
	Echolucency
	IVH grade _____
	Germinal matrix bleed (Grade I IVH)
	Other bleed
	PVL/cavitation/white matter necrosis
	Malformation
	Subarachnoid hemorrhage/blood
	Other findings, specify.
3. Date _ _/_ _/_ _ _ _		Results 1 Normal 2 Abnormal		Hemisphere: 1 = Right, 2 = Left, 3 = Bilateral, 9 = NK Location: 1 = Anterior/Frontal, 2 = Posterior/Occipital, 3 = Parietal, 4 = Temporal, 9 = NK Size: 1 = Small/Mild, 2 = Medium/Moderate, 3 = Large/Severe, 9 = NK
	Findings (1= No, 2= Definite, 3=Suspect)			H	L	S	Description/Comments
	Ventriculomegaly
	Echodensity/echogenicity
	Echolucency
	IVH grade _____
	Germinal matrix bleed (Grade I IVH)
	Other bleed
	PVL/cavitation/white matter necrosis
	Malformation
	Subarachnoid hemorrhage/blood
	Other findings, specify.
4. Date _ _/_ _/_ _ _ _		Results 1 Normal 2 Abnormal		Hemisphere: 1 = Right, 2 = Left, 3 = Bilateral, 9 = NK Location: 1 = Anterior/Frontal, 2 = Posterior/Occipital, 3 = Parietal, 4 = Temporal, 9 = NK Size: 1 = Small/Mild, 2 = Medium/Moderate, 3 = Large/Severe, 9 = NK
	Findings (1= No, 2= Definite, 3=Suspect)			H	L	S	Description/Comments
	Ventriculomegaly
	Echodensity/echogenicity
	Echolucency
	IVH grade _____
	Germinal matrix bleed (Grade I IVH)
	Other bleed
	PVL/cavitation/white matter necrosis
	Malformation
	Subarachnoid hemorrhage/blood
	Other findings, specify.

K. OTHER Procedure or study (ECG, Chest X-ray, Genetic study, etc.)  NO INFO
Refer No.: Please indicate the event number from the appropriate section (e.g. D2 – for Section D, #2), otherwise enter the reason from the chart.
	Refer No./ Reason	Type of Procedure	Date	Outcome
1.			_ _/_ _/_ _ _ _
2.			_ _/_ _/_ _ _ _
3.			_ _/_ _/_ _ _ _
4.			_ _/_ _/_ _ _ _
5.			_ _/_ _/_ _ _ _
6.			_ _/_ _/_ _ _ _
7.			_ _/_ _/_ _ _ _
8.			_ _/_ _/_ _ _ _
9.			_ _/_ _/_ _ _ _
10.			_ _/_ _/_ _ _ _

L. NEWBORN SCREENING RESULTS  NO INFO
Check the box in front of the test if it was performed, and complete the results.
	Biotinidase Date: __ __/__ __/__ __ __ __ Results: 1 Normal 2 Abnormal 9  Unknown		Homocystinuria Date: __ __/__ __/__ __ __ __ Results: 1 Normal 2 Abnormal 9  Unknown		Toxoplasmosis Date: __ __/__ __/__ __ __ __ Results: 1 Normal 2 Abnormal 9  Unknown
	Congenital Adrenal Hyperplasia (CAH) Date: __ __/__ __/__ __ __ __ Results: 1 Normal 2 Abnormal 9  Unknown		Hypothyroidism Date: __ __/__ __/__ __ __ __ Results: 1 Normal 2 Abnormal 9  Unknown		Tyrosinemia Date: __ __/__ __/__ __ __ __ Results: 1 Normal 2 Abnormal 9  Unknown
	Cystic Fibrosis Date: __ __/__ __/__ __ __ __ Results: 1 Normal 2 Abnormal 9  Unknown		Maple Syrup Urine Disease Date: __ __/__ __/__ __ __ __ Results: 1 Normal 2 Abnormal 9  Unknown		Glucose-6-dehydrogenase Date: __ __/__ __/__ __ __ __ Results: 1 Normal 2 Abnormal 9  Unknown
	Galactosemia Date: __ __/__ __/__ __ __ __ Results: 1 Normal 2 Abnormal 9  Unknown		Phenylketonuria/PKU Date: __ __/__ __/__ __ __ __ Results: 1 Normal 2 Abnormal 9  Unknown		Sickle Cell Anemia Date: __ __/__ __/__ __ __ __ Results: 1 Normal 2 Abnormal 9  Unknown
	Other (specify) _________________ Date: __ __/__ __/__ __ __ __ Results: 1 Normal 2 Abnormal 9  Unknown		Other (specify) _________________ Date: __ __/__ __/__ __ __ __ Results: 1 Normal 2 Abnormal 9  Unknown		Other (specify) _________________ Date: __ __/__ __/__ __ __ __ Results: 1 Normal 2 Abnormal 9  Unknown

Appendix S5 Page 11 of 23