Pediatric Chart Abstraction Form

Appendix S.5 Pediatric MR Form.DOC

The National Centers for Autism and Developmental Disabilities Research and Epidemiology (CADDRE) Study

Pediatric Chart Abstraction Form

OMB: 0920-0741

Document [doc]
Download: doc | pdf

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

_ _ /_ _/_ _ _ _

  1. 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

  1. Date Abstracted


__ __/__ __/__ __ __ __

53. Abstractor

54. Start Time

__ __ : __ __

  1. 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

  1. Date Abstracted


__ __/__ __/__ __ __ __

65. Abstractor

66. Start Time

__ __ : __ __

  1. 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

  1. Date Abstracted


__ __/__ __/__ __ __ __

77. Abstractor

78. Start Time

__ __ : __ __

  1. 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

File Typeapplication/msword
File Title....Maternal Abstract Form
AuthorMOD
Last Modified Bypax1
File Modified2006-12-29
File Created2006-12-29

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