Appendix_S

Appendix_S.2 Prenatal MR Form FINAL STUDY START VERSION.doc

The Study to Explore Early Development (SEED)

Appendix_S

OMB: 0920-0741

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Study ID Number _____________________ # continuation sheets for this section (enter only on first page of section)________

Prenatal Care Medical Record Abstraction Form

This form should be used for abstraction of medical records from all prenatal care providers seen during index pregnancy, as well as medical records from other providers that provided care for the biological mother in the 3 years preceding the pregnancy with the index child.

These other providers include internists, infertility treatment providers, psychiatrists and other mental health care providers, allergists, immunologists, etc.

A single abstraction form should be used for all relevant providers.

Notes: if a record from an infertility treatment provider is received and reviewed, additional details of treatments just before the index pregnancy should be recorded in various appendices as indicated.

Below list all providers that contributed data to this form.

OF NOTE: It is NOT necessary to indicate the specific provider record source for each individual data item on this form. It will be too cumbersome to try and detail exactly which record(s) provided which data. Hopefully, in most cases if the same information is provided in multiple different provider records, it will be consistent and complimentary. However, there might be cases in which conflicting information is presented in 2 different records. Use the data available to make your best judgment about the correct information and then add a comment providing details of the conflict between provider sources.

CONTRIBUTING PROVIDERS (Extra sheets in Appendix A if necessary)
A.1. Name of Provider/Hospital
A.2. Street Address
A.3. City		A.4. State		A.5. Zip Code
ABSTRACTION LOG
A.6. Date__ __/__ __/__ __ __ __	A.7. Date__ __/__ __/__ __ __ __		A.8. Date__ __/__ __/__ __ __ __
A.6.1 to A.6.8 Time (use military time)* Start __ __ : __ __ Stop __ __: __ __ Start __ __ : __ __ Stop __ __: __ __ Start __ __ : __ __ Stop __ __: __ __ Start __ __ : __ __ Stop __ __: __ __	A.71 to A.7.8 Time (use military time)* Start __ __ : __ __ Stop __ __: __ __ Start __ __ : __ __ Stop __ __: __ __ Start __ __ : __ __ Stop __ __: __ __ Start __ __ : __ __ Stop __ __: __ __		A.8.1 to A.8.8 Time (use military time)* Start __ __ : __ __ Stop __ __: __ __ Start __ __ : __ __ Stop __ __: __ __ Start __ __ : __ __ Stop __ __: __ __ Start __ __ : __ __ Stop __ __: __ __
A.9. Date__ __/__ __/__ __ __ __	A.10. Date__ __/__ __/__ __ __ __		A.11. Date__ __/__ __/__ __ __ __
A.9.1 to A.9.8 Time (use military time)* Start __ __ : __ __ Stop __ __: __ __ Start __ __ : __ __ Stop __ __: __ __ Start __ __ : __ __ Stop __ __: __ __ Start __ __ : __ __ Stop __ __: __ __	A.10.1 to A.10.8 Time (use military time)* Start __ __ : __ __ Stop __ __: __ __ Start __ __ : __ __ Stop __ __: __ __ Start __ __ : __ __ Stop __ __: __ __ Start __ __ : __ __ Stop __ __: __ __		A.11.1 to A.11.8 Time (use military time)* Start __ __ : __ __ Stop __ __: __ __ Start __ __ : __ __ Stop __ __: __ __ Start __ __ : __ __ Stop __ __: __ __ Start __ __ : __ __ Stop __ __: __ __

B.1. Name of Provider/Hospital
B.2. Street Address
B.3. City		B.4. State		B.5. Zip Code
ABSTRACTION LOG
B.6. Date__ __/__ __/__ __ __ __	B.7. Date__ __/__ __/__ __ __ __		B.8. Date__ __/__ __/__ __ __ __
B.6.1 to B.6.8 Time (use military time)* Start __ __ : __ __ Stop __ __: __ __ Start __ __ : __ __ Stop __ __: __ __ Start __ __ : __ __ Stop __ __: __ __ Start __ __ : __ __ Stop __ __: __ __	B.71 to B.7.8 Time (use military time)* Start __ __ : __ __ Stop __ __: __ __ Start __ __ : __ __ Stop __ __: __ __ Start __ __ : __ __ Stop __ __: __ __ Start __ __ : __ __ Stop __ __: __ __		B.8.1 to B.8.8 Time (use military time)* Start __ __ : __ __ Stop __ __: __ __ Start __ __ : __ __ Stop __ __: __ __ Start __ __ : __ __ Stop __ __: __ __ Start __ __ : __ __ Stop __ __: __ __
B.9. Date__ __/__ __/__ __ __ __	B.10. Date__ __/__ __/__ __ __ __		B.11. Date__ __/__ __/__ __ __ __
B.9.1 to B.9.8 Time (use military time)* Start __ __ : __ __ Stop __ __: __ __ Start __ __ : __ __ Stop __ __: __ __ Start __ __ : __ __ Stop __ __: __ __ Start __ __ : __ __ Stop __ __: __ __	B.10.1 to B.10.8 Time (use military time)* Start __ __ : __ __ Stop __ __: __ __ Start __ __ : __ __ Stop __ __: __ __ Start __ __ : __ __ Stop __ __: __ __ Start __ __ : __ __ Stop __ __: __ __		B.11.1 to B.11.8 Time (use military time)* Start __ __ : __ __ Stop __ __: __ __ Start __ __ : __ __ Stop __ __: __ __ Start __ __ : __ __ Stop __ __: __ __ Start __ __ : __ __ Stop __ __: __ __
C.1. Name of Provider/Hospital
C.2. Street Address
C.3. City		C.4. State		C.5. Zip Code
ABSTRACTION LOG
C.6. Date__ __/__ __/__ __ __ __	C.7. Date__ __/__ __/__ __ __ __		C.8. Date__ __/__ __/__ __ __ __
C.6.1 to C.6.8 Time (use military time)* Start __ __ : __ __ Stop __ __: __ __ Start __ __ : __ __ Stop __ __: __ __ Start __ __ : __ __ Stop __ __: __ __ Start __ __ : __ __ Stop __ __: __ __	C.71 to C.7.8 Time (use military time)* Start __ __ : __ __ Stop __ __: __ __ Start __ __ : __ __ Stop __ __: __ __ Start __ __ : __ __ Stop __ __: __ __ Start __ __ : __ __ Stop __ __: __ __		C.8.1 to C.8.8 Time (use military time)* Start __ __ : __ __ Stop __ __: __ __ Start __ __ : __ __ Stop __ __: __ __ Start __ __ : __ __ Stop __ __: __ __ Start __ __ : __ __ Stop __ __: __ __
C.9. Date__ __/__ __/__ __ __ __	C.10. Date__ __/__ __/__ __ __ __		C.11. Date__ __/__ __/__ __ __ __
C.9.1 to C.9.8 Time (use military time)* Start __ __ : __ __ Stop __ __: __ __ Start __ __ : __ __ Stop __ __: __ __ Start __ __ : __ __ Stop __ __: __ __ Start __ __ : __ __ Stop __ __: __ __	C.10.1 to C.10.8 Time (use military time)* Start __ __ : __ __ Stop __ __: __ __ Start __ __ : __ __ Stop __ __: __ __ Start __ __ : __ __ Stop __ __: __ __ Start __ __ : __ __ Stop __ __: __ __		C.11.1 to C.11.8 Time (use military time)* Start __ __ : __ __ Stop __ __: __ __ Start __ __ : __ __ Stop __ __: __ __ Start __ __ : __ __ Stop __ __: __ __ Start __ __ : __ __ Stop __ __: __ __

D.1. Name of Provider/Hospital
D.2. Street Address
D.3. City		D.4. State		D.5. Zip Code
ABSTRACTION LOG
D.6. Date__ __/__ __/__ __ __ __	D.7. Date__ __/__ __/__ __ __ __		D.8. Date__ __/__ __/__ __ __ __
D.6.1 to D.6.8 Time (use military time)* Start __ __ : __ __ Stop __ __: __ __ Start __ __ : __ __ Stop __ __: __ __ Start __ __ : __ __ Stop __ __: __ __ Start __ __ : __ __ Stop __ __: __ __	D.71 to D.7.8 Time (use military time)* Start __ __ : __ __ Stop __ __: __ __ Start __ __ : __ __ Stop __ __: __ __ Start __ __ : __ __ Stop __ __: __ __ Start __ __ : __ __ Stop __ __: __ __		D.8.1 to D.8.8 Time (use military time)* Start __ __ : __ __ Stop __ __: __ __ Start __ __ : __ __ Stop __ __: __ __ Start __ __ : __ __ Stop __ __: __ __ Start __ __ : __ __ Stop __ __: __ __
D.9. Date__ __/__ __/__ __ __ __	D.10. Date__ __/__ __/__ __ __ __		D.11. Date__ __/__ __/__ __ __ __
D.9.1 to D.9.8 Time (use military time)* Start __ __ : __ __ Stop __ __: __ __ Start __ __ : __ __ Stop __ __: __ __ Start __ __ : __ __ Stop __ __: __ __ Start __ __ : __ __ Stop __ __: __ __	D.10.1 to D.10.8 Time (use military time)* Start __ __ : __ __ Stop __ __: __ __ Start __ __ : __ __ Stop __ __: __ __ Start __ __ : __ __ Stop __ __: __ __ Start __ __ : __ __ Stop __ __: __ __		D.11.1 to D.11.8 Time (use military time)* Start __ __ : __ __ Stop __ __: __ __ Start __ __ : __ __ Stop __ __: __ __ Start __ __ : __ __ Stop __ __: __ __ Start __ __ : __ __ Stop __ __: __ __
E.1. Name of Provider/Hospital
E.2. Street Address
E.3. City		E.4. State		E.5. Zip Code
ABSTRACTION LOG
E.6. Date__ __/__ __/__ __ __ __	E.7. Date__ __/__ __/__ __ __ __		E.8. Date__ __/__ __/__ __ __ __
E.6.1 to E.6.8 Time (use military time)* Start __ __ : __ __ Stop __ __: __ __ Start __ __ : __ __ Stop __ __: __ __ Start __ __ : __ __ Stop __ __: __ __ Start __ __ : __ __ Stop __ __: __ __	E.71 to E.7.8 Time (use military time)* Start __ __ : __ __ Stop __ __: __ __ Start __ __ : __ __ Stop __ __: __ __ Start __ __ : __ __ Stop __ __: __ __ Start __ __ : __ __ Stop __ __: __ __		E.8.1 to E.8.8 Time (use military time)* Start __ __ : __ __ Stop __ __: __ __ Start __ __ : __ __ Stop __ __: __ __ Start __ __ : __ __ Stop __ __: __ __ Start __ __ : __ __ Stop __ __: __ __
E.9. Date__ __/__ __/__ __ __ __	E.10. Date__ __/__ __/__ __ __ __		E.11. Date__ __/__ __/__ __ __ __
E.9.1 to E.9.8 Time (use military time)* Start __ __ : __ __ Stop __ __: __ __ Start __ __ : __ __ Stop __ __: __ __ Start __ __ : __ __ Stop __ __: __ __ Start __ __ : __ __ Stop __ __: __ __	E.10.1 to E.10.8 Time (use military time)* Start __ __ : __ __ Stop __ __: __ __ Start __ __ : __ __ Stop __ __: __ __ Start __ __ : __ __ Stop __ __: __ __ Start __ __ : __ __ Stop __ __: __ __		E.11.1 to E.11.8 Time (use military time)* Start __ __ : __ __ Stop __ __: __ __ Start __ __ : __ __ Stop __ __: __ __ Start __ __ : __ __ Stop __ __: __ __ Start __ __ : __ __ Stop __ __: __ __

(Add extra sheets as needed)

A. IDENTIFYING INFORMATION No information for any item in section
1. Mother’s Name (Last, First, Middle)		2. Study ID#
3. Maiden Name	4. AKA	5. Mother’s DOB
6. Street Address
7. City	8. State	9. Zip Code
10. Delivery Hospital	11. Delivery Hospital Address
12. City	13. State	14. Zip Code
Comments:

A. IDENTIFYING INFORMATION (continued) Maternal Address History (List in reverse chronological order)
15. Date _ _ / _ _ / _ _ _ _ (last known at this address)	16. Mother’s Street Address
17. City		18. State	19. Zip Code
20. Date _ _ / _ _ / _ _ _ _ (last known at this address)	21. Mother’s Street Address
22. City		23. State	24. Zip Code
25. Date _ _ / _ _ / _ _ _ _ (last known at this address)	26. Mother’s Street Address
27. City		28. State	29. Zip Code
30. Date _ _ / _ _ / _ _ _ _ (last known at this address)	31. Mother’s Street Address
32. City		33. State	34. Zip Code
35. Date _ _ / _ _ / _ _ _ _ (last known at this address)	36. Mother’s Street Address
37. City		38. State	39. Zip Code
40. Date _ _ / _ _ / _ _ _ _ (last known at this address)	41. Mother’s Street Address
42. City		43. State	44. Zip Code
45. Date _ _ / _ _ / _ _ _ _ (last known at this address)	46. Mother’s Street Address
47. City		48. State	49. Zip Code
Comments:

Sections B-Q: How to Document Various Types of Missing Information

A. No information -- entire section

Each section of each form will include either one or two universal missing check boxes. If either are checked, no further data are recorded for the entire section.

1. No information for any item in section

Checked if:

No relevant tests or procedures appear to have been ordered by any contributing medical care providers; and/or

No information was recorded for relevant health status, medical conditions, medications.

2. Test/procedure for one or more items in section indicated but no information on dates, results, etc.

(will only apply to certain sections as indicated)

B. Information available for one or more items within a section BUT no information for selected items

If there is information in the chart for one or more items in a given section on a given abstraction form, all pertinent data should be recorded. However, there is still the possibility that there will be missing data within these sections. Three types of missing data codes are recognized:

NA – NOT APPLICABLE (for use with certain items such as those with skip patterns and those for which multiple tests/procedures/etc. might have been performed and all are requested in abstraction form. After last relevant item is recorded, the subsequent item on abstract form is NA to indicate the end of reporting).

IL -- NOT LEGIBLE (self-explanatory)

NR – NO info in RECORD (“true missing” There should be information for an item, but it cannot be located.)

The following coding schemes will be applied to code these 3 types of missing:

Categorical variables with a finite coding scheme

99 NR

Dates and times – these may be completely missing or partially missing.

Data entry format is __ __/__ __/__ __ __ __ and __ __:__ __

For dates and time (military hours and minutes)

For day, month, hours, and minutes, enter 77, 88, or 99 as appropriate

For year the enter 7777, 8888, or 9999 as appropriate

Thus, these can be completely missing or mixed with valid data such as:

03/99/2003 and 10:88

Continuous/open ended data items: Since it will be overly burdensome to develop and employ a missing data scheme which individually considers each data item and the appropriate number of digits for missing values use the alpha codes for missing in these instances:

NA, IL, or NR

B. MENSTRUAL HISTORY, CONCEPTION, INFERTILITY, PRENATAL CARE No information for any item in section
1. Date of first PNV _ _ / _ _ / _ _ _ _				2. Date of last PNV _ _ / _ _ / _ _ _ _				3. Total # of Visits __ __ Record IL or NR as relevant
4. LMP Date _ _ / _ _ / _ _ _ _	5. LMP Date Certain 1 yes 2 no 77 NA 88 Illegible 99 Not Recorded				6. EDC – LMP _ _ / _ _ / _ _ _ _			7. EDC – US _ _ / _ _ / _ _ _ _
8. Number of months index pregnancy attempted _______ Months OR Not Planned Record IL or NR as relevant			9. Contraception in use at time of conception 1 none/rhythm 2 barrier/chemical 3 hormonal 4 IUD 88 Illegible 99 Not recorded					10. Date contraception stopped _ _ / _ _ / _ _ _ _
11. Menstrual History Age of onset _____ Record IL or NR as relevant	12. Menstrual Cycles 1 regular 2 irregular 88 Illegible 99 Not recorded				13. Intercycle Interval _____ Days If range provided, record midpoint. Record IL or NR as relevant				14. Duration _____ Days (If range provided, record midpoint) Record IL or NR as relevant
15. Any indication of infertility problems and/or treatments prior to or at the time of the index pregnancy? 1 yes 2 no 88 Illegible If no, skip to section C. If yes, complete items 16 (diagnoses), 17 (treatment history prior to index pregnancy) and 18 (conception/treatment index pregnancy). If unsure where to place a given treatment (because dates of treatment are not clear), record in 18 with “Maybe” Box (18c) checked. If records from infertility providers available, complete Section Q or Appendix C for treatment details index pregnancy.
16. Infertility Disorders/Diagnoses 17. Treatment History (Prior to Index Pregnancy) 17a. Codes for treatment type: 1=ovulation induction medications; 2=other (non-ovulation) medications mother; 3= medication for mother indicated but type NOT indicated or abstractor unsure; 4= IUI or artificial insemination; 5=Assisted Reproductive Technology (ART) procedure; 6= surgery mother; 7=medication/procedure/surgery father; 8=other infertility treatment; 9= treatment indicated but type not specified; 77 NA; 88 Illegible
PAST DISORDERS/DIAGNOSES						PAST TREATMENTS/MEDICATIONS (Treatments do not need to correspond with specific diagnoses. List in reverse chronological order. Extra sheet provided in Appendix A)
16a. 1 – 16a.8 Check all that apply		16b. 1 – 16b.8 Date First Diagnosed (mm/yyyy OR yyyy)				17a. 1– 17a.x Treatment Code	17b. 1– 17b.x Specifications			17c. 1– 17c.x Treatment Date* (mm/yyyy OR yyyy)
Tubal infertility		__ __/__ __ __ __								__ __/__ __ __ __
Ovulatory dysfunction or Polycystic Ovaries (PCO)		__ __/__ __ __ __								__ __/__ __ __ __
Diminished ovarian reserve/ premature ovarian failure/infertility resulting from advanced maternal age		__ __/__ __ __ __								__ __/__ __ __ __
Endometriosis		__ __/__ __ __ __								__ __/__ __ __ __
Structural uterine abnormalities		__ __/__ __ __ __								__ __/__ __ __ __
Male Factor		__ __/__ __ __ __								__ __/__ __ __ __
Unexplained or Idiopathic Infertility specifically noted		__ __/__ __ __ __								__ __/__ __ __ __
Infertility noted but no info on specific diagnosis (including idiopathic)		__ __/__ __ __ __								__ __/__ __ __ __
Comments:						Comments:
						*Record only treatments earlier than time periods indicated in #18

B. MENSTRUAL HISTORY, CONCEPTION, INFERTILITY, PRENATAL CARE (continued)

18. Mode of Conception and Infertility Treatment Index Pregnancy*

Treatments Prior to Index Pregnancy (check all that apply)

18a.1 -18a.9

Yes

18b.1 -18b.7

Maybe**

18c.1 -18c.7

Medications/Treatments Specifications

18d.1 -18d.7

Dates

1. Ovulation induction medication (OI)

(Started within 3 months of conception)*

Specify medication(s)

If infertility treatment provider record available for Non-ART treatments, provide medication details in Section Q. Note, infertility treatment provider might be same as prenatal care provider.

_ _ / _ _ / _ _ _ _

2. Other medication(s) taken by mother

(within 3 months of conception)*

Specify medication(s)

_ _ / _ _ / _ _ _ _

3. Intrauterine insemination (IUI)/artificial insemination

(within 1 month of conception)*

Provide related details

_ _ / _ _ / _ _ _ _

4. Assisted reproductive technology (ART) (eg in vitro fertilization (IVF), intracytoplasmic sperm injection (ICSI))

(any stage of procedure within 1 month of conception)*

Note; All stages in an ART treatment might occur over >4 weeks

Record any additional info from prenatal care record in Appendix B (short form) and info from ART provider record in Appendix C (long form).

_ _ / _ _ / _ _ _ _

5. Mother had surgery for infertility disorder (eg tubal surgery)

(within 6 months of conception)*

Specify type of surgery

_ _ / _ _ / _ _ _ _

6. Father had medication, surgery or other treatment for an infertility-related disorder (such as hormonal imbalance or varicocele)

(within 6 months of conception)*

Specify type of treatment(s)/medication(s)/surgery(ies)

_ _ / _ _ / _ _ _ _

7. Assisted conception indicated for index pregnancy but treatment type not provided

Provide related details

_ _ / _ _ / _ _ _ _

*If available B4. LMP Date should be used to determine start of pregnancy in calculating intervals specified above. In some cases LMP or treatment date might be missing, but provider notation will indicate that treatment occurred within the specified interval.

**Maybe: In some cases an infertility treatment might be noted but the date of treatment is not recorded and the notation in the record is not clear as to whether the treatment occurred in the specified interval; thus, the abstractor will not be able to determine if treatment was within timeframe of just before index pregnancy and should check the Maybe box.

8. Infertility problem indicated but index pregnancy conceived without assistance

9. Cannot determine if natural or assisted conception

COMMENTS:

C. PREGNANCY HISTORY UP TO AND INCLUDING INDEX PREGNANCY

No information for any item in section

1. TOTAL Pregnancies

2. Full Term Birth (still + live)

3. Premature

Birth (still + live)

4. Stillbirths

5. Live births

6. Ab – Induced

7. Ab – Spontaneous

8. Ectopic

9. Multiple Births (still +live)

**Use the following codes to complete the table below**(If needed, extra sheet provided in Appendix A)

Pregnancy Number/Baby Number

Outcome

Plurality

Birth Weight

Sex

Type Delivery

Number past pregnancies in reverse chronological order (most recent = 1).

If plurality 77, 88 or 99, baby number not needed.

For singletons enter 1/1.

For pregnancies specified as multiple gestations, list each fetus/infant born separately. E.g. 1/1, 1/2, 1/3, pertain to infants 1, 2, and 3 from pregnancy 1.

1. Live Birth

2. Stillbirth

3. Induced Abortion

4. Spontaneous Abortion

5. Ectopic Pregnancy

6. Molar Pregnancy

7. Maternal Death prior to Birth

8. other specify

88. IL

99. NR

1. Singleton

2. Twin

3. Triplet

4. Quad

5. Quint

Etc….

77. NA

(outcomes 3-8)

88. IL

99. NR

Grams preferred, if available

Not applicable for outcomes 3-8, record NA

Record IL or NR for other missing values as needed.

1. Male

2. Female

3. Ambiguous

77. NA

(outcomes 3-8)

88. IL

99. NR

1. Vaginal

2. Primary C-Section

3. Secondary C-Section

4. VBAC

77. NA

(outcomes 3-8)

88. IL

99. NR

Prenatal, Delivery, Post Partum Problems/Complications

No complications specifically noted
Abruptio placentae
Birth defect (specify if yes)
Cephalopelvic disproportion
Chorioamnionitis
Deep vein thrombosis
Eclampsia
Fetal reduction
Gestational Diabetes
HELLP
Hyperemesis
Infant Death, neonatal (<28 days)
Infant Death, post-neonatal (28 days – 1 year)
Intrauterine growth restriction/retardation (IUGR)

Macrosomia
Placenta previa
Postpartum depression
Postpartum hemorrhage
Pregnancy induced hypertension/

preeclampsia/gestational hypertension

Premature rupture of membranes (PROM)
Preterm labor
Pulmonary edema
Pulmonary embolus (PE)
Uterine rupture
Vaginal bleeding

26. Other: specify

99. Unknown/ Not documented

10a.1preg – 10a.20preg

AND

10a.1baby – 10a.20baby

Preg # Baby #

10b.1 – 10b.20

Outcome

10c.1 – 10c.20

Plurality

10d.1 – 10d.20

Outcome Month

10e.1 – 10e.20

Outcome

Year

yyyy

10f.1 – 10f.20

Wks

10g.1 – 10g.20

10h.1 – 10h.20 (lb)

10i.1 – 10i.20

(oz)

Birth Weight

g lbs/oz

10j.1 – 10j.20

Sex

10k.1 – 10k.20

Type Delivery

10L..1.1 – 10L.20.28

(Each complication will be a separate y/n variable for each pregnancy+ other specify and NR)

Complications with mother/infant (record codes; specify detail for “other”)

COMMENTS: Provide indication of preg no/baby no for each comment.

D. MATERNAL MEASUREMENTS INDEX PREGNANCY (Extra sheets in Appendix A if necessary)

No information for any item in section

Test/procedure for one or more items in section indicated but no information on dates, results, etc.

1. Pre-Pregnancy weight 1a. __ __ __ .__ __ 1b Unit: 1. pounds 2. kg 88. Illegible 99. NR

2. Date of Pre-Pregnancy weight 2a. _ _ / _ _ / _ _ _ _ OR 2b. self-reported

3. Maternal height 3a. ___ ft 3b ___ ___ in OR 3c. ___ ___ ___ cm OR 3d. Illegible Not Recorded

4. PRENATAL VISITS Record IL or NR for missing information

4a.1 – 4a.26

Visit No

4b1 – 4b.26

Date

mm/dd/yyyyy

4c1 – 4c.26

Wks Gestation (provider’s best estimate)

4d1 – 4d.26

4e1 – 4e.26

Fundal Ht

inches

IL (all)

NR (all)

4f1 – 4f.26

Fetal Heart Rate

4g1 – 4g.26

Preterm labor

signs/ symptoms*

4h1 – 4h.26

4i1 – 4i.26

Blood Pressure

Systolic Diastolic

4j1 – 4j.26

4k1 – 4k.26

Weight

Lb kg

IL (all)

NR (all)

4L1 – 4L.26

4m1 – 4m.26

Urine

+albumin +glucose

IL (all) IL (all)

NR (all) NR (all)

1 first

__ last

5. HOSPITAL DELIVERY ADMISSION(S) Record IL or NR for missing information

5a.1 – 5a.3

Date

mm/dd/yyyyy

5b.1 – 5b.3

Weeks Gestation

(provider’s best estimate)

5c.1 – 5d.3

5d.1 – 5d.3

Fundal Ht

inches

IL (all)

NR (all)

5e.1 – 5e.3

Fetal Heart Rate

5f.1 – 5f.3

Preterm labor

signs/ symptoms*

5g.1 – 5g.3

5h.1 – 5h.3

Blood Pressure

Systolic Diastolic

5i.1 – 5i.3

5j.1 – 5j.3

Weight

IL (all)

NR (all)

5k.1 – 5k.3

5L.1 – 5L.3

Urine

+albumin +glucose

IL (all) IL (all)

NR (all) NR (al

* If preterm labor signs/symptoms are present, provide details in Section L.

COMMENTS: Indicate visit no and date.

E. BLOOD TYPE, SCREENING, AND OTHER REPORTS (excluding cultures/rapid strep screens) INDEX PREGNANCY No information for any item in section

1a. Blood Type

_______

1b. Rh

1. negative

2. positive

3. tested,

results unknown

4. not tested

88 Illegible

99 NR

1c. Date

_ _ / _ _ / _ _ _ _

2a. Antibody Screen

1. negative

2. positive

3. tested,

results unknown

4. not tested

88 Illegible

99 NR

2b. Date

_ _ / _ _ / _ _ _ _

3a. RPR/VDRL

1. negative

2. positive

3. tested,

results unknown

4. not tested

88 Illegible

99 NR

3b. Date

_ _ / _ _ / _ _ _ _

4a. HbsAG

1. negative

2. positive

3. tested,

results unknown

4. not tested

88 Illegible

99 NR

4b. Date

_ _ / _ _ / _ _ _ _

5a. Rubella Titer

1. immune

2. non-immune

3. tested,

results unknown

4. not tested

88 Illegible

99 NR

5b. Date

_ _ / _ _ / _ _ _ _

6a. HIV

1. negative

2. positive

3. tested,

results unknown

4. not tested

88 Illegible

99 NR

6b. Date

_ _ / _ _ / _ _ _ _

7a. Chlamydia Screen

1. negative

2. positive

3. tested,

results unknown

4. not tested

88 Illegible

99 NR

7b. Date

_ _ / _ _ / _ _ _ _

8a. Diabetes Screen (1 hour)

1. NL

2. ABNL

3. tested,

results unknown

4. not tested

88 Illegible

99 NR

8b. Date

_ _ / _ _ / _ _ _ _

9. Glucose Tolerance Tests

9a. FBS

1. NL

2. ABNL

3. tested,

results unknown

4. not tested

88 Illegible

99 NR

9b. Date

_ _ / _ _ / _ _ _ _

9c.

1 hour

1. NL

2. ABNL

3. tested,

results unknown

4. not tested

88 Illegible

99 NR

9d.

2 hour

1. NL

2. ABNL

3. tested,

results unknown

4. not tested

88 Illegible

99 NR

9e.

3 hour

1. NL

2. ABNL

3. tested,

results unknown

4. not tested

88 Illegible

99 NR

9f more than one GTT – record additional GTT results in #22

HGB (g/dL)

10a.1

_______.___

tested,

results unknown

not tested

Illegible

10a.2. Date

_ _ / _ _ / _ _ _ _

HGB (g/dL)

10b.1

_______.___

tested,

results unknown

not tested

Illegible

10b.2. Date

_ _ / _ _ / _ _ _ _

HGB (g/dL)

10c.1

_______.___

tested,

results unknown

not tested

Illegible

10c.2. Date

_ _ / _ _ / _ _ _ _

HCT (%)

11a.1

_______

tested,

results unknown

not tested

Illegible

11a.2. Date

_ _ / _ _ / _ _ _ _

HCT (%)

11b.1

_______

tested,

results unknown

not tested

Illegible

11b.2. Date

_ _ / _ _ / _ _ _ _

HCT (%)

11c.1

_______

tested,

results unknown

not tested

Illegible

11c.2. Date

_ _ / _ _ / _ _ _ _

E. BLOOD TYPE, SCREENING, AND OTHER REPORTS (excluding cultures/rapid strep screens) (continued)

12a. HGB electrophoresis

13a. Progesterone Level

1. tested

2. declined

3. tested but results unknown

4. not tested, unknown if offered test

88. Illegible

99. NR

13b.Date _ _ / _ _ / _ _ _ _

13c. Results ______ ng/ml

13d.

more than one test – record additional results in #22

14a. Elected Maternal Serum Screening (MS-AFP, Triple Screen, Quad Screen, or First Tri Screening)

1. accepted (see results)

2. declined

3. tested, results unknown

4. not tested, unknown if offered test

88 Illegible

99. NR

1. tested

2. declined

3. tested but results unknown

4. not tested, unknown if offered test

88. Illegible

99. NR

12b. Date

_ _ / _ _ / _ _ _ _

12c.

Results (Hb):

AA SS

AS SC

AC AF

A₂

Illegible

15. Maternal Serum Screening (MS-AFP, Triple Screen, Quad Screen, or First Tri Screening) results

15a.1

Date

_ _ / _ _ / _ _ _ _

15b.1

Test:

1. MS-AFP

2. Triple Screen

3. Quad Screen

4. 1^st Trimester

Screen

5. redraw/recalculated

88. Illegible

99. NR

Results:

15c.1.1

1. screen negative

2. screen positive

3. tested, results unknown

88. Illegible

99. NR

15c1.2

FOR: 1. Trisomy 18

2. Trisomy 21

3. ONTD

4. abn. high levels

5. abn. low levels

OR 15c.1.3, 15c.1.4

1 in ____ chance for

1. Trisomy 18

2. Trisomy 21

3. ONTD

Numeric Results (if present):

15d.1.1 to 15d.1.11

MS-AFP:_____ MoM or _____ng/mL

uE₃: _____ MoM or _____ng/mL

hCG: _____ MoM or _____ng/mL

PAPP-A: _____ MoM or _____ng/mL

Inhibin A or DIA:

_____ MoM or _____ng/mL

Nuchal Translucency (NT):

______mm

15a.2

Date

_ _ / _ _ / _ _ _ _

15b.2

Test:

1. MS-AFP

2. Triple Screen

3. Quad Screen

4. 1^st Trimester

Screen

5. redraw/recalculated

88. Illegible

99. NR

Results:

15c.2.1

1. screen negative

2. screen positive

3. tested, results unknown

88. Illegible

99. NR

15c2.2

FOR: 1. Trisomy 18

2. Trisomy 21

3. ONTD

4. abn. high levels

5. abn. low levels

OR 15c.2.3, 15c.2.4

1 in ____ chance for

1. Trisomy 18

2. Trisomy 21

3. ONTD

Numeric Results (if present):

15d.2.1 to 15d.2.11

MS-AFP:_____ MoM or _____ng/mL

uE₃: _____ MoM or _____ng/mL

hCG: _____ MoM or _____ng/mL

PAPP-A: _____ MoM or _____ng/mL

Inhibin A or DIA:

_____ MoM or _____ng/mL

Nuchal Translucency (NT):

______mm

E. BLOOD TYPE, SCREENING, AND OTHER REPORTS (excluding cultures/rapid strep screens) (continued)

16. Chorionic Villi Sampling (CVS)

Procedure

16a.

Outcome of Procedure:

1. tested (see results)

2 . tested, results

unknown

3. not tested – not

enough sample

4. not tested

88. Illegible

99. NR

16b. Date

_ _ / _ _ / _ _ _ _

Test results from CVS:

16c.Karyotype:

_____________________

Genetic tests (16d-16i):

Name: Result:

_______________ ___________

17. Amniocentesis

Procedure

17a.

Outcome of Procedure:

1. tested (see results)

2 . tested, results

unknown

3. not tested – not

enough sample

4. not tested

88. Illegible

99. NR

17b Date

_ _ / _ _ / _ _ _ _

Test results from amniocentesis:

17c Karyotype:

_____________________

Genetic tests (17d-17i.):

Name: Result:

_______________ ___________

18. Second

Amniocentesis

Procedure

18a

Outcome of Procedure:

1. tested (see results)

2 . tested, results

unknown

3. not tested – not

enough sample

4. not tested

88. Illegible

99. NR

18b Date

_ _ / _ _ / _ _ _ _

Test results from amniocentesis:

18c Karyotype:

_____________________

Genetic tests (18d-18i):

Name: Result:

_______________ ___________

19. AFP and AChE (Direct from amnio fluid NOT maternal serum)

19a.

Outcome of Procedure:

1. tested (see results)

2 . tested, results

unknown

3. not tested – not

enough sample

4. not tested

88. Illegible

99. NR

19b. Date

_ _ / _ _ / _ _ _ _

AFP & AChE Results:

19c.

1. negative

2. positive

19d.

FOR:

1. ONTD

2. abn. high levels

3. abn. low levels

19e.1-19e.5

1 in ____ chance for

ONTD

AF-AFP:

_____ MoM or _____ng/mL

AChE:

_____ MoM or _____ng/mL

20. Amnio Gram Stain

20a. Outcome

1. tested (see results)

2 . tested, results

unknown

3. not tested – not

enough sample

4. not tested

88. Illegible

99. NR

20b. Date

_ _ / _ _ / _ _ _ _

20c. Results

1. negative

2. positive

88. Illegible

99. NR

21. Amnio Lung Maturity

21a 21b 21c

LS ______ PG _____ FSI ______

21d Date

_ _ / _ _ / _ _ _ _

E. BLOOD TYPE, SCREENING, AND OTHER REPORTS (excluding cultures/rapid strep screens) (continued)

22. Other Lab Reports (except cultures: to be reported in Section I) Extra sheet provided in Appendix A if needed

22a.1-22a.20

Test Date

22b.1-22b.20

Test Name/Description

22c.1-22c.20

(22c.[1-20].oth.sp)

Results

22d.1-22d.20

Normal Lab Range (if available)

22e.1-22e.20

Comments

_ _ / _ _ / _ _ _ _

1. normal

2. abnormal

3. other ______________

4. tested, results unknown

88. Illegible

99. NR

_ _ / _ _ / _ _ _ _

1. normal

2. abnormal

3. other ______________

4. tested, results unknown

88. Illegible

99. NR

_ _ / _ _ / _ _ _ _

1. normal

2. abnormal

3. other ______________

4. tested, results unknown

88. Illegible

99. NR

_ _ / _ _ / _ _ _ _

1. normal

2. abnormal

3. other ______________

4. tested, results unknown

88. Illegible

99. NR

_ _ / _ _ / _ _ _ _

1. normal

2. abnormal

3. other ______________

4. tested, results unknown

88. Illegible

99. NR

_ _ / _ _ / _ _ _ _

1. normal

2. abnormal

3. other ______________

4. tested, results unknown

88. Illegible

99. NR

_ _ / _ _ / _ _ _ _

1. normal

2. abnormal

3. other ______________

4. tested, results unknown

88. Illegible

99. NR

COMMENTS: Indicate item #

F. PREGNANCY ULTRASOUND REPORTS INDEX PREGNANCY

(Extra sheet provided in Appendix A if needed)

No information for any item in section

Test/procedure for one or more items in section indicated but no information on dates, results, etc.

1a.

Date of scan

_ _ / _ _ / _ _ _ _

1b.

# fetuses

1c.

EGA – LMP

___ ___

1d.

EGA – US

___ ___

1e to 1n (1L.sp)

Reason (check all that apply)

(Each reason choice will be a separate y/n variable + other specify, IL, NR)

1. confirm dates

2. fetal growth

3. placenta

4. BPP

5. decreased fetal movement

6. amniotic fluid volume

7. malformation

8. other: (specify)

_____________________

88. Illegible

99. NR

1o. (1o.ab.sp, 1o.oth.sp)

Results:

1. normal

2. abnormal (specify)

________________

3. other (specify)

______________

88. Illegible

99. NR

2a.

Date of scan

_ _ / _ _ / _ _ _ _

2b.

# fetuses

2c.

EGA – LMP

___ ___

2d.

EGA – US

___ ___

2e to 2n (2L.sp)

Reason (check all that apply)

(Each reason choice will be a separate y/n variable + other specify, IL, NR)

1. confirm dates

2. fetal growth

3. placenta

4. BPP

5. decreased fetal movement

6. amniotic fluid volume

7. malformation

8. other: (specify)

_____________________

88. Illegible

99. NR

2o. (2o.ab.sp, 2o.oth.sp)

Results:

1. normal

2. abnormal (specify)

________________

3. other (specify)

______________

88. Illegible

99. NR

3a.

Date of scan

_ _ / _ _ / _ _ _ _

3b.

# fetuses

3c.

EGA – LMP

___ ___

3d.

EGA – US

___ ___

3e to 3n (3L.sp

Reason (check all that apply)

(Each reason choice will be a separate y/n variable + other specify, IL, NR)

1. confirm dates

2. fetal growth

3. placenta

4. BPP

5. decreased fetal movement

6. amniotic fluid volume

7. malformation

8. other: (specify)

_____________________

88. Illegible

99. NR

3o. (3o.ab.sp, 3o.oth.sp)

Results:

1. normal

2. abnormal (specify)

________________

3. other (specify)

______________

88. Illegible

99. NR

F. ULTRASOUND REPORTS (continued)

4a.

Date of scan

_ _ / _ _ / _ _ _ _

4b.

# fetuses

4c.

EGA – LMP

___ ___

4d.

EGA – US

___ ___

4e to 4n (4L.sp)

Reason (check all that apply)

(Each reason choice will be a separate y/n variable + other specify, IL, NR)

1. confirm dates

2. fetal growth

3. placenta

4. BPP

5. decreased fetal movement

6. amniotic fluid volume

7. malformation

8. other: (specify)

_____________________

88. Illegible

99. NR

4o. (4o.ab.sp, 4o.oth.sp)

Results:

1. normal

2. abnormal (specify)

________________

3. other (specify)

______________

88. Illegible

99. NR

5a.

Date of scan

_ _ / _ _ / _ _ _ _

5b.

# fetuses

5c.

EGA – LMP

___ ___

5d.

EGA – US

___ ___

5e to 5n (5l.sp)

Reason (check all that apply)

(Each reason choice will be a separate y/n variable + other specify, IL, NR)

1. confirm dates

2. fetal growth

3. placenta

4. BPP

5. decreased fetal movement

6. amniotic fluid volume

7. malformation

8. other: (specify)

_____________________

88. Illegible

99. NR

5o. (5o.ab.sp, 5o.oth.sp)

Results:

1. normal

2. abnormal (specify)

________________

3. other (specify)

______________

88. Illegible

99. NR

6a.

Date of scan

_ _ / _ _ / _ _ _ _

6b.

# fetuses

6c.

EGA – LMP

___ ___

6d.

EGA – US

___ ___

6e to 6n (6L.sp)

Reason (check all that apply)

(Each reason choice will be a separate y/n variable + other specify, IL, NR)

1. confirm dates

2. fetal growth

3. placenta

4. BPP

5. decreased fetal movement

6. amniotic fluid volume

7. malformation

8. other: (specify)

_____________________

88. Illegible

99. NR

6o. (6o.ab.sp, 6o.oth.sp)

Results:

1. normal

2. abnormal (specify)

________________

3. other (specify)

______________

88. Illegible

99. NR

Comments:

G. SUBSTANCE ABUSE INDEX PREGNANCY No information for any item in section

Drugs/Substance

3 months prior to conception through conception

Trimester 1

Weeks 1 – 12

Trimester 2 Weeks 13 – 26

Trimester 3

Weeks 27 – 40+

Date Stopped

1. Marijuana

1.ns

Hx of use during/near pregnancy but timing NOT specified?

1.pc

1. Yes

2. No

77 NA

88 Illegible

99 NR

1.t1

1. Yes

2. No

77 NA

88 Illegible

99 NR

1.t2

1. Yes

2. No

77 NA

88 Illegible

99 NR

1.t3

1. Yes

2. No

77 NA

88 Illegible

99 NR

1.ds

_ _ / _ _ / _ _ _ _

Ongoing Use

2. Cocaine

2.ns

Hx of use during/near pregnancy but timing NOT specified?

2.pc

1. Yes

2. No

77 NA

88 Illegible

99 NR

2.t1

1. Yes

2. No

77 NA

88 Illegible

99 NR

2.t2

1. Yes

2. No

77 NA

88 Illegible

99 NR

2.t3

1. Yes

2. No

77 NA

88 Illegible

99 NR

2.ds

_ _ / _ _ / _ _ _ _

Ongoing Use

3. Ecstasy, speed, methamphetamines

3.ns

Hx of use during/near pregnancy but timing NOT specified?

3.pc

1. Yes

2. No

77 NA

88 Illegible

99 NR

3.t1

1. Yes

2. No

77 NA

88 Illegible

99 NR

3.t2

1. Yes

2. No

77 NA

88 Illegible

99 NR

3.t3

1. Yes

2. No

77 NA

88 Illegible

99 NR

3.ds

_ _ / _ _ / _ _ _ _

Ongoing Use

4. Other

4.sp (specify):

4.ns

Hx of use during/near pregnancy but timing NOT specified?

4.pc

1. Yes

2. No

77 NA

88 Illegible

99 NR

4.t1

1. Yes

2. No

77 NA

88 Illegible

99 NR

4.t2

1. Yes

2. No

77 NA

88 Illegible

99 NR

4.t3

1. Yes

2. No

77 NA

88 Illegible

99 NR

4.ds

_ _ / _ _ / _ _ _ _

Ongoing Use

COMMENTS:

G. SUBSTANCE ABUSE (continued)

Drugs/Substance

3 months prior to conception

Trimester 1

Weeks 1 – 12

Trimester 2 Weeks 13 – 26

Trimester 3

Weeks 27 – 40+

Date Stopped

5. Tobacco

5.ns

Hx of use during/near pregnancy but timing NOT specified?

IF CHECKED:

5.2.notspec

Number ______

5.3.notspec

Unit

1. cigs/day

2. cigs/week

3. packs/day

4. packs/week

5. other ________

77 NA

88 Illegible

99 NR

5.1.pc

1. Yes

2. No

77 NA

88 Illegible

99 NR

5.2.pc

Number ______

5.3.pc

Unit

1. cigs/day

2. cigs/week

3. packs/day

4. packs/week

5. other ______

77 NA

88 Illegible

99 NR

5.1.t1

1. Yes

2. No

77 NA

88 Illegible

99 NR

5.2.t1

Number ______

5.3.t1

Unit

1. cigs/day

2. cigs/week

3. packs/day

4. packs/week

5. other ______

77 NA

88 Illegible

99 NR

5.1.t2

1. Yes

2. No

77 NA

88 Illegible

99 NR

5.2.t2

Number ______

5.3.t2

Unit

1. cigs/day

2. cigs/week

3. packs/day

4. packs/week

5. other ______

77 NA

88 Illegible

99 NR

5.1.t3

1. Yes

2. No

77 NA

88 Illegible

99 NR

5.2.t3

Number ______

5.3.t3

Unit

1. cigs/day

2. cigs/week

3. packs/day

4. packs/week

5. other _____

77 NA

88 Illegible

99 NR

5.ds

_ _ / _ _ / _ _ _ _

Ongoing Use

6. Alcohol

6.ns

Hx of use during/near pregnancy but timing NOT specified?

IF CHECKED:

6.1.ns

1. heavy

2. moderate

3. occasional

4. rare/min.

88 Illegible

99 NR

6.2.ns

Drink

Number ______

6.3.ns

Unit

1. drinks/day

2. drinks/week

3. drinks/mth

77 NA

88 Illegible

99 NR

6.1.pc

1. heavy

2. moderate

3. occasional

4. rare/min.

5. none

88 Illegible

99 NR

6.2.pc

Drink

Number ______

6.3.pc

Unit

1. drinks/day

2. drinks/week

3. drinks/mth

77 NA

88 Illegible

99 NR

6.1.t1

1. heavy

2. moderate

3. occasional

4. rare/min.

5. none

88 Illegible

99 NR

6.2.t1

Drink

Number ______

6.3.t1

Unit

1. drinks/day

2. drinks/week

3. drinks/mth

77 NA

88 Illegible

99 NR

6.1.t2

1. heavy

2. moderate

3. occasional

4. rare/min.

5. none

88 Illegible

99 NR

6.2.t2

Drink

Number ______

6.3.t2

Unit

1. drinks/day

2. drinks/week

3. drinks/mth

77 NA

88 Illegible

99 NR

6.1.t3

1. heavy

2. moderate

3. occasional

4. rare/min.

5. none

88 Illegible

99 NR

6.2.t3

Drink

Number ______

6.3.t3

Unit

1. drinks/day

2. drinks/week

3. drinks/mth

77 NA

88 Illegible

99 NR

6.ds

_ _ / _ _ / _ _ _ _

Ongoing Use

Comments:

H (part 1). MATERNAL INFECTIONS ANYTIME DURING INDEX PREGNANCY

Extra sheet provided in Appendix A if needed

Dx: Use codes from infection list (Appendix D)

If cultures or rapid strep screens were performed, note in section I.

If “yes” is indicated for medications, please fill out Section Q. No information for any item in section

1b.1

Date diagnosed

_ _ / _ _ / _ _ _ _

1b.ga

GA _____ wks

1b.tri

Trimester _____

Duration

______ days

Certainty of Dx

1. Lab/Test

2. Clinical

3. Suspect

9. unknown

1e.1

Highest Temp

_______

1e.2

Unit

1. ^oC

2 ^oF

88 IL

99 NR

1f.1

Lowest Temp

_______

1f.2

Unit

1. ^oC

2 ^oF

88 IL

99 NR

Cultures/Rapid Screen done?

1 Yes

2 No

88 IL

99 NR

Meds given?

1 Yes

2 No

88 IL

99 NR

2b.1

Date diagnosed

_ _ / _ _ / _ _ _ _

2b.ga

GA _____ wks

2b.tri

Trimester _____

Duration

______ days

Certainty of Dx

1. Lab/Test

2. Clinical

3. Suspect

9. unknown

2e.1

Highest Temp

_______

2e.2

Unit

1. ^oC

2 ^oF

88 IL

99 NR

2f.1

Lowest Temp

_______

2f.2

Unit

1. ^oC

2 ^oF

88 IL

99 NR

Cultures/Rapid Screen done?

1 Yes

2 No

88 IL

99 NR

Meds given?

1 Yes

2 No

88 IL

99 NR

3b.1

Date diagnosed

_ _ / _ _ / _ _ _ _

3b.ga

GA _____ wks

3b.tri

Trimester _____

Duration

______ days

Certainty of Dx

1. Lab/Test

2. Clinical

3. Suspect

9. unknown

3e.1

Highest Temp

_______

3e.2

Unit

1. ^oC

2 ^oF

88 IL

99 NR

3f.1

Lowest Temp

_______

3f.2

Unit

1. ^oC

2 ^oF

88 IL

99 NR

Cultures/Rapid Screen done?

1 Yes

2 No

88 IL

99 NR

Meds given?

1 Yes

2 No

88 IL

99 NR

4b.1

Date diagnosed

_ _ / _ _ / _ _ _ _

4b.ga

GA _____ wks

4b.tri

Trimester _____

Duration

______ days

Certainty of Dx

1. Lab/Test

2. Clinical

3. Suspect

9. unknown

4e.1

Highest Temp

_______

4e.2

Unit

1. ^oC

2 ^oF

88 IL

99 NR

4f.1

Lowest Temp

_______

4f.2

Unit

1. ^oC

2 ^oF

88 IL

99 NR

Cultures/Rapid Screen done?

1 Yes

2 No

88 IL

99 NR

Meds given?

1 Yes

2 No

88 IL

99 NR

Comments: Specify any other DX (code=600) as 1a.sp, 2a.sp, 3a.sp, 4a.sp

Also list other comments.

H (part 2). Fever >37.7 ^oC or 100 ^oF No information for any item in section

5 highest fevers

Date

Time

1a.1

Highest Temp

_______

1a.2

Unit

1. ^oC

2 ^oF

88 IL

99 NR

_ _ / _ _ / _ _ _ _

1c (military time)

___ ___ : ___ ___

2a.1

Highest Temp

_______

2a.2

Unit

1. ^oC

2 ^oF

88 IL

99 NR

_ _ / _ _ / _ _ _ _

2c (military time)

___ ___ : ___ ___

3a.1

Highest Temp

_______

3a.2

Unit

1. ^oC

2 ^oF

88 IL

99 NR

_ _ / _ _ / _ _ _ _

3c (military time)

___ ___ : ___ ___

4a.1

Highest Temp

_______

4a.2

Unit

1. ^oC

2 ^oF

88 IL

99 NR

_ _ / _ _ / _ _ _ _

4c (military time)

___ ___ : ___ ___

5a.1

Highest Temp

_______

5a.2

Unit

1. ^oC

2 ^oF

88 IL

99 NR

_ _ / _ _ / _ _ _ _

5c (military time)

___ ___ : ___ ___

Comments:

I.CULTURES/RAPID STREP SCREENS ANYTIME DURING INDEX PREGNANCY (RECORD ALL CULTURES /STREP SCREENS OBTAINED) Extra sheet provided in Appendix A if needed Indicate the number of the event from section H or ‘0’ If culture does not correspond to an event in section H. No information for any item in section Test/procedure for one or more items in section indicated but no information on dates, results, etc.
Source: 1 = amniotic fluid; 2 = placenta; 3 = cervix; 4 = vagina; 5 = urine; 6 = blood; 7 = sputum; 8=throat; 9 = stool; 10=wound; 11= other (specify); 88 = Illegible 99=Not recorded
1a – 20a REF	1b – 20b Date Cultured	1c–20c 1c.sp-20c.sp (specify) Source	1d – 20d (1d.6.sp – 20d.6.sp and 1d.9.sp – 20d.9.sp for specify fields) Results	1e – 20e Description (organisms, etc.)
	_ _ / _ _ / _ _ _ _		1. no growth 2. Normal flora 3. light growth 4. mod-heavy growth 5. growth noted, not specified 6. urine culture colony count (specify)_________________________ 7. rapid strep screen pos 8. rapid strep screen neg 9. other (specify)_________________________ 88. IL 99. NR
	_ _ / _ _ / _ _ _ _		1. no growth 2. Normal flora 3. light growth 4. mod-heavy growth 5. growth noted, not specified 6. urine culture colony count (specify)_________________________ 7. rapid strep screen pos 8. rapid strep screen neg 9. other (specify)_________________________ 88. IL 99. NR
	_ _ / _ _ / _ _ _ _		1. no growth 2. Normal flora 3. light growth 4. mod-heavy growth 5. growth noted, not specified 6. urine culture colony count (specify)_________________________ 7. rapid strep screen pos 8. rapid strep screen neg 9. other (specify)_________________________ 88. IL 99. NR
	_ _ / _ _ / _ _ _ _		1. no growth 2. Normal flora 3. light growth 4. mod-heavy growth 5. growth noted, not specified 6. urine culture colony count (specify)_________________________ 7. rapid strep screen pos 8. rapid strep screen neg 9. other (specify)_________________________ 88. IL 99. NR
	_ _ / _ _ / _ _ _ _		1. no growth 2. Normal flora 3. light growth 4. mod-heavy growth 5. growth noted, not specified 6. urine culture colony count (specify)_________________________ 7. rapid strep screen pos 8. rapid strep screen neg 9. other (specify)_________________________ 88. IL 99. NR

I.CULTURES/RAPID STREP SCREENS (continued)
Source: 1 = amniotic fluid; 2 = placenta; 3 = cervix; 4 = vagina; 5 = urine; 6 = blood; 7 = sputum; 8=throat; 9 = stool; 10=wound; 11= other (specify); 88 = Illegible 99=Not recorded
1a – 20a REF	1b – 20b Date Cultured	1c–20c 1c.sp-20c.sp (specify) Source	1d – 20d (1d.6.sp – 20d.6.sp and 1d.9.sp – 20d.9.sp for specify fields) Results	1e – 20e Description (organisms, etc.)
	_ _ / _ _ / _ _ _ _		1. no growth 2. Normal flora 3. light growth 4. mod-heavy growth 5. growth noted, not specified 6. urine culture colony count (specify)_________________________ 7. rapid strep screen pos 8. rapid strep screen neg 9. other (specify)_________________________ 88. IL 99. NR
	_ _ / _ _ / _ _ _ _		1. no growth 2. Normal flora 3. light growth 4. mod-heavy growth 5. growth noted, not specified 6. urine culture colony count (specify)_________________________ 7. rapid strep screen pos 8. rapid strep screen neg 9. other (specify)_________________________ 88. IL 99. NR
	_ _ / _ _ / _ _ _ _		1. no growth 2. Normal flora 3. light growth 4. mod-heavy growth 5. growth noted, not specified 6. urine culture colony count (specify)_________________________ 7. rapid strep screen pos 8. rapid strep screen neg 9. other (specify)_________________________ 88. IL 99. NR
	_ _ / _ _ / _ _ _ _		1. no growth 2. Normal flora 3. light growth 4. mod-heavy growth 5. growth noted, not specified 6. urine culture colony count (specify)_________________________ 7. rapid strep screen pos 8. rapid strep screen neg 9. other (specify)_________________________ 88. IL 99. NR
	_ _ / _ _ / _ _ _ _		1. no growth 2. Normal flora 3. light growth 4. mod-heavy growth 5. growth noted, not specified 6. urine culture colony count (specify)_________________________ 7. rapid strep screen pos 8. rapid strep screen neg 9. other (specify)_________________________ 88. IL 99. NR
Comments:

J. INJECTIONS/VACCINATIONS DURING INDEX PREGNANCY

Extra sheet provided in Appendix A if needed

No information for any item in section

Injection/Vaccination

1. Rhogam (other RH(D)) Immunoglobulin

1 Yes

2 No

88 IL

99 NR

Date

(1.dt1, 1.dt2)

1st _ _ / _ _ / _ _ _ _

2nd _ _ / _ _ / _ _ _ _

Dose

(1.ds.1, 1.ds.2)

1st __________

2nd ________

Manufacturer

(1.m.1, 1.m.2)

1st _________

2nd ________

Product Name

(1.p.1, 1.p.2)

1st _________

2nd ________

Lot #

(1.lot.1, 1.lot.2)

_________

__________

2. Influenza Vaccine

1 Yes

2 No

88 IL

99 NR

2.dt

Date

_ _ / _ _ / _ _ _ _

2.m

Manufacturer

______________

2.lot

Lot #

___________

3. Other

1 Yes

2 No

88 IL

99 NR

3a.sp

(specify)

_________________

3a.dt

Date

_ _ / _ _ / _ _ _ _

3a.m

Manufacturer

______________

3a.lot

Lot #

___________

3b.sp

Other (specify)

_________________

3b.dt

Date

_ _ / _ _ / _ _ _ _

3b.m

Manufacturer

______________

3b.lot

Lot #

___________

3c.sp

Other (specify)

_________________

3c.dt

Date

_ _ / _ _ / _ _ _ _

3c.m

Manufacturer

______________

3c.lot

Lot #

___________

3d.sp

Other (specify)

_________________

3d.dt

Date

_ _ / _ _ / _ _ _ _

3d.m

Manufacturer

______________

3d.lot

Lot #

___________

3e.sp

Other (specify)

_________________

3e.dt

Date

_ _ / _ _ / _ _ _ _

3e.m

Manufacturer

______________

3e.lot

Lot #

___________

3f.sp

Other (specify)

_________________

3f.dt

Date

_ _ / _ _ / _ _ _ _

3f.m

Manufacturer

______________

3f.lot

Lot #

___________

Comments:

K.VAGINAL BLEEDING ANYTIME DURING INDEX PREGNANCY

Extra sheet provided in Appendix A if needed

No information for any item in section

Dx: 1 = Placenta Previa; 2 = Placenta Abruption; 3 = Trauma; 4 = Effaced/Dilated; 5 = Uterine Rupture; 6 = Implantation Bleeding; 7 = Placenta Accreta; 8 = Other (specify); 88=Illegible, 99=Not Recorded

If “yes” is indicated for medications, please fill out Section Q

1a.

Date Occurred

_ _ / _ _ / _ _ _ _

1a.ga GA _____ wks

1a.tri Trimester _____

1b.

Dx (code)

______

If dx=8:

1b.sp

Other, specify

_____________

1c.

Duration

__ __

1c.unit

Unit

1. days

2. weeks

88 Illegible

99 NR

1d.

Pain

1. Yes

2. No (stated)

3. Suspect

88 Illegible

99 NR

1e.

Cramping

1. Yes

2. No (stated)

3. Suspect

88 Illegible

99 NR

1f.

Medication Given

1. Yes

2. No (stated)

88 Illegible

99 NR

2a.

Date Occurred

_ _ / _ _ / _ _ _ _

2a.ga GA _____ wks

2a.tri Trimester _____

2b.

Dx (code)

______

If dx=8:

2b.sp

Other, specify

_____________

2c.

Duration

__ __

2c.unit

Unit

1. days

2. weeks

88 Illegible

99 NR

2d.

Pain

1. Yes

2. No (stated)

3. Suspect

88 Illegible

99 NR

2e.

Cramping

1. Yes

2. No (stated)

3. Suspect

88 Illegible

99 NR

2f.

Medication Given

1. Yes

2. No (stated)

88 Illegible

99 NR

3a.

Date Occurred

_ _ / _ _ / _ _ _ _

3a.ga GA _____ wks

3a.tri Trimester _____

3b.

Dx (code)

______

If dx=8:

3b.sp

Other, specify

_____________

3c.

Duration

__ __

3c.unit

Unit

1. days

2. weeks

88 Illegible

99 NR

3d.

Pain

1. Yes

2. No (stated)

3. Suspect

88 Illegible

99 NR

3e.

Cramping

1. Yes

2. No (stated)

3. Suspect

88 Illegible

99 NR

3f.

Medication Given

1. Yes

2. No (stated)

88 Illegible

99 NR

4a.

Date Occurred

_ _ / _ _ / _ _ _ _

4a.ga GA _____ wks

4a.tri Trimester _____

4b.

Dx (code)

______

If dx=8:

4b.sp

Other, specify

_____________

4c.

Duration

__ __

4c.unit

Unit

1. days

2. weeks

88 Illegible

99 NR

4d.

Pain

1. Yes

2. No (stated)

3. Suspect

88 Illegible

99 NR

4e.

Cramping

1. Yes

2. No (stated)

3. Suspect

88 Illegible

99 NR

4f.

Medication Given

1. Yes

2. No (stated)

88 Illegible

99 NR

Comments:

L. PRETERM LABOR DURING INDEX PREGNANCY

If “yes” is indicated for medications, please fill out Section Q.

Extra sheet provided in Appendix A if needed

No information for any item in section

1a.

Date Reported

_ _ / _ _ / _ _ _ _

1a.ga GA _____ wks

1a.tri Trimester _____

1b.

Onset of s/s per patient

1. no s/s (stated)

2. < 12 h

3. 12 – 24 h

4. > 24 h

88 Illegible

99 NR

1c. and 1c.sp

Signs/symptoms

1. uterine contractions

2. cramping (per patient)

3. cervical change

4. PROM

5. other, specify ________________________

88 Illegible

99 NR

1d. and 1d.sp

Treatments

1. meds (fill out section Q)

2. bed rest

3. IV Hydration

4. other, specify ________________________

88 Illegible

99 NR

Date Occurred

_ _ / _ _ / _ _ _ _

2a.ga GA _____ wks

2a.tri Trimester _____

2b.

Onset of s/s per patient

1. no s/s (stated)

2. < 12 h

3. 12 – 24 h

4. > 24 h

88 Illegible

99 NR

2c. and 2c.sp

Signs/symptoms

1. uterine contractions

2. cramping (per patient)

3. cervical change

4. PROM

5. other, specify ________________________

88 Illegible

99 NR

2d. and 2d.sp

Treatments

1. meds (fill out section Q)

2. bed rest

3. IV Hydration

4. other, specify ________________________

88 Illegible

99 NR

3a.

Date Occurred

_ _ / _ _ / _ _ _ _

3a.ga GA _____ wks

3a.tri Trimester _____

3b.

Onset of s/s per patient

1. no s/s (stated)

2. < 12 h

3. 12 – 24 h

4. > 24 h

88 Illegible

99 NR

3c. and 3c.sp

Signs/symptoms

1. uterine contractions

2. cramping (per patient)

3. cervical change

4. PROM

5. other, specify ________________________

88 Illegible

99 NR

3d. and 3d.sp

Treatments

1. meds (fill out section Q)

2. bed rest

3. IV Hydration

4. other, specify ________________________

88 Illegible

99 NR

4a.

Date Occurred

_ _ / _ _ / _ _ _ _

4a.ga GA _____ wks

4a.tri Trimester _____

4b.

Onset of s/s per patient

1. no s/s (stated)

2. < 12 h

3. 12 – 24 h

4. > 24 h

88 Illegible

99 NR

4c. and 4c.sp

Signs/symptoms

1. uterine contractions

2. cramping (per patient)

3. cervical change

4. PROM

5. other, specify ________________________

88 Illegible

99 NR

4d. and 4d.sp

Treatments

1. meds (fill out section Q)

2. bed rest

3. IV Hydration

4. other, specify ________________________

88 Illegible

99 NR

Comments:

M (part 1). MEDICAL CONDITIONS PRECEDING OR DURING INDEX PREGNANCY

Extra sheet provided in Appendix A if needed

Use codes from Medical History List (Appendix E) -- M indicates medical condition

If “yes” is indicated for medications, please fill out Section Q

No information for any item in section

Precision Code: 1 = Definite diagnosis – ICD or DSM code listed in the provider record; 2 = Specific diagnosis listed by provider in record but no ICD/DSM code listed; 3 = Signs and symptoms of a condition noted by provider in record but diagnosis unclear; 88=Illegible; 99=NR

No.

Condition Code (appendix)

1a.-20a

Precision Code

1b-20b

Time Period Condition Active (Check all that apply)

1c.pc - 20c.pc 1c.t1 - 20c.t1 1c.t2 - 20c.t2,

1c.t3 - 20c.t3 1c.ns - 20c.ns

1c.IL - 20c.IL 1c.NR - 20c.NR

Date/Age at First Diagnosis

1d.date - 20d.date

1d.age - 20d.age

Medication Given

1e - 20e

1. Active before index pregnancy

2. Active during 1^st trimester (1-13 weeks GA)

3. Active during 2^nd trimester (14-26 weeks GA)

4. Active during 3^rd trimester (27-40+ weeks GA)

5. Active during index pregnancy, trimester unknown

88. Illegible

99. NR

Date:

_ _ / _ _ / _ _ _ _

Age: ___ ___

1. Yes

2. No

88. IL

99. NR

1. Active before index pregnancy

2. Active during 1^st trimester (1-13 weeks GA)

3. Active during 2^nd trimester (14-26 weeks GA)

4. Active during 3^rd trimester (27-40+ weeks GA)

5. Active during index pregnancy, trimester unknown

88. Illegible

99. NR

Date:

_ _ / _ _ / _ _ _ _

Age: ___ ___

1. Yes

2. No

88. IL

99. NR

1. Active before index pregnancy

2. Active during 1^st trimester (1-13 weeks GA)

3. Active during 2^nd trimester (14-26 weeks GA)

4. Active during 3^rd trimester (27-40+ weeks GA)

5. Active during index pregnancy, trimester unknown

88. Illegible

99. NR

Date:

_ _ / _ _ / _ _ _ _

Age: ___ ___

1. Yes

2. No

88. IL

99. NR

1. Active before index pregnancy

2. Active during 1^st trimester (1-13 weeks GA)

3. Active during 2^nd trimester (14-26 weeks GA)

4. Active during 3^rd trimester (27-40+ weeks GA)

5. Active during index pregnancy, trimester unknown

88. Illegible

99. NR

Date:

_ _ / _ _ / _ _ _ _

Age: ___ ___

1. Yes

2. No

88. IL

99. NR

1. Active before index pregnancy

2. Active during 1^st trimester (1-13 weeks GA)

3. Active during 2^nd trimester (14-26 weeks GA)

4. Active during 3^rd trimester (27-40+ weeks GA)

5. Active during index pregnancy, trimester unknown

88. Illegible

99. NR

Date:

_ _ / _ _ / _ _ _ _

Age: ___ ___

1. Yes

2. No

88. IL

99. NR

1. Active before index pregnancy

2. Active during 1^st trimester (1-13 weeks GA)

3. Active during 2^nd trimester (14-26 weeks GA)

4. Active during 3^rd trimester (27-40+ weeks GA)

5. Active during index pregnancy, trimester unknown

88. Illegible

99. NR

Date:

_ _ / _ _ / _ _ _ _

Age: ___ ___

1. Yes

2. No

88. IL

99. NR

Comments:

M (part 2). PSYCHIATRIC/BEHAVIORAL/DEVELOPMENTAL CONDITIONS PRECEDING OR DURING INDEX PREGNANCY

Extra sheet provided in Appendix A if needed

Use codes from Medical History List (Appendix E) – PBD indicates psychiatric/ behavioral/ developmental condition

If “yes” is indicated for medications, please fill out Section Q

No information for any item in section

No.

Condition Code (appendix)

1a.-20a

Precision Code

1b-20b

Time Period Condition Active (Check all that apply)

1c.pc - 20c.pc 1c.t1 - 20c.t1 1c.t2 - 20c.t2,

1c.t3 - 20c.t3 1c.ns - 20c.ns

1c.IL - 20c.IL 1c.NR - 20c.NR

Date/Age at First Diagnosis

1d.date - 20d.date

1d.age - 20d.age

Medication Given

1e - 20e

1. Active before index pregnancy

2. Active during 1^st trimester (1-13 weeks GA)

3. Active during 2^nd trimester (14-26 weeks GA)

4. Active during 3^rd trimester (27-40+ weeks GA)

5. Active during index pregnancy, trimester unknown

88. Illegible

99. NR

Date:

_ _ / _ _ / _ _ _ _

Age: ___ ___

1. Yes

2. No

88. IL

99. NR

1. Active before index pregnancy

2. Active during 1^st trimester (1-13 weeks GA)

3. Active during 2^nd trimester (14-26 weeks GA)

4. Active during 3^rd trimester (27-40+ weeks GA)

5. Active during index pregnancy, trimester unknown

88. Illegible

99. NR

Date:

_ _ / _ _ / _ _ _ _

Age: ___ ___

1. Yes

2. No

88. IL

99. NR

1. Active before index pregnancy

2. Active during 1^st trimester (1-13 weeks GA)

3. Active during 2^nd trimester (14-26 weeks GA)

4. Active during 3^rd trimester (27-40+ weeks GA)

5. Active during index pregnancy, trimester unknown

88. Illegible

99. NR

Date:

_ _ / _ _ / _ _ _ _

Age: ___ ___

1. Yes

2. No

88. IL

99. NR

1. Active before index pregnancy

2. Active during 1^st trimester (1-13 weeks GA)

3. Active during 2^nd trimester (14-26 weeks GA)

4. Active during 3^rd trimester (27-40+ weeks GA)

5. Active during index pregnancy, trimester unknown

88. Illegible

99. NR

Date:

_ _ / _ _ / _ _ _ _

Age: ___ ___

1. Yes

2. No

88. IL

99. NR

1. Active before index pregnancy

2. Active during 1^st trimester (1-13 weeks GA)

3. Active during 2^nd trimester (14-26 weeks GA)

4. Active during 3^rd trimester (27-40+ weeks GA)

5. Active during index pregnancy, trimester unknown

88. Illegible

99. NR

Date:

_ _ / _ _ / _ _ _ _

Age: ___ ___

1. Yes

2. No

88. IL

99. NR

1. Active before index pregnancy

2. Active during 1^st trimester (1-13 weeks GA)

3. Active during 2^nd trimester (14-26 weeks GA)

4. Active during 3^rd trimester (27-40+ weeks GA)

5. Active during index pregnancy, trimester unknown

88. Illegible

99. NR

Date:

_ _ / _ _ / _ _ _ _

Age: ___ ___

1. Yes

2. No

88. IL

99. NR

Comments

N. PRENATAL PROCEDURES INDEX PREGNANCY

No information for any item in section

Procedure

1a. Fetal Echocardiogram

1 Yes

2 No

88 IL

99 NR

1b. Date:

_ _ / _ _ / _ _ _ _

1c. Results

1. normal

2. abnormal

88. IL

99. NR

2a. External Version

1 Yes

2 No

88 IL

99 NR

2b.

# attempts _________

2c. Results

1. successful

2. unsuccessful

88. IL

99. NR

3a. Fetal Reduction

1 Yes

2 No

88 IL

99 NR

3b. Date:

_ _ / _ _ / _ _ _ _

3c.1

# of fetuses originally _____

3c.2

# of fetuses remaining _____

4a. Cerclage

1 Yes

2 No

88 IL

99 NR

4b.1

Date Placed: _ _ / _ _ / _ _ _ _

4b.2

Date Removed: _ _ / _ _ / _ _ _ _

5a. Fetal Transfusion

1 Yes

2 No

88 IL

99 NR

5b. Date:

_ _ / _ _ / _ _ _ _

5c. Reason:

6a. Fetal Surgery

1 Yes

2 No

88 IL

99 NR

6b. Date:

_ _ / _ _ / _ _ _ _

6c. Type/Description:

7a. Nonstress Test (NST)

1 Yes

2 No

88 IL

99 NR

7b. 2

Date: _ _ / _ _ / _ _ _ _

7b.1 Date: _ _ / _ _ / _ _ _ _

7c.1 and 7c.2 Findings:

8a. Contraction Stress Test (CST)

1 Yes

2 No

88 IL

99 NR

8b. Date:

_ _ / _ _ / _ _ _ _

8c. Findings:

9a and 9a.sp Other,

1 Yes: specify ________________

2 No

88 IL

99 NR

9b Date:

_ _ / _ _ / _ _ _ _

9c Specify findings:

Comments:

O. OTHER CONDITIONS OR TRAUMA ANYTIME DURING INDEX PREGNANCY Record only conditions NOT covered in other sections on this form that detail maternal conditions (B, H, K, L, M). Extra sheet provided in Appendix A if needed No information for any item in section
Dx: 1 = Decreased Fetal Movement; 2 = Trauma/Injury; 3 = Oligohydramnios; 4 = Polyhydramnios; 5 = IUGR; 6 = Macrosomia; 7 = loss of consciousness; 8 = Spontaneous Reduction; 10 = other, (specify); 88=IL; 99=NR If “yes” is indicated for medications, please fill out Section Q
1a.date – 10a.date OR 1a.ga – 10a.ga OR 1a.tri – 10a.tri	1b – 10b	1c – 10c	1d – 10d
Date Reported _ _ / _ _ / _ _ _ _ OR GA _____ _____wks OR Trimester ___	Dx	Description	Medication Given 1. Yes 2. No 88. IL 99. NR
Date Reported _ _ / _ _ / _ _ _ _ OR GA _____ _____wks OR Trimester ___	Dx	Description	Medication Given 1. Yes 2. No 88. IL 99. NR
Date Reported _ _ / _ _ / _ _ _ _ OR GA _____ _____wks OR Trimester ___	Dx	Description	Medication Given 1. Yes 2. No 88. IL 99. NR
Date Reported _ _ / _ _ / _ _ _ _ OR GA _____ _____wks OR Trimester ___	Dx	Description	Medication Given 1. Yes 2. No 88. IL 99. NR
Date Reported _ _ / _ _ / _ _ _ _ OR GA _____ _____wks OR Trimester ___	Dx	Description	Medication Given 1. Yes 2. No 88. IL 99. NR
Date Reported _ _ / _ _ / _ _ _ _ OR GA _____ _____wks OR Trimester ___	Dx	Description	Medication Given 1. Yes 2. No 88. IL 99. NR
Date Reported _ _ / _ _ / _ _ _ _ OR GA _____ _____wks OR Trimester ___	Dx	Description	Medication Given 1. Yes 2. No 88. IL 99. NR
Date Reported _ _ / _ _ / _ _ _ _ OR GA _____ _____wks OR Trimester ___	Dx	Description	Medication Given 1. Yes 2. No 88. IL 99. NR
Date Reported _ _ / _ _ / _ _ _ _ OR GA _____ _____wks OR Trimester ___	Dx	Description	Medication Given 1. Yes 2. No 88. IL 99. NR
Comments:

P. HOSPITAL ADMISSIONS/VISITS INDEX PREGNANCY (INPATIENT AND OUTPATIENT)

Do NOT include admissions for delivery. These should be recorded in Section D (#5).

Do NOT include admissions for prenatal testing. These should be recorded in Section N.

For the medical history code(s), use codes from either Appendix D or Appendix E (indicate as d.# or E.#)

If “yes” is indicated for medications, please fill out Section Q.

Extra sheet provided in Appendix A if needed

No information for any item in section

1a. Treated in/as

1 ER 2. outpatient

3. inpatient

88. IL 99. NR

1b. Hospital/Facility

1c Admit Date

_ _ / _ _ / _ _ _ _

1d GA

1e Discharge Date

_ _ / _ _ / _ _ _ _

1f .1-1f.8 and 1f.sp

Procedures (check all that apply)

1. x-rays, including dental

2. mammograms

3. CT/CAT scans

4. MRI/Magnetic Resonance

5. Radionuclide study or scan

6. radiation treatments or scan

7. other, specify ________________________

88. IL

99. NR

1g.icd1 Dx 1

ICD9

1g.prob1 Dx 1

Problem

1g.mhc1 Dx 1

Medical History Code

1h.1-1h.5 and 1h.sp

Treatment: (all that apply)

1. Surgery

2. Meds

3. Other, specify____________________________________

88. IL

99. none recorded

1g.icd2 Dx 2

ICD9

1g.prob2 Dx 2

Problem

1g.mhc2 Dx 2

Medical History Code

1g.icd3 Dx 3

ICD9

1g.prob3 Dx 3

Problem

1g.mhc3 Dx 3

Medical History Code

2a. Treated in/as

1 ER 2. outpatient

3. inpatient

88. IL 99. NR

2b. Hospital/Facility

2c Admit Date

_ _ / _ _ / _ _ _ _

2d GA

2e Discharge Date

_ _ / _ _ / _ _ _ _

2f .1-2f.8 and 2f.sp

Procedures

1. x-rays, including dental

2. mammograms

3. CT/CAT scans

4. MRI/Magnetic Resonance

5. Radionuclide study or scan

6. radiation treatments or scan

7. other, specify ________________________

88. IL

99. NR

2g.icd1 Dx 1

ICD9

2g.prob1 Dx 1

Problem

2g.mhc1 Dx 1

Medical History Code

2h.1-2h.5 and 2h.sp

Treatment (all that apply)

1. Surgery

2. Meds

3. Other, specify____________________________________

88. IL

99. none recorded

2g.icd2 Dx 2

ICD9

2g.prob2 Dx 2

Problem

2g.mhc2 Dx 2

Medical History Code

2g.icd3 Dx 3

ICD9

2g.prob3 Dx 3

Problem

2g.mhc3 Dx 3

Medical History Code

3a. Treated in/as

1 ER 2. outpatient

3. inpatient

88. IL 99. NR

3b. Hospital/Facility

3c Admit Date

_ _ / _ _ / _ _ _ _

3d GA

3e Discharge Date

_ _ / _ _ / _ _ _ _

3f .1-3f.8 and 3f.sp

Procedures

1. x-rays, including dental

2. mammograms

3. CT/CAT scans

4. MRI/Magnetic Resonance

5. Radionuclide study or scan

6. radiation treatments or scan

7 other, specify ________________________

88. IL

99. NR

3g.icd1 Dx 1

ICD9

3g.prob1 Dx 1

Problem

3g.mhc1 Dx 1

Medical History Code

3h.1-3h.5 and 3h.sp

Treatment (all that apply)

1. Surgery

2. Meds

3. Other, specify____________________________________

88. IL

99. none recorded

3g.icd2 Dx 2

ICD9

3g.prob2 Dx 2

Problem

3g.mhc2 Dx 2

Medical History Code

3g.icd3 Dx 3

ICD9

3g.prob3 Dx 3

Problem

3g.mhc3 Dx 3

Medical History Code

P. HOSPITAL ADMISSIONS/VISITS INDEX PREGNANCY (INPATIENT AND OUTPATIENT) (continued)

4a. Treated in/as

1 ER 2. outpatient

3. inpatient

88. IL 99. NR

4b. Hospital/Facility

4c Admit Date

_ _ / _ _ / _ _ _ _

4d GA

4e Discharge Date

_ _ / _ _ / _ _ _ _

4f .1-4f.8 and 4f.sp

Procedures

1. x-rays, including dental

2. mammograms

3. CT/CAT scans

4. MRI/Magnetic Resonance

5. Radionuclide study or scan

6. radiation treatments or scan

7. other, specify ________________________

88. IL

99. NR

4g.icd1 Dx 1

ICD9

4g.prob1 Dx 1

Problem

4g.mhc1 Dx 1

Medical History Code

4h.1-4h.5 and 4h.sp

Treatment (all that apply)

1. Surgery

2. Meds

3. Other, specify____________________________________

88. IL

99. none recorded

4g.icd2 Dx 2

ICD9

4g.prob2 Dx 2

Problem

4g.mhc2 Dx 2

Medical History Code

4g.icd3 Dx 3

ICD9

4g.prob3 Dx 3

Problem

4g.mhc3 Dx 3

Medical History Code

Comments:

Q. ALL MEDICATIONS (INCLUDING ALL ANTI-INFECTIVES, STEROIDS, HORMONES, AND OTHER MEDICATIONS) GIVEN THREE MONTHS PRIOR TO INDEX PREGNANCY OR DURING INDEX PREGNANCY Extra sheet provided in Appendix A if needed

Indicate the number of the event from the corresponding section.

If the medication does not correspond to a section above, enter ‘0’. No information for any item in section

Drug Codes: 9 = Steroids (lung maturity); 10 = antidiabetes; 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 agents; 23 = ergotrate; 24 = antidepressants; 25 = prenatal vitamins; 26 = asthma; 27 = preterm labor prevention; 28 = other (specify); 99 = unknown

Exclusions: laxatives, enemas, disinfectants, cough medicine, non-prenatal vitamins, antacids, stool softeners, benadryl, Tylenol, methergine

1a - 30a

Refer

1b - 30b

Code

1c - 30c

Drug Name

1d - 30d

Start Date

1e - 30e

1e.ep – 30e.ep

Stop Date

1f - 30f

1f.sp – 30f.sp

Dose

1g - 30g

1g.sp – 30g.sp

Unit

1h - 30h

1h.sp – 30h.sp

Freq

_ _ / _ _ / _ _ _ _

Entire pregnancy or ongoing

8. variable

1. gm

2. mg

3. mcg

4. mU

5. cc/ml

8. other_____

77. NA

88. Illegible

99. NR

1. QD

2. BID

3. TID

4. QID

5. PRN

6. Every ___ hrs

7. Per week

8. Total dose

77. NA

88. Illegible

99. NR

_ _ / _ _ / _ _ _ _

Entire pregnancy or ongoing

8. variable

1. gm

2. mg

3. mcg

4. mU

5. cc/ml

8. other_____

77. NA

88. Illegible

99. NR

1. QD

2. BID

3. TID

4. QID

5. PRN

6. Every ___ hrs

7. Per week

8. Total dose

77. NA

88. Illegible

99. NR

_ _ / _ _ / _ _ _ _

Entire pregnancy or ongoing

8. variable

1. gm

2. mg

3. mcg

4. mU

5. cc/ml

8. other_____

77. NA

88. Illegible

99. NR

1. QD

2. BID

3. TID

4. QID

5. PRN

6. Every ___ hrs

7. Per week

8. Total dose

77. NA

88. Illegible

99. NR

_ _ / _ _ / _ _ _ _

Entire pregnancy or ongoing

8. variable

1. gm

2. mg

3. mcg

4. mU

5. cc/ml

8. other_____

77. NA

88. Illegible

99. NR

1. QD

2. BID

3. TID

4. QID

5. PRN

6. Every ___ hrs

7. Per week

8. Total dose

77. NA

88. Illegible

99. NR

Q. ALL MEDICATIONS (continued)

Exclusions: laxatives, enemas, disinfectants, cough medicine, non-prenatal vitamins, antacids, stool softeners, benadryl, Tylenol, methergine

1a - 30a

Refer

1b - 30b

Code

1c - 30c

Drug Name

1d - 30d

Start Date

1e - 30e

1e.ep – 30e.ep

Stop Date

1f - 30f

1f.sp – 30f.sp

Dose

1g - 30g

1g.sp – 30g.sp

Unit

1h - 30h

1h.sp – 30h.sp

Freq

_ _ / _ _ / _ _ _ _

Entire pregnancy or ongoing

8. variable

1. gm

2. mg

3. mcg

4. mU

5. cc/ml

8. other_____

77. NA

88. Illegible

99. NR

1. QD

2. BID

3. TID

4. QID

5. PRN

6. Every ___ hrs

7. Per week

8. Total dose

77. NA

88. Illegible

99. NR

_ _ / _ _ / _ _ _ _

Entire pregnancy or ongoing

8. variable

1. gm

2. mg

3. mcg

4. mU

5. cc/ml

8. other_____

77. NA

88. Illegible

99. NR

1. QD

2. BID

3. TID

4. QID

5. PRN

6. Every ___ hrs

7. Per week

8. Total dose

77. NA

88. Illegible

99. NR

_ _ / _ _ / _ _ _ _

Entire pregnancy or ongoing

8. variable

1. gm

2. mg

3. mcg

4. mU

5. cc/ml

8. other_____

77. NA

88. Illegible

99. NR

1. QD

2. BID

3. TID

4. QID

5. PRN

6. Every ___ hrs

7. Per week

8. Total dose

77. NA

88. Illegible

99. NR

_ _ / _ _ / _ _ _ _

Entire pregnancy or ongoing

8. variable

1. gm

2. mg

3. mcg

4. mU

5. cc/ml

8. other_____

77. NA

88. Illegible

99. NR

1. QD

2. BID

3. TID

4. QID

5. PRN

6. Every ___ hrs

7. Per week

8. Total dose

77. NA

88. Illegible

99. NR

Q. ALL MEDICATIONS (continued)

Exclusions: laxatives, enemas, disinfectants, cough medicine, non-prenatal vitamins, antacids, stool softeners, benadryl, Tylenol, methergine

1a - 30a

Refer

1b - 30b

Code

1c - 30c

Drug Name

1d - 30d

Start Date

1e - 30e

1e.ep – 30e.ep

Stop Date

1f - 30f

1f.sp – 30f.sp

Dose

1g - 30g

1g.sp – 30g.sp

Unit

1h - 30h

1h.sp – 30h.sp

Freq

_ _ / _ _ / _ _ _ _

Entire pregnancy or ongoing

8. variable

1. gm

2. mg

3. mcg

4. mU

5. cc/ml

8. other_____

77. NA

88. Illegible

99. NR

1. QD

2. BID

3. TID

4. QID

5. PRN

6. Every ___ hrs

7. Per week

8. Total dose

77. NA

88. Illegible

99. NR

_ _ / _ _ / _ _ _ _

Entire pregnancy or ongoing

8. variable

1. gm

2. mg

3. mcg

4. mU

5. cc/ml

8. other_____

77. NA

88. Illegible

99. NR

1. QD

2. BID

3. TID

4. QID

5. PRN

6. Every ___ hrs

7. Per week

8. Total dose

77. NA

88. Illegible

99. NR

_ _ / _ _ / _ _ _ _

Entire pregnancy or ongoing

8. variable

1. gm

2. mg

3. mcg

4. mU

5. cc/ml

8. other_____

77. NA

88. Illegible

99. NR

1. QD

2. BID

3. TID

4. QID

5. PRN

6. Every ___ hrs

7. Per week

8. Total dose

77. NA

88. Illegible

99. NR

_ _ / _ _ / _ _ _ _

Entire pregnancy or ongoing

8. variable

1. gm

2. mg

3. mcg

4. mU

5. cc/ml

8. other_____

77. NA

88. Illegible

99. NR

1. QD

2. BID

3. TID

4. QID

5. PRN

6. Every ___ hrs

7. Per week

8. Total dose

77. NA

88. Illegible

99. NR

Q. ALL MEDICATIONS (continued)

Exclusions: laxatives, enemas, disinfectants, cough medicine, non-prenatal vitamins, antacids, stool softeners, benadryl, Tylenol, methergine

1a - 30a

Refer

1b - 30b

Code

1c - 30c

Drug Name

1d - 30d

Start Date

1e - 30e

1e.ep – 30e.ep

Stop Date

1f - 30f

1f.sp – 30f.sp

Dose

1g - 30g

1g.sp – 30g.sp

Unit

1h - 30h

1h.sp – 30h.sp

Freq

_ _ / _ _ / _ _ _ _

Entire pregnancy or ongoing

8. variable

1. gm

2. mg

3. mcg

4. mU

5. cc/ml

8. other_____

77. NA

88. Illegible

99. NR

1. QD

2. BID

3. TID

4. QID

5. PRN

6. Every ___ hrs

7. Per week

8. Total dose

77. NA

88. Illegible

99. NR

_ _ / _ _ / _ _ _ _

Entire pregnancy or ongoing

8. variable

1. gm

2. mg

3. mcg

4. mU

5. cc/ml

8. other_____

77. NA

88. Illegible

99. NR

1. QD

2. BID

3. TID

4. QID

5. PRN

6. Every ___ hrs

7. Per week

8. Total dose

77. NA

88. Illegible

99. NR

_ _ / _ _ / _ _ _ _

Entire pregnancy or ongoing

8. variable

1. gm

2. mg

3. mcg

4. mU

5. cc/ml

8. other_____

77. NA

88. Illegible

99. NR

1. QD

2. BID

3. TID

4. QID

5. PRN

6. Every ___ hrs

7. Per week

8. Total dose

77. NA

88. Illegible

99. NR

_ _ / _ _ / _ _ _ _

Entire pregnancy or ongoing

8. variable

1. gm

2. mg

3. mcg

4. mU

5. cc/ml

8. other_____

77. NA

88. Illegible

99. NR

1. QD

2. BID

3. TID

4. QID

5. PRN

6. Every ___ hrs

7. Per week

8. Total dose

77. NA

88. Illegible

99. NR

Appendix A

CONTINUATION SHEETS

CONTRIBUTING PROVIDERS Continuation Sheet Data labeling scheme for providers listed on continuation sheets should follow original (see A-E labeling) beginning with F.
1. Name of Provider/Hospital
2. Street Address				2. Street Address
3. City		3. City		3. City
ABSTRACTION LOG
6. Date__ __/__ __/__ __ __ __	6. Date__ __/__ __/__ __ __ __		6. Date__ __/__ __/__ __ __ __
6.1 to 6.8 Time (use military time)* Start __ __ : __ __ Stop __ __: __ __ Start __ __ : __ __ Stop __ __: __ __ Start __ __ : __ __ Stop __ __: __ __ Start __ __ : __ __ Stop __ __: __ __	6.1 to 6.8 Time (use military time)* Start __ __ : __ __ Stop __ __: __ __ Start __ __ : __ __ Stop __ __: __ __ Start __ __ : __ __ Stop __ __: __ __ Start __ __ : __ __ Stop __ __: __ __		6.1 to 6.8 Time (use military time)* Start __ __ : __ __ Stop __ __: __ __ Start __ __ : __ __ Stop __ __: __ __ Start __ __ : __ __ Stop __ __: __ __ Start __ __ : __ __ Stop __ __: __ __
9. Date__ __/__ __/__ __ __ __	9. Date__ __/__ __/__ __ __ __		9. Date__ __/__ __/__ __ __ __
9.1 to 9.8 Time (use military time)* Start __ __ : __ __ Stop __ __: __ __ Start __ __ : __ __ Stop __ __: __ __ Start __ __ : __ __ Stop __ __: __ __ Start __ __ : __ __ Stop __ __: __ __	9.1 to 9.8 Time (use military time)* Start __ __ : __ __ Stop __ __: __ __ Start __ __ : __ __ Stop __ __: __ __ Start __ __ : __ __ Stop __ __: __ __ Start __ __ : __ __ Stop __ __: __ __		9.1 to 9.8 Time (use military time)* Start __ __ : __ __ Stop __ __: __ __ Start __ __ : __ __ Stop __ __: __ __ Start __ __ : __ __ Stop __ __: __ __ Start __ __ : __ __ Stop __ __: __ __
1. Name of Provider/Hospital
2. Street Address				2. Street Address
3. City		3. City		3. City
ABSTRACTION LOG
6. Date__ __/__ __/__ __ __ __	6. Date__ __/__ __/__ __ __ __		6. Date__ __/__ __/__ __ __ __
6.1 to 6.8 Time (use military time)* Start __ __ : __ __ Stop __ __: __ __ Start __ __ : __ __ Stop __ __: __ __ Start __ __ : __ __ Stop __ __: __ __ Start __ __ : __ __ Stop __ __: __ __	6.1 to 6.8 Time (use military time)* Start __ __ : __ __ Stop __ __: __ __ Start __ __ : __ __ Stop __ __: __ __ Start __ __ : __ __ Stop __ __: __ __ Start __ __ : __ __ Stop __ __: __ __		6.1 to 6.8 Time (use military time)* Start __ __ : __ __ Stop __ __: __ __ Start __ __ : __ __ Stop __ __: __ __ Start __ __ : __ __ Stop __ __: __ __ Start __ __ : __ __ Stop __ __: __ __
9. Date__ __/__ __/__ __ __ __	9. Date__ __/__ __/__ __ __ __		9. Date__ __/__ __/__ __ __ __
9.1 to 9.8 Time (use military time)* Start __ __ : __ __ Stop __ __: __ __ Start __ __ : __ __ Stop __ __: __ __ Start __ __ : __ __ Stop __ __: __ __ Start __ __ : __ __ Stop __ __: __ __	9.1 to 9.8 Time (use military time)* Start __ __ : __ __ Stop __ __: __ __ Start __ __ : __ __ Stop __ __: __ __ Start __ __ : __ __ Stop __ __: __ __ Start __ __ : __ __ Stop __ __: __ __		9.1 to 9.8 Time (use military time)* Start __ __ : __ __ Stop __ __: __ __ Start __ __ : __ __ Stop __ __: __ __ Start __ __ : __ __ Stop __ __: __ __ Start __ __ : __ __ Stop __ __: __ __

Section A: Maternal Address History Continuation Sheet (List in reverse chronological order) Data labeling/numbering scheme for prior addresses listed on continuation sheets should follow original beginning with item #50 for date last known at address
Date _ _ / _ _ / _ _ _ _ (last known at this address)	Mother’s Street Address
City		State	Zip Code
Date _ _ / _ _ / _ _ _ _ (last known at this address)	Mother’s Street Address
City		State	Zip Code
Date _ _ / _ _ / _ _ _ _ (last known at this address)	Mother’s Street Address
City		State	Zip Code
Date _ _ / _ _ / _ _ _ _ (last known at this address)	Mother’s Street Address
City		State	Zip Code
Date _ _ / _ _ / _ _ _ _ (last known at this address)	Mother’s Street Address
City		State	Zip Code
Date _ _ / _ _ / _ _ _ _ (last known at this address)	Mother’s Street Address
City		State	Zip Code
Date _ _ / _ _ / _ _ _ _ (last known at this address)	Mother’s Street Address
City		State	Zip Code
Comments:

Section B, Item17 Infertility prior to Index Pregnancy PAST TREATMENTS/MEDICATIONS Continuation Sheet List in reverse chronological order Data labeling scheme for treatments listed on continuation sheets should follow original beginning with 17a.9- 17c.9.
17a. Treatment Code	17b. Specifications	17c. Treatment Date* (mm/yyyy OR yyyy)

C. PREGNANCY HISTORY UP TO AND INCLUDING INDEX PREGNANCY Continuation Sheet

Data labeling scheme for pregnancies listed on continuation sheets should follow original beginning with Baby #12 (and/or Pregnancy #12 if no multiple births).

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

Pregnancy Number/Baby Number

Outcome

Plurality

Birth Weight

Sex

Type Delivery

Number past pregnancies in reverse chronological order (most recent = 1).

If plurality 77, 88 or 99, baby number not needed.

For singletons enter 1/1.

For pregnancies specified as multiple gestations, list each fetus/infant born separately. E.g. 1/1, 1/2, 1/3, pertain to infants 1, 2, and 3 from pregnancy 1.

1. Live Birth

2. Stillbirth

3. Induced Abortion

4. Spontaneous Abortion

5. Ectopic Pregnancy

6. Molar Pregnancy

7. Maternal Death prior to Birth

8. other specify

88. IL

99. NR

1. Singleton

2. Twin

3. Triplet

4. Quad

5. Quint

Etc….

77. NA

(outcomes 3-8)

88. IL

99. NR

Grams preferred, if available

Not applicable for outcomes 3-8, record NA

Record IL or NR for other missing values as needed.

1. Male

2. Female

3. Ambiguous

77. NA

(outcomes 3-8)

88. IL

99. NR

1. Vaginal

2. Primary C-Section

3. Secondary C-Section

4. VBAC

77. NA

(outcomes 3-8)

88. IL

99. NR

Prenatal, Delivery, Post Partum Problems/Complications

No complications specifically noted
Abruptio placentae
Birth defect (specify if yes)
Cephalopelvic disproportion
Chorioamnionitis
Deep vein thrombosis
Eclampsia
Fetal reduction
Gestational Diabetes
HELLP
Hyperemesis
Infant Death, neonatal (<28 days)
Infant Death, post-neonatal (28 days – 1 year)
Intrauterine growth restriction/retardation (IUGR)

Macrosomia
Placenta previa
Postpartum depression
Postpartum hemorrhage
Pregnancy induced hypertension/

preeclampsia/gestational hypertension

Premature rupture of membranes (PROM)
Preterm labor
Pulmonary edema
Pulmonary embolus (PE)
Uterine rupture
Vaginal bleeding

26. Other: specify

99. Unknown/ Not documented

10a.1preg – 10a.20preg

AND

10a.1baby – 10a.20baby

Preg # Baby #

10b.1 – 10b.20

Outcome

10c.1 – 10c.20

Plurality

10d.1 – 10d.20

Outcome Month

10e.1 – 10e.20

Outcome

Year

yyyy

10f.1 – 10f.20

Wks

10g.1 – 10g.20

10h.1 – 10h.20 (lb)

10i.1 – 10i.20

(oz)

Birth Weight

g lbs/oz

10j.1 – 10j.20

Sex

10k.1 – 10k.20

Type Delivery

10L..1.1 – 10L.20.28

(Each complication will be a separate y/n variable for each pregnancy+ other specify and NR)

Complications with mother/infant (record codes; specify detail for “other”)

COMMENTS: Provide indication of preg no/baby no for each comment.

D. MATERNAL MEASUREMENTS INDEX PREGNANCY Continuation Sheet Data labeling scheme for prenatal visits listed on continuation sheets should follow original beginning with Visit #22.
4. PRENATAL VISITS Record IL or NR for missing information
4a.1 – 4a.x Visit No	4b1 – 4b.x Date mm/dd/yyyyy	4c1 – 4c.x Wks Gestation (provider’s best estimate)	4d1 – 4d.x 4e1 – 4e.x Fundal Ht cm inches IL (all) NR (all)	4f1 – 4f.x Fetal Heart Rate	4g1 – 4g.x Preterm labor signs/ symptoms*	4h1 – 4h.x 4i1 – 4i.x Blood Pressure Systolic Diastolic	4j1 – 4j.x 4k1 – 4k.x Weight Lb kg IL (all) NR (all)	4L1 – 4L.x 4m1 – 4m.x Urine +albumin +glucose IL (all) IL (all) NR (all) NR (all)





















COMMENTS: Indicate visit no and date.

D. MATERNAL MEASUREMENTS INDEX PREGNANCY Continuation Sheet Data labeling scheme for hospital admissions listed on continuation sheets should follow original beginning with Admission #5a.4.
5. HOSPITAL DELIVERY ADMISSION(S) Record IL or NR for missing information
5a.1 – 5a.x Date mm/dd/yyyyy	5b.1 – 5b.x Weeks Gestation (provider’s best estimate)	5c.1 – 5d.x 5d.1 – 5d.x Fundal Ht cm inches IL (all) NR (all)	5e.1 – 5e.x Fetal Heart Rate	5f.1 – 5f.x Preterm labor signs/ symptoms*	5g.1 – 5g.x 5h.1 – 5h.x Blood Pressure Systolic Diastolic	5i.1 – 5i.x 5j.1 – 5j.x Weight Lb kg IL (all) NR (all)	5k.1 – 5k.x 5L.1 – 5L.x Urine +albumin +glucose IL (all) IL (all) NR (all) NR (all)









COMMENTS: Indicate visit no and date.

E. BLOOD TYPE, SCREENING, AND OTHER REPORTS (excluding cultures/rapid strep screens) INDEX PREGNANCY
22. Other Lab Reports (except cultures: to be reported in Section I) Continuation Sheet Data labeling scheme for other lab reports listed on continuation sheets should follow original beginning with Test # 22a.8.
22a.1-22a.x Test Date	22b.1-22b.x Test Name/Description	22c.1-22c.x (22c.[1-x].oth.sp) Results	22d.1-22d.x Normal Lab Range (if available)	22e.1-22e.x Comments
_ _ / _ _ / _ _ _ _		1. normal 2. abnormal 3. other ______________ 4. tested, results unknown 88. Illegible 99. NR
_ _ / _ _ / _ _ _ _		1. normal 2. abnormal 3. other ______________ 4. tested, results unknown 88. Illegible 99. NR
_ _ / _ _ / _ _ _ _		1. normal 2. abnormal 3. other ______________ 4. tested, results unknown 88. Illegible 99. NR
_ _ / _ _ / _ _ _ _		1. normal 2. abnormal 3. other ______________ 4. tested, results unknown 88. Illegible 99. NR
_ _ / _ _ / _ _ _ _		1. normal 2. abnormal 3. other ______________ 4. tested, results unknown 88. Illegible 99. NR
_ _ / _ _ / _ _ _ _		1. normal 2. abnormal 3. other ______________ 4. tested, results unknown 88. Illegible 99. NR
_ _ / _ _ / _ _ _ _		1. normal 2. abnormal 3. other ______________ 4. tested, results unknown 88. Illegible 99. NR
COMMENTS: Indicate item #

F. PREGNANCY ULTRASOUND REPORTS, INDEX PREGNANCY Continuation Sheet

Data labeling scheme for ultrasound reports listed on continuation sheets should follow original beginning with Ultrasound # 7a.

Date of scan

_ _ / _ _ / _ _ _ _

# fetuses

EGA – LMP

___ ___

EGA – US

___ ___

e to n (L.sp)

Reason (check all that apply)

(Each reason choice will be a separate y/n variable + other specify, IL, NR)

1. confirm dates

2. fetal growth

3. placenta

4. BPP

5. decreased fetal movement

6. amniotic fluid volume

7. malformation

8. other: (specify)

_____________________

88. Illegible

99. NR

o. (o.ab.sp, o.oth.sp)

Results:

1. normal

2. abnormal (specify)

________________

3. other (specify)

______________

88. Illegible

99. NR

Date of scan

_ _ / _ _ / _ _ _ _

# fetuses

EGA – LMP

___ ___

EGA – US

___ ___

e to n (L.sp)

Reason (check all that apply)

(Each reason choice will be a separate y/n variable + other specify, IL, NR)

1. confirm dates

2. fetal growth

3. placenta

4. BPP

5. decreased fetal movement

6. amniotic fluid volume

7. malformation

8. other: (specify)

_____________________

88. Illegible

99. NR

o. (o.ab.sp, o.oth.sp)

Results:

1. normal

2. abnormal (specify)

________________

3. other (specify)

______________

88. Illegible

99. NR

Date of scan

_ _ / _ _ / _ _ _ _

# fetuses

EGA – LMP

___ ___

EGA – US

___ ___

e to n (L.sp)

Reason (check all that apply)

(Each reason choice will be a separate y/n variable + other specify, IL, NR)

1. confirm dates

2. fetal growth

3. placenta

4. BPP

5. decreased fetal movement

6. amniotic fluid volume

7. malformation

8. other: (specify)

_____________________

88. Illegible

99. NR

o. (o.ab.sp, o.oth.sp)

Results:

1. normal

2. abnormal (specify)

________________

3. other (specify)

______________

88. Illegible

99. NR

Comments:

G. SUBSTANCE ABUSE Continuation Sheet

Data labeling scheme for other substances listed on continuation sheet should follow original beginning with # 5.

Drugs/Substance

3 months prior to conception through conception

Trimester 1

Weeks 1 – 12

Trimester 2 Weeks 13 – 26

Trimester 3

Weeks 27 – 40+

Date Stopped

Other

sp (specify):

Hx of use during/near pregnancy but timing NOT specified?

1. Yes

2. No

77 NA

88 Illegible

99 NR

1. Yes

2. No

77 NA

88 Illegible

99 NR

1. Yes

2. No

77 NA

88 Illegible

99 NR

1. Yes

2. No

77 NA

88 Illegible

99 NR

_ _ / _ _ / _ _ _ _

Ongoing Use

Other

sp (specify):

Hx of use during/near pregnancy but timing NOT specified?

1. Yes

2. No

77 NA

88 Illegible

99 NR

1. Yes

2. No

77 NA

88 Illegible

99 NR

1. Yes

2. No

77 NA

88 Illegible

99 NR

1. Yes

2. No

77 NA

88 Illegible

99 NR

_ _ / _ _ / _ _ _ _

Ongoing Use

Other

sp (specify):

Hx of use during/near pregnancy but timing NOT specified?

1. Yes

2. No

77 NA

88 Illegible

99 NR

1. Yes

2. No

77 NA

88 Illegible

99 NR

1. Yes

2. No

77 NA

88 Illegible

99 NR

1. Yes

2. No

77 NA

88 Illegible

99 NR

_ _ / _ _ / _ _ _ _

Ongoing Use

Other

sp (specify):

Hx of use during/near pregnancy but timing NOT specified?

1. Yes

2. No

77 NA

88 Illegible

99 NR

1. Yes

2. No

77 NA

88 Illegible

99 NR

1. Yes

2. No

77 NA

88 Illegible

99 NR

1. Yes

2. No

77 NA

88 Illegible

99 NR

_ _ / _ _ / _ _ _ _

Ongoing Use

Other

sp (specify):

Hx of use during/near pregnancy but timing NOT specified?

1. Yes

2. No

77 NA

88 Illegible

99 NR

1. Yes

2. No

77 NA

88 Illegible

99 NR

1. Yes

2. No

77 NA

88 Illegible

99 NR

1. Yes

2. No

77 NA

88 Illegible

99 NR

_ _ / _ _ / _ _ _ _

Ongoing Use

COMMENTS:

H (part 1). MATERNAL INFECTIONS ANYTIME DURING INDEX PREGNANCY Continuation Sheet

Dx: Use codes from infection list (Appendix D)

If cultures or rapid strep screens were performed, note in section I.

If “yes” is indicated for medications, please fill out Section Q.

Data labeling scheme for infections listed on continuation sheet should follow original beginning with # 5a.

b.1

Date diagnosed

_ _ / _ _ / _ _ _ _

b.ga

GA _____ wks

b.tri

Trimester _____

Duration

______ days

Certainty of Dx

1. Lab/Test

2. Clinical

3. Suspect

9. unknown

e.1

Highest Temp

_______

e.2

Unit

1. ^oC

2 ^oF

88 IL

99 NR

f.1

Lowest Temp

_______

f.2

Unit

1. ^oC

2 ^oF

88 IL

99 NR

Cultures/Rapid Screen done?

1 Yes

2 No

88 IL

99 NR

Meds given?

1 Yes

2 No

88 IL

99 NR

b.1

Date diagnosed

_ _ / _ _ / _ _ _ _

b.ga

GA _____ wks

b.tri

Trimester _____

Duration

______ days

Certainty of Dx

1. Lab/Test

2. Clinical

3. Suspect

9. unknown

e.1

Highest Temp

_______

e.2

Unit

1. ^oC

2 ^oF

88 IL

99 NR

f.1

Lowest Temp

_______

f.2

Unit

1. ^oC

2 ^oF

88 IL

99 NR

Cultures/Rapid Screen done?

1 Yes

2 No

88 IL

99 NR

Meds given?

1 Yes

2 No

88 IL

99 NR

b.1

Date diagnosed

_ _ / _ _ / _ _ _ _

b.ga

GA _____ wks

b.tri

Trimester _____

Duration

______ days

Certainty of Dx

1. Lab/Test

2. Clinical

3. Suspect

9. unknown

e.1

Highest Temp

_______

e.2

Unit

1. ^oC

2 ^oF

88 IL

99 NR

f.1

Lowest Temp

_______

f.2

Unit

1. ^oC

2 ^oF

88 IL

99 NR

Cultures/Rapid Screen done?

1 Yes

2 No

88 IL

99 NR

Meds given?

1 Yes

2 No

88 IL

99 NR

b.1

Date diagnosed

_ _ / _ _ / _ _ _ _

b.ga

GA _____ wks

b.tri

Trimester _____

Duration

______ days

Certainty of Dx

1. Lab/Test

2. Clinical

3. Suspect

9. unknown

e.1

Highest Temp

_______

e.2

Unit

1. ^oC

2 ^oF

88 IL

99 NR

f.1

Lowest Temp

_______

f.2

Unit

1. ^oC

2 ^oF

88 IL

99 NR

Cultures/Rapid Screen done?

1 Yes

2 No

88 IL

99 NR

Meds given?

1 Yes

2 No

88 IL

99 NR

Comments: Specify any other DX (code=600) as 5a.sp, etc

Also list other comments.

I.CULTURES/RAPID STREP SCREENS ANYTIME DURING INDEX PREGNANCY (RECORD ALL CULTURES /STREP SCREENS OBTAINED) Continuation Sheet

Indicate the number of the event from section H or ‘0’ If culture does not correspond to an event in section H.

Data labeling scheme for cultures listed on continuation sheet should follow original beginning with # 11a.

Source: 1 = amniotic fluid; 2 = placenta; 3 = cervix; 4 = vagina; 5 = urine; 6 = blood; 7 = sputum; 8=throat; 9 = stool; 10=wound; 11= other (specify); 88 = Illegible 99=Not recorded

REF

Date Cultured

c.sp (specify)

Source

(d.6.sp and d.9.sp for specify fields)

Results

Description (organisms, etc.)

_ _ / _ _ / _ _ _ _

1. no growth 2. Normal flora

3. light growth 4. mod-heavy growth

5. growth noted, not specified

6. urine culture colony count

(specify)_________________________

7. rapid strep screen pos 8. rapid strep screen neg

9. other

(specify)_________________________

88. IL 99. NR

_ _ / _ _ / _ _ _ _

1. no growth 2. Normal flora

3. light growth 4. mod-heavy growth

5. growth noted, not specified

6. urine culture colony count

(specify)_________________________

7. rapid strep screen pos 8. rapid strep screen neg

9. other

(specify)_________________________

88. IL 99. NR

_ _ / _ _ / _ _ _ _

1. no growth 2. Normal flora

3. light growth 4. mod-heavy growth

5. growth noted, not specified

6. urine culture colony count

(specify)_________________________

7. rapid strep screen pos 8. rapid strep screen neg

9. other

(specify)_________________________

88. IL 99. NR

_ _ / _ _ / _ _ _ _

1. no growth 2. Normal flora

3. light growth 4. mod-heavy growth

5. growth noted, not specified

6. urine culture colony count

(specify)_________________________

7. rapid strep screen pos 8. rapid strep screen neg

9. other

(specify)_________________________

88. IL 99. NR

_ _ / _ _ / _ _ _ _

1. no growth 2. Normal flora

3. light growth 4. mod-heavy growth

5. growth noted, not specified

6. urine culture colony count

(specify)_________________________

7. rapid strep screen pos 8. rapid strep screen neg

9. other

(specify)_________________________

88. IL 99. NR

Comments:

J. INJECTIONS/VACCINATIONS DURING INDEX PREGNANCY Continuation Sheet

Data labeling scheme for injections listed on continuation sheet should follow original beginning with # 3g.sp.

Injection/Vaccination

Other (specify)

_________________

Date

_ _ / _ _ / _ _ _ _

Manufacturer

______________

lot

Lot #

___________

Other (specify)

_________________

Date

_ _ / _ _ / _ _ _ _

Manufacturer

______________

lot

Lot #

___________

Other (specify)

_________________

Date

_ _ / _ _ / _ _ _ _

Manufacturer

______________

lot

Lot #

___________

Other (specify)

_________________

Date

_ _ / _ _ / _ _ _ _

Manufacturer

______________

lot

Lot #

___________

Other (specify)

_________________

Date

_ _ / _ _ / _ _ _ _

Manufacturer

______________

lot

Lot #

___________

Comments:

K.VAGINAL BLEEDING ANYTIME DURING INDEX PREGNANCY Continuation Sheet

Data labeling scheme for vaginal bleeding episodes listed on continuation sheet should follow original beginning with # 5a.

If “yes” is indicated for medications, please fill out Section Q

Date Occurred

_ _ / _ _ / _ _ _ _

a.ga GA _____ wks

a.tri Trimester _____

Dx (code)

______

If dx=8:

b.sp

Other, specify

_____________

Duration

__ __

c.unit

Unit

1. days

2. weeks

88 Illegible

99 NR

Pain

1. Yes

2. No (stated)

3. Suspect

88 Illegible

99 NR

Cramping

1. Yes

2. No (stated)

3. Suspect

88 Illegible

99 NR

Medication Given

1. Yes

2. No (stated)

88 Illegible

99 NR

Date Occurred

_ _ / _ _ / _ _ _ _

a.ga GA _____ wks

a.tri Trimester _____

Dx (code)

______

If dx=8:

b.sp

Other, specify

_____________

Duration

__ __

c.unit

Unit

1. days

2. weeks

88 Illegible

99 NR

Pain

1. Yes

2. No (stated)

3. Suspect

88 Illegible

99 NR

Cramping

1. Yes

2. No (stated)

3. Suspect

88 Illegible

99 NR

Medication Given

1. Yes

2. No (stated)

88 Illegible

99 NR

Date Occurred

_ _ / _ _ / _ _ _ _

a.ga GA _____ wks

a.tri Trimester _____

Dx (code)

______

If dx=8:

b.sp

Other, specify

_____________

Duration

__ __

c.unit

Unit

1. days

2. weeks

88 Illegible

99 NR

Pain

1. Yes

2. No (stated)

3. Suspect

88 Illegible

99 NR

Cramping

1. Yes

2. No (stated)

3. Suspect

88 Illegible

99 NR

Medication Given

1. Yes

2. No (stated)

88 Illegible

99 NR

Date Occurred

_ _ / _ _ / _ _ _ _

a.ga GA _____ wks

a.tri Trimester _____

Dx (code)

______

If dx=8:

b.sp

Other, specify

_____________

Duration

__ __

c.unit

Unit

1. days

2. weeks

88 Illegible

99 NR

Pain

1. Yes

2. No (stated)

3. Suspect

88 Illegible

99 NR

Cramping

1. Yes

2. No (stated)

3. Suspect

88 Illegible

99 NR

Medication Given

1. Yes

2. No (stated)

88 Illegible

99 NR

Comments:

L. PRETERM LABOR INDEX PREGNANCY Continuation Sheet

If “yes” is indicated for medications, please fill out Section Q.

Data labeling scheme for preterm labor episodes listed on continuation sheet should follow original beginning with # 5a.

Date Reported

_ _ / _ _ / _ _ _ _

a.ga GA _____ wks

a.tri Trimester _____

Onset of s/s per patient

1. no s/s (stated)

2. < 12 h

3. 12 – 24 h

4. > 24 h

88 Illegible

99 NR

c. and c.sp

Signs/symptoms

1. uterine contractions

2. cramping (per patient)

3. cervical change

4. PROM

5. other, specify ________________________

88 Illegible

99 NR

d. and d.sp

Treatments

1. meds (fill out section Q)

2. bed rest

3. IV Hydration

4. other, specify ________________________

88 Illegible

99 NR

Date Reported

_ _ / _ _ / _ _ _ _

a.ga GA _____ wks

a.tri Trimester _____

Onset of s/s per patient

1. no s/s (stated)

2. < 12 h

3. 12 – 24 h

4. > 24 h

88 Illegible

99 NR

c. and c.sp

Signs/symptoms

1. uterine contractions

2. cramping (per patient)

3. cervical change

4. PROM

5. other, specify ________________________

88 Illegible

99 NR

d. and d.sp

Treatments

1. meds (fill out section Q)

2. bed rest

3. IV Hydration

4. other, specify ________________________

88 Illegible

99 NR

Date Reported

_ _ / _ _ / _ _ _ _

a.ga GA _____ wks

a.tri Trimester _____

Onset of s/s per patient

1. no s/s (stated)

2. < 12 h

3. 12 – 24 h

4. > 24 h

88 Illegible

99 NR

c. and c.sp

Signs/symptoms

1. uterine contractions

2. cramping (per patient)

3. cervical change

4. PROM

5. other, specify ________________________

88 Illegible

99 NR

d. and d.sp

Treatments

1. meds (fill out section Q)

2. bed rest

3. IV Hydration

4. other, specify ________________________

88 Illegible

99 NR

Date Reported

_ _ / _ _ / _ _ _ _

a.ga GA _____ wks

a.tri Trimester _____

Onset of s/s per patient

1. no s/s (stated)

2. < 12 h

3. 12 – 24 h

4. > 24 h

88 Illegible

99 NR

c. and c.sp

Signs/symptoms

1. uterine contractions

2. cramping (per patient)

3. cervical change

4. PROM

5. other, specify ________________________

88 Illegible

99 NR

d. and d.sp

Treatments

1. meds (fill out section Q)

2. bed rest

3. IV Hydration

4. other, specify ________________________

88 Illegible

99 NR

Comments:

M (part 1). MEDICAL CONDITIONS PRECEDING OR DURING INDEX PREGNANCY

Continuation Sheet

Use codes from Medical History List (Appendix E) -- M indicates medical condition

If “yes” is indicated for medications, please fill out Section Q

Data labeling scheme for medical conditions listed on continuation sheet should follow original beginning with # 7.

Precision Code: 1 = Definite diagnosis – ICD or DSM code listed in the prenatal record; 2 = Specific diagnosis listed by provider in prenatal record but no ICD/DSM code listed; 3 = Signs and symptoms of a condition noted in prenatal record but diagnosis unclear; 88=Illegible; 99=NR

No.

Condition Code (appendix)

1a.-20a

Precision Code

1b-20b

Time Period Condition Active (Check all that apply)

1c.pc - 20c.pc 1c.t1 - 20c.t1 1c.t2 - 20c.t2,

1c.t3 - 20c.t3 1c.ns - 20c.ns

1c.IL - 20c.IL 1c.NR - 20c.NR

Date/Age at First Diagnosis

1d.date - 20d.date

1d.age - 20d.age

Medication Given

1e - 20e

1. Active before index pregnancy

2. Active during 1^st trimester (1-13 weeks GA)

3. Active during 2^nd trimester (14-26 weeks GA)

4. Active during 3^rd trimester (27-40+ weeks GA)

5. Active during index pregnancy, trimester unknown

88. Illegible

99. NR

Date:

_ _ / _ _ / _ _ _ _

Age: ___ ___

1. Yes

2. No

88. IL

99. NR

1. Active before index pregnancy

2. Active during 1^st trimester (1-13 weeks GA)

3. Active during 2^nd trimester (14-26 weeks GA)

4. Active during 3^rd trimester (27-40+ weeks GA)

5. Active during index pregnancy, trimester unknown

88. Illegible

99. NR

Date:

_ _ / _ _ / _ _ _ _

Age: ___ ___

1. Yes

2. No

88. IL

99. NR

1. Active before index pregnancy

2. Active during 1^st trimester (1-13 weeks GA)

3. Active during 2^nd trimester (14-26 weeks GA)

4. Active during 3^rd trimester (27-40+ weeks GA)

5. Active during index pregnancy, trimester unknown

88. Illegible

99. NR

Date:

_ _ / _ _ / _ _ _ _

Age: ___ ___

1. Yes

2. No

88. IL

99. NR

1. Active before index pregnancy

2. Active during 1^st trimester (1-13 weeks GA)

3. Active during 2^nd trimester (14-26 weeks GA)

4. Active during 3^rd trimester (27-40+ weeks GA)

5. Active during index pregnancy, trimester unknown

88. Illegible

99. NR

Date:

_ _ / _ _ / _ _ _ _

Age: ___ ___

1. Yes

2. No

88. IL

99. NR

1. Active before index pregnancy

2. Active during 1^st trimester (1-13 weeks GA)

3. Active during 2^nd trimester (14-26 weeks GA)

4. Active during 3^rd trimester (27-40+ weeks GA)

5. Active during index pregnancy, trimester unknown

88. Illegible

99. NR

Date:

_ _ / _ _ / _ _ _ _

Age: ___ ___

1. Yes

2. No

88. IL

99. NR

1. Active before index pregnancy

2. Active during 1^st trimester (1-13 weeks GA)

3. Active during 2^nd trimester (14-26 weeks GA)

4. Active during 3^rd trimester (27-40+ weeks GA)

5. Active during index pregnancy, trimester unknown

88. Illegible

99. NR

Date:

_ _ / _ _ / _ _ _ _

Age: ___ ___

1. Yes

2. No

88. IL

99. NR

Comments:

M (part 2). PSYCHIATRIC/BEHAVIORAL/DEVELOPMENTAL CONDITIONS PRECEDING OR DURING INDEX PREGNANCY Continuation Sheet

Use codes from Medical History List (Appendix E) – PBD indicates psychiatric/ behavioral/ developmental condition

If “yes” is indicated for medications, please fill out Section Q

Data labeling scheme for PBD conditions listed on continuation sheet should follow original beginning with # 7.

No.

Condition Code (appendix)

1a.-20a

Precision Code

1b-20b

Time Period Condition Active (Check all that apply)

1c.pc - 20c.pc 1c.t1 - 20c.t1 1c.t2 - 20c.t2,

1c.t3 - 20c.t3 1c.ns - 20c.ns

1c.IL - 20c.IL 1c.NR - 20c.NR

Date/Age at First Diagnosis

1d.date - 20d.date

1d.age - 20d.age

Medication Given

1e - 20e

1. Active before index pregnancy

2. Active during 1^st trimester (1-13 weeks GA)

3. Active during 2^nd trimester (14-26 weeks GA)

4. Active during 3^rd trimester (27-40+ weeks GA)

5. Active during index pregnancy, trimester unknown

88. Illegible

99. NR

Date:

_ _ / _ _ / _ _ _ _

Age: ___ ___

1. Yes

2. No

88. IL

99. NR

1. Active before index pregnancy

2. Active during 1^st trimester (1-13 weeks GA)

3. Active during 2^nd trimester (14-26 weeks GA)

4. Active during 3^rd trimester (27-40+ weeks GA)

5. Active during index pregnancy, trimester unknown

88. Illegible

99. NR

Date:

_ _ / _ _ / _ _ _ _

Age: ___ ___

1. Yes

2. No

88. IL

99. NR

1. Active before index pregnancy

2. Active during 1^st trimester (1-13 weeks GA)

3. Active during 2^nd trimester (14-26 weeks GA)

4. Active during 3^rd trimester (27-40+ weeks GA)

5. Active during index pregnancy, trimester unknown

88. Illegible

99. NR

Date:

_ _ / _ _ / _ _ _ _

Age: ___ ___

1. Yes

2. No

88. IL

99. NR

1. Active before index pregnancy

2. Active during 1^st trimester (1-13 weeks GA)

3. Active during 2^nd trimester (14-26 weeks GA)

4. Active during 3^rd trimester (27-40+ weeks GA)

5. Active during index pregnancy, trimester unknown

88. Illegible

99. NR

Date:

_ _ / _ _ / _ _ _ _

Age: ___ ___

1. Yes

2. No

88. IL

99. NR

1. Active before index pregnancy

2. Active during 1^st trimester (1-13 weeks GA)

3. Active during 2^nd trimester (14-26 weeks GA)

4. Active during 3^rd trimester (27-40+ weeks GA)

5. Active during index pregnancy, trimester unknown

88. Illegible

99. NR

Date:

_ _ / _ _ / _ _ _ _

Age: ___ ___

1. Yes

2. No

88. IL

99. NR

1. Active before index pregnancy

2. Active during 1^st trimester (1-13 weeks GA)

3. Active during 2^nd trimester (14-26 weeks GA)

4. Active during 3^rd trimester (27-40+ weeks GA)

5. Active during index pregnancy, trimester unknown

88. Illegible

99. NR

Date:

_ _ / _ _ / _ _ _ _

Age: ___ ___

1. Yes

2. No

88. IL

99. NR

Comments

N. PRENATAL PROCEDURES INDEX PREGNANCY Continuation Sheet

Data labeling scheme for other prenatal procedures listed on continuation sheet should follow original beginning with # 10.

Procedure

a and a.sp Other,

1 Yes: specify ________________

2 No

88 IL

99 NR

b Date:

_ _ / _ _ / _ _ _ _

c Specify findings:

a and a.sp Other,

1 Yes: specify ________________

2 No

88 IL

99 NR

b Date:

_ _ / _ _ / _ _ _ _

c Specify findings:

a and a.sp Other,

1 Yes: specify ________________

2 No

88 IL

99 NR

b Date:

_ _ / _ _ / _ _ _ _

c Specify findings:

a and a.sp Other,

1 Yes: specify ________________

2 No

88 IL

99 NR

b Date:

_ _ / _ _ / _ _ _ _

c Specify findings:

a and a.sp Other,

1 Yes: specify ________________

2 No

88 IL

99 NR

b Date:

_ _ / _ _ / _ _ _ _

c Specify findings:

a and a.sp Other,

1 Yes: specify ________________

2 No

88 IL

99 NR

b Date:

_ _ / _ _ / _ _ _ _

c Specify findings:

a and a.sp Other,

1 Yes: specify ________________

2 No

88 IL

99 NR

b Date:

_ _ / _ _ / _ _ _ _

c Specify findings:

a and a.sp Other,

1 Yes: specify ________________

2 No

88 IL

99 NR

b Date:

_ _ / _ _ / _ _ _ _

c Specify findings:

Comments:

O. OTHER CONDITIONS OR TRAUMA ANYTIME DURING INDEX PREGNANCY Continuation Sheet Record only conditions NOT covered in other sections on this form that detail maternal conditions (B, H, K, L, M). Data labeling scheme for other conditions/trauma listed on continuation sheet should follow original beginning with # 10.
Dx: 1 = Decreased Fetal Movement; 2 = Trauma/Injury; 3 = Oligohydramnios; 4 = Polyhydramnios; 5 = IUGR; 6 = Macrosomia; 7 = loss of consciousness; 8 = Spontaneous Reduction; 10 = other, (specify); 88=IL; 99=NR If “yes” is indicated for medications, please fill out Section Q
a.date OR a.ga OR a.tri	b	c	d
Date Reported _ _ / _ _ / _ _ _ _ OR GA _____ _____wks OR Trimester ___	Dx	Description	Medication Given 1. Yes 2. No 88. IL 99. NR
Date Reported _ _ / _ _ / _ _ _ _ OR GA _____ _____wks OR Trimester ___	Dx	Description	Medication Given 1. Yes 2. No 88. IL 99. NR
Date Reported _ _ / _ _ / _ _ _ _ OR GA _____ _____wks OR Trimester ___	Dx	Description	Medication Given 1. Yes 2. No 88. IL 99. NR
Date Reported _ _ / _ _ / _ _ _ _ OR GA _____ _____wks OR Trimester ___	Dx	Description	Medication Given 1. Yes 2. No 88. IL 99. NR
Date Reported _ _ / _ _ / _ _ _ _ OR GA _____ _____wks OR Trimester ___	Dx	Description	Medication Given 1. Yes 2. No 88. IL 99. NR
Date Reported _ _ / _ _ / _ _ _ _ OR GA _____ _____wks OR Trimester ___	Dx	Description	Medication Given 1. Yes 2. No 88. IL 99. NR
Date Reported _ _ / _ _ / _ _ _ _ OR GA _____ _____wks OR Trimester ___	Dx	Description	Medication Given 1. Yes 2. No 88. IL 99. NR
Date Reported _ _ / _ _ / _ _ _ _ OR GA _____ _____wks OR Trimester ___	Dx	Description	Medication Given 1. Yes 2. No 88. IL 99. NR
Date Reported _ _ / _ _ / _ _ _ _ OR GA _____ _____wks OR Trimester ___	Dx	Description	Medication Given 1. Yes 2. No 88. IL 99. NR
Comments:

P. HOSPITAL ADMISSIONS/VISITS INDEX PREGNANCY (INPATIENT AND OUTPATIENT)

Continuation Sheet

Do NOT include admissions for delivery. These should be recorded in Section D (#5).

Do NOT include admissions for prenatal testing. These should be recorded in Section N.

For the medical history code(s), use codes from either Appendix D or Appendix E (indicate as d.# or E.#)

If “yes” is indicated for medications, please fill out Section Q.

Data labeling scheme for hospital admissions/visits listed on continuation sheet should follow original beginning with # 5a.

a. Treated in/as

1 ER 2. outpatient

3. inpatient

88. IL 99. NR

b. Hospital/Facility

c Admit Date

_ _ / _ _ / _ _ _ _

d GA

e Discharge Date

_ _ / _ _ / _ _ _ _

f .1-f.8 and f.sp

Procedures (check all that apply)

1. x-rays, including dental

2. mammograms

3. CT/CAT scans

4. MRI/Magnetic Resonance

5. Radionuclide study or scan

6. radiation treatments or scan

7. other, specify ________________________

88. IL

99. NR

g.icd1 Dx 1

ICD9

g.prob1 Dx 1

Problem

g.mhc1 Dx 1

Medical History Code

h.1-h.5 and h.sp

Treatment: (all that apply)

1. Surgery

2. Meds

3. Other, specify____________________________________

88. IL

99. none recorded

g.icd2 Dx 2

ICD9

g.prob2 Dx 2

Problem

g.mhc2 Dx 2

Medical History Code

g.icd3 Dx 3

ICD9

g.prob3 Dx 3

Problem

g.mhc3 Dx 3

Medical History Code

a. Treated in/as

1 ER 2. outpatient

3. inpatient

88. IL 99. NR

b. Hospital/Facility

c Admit Date

_ _ / _ _ / _ _ _ _

d GA

e Discharge Date

_ _ / _ _ / _ _ _ _

f .1-f.8 and f.sp

Procedures (check all that apply)

1. x-rays, including dental

2. mammograms

3. CT/CAT scans

4. MRI/Magnetic Resonance

5. Radionuclide study or scan

6. radiation treatments or scan

7. other, specify ________________________

88. IL

99. NR

g.icd1 Dx 1

ICD9

g.prob1 Dx 1

Problem

g.mhc1 Dx 1

Medical History Code

h.1-h.5 and h.sp

Treatment: (all that apply)

1. Surgery

2. Meds

3. Other, specify____________________________________

88. IL

99. none recorded

g.icd2 Dx 2

ICD9

g.prob2 Dx 2

Problem

g.mhc2 Dx 2

Medical History Code

g.icd3 Dx 3

ICD9

g.prob3 Dx 3

Problem

g.mhc3 Dx 3

Medical History Code

a. Treated in/as

1 ER 2. outpatient

3. inpatient

88. IL 99. NR

b. Hospital/Facility

c Admit Date

_ _ / _ _ / _ _ _ _

d GA

e Discharge Date

_ _ / _ _ / _ _ _ _

f .1-f.8 and f.sp

Procedures (check all that apply)

1. x-rays, including dental

2. mammograms

3. CT/CAT scans

4. MRI/Magnetic Resonance

5. Radionuclide study or scan

6. radiation treatments or scan

7. other, specify ________________________

88. IL

99. NR

g.icd1 Dx 1

ICD9

g.prob1 Dx 1

Problem

g.mhc1 Dx 1

Medical History Code

h.1-h.5 and h.sp

Treatment: (all that apply)

1. Surgery

2. Meds

3. Other, specify____________________________________

88. IL

99. none recorded

g.icd2 Dx 2

ICD9

g.prob2 Dx 2

Problem

g.mhc2 Dx 2

Medical History Code

g.icd3 Dx 3

ICD9

g.prob3 Dx 3

Problem

g.mhc3 Dx 3

Medical History Code

Comments:

Q. ALL MEDICATIONS (INCLUDING ALL ANTI-INFECTIVES, STEROIDS, HORMONES, AND OTHER Q. MEDICATIONS) GIVEN THREE MONTHS PRIOR TO INDEX PREGNANCY OR DURING INDEX PREGNANCY Continuation Sheet

Indicate the number of the event from the corresponding section.

If the medication does not correspond to a section above, enter ‘0’.

Data labeling scheme for medications listed on continuation sheet should follow original beginning with # 17a.

Exclusions: laxatives, enemas, disinfectants, cough medicine, non-prenatal vitamins, antacids, stool softeners, benadryl, Tylenol, methergine

Refer

Code

Drug Name

Start Date

e, e.ep

Stop Date

f f.sp

Dose

g g.sp

Unit

h h.sp

Freq

_ _ / _ _ / _ _ _ _

Entire pregnancy or ongoing

8. variable

1. gm

2. mg

3. mcg

4. mU

5. cc/ml

8. other_____

77. NA

88. Illegible

99. NR

1. QD

2. BID

3. TID

4. QID

5. PRN

6. Every ___ hrs

7. Per week

8. Total dose

77. NA

88. Illegible

99. NR

_ _ / _ _ / _ _ _ _

Entire pregnancy or ongoing

8. variable

1. gm

2. mg

3. mcg

4. mU

5. cc/ml

8. other_____

77. NA

88. Illegible

99. NR

1. QD

2. BID

3. TID

4. QID

5. PRN

6. Every ___ hrs

7. Per week

8. Total dose

77. NA

88. Illegible

99. NR

_ _ / _ _ / _ _ _ _

Entire pregnancy or ongoing

8. variable

1. gm

2. mg

3. mcg

4. mU

5. cc/ml

8. other_____

77. NA

88. Illegible

99. NR

1. QD

2. BID

3. TID

4. QID

5. PRN

6. Every ___ hrs

7. Per week

8. Total dose

77. NA

88. Illegible

99. NR

_ _ / _ _ / _ _ _ _

Entire pregnancy or ongoing

8. variable

1. gm

2. mg

3. mcg

4. mU

5. cc/ml

8. other_____

77. NA

88. Illegible

99. NR

1. QD

2. BID

3. TID

4. QID

5. PRN

6. Every ___ hrs

7. Per week

8. Total dose

77. NA

88. Illegible

99. NR

APPENDIX B. ART TREATMENT DETAIL, INDEX PREGNANCY

Short Form: Use to record information from PRENATAL CARE RECORD on ART treatments

If ART PROVIDER RECORD available complete APPENDIX C.

Appendix C completed instead of Appendix B

ART treatment was used for index pregnancy, but no information provided for any item in Appendix B (or Appendix C).

1. Date ART treatment cycle started (start of ovulation medication) (mm/dd/yyyy) _ _ / _ _ / _ _ _ _

2. Date oocytes retrieved from mother/woman serving as egg donor (mm/dd/yyyy) _ _ / _ _ / _ _ _ _

3. Date embryos transferred (mm/dd/yyyy) _ _ / _ _ / _ _ _ _

4a-4e Oocyte embryo source (CHECK ALL THAT APPLY OR 88 or 99):

1. PATIENT – used own oocytes embryos

2. DONOR OOCYTE -- used oocytes from donor

3. DONOR EMBRYO -- used embryos donated from another couple’s ART

88. Illegible

99. Not recorded

5a-5d Oocyte embryo state (CHECK ALL THAT APPLY OR 88 or 99):

1. FRESH – transferred fresh oocytes/embryos retrieved during treatment cycle

2. FROZEN – transferred thawed embryos from a previous treatment cycle

88. Illegible

99. Not recorded

6a-6f Transfer Method (CHECK ALL THAT APPLY OR 88 or 99):

1. IVF: Transcervical

2. GIFT: Gametes to tubes

3. ZIFT: Zygotes to tubes

4. TET: tubal embryo transfer

88. Illegible

99. Not recorded

7. Gestational carrier (surrogate) used? 1. Yes 2. No 88. Illegible 99. Not recorded

8. Intracytoplasmic sperm injection (ICSI) performed on oocytes:

1. Yes 2. No 88. Illegible 99. Not recorded

9. Pre-implantation genetic diagnosis (PGD) performed on embryos

1. Yes 2. No 88. Illegible 99. Not recorded

9.sp If Yes, record any comments on type/reason for PGD_______________________________________________

COMMENTS

APPENDIX C. ART TREATMENT DETAIL, INDEX PREGNANCY

Long Form: Use to record treatment information from ART PROVIDER RECORD.

If ART PROVIDER RECORD not available, but some information in PRENATAL CARE RECORD complete APPENDIX B and leave APPENDIX C blank.

Historical data:

1a. Number prior fresh ART cycles _____

1b. Number prior frozen ART cycles_____

1c. Number prior ART cycles (unknown fresh or frozen) _____

2a-2L and 2i.sp Reason for ART (select all that apply)

1. Male infertility 7. Diminished ovarian reserve

2. History of endometriosis 8. Uterine factor

3. Tubal ligation (not reversed) 9. Other reason________________

4. Tubal disease (hydrosalpinx) 10. Unexplained infertility

5. Other tubal disease 88. Illegible

(not hydrosalpinx)

6. Ovulatory disorder/PCO 99. Not recorded

3. Date ART treatment cycle started (start of ovulation medication) (mm/dd/yyyy) _ _ / _ _ / _ _ _ _

4a – 4e. Oocyte embryo source (CHECK ALL THAT APPLY OR 88 or 99):

1. PATIENT – used own oocytes embryos

2. DONOR OOCYTE -- used oocytes from donor

3. DONOR EMBRYO -- used embryos donated from another couple’s ART

88. Illegible

99. Not recorded

5a – 5d. Oocyte embryo state (CHECK ALL THAT APPLY OR 88 or 99):

1. FRESH – transferred fresh oocytes/embryos retrieved during treatment cycle

2. FROZEN – transferred thawed embryos from a previous treatment cycle

88. Illegible

99. Not recorded

6a – 6f. Transfer Method (CHECK ALL THAT APPLY OR 88 or 99):

1. IVF: Transcervical

2. GIFT: Gametes to tubes

3. ZIFT: Zygotes to tubes

4. TET: tubal embryo transfer

88. Illegible

99. Not recorded

7. Gestational carrier (surrogate) used? 1. Yes 2. No 88. Illegible 99. Not recorded

Patient Medication:

8. Patient medicated to stimulate follicular development?

1. Yes 2. No 77. Not applicable 88. Illegible 99. Not recorded

8.cl. Medications containing clomiphene? 1. Yes 2. No 77. Not applicable 88. Illegible 99. Not recorded

8.cl.dose If yes, Clomiphene dosage (total mgs): ____________

8.fsh. Medications containing FSH? 1. Yes 2. No 77. Not applicable 88. Illegible 99. Not recorded

8.fsh .dose If Yes, FSH Medication dosage (total IUs): ____________

8.gnrh GnRH Protocol (select only one, if applicable)

1. GnRH Agonist Suppression 77. Not Applicable

2. GnRH Agonist Flare 88. Illegible

3. GnRH Antagonist Suppression 99. Not recorded

APPENDIX C. ART TREATMENT DETAIL, INDEX PREGNANCY

Long Form: Use to record treatment information from ART PROVIDER RECORD (Continued)

Donor Medication:

9. Donor medicated to stimulate follicular development?

1. Yes 2. No 77. Not applicable 88. Illegible 99. Not recorded

9.cl Donor medications containing clomiphene?

1. Yes 2. No 77. Not applicable 88. Illegible 99. Not recorded

9.cl .dose If yes, Donor Clomiphene dosage (total mgs): ____________

9.fsh Donor Medications containing FSH?

1. Yes 2. No 77. Not applicable 88. Illegible 99. Not recorded

9.fsh.dose If Yes, Donor FSH Medication dosage (total IUs): ____________

9.gnrh Donor GnRH Protocol (select only one, if applicable)

1. GnRH Agonist Suppression 77. Not Applicable

2. GnRH Agonist Flare 88. Illegible

3. GnRH Antagonist Suppression 99. Not recorded

10a-10k and 10h.sp Complications related to ART (Select all that apply)

1. Infection 5. Medication side effect 9. None (specified as none)

2. Hemorrhage 6. Anesthetic complication 88. Illegible

3. Moderate ovarian hyperstimulation 7. Psychological stress 99. Not recorded

4. Severe ovarian hyperstimulation 8. Other ________________

10.hosp Hospitalization related to a complication above?

1. Yes 2. No 77. Not applicable 88. Illegible 99. Not recorded

Patient retrieval data:

11a Date patient oocyte retrieval performed mm/dd/yyyy _ _ - _ _ - _ _ _ _

11b Number of oocytes retrieved ______

Donor retrieval data:

12a Date donor oocyte retrieval performed mm/dd/yyyy _ _ - _ _ - _ _ _ _

12b Number of donor oocytes retrieved _____

13. Source of semen used for fertilization:

1. partner 4. unknown because embryos thawed from a previous cycle

2. donor 88. Illegible

3. mixed 99. Not recorded

Manipulation techniques:

14a. Intracytoplasmic sperm injection (ICSI) performed on oocytes

1. Yes 2. No 88. Illegible 99. Not recorded

14b. Assisted hatching performed on embryos 1. Yes 2. No 88. Illegible 99. Not recorded

14c.1 Pre-implantation genetic diagnosis (PGD) performed on embryos

1. Yes 2. No 3. Unknown because embryos thawed from previous cycle

88. Illegible 99. Not recorded

14c.2 If Yes, PGD Reason:

1. prevention genetic disorders 88. Illegible

2. screening for aneuploidy 99. Not recorded

3. Other_______________________________________

APPENDIX C. ART TREATMENT DETAIL, INDEX PREGNANCY

Long Form: Use to record treatment information from ART PROVIDER RECORD (Continued)

Embryo Transfer:

15a. Date of embryo transfer: mm/dd/yyyy _ _ - _ _ - _ _ _ _

15b. Number of FRESH embryos transferred to uterus _____

15c. Number of THAWED embryos transferred to uterus _____

15d. Number of FRESH embryos transferred to FALLOPIAN TUBES _____

15e. Number of THAWED embryos transferred to FALLOPIAN TUBES _____

15f. Number of OOCYTES transferred to FALLOPIAN TUBES _____

Pregnancy ultrasound:

16a. Once pregnant was ultrasound performed? 1. Yes 2. No 88. Illegible 99. Not recorded

16b. Date ultrasound with max number fetal hearts observed: mm/dd/yyyy _ _ - _ _ - _ _ _ _

16c. Maximum fetal hearts on ultrasound prior to reduction,

(record 0 if ultrasound performed but no hearts observed) _________

COMMENTS

APPENDIX D. DIAGNOSTIC CODES, SECTION H – INFECTIONS
Code	Infection	Code	Infection
501	Bacteremia/sepsis	528	Myocarditis
502	Chicken pox / Varicella (other than Shingles)	512	Parvovirus / Fifth disease
503	Chlamydia	529	Periodontitis
504	Chorioamnionitis	530	Pertussis / Whooping Cough
505	Congenital or intrauterine viral infections (TORCHS)	531	Pneumonia, bacterial
506	Cytomegalovirus	532	Pneumonia, viral
507	Diphtheria	533	Pneumonia, NOS
508	Ear Infection	534	Respiratory infection, NOS (includes, sinuses, throat, bronchi, and lungs) (see separate headings for ear infection, pneumonia, tonsillitis, tuberculosis, and specific viral infections such as influenza, RSV, etc.)
509	Encephalitis	535	Respiratory Syncytial Virus (RSV)
510	Endocarditis	536	Rheumatic fever
511	Eye Infection	513	Rubella/ German Measles
512	Fifth disease / Parvovirus	501	Sepsis/bacteremia
513	German Measles / Rubella	537	Sepsis, Presumed
514	Hepatitis A	538	Shingles
515	Hepatitis B	539	Skin Infection, NOS
516	Hepatitis C	540	Syphilis
517	Hepatitis (type Unknown)	541	Tetanus
518	Herpes Virus	542	Tonsillitis (includes enlargement of tonsils or adnoids at least one month)
519	Human Immunodeficiency Virus (HIV)	543	Toxoplasmosis
520	Influenza	544	Tuberculosis
521	Lyme Disease	545	Urinary tract infection (includes bladder infection and pyelonephritis)
513	Measles, German / Rubella	546	Vaginal Infection/Vaginitis/Vaginosis
522	Measles NOS	502	Varicella / Chicken pox (other than Shingles)
523	Meningitis, bacterial	530	Whooping Cough / Pertussis
524	Meningitis, viral	547	Wound Infection
525	Meningitis, NOS	600	Other (specify)
526	Mononucleosis	IL	Illegible
527	Mumps	NR	Not recorded

APPENDIX E MEDICAL (M) AND PSYCHIATRIC/BEHAVIORAL/DEVELOPMENTAL (PBD) CODE LIST

(Separate attachment)

Version 6-2008 Page 62 of 62

File Type	application/msword
Author	University of Pennsylvania
Last Modified By	ljs9
File Modified	2008-09-05
File Created	2008-09-05

Appendix_S

Appendix_S.2 Prenatal MR Form FINAL STUDY START VERSION.doc

The Study to Explore Early Development (SEED)

Appendix_S

OMB: 0920-0741

ABSTRACTION LOG

ABSTRACTION LOG

ABSTRACTION LOG

ABSTRACTION LOG

ABSTRACTION LOG

ABSTRACTION LOG

ABSTRACTION LOG