Form 38.1 Log

OMB control number: 0925-0593
Expiration Date: 07/31/2013

Pregnancy Health Care Log
BRING THIS LOG TO ALL HEALTH CARE VISITS.
USE THIS LOG FOR ALL TELEPHONE CALLS OR VISITS.
Save all bottles and containers of medications including:
• Medications (those prescribed by a health care provider and those bought over-the-counter)
• Vitamins, minerals, herbs, and any other supplements

Last name: ______________________ First name: _______________________
Public reporting for this collection of information is estimated to average 20 minutes per response including the time for reviewing
instructions, searching existing data sources, gathering and maintaining the data needed, and completing and reviewing the collection
of information. An agency may not conduct or sponsor, and a person is not required to respond to, a collection of
information unless it displays a currently valid OMB control number. Send comments regarding this burden estimate or any
other aspect of this collection of information, including suggestions for reducing this burden, to: NIH, Project Clearance Branch, 6705
Rockledge Drive, MSC 7974, Bethesda, MD 20892-7974, ATTN: PRA (0925-0593). Do not return the completed form to this address.

Pregnancy Health Care Log

This Pregnancy Health Care Log
will help you keep track of all
your visits to doctors or other
health care providers (such as
your obstetrician (OB-GYN),
family doctor, nurse, midwife, or
other type of provider) during
your pregnancy. We will ask you
about all of your visits whenever
we interview you by telephone
or in person.

Health Care Provider Log Instructions

The log has two parts:

Column 3

Write in the name of the health care provider.

1. Health Care Provider Log is to record information
about where you visit your doctor or other health
care provider.

Column 4

Check the box for the type of provider. If it was “Another Type
of Provider,” write in the type of health care provider.

Column 5

Check the box for the type of place where you saw the provider.
If it was “Some other place,” write in the type of place where you
visited the health care provider.

Columns 6–9

Write in the address of the place including city/town, state, and
ZIP Code.

Column 10

Write in the telephone number of the health care provider

2. Health Care Visits and Overnight Hospital Stays
Log is to record information about all your visits to
doctors, other health care providers, or an emergency
room. This includes overnight hospital stays as well as
outpatient visits. Use one page for each visit or
hospital stay.
BRING this Pregnancy Health Care Log with you to all
health care and National Children’s Study visits. Also, have
it available for all National Children’s Study telephone
interviews.
If you forget to bring it with you to a health care visit, please
fill it in as soon as possible.

The Health Care Provider is the person who cared for you at this visit
(doctor, midwife, nurse, etc.)
Column 1

A number is listed for each health care provider (for example,
1,2,3,4, etc). This number will be referred to on the Health
Care Visits and Overnight Hospital Stays log page.

Column 2

Attach the health care provider’s business card here.

Fill in columns 3–10 only if you have not attached the health care
provider’s business card.

See sample log on next page.
After you fill out the Health Care Provider Log, please fill out the
Health Care Visits and Overnight Hospital Stays Log.

The National Children’s Study

Pregnancy Health Care Log

Health Care Provider Log
1

2

Health Care
Provider
Number

Attach Health Care Provider
Business Card

0

Fill in ONLY if you HAVE NOT attached a business card
3

4

5

6

7

8

9

10

Name of Health Care
Provider

Type of
Health Care
Provider

Type of Place

Street Number
and Name

City or Town

State

ZIP
Code

Telephone
Number

☐ Obstetrician/
Gynecologist
(OB/GYN)
☐ Family Physician
☐ Nurse
☐ Midwife
☐ Another Type
of Provider
(specify)

☐ Doctor’s office,
clinic, or health
center
☐ Emergency
room
☐ Urgent care
center
☐ Hospital for
hospitalization
☐ Some other
place (specify):

400 Main
Street

Capitol
City

MN

☐ Obstetrician/
Gynecologist
(OB/GYN)
☐ Family
Physician
☐ Nurse
☐ Midwife
☐ Another Type
of Provider
(specify)

☐ Doctor’s office,
clinic, or health
center
☐ Emergency
room
☐ Urgent care
center
☐ Hospital for
hospitalization
☐ Some other
place (specify):

☐ Obstetrician/
Gynecologist
(OB/GYN)
☐ Family
Physician
☐ Nurse
☐ Midwife
☐ Another Type
of Provider
(specify)

☐ Doctor’s office,
clinic, or health
center
☐ Emergency
room
☐ Urgent care
center
☐ Hospital for
hospitalization
☐ Some other
place (specify):

☐ Obstetrician/
Gynecologist
(OB/GYN)
☐ Family
Physician
☐ Nurse
☐ Midwife
☐ Another Type
of Provider
(specify)

☐ Doctor’s office,
clinic, or health
center
☐ Emergency
room
☐ Urgent care
center
☐ Hospital for
hospitalization
☐ Some other
place (specify):

Dr. Robert Jones

(Sample)

1

2

3

Bring this log to all health care visits. Use this log for all National Children’s Study telephone calls and visits.
Save all bottles and containers of medications and bring to National Children’s Study visits and have available
for telephone calls:
• Medicines (those prescribed by a health care provider and those bought ”over-the-counter”)
• Vitamins, minerals, herbs, and any other supplements

56087 937-8899275

Please remember to fill out the Health Care Visits and Overnight Hospital Stays Log.

The National Children’s Study

Pregnancy Health Care Log

Health Care Provider Log
1

2

Health Care
Provider
Number

Attach Health Care Provider
Business Card

Fill in ONLY if you HAVE NOT attached a business card
3

4

5

6

7

8

9

10

Name of Health Care
Provider

Type of
Health Care
Provider

Type of Place

Street Number
and Name

City or Town

State

ZIP
Code

Telephone
Number

4

☐ Obstetrician/
Gynecologist
(OB/GYN)
☐ Family
Physician
☐ Nurse
☐ Midwife
☐ Another Type
of Provider
(specify)

☐ Doctor’s office,
clinic, or health
center
☐ Emergency
room
☐ Urgent care
center
☐ Hospital for
hospitalization
☐ Some other
place (specify):

5

☐ Obstetrician/
Gynecologist
(OB/GYN)
☐ Family
Physician
☐ Nurse
☐ Midwife
☐ Another Type
of Provider
(specify)

☐ Doctor’s office,
clinic, or health
center
☐ Emergency
room
☐ Urgent care
center
☐ Hospital for
hospitalization
☐ Some other
place (specify):

6

☐ Obstetrician/
Gynecologist
(OB/GYN)
☐ Family
Physician
☐ Nurse
☐ Midwife
☐ Another Type
of Provider
(specify)

☐ Doctor’s office,
clinic, or health
center
☐ Emergency
room
☐ Urgent care
center
☐ Hospital for
hospitalization
☐ Some other
place (specify):

7

☐ Obstetrician/
Gynecologist
(OB/GYN)
☐ Family
Physician
☐ Nurse
☐ Midwife
☐ Another Type
of Provider
(specify)

☐ Doctor’s office,
clinic, or health
center
☐ Emergency
room
☐ Urgent care
center
☐ Hospital for
hospitalization
☐ Some other
place (specify):

Bring this log to all health care visits. Use this log for all National Children’s Study telephone calls and visits.
Save all bottles and containers of medications and bring to National Children’s Study visits and have available
for telephone calls:
• Medicines (those prescribed by a health care provider and those bought ”over-the-counter”)
• Vitamins, minerals, herbs, and any other supplements

Please remember to fill out the Health Care Visits and Overnight Hospital Stays Log.

The National Children’s Study

Pregnancy Health Care Log

Health Care Provider Log
1

2

Health Care
Provider
Number

Attach Health Care Provider
Business Card

Fill in ONLY if you HAVE NOT attached a business card
3

4

5

6

7

8

9

10

Name of Health Care
Provider

Type of
Health Care
Provider

Type of Place

Street Number
and Name

City or Town

State

ZIP
Code

Telephone
Number

8

☐ Obstetrician/
Gynecologist
(OB/GYN)
☐ Family
Physician
☐ Nurse
☐ Midwife
☐ Another Type
of Provider
(specify)

☐ Doctor’s office,
clinic, or health
center
☐ Emergency
room
☐ Urgent care
center
☐ Hospital for
hospitalization
☐ Some other
place (specify):

9

☐ Obstetrician/
Gynecologist
(OB/GYN)
☐ Family
Physician
☐ Nurse
☐ Midwife
☐ Another Type
of Provider
(specify)

☐ Doctor’s office,
clinic, or health
center
☐ Emergency
room
☐ Urgent care
center
☐ Hospital for
hospitalization
☐ Some other
place (specify):

10

☐ Obstetrician/
Gynecologist
(OB/GYN)
☐ Family
Physician
☐ Nurse
☐ Midwife
☐ Another Type
of Provider
(specify)

☐ Doctor’s office,
clinic, or health
center
☐ Emergency
room
☐ Urgent care
center
☐ Hospital for
hospitalization
☐ Some other
place (specify):

11

☐ Obstetrician/
Gynecologist
(OB/GYN)
☐ Family
Physician
☐ Nurse
☐ Midwife
☐ Another Type
of Provider
(specify)

☐ Doctor’s office,
clinic, or health
center
☐ Emergency
room
☐ Urgent care
center
☐ Hospital for
hospitalization
☐ Some other
place (specify):

Bring this log to all health care visits. Use this log for all National Children’s Study telephone calls and visits.
Save all bottles and containers of medications and bring to National Children’s Study visits and have available
for telephone calls:
• Medicines (those prescribed by a health care provider and those bought ”over-the-counter”)
• Vitamins, minerals, herbs, and any other supplements

Please remember to fill out the Health Care Visits and Overnight Hospital Stays Log.

Pregnancy Health Care Log

Health Care Visits and Overnight Hospital Stays Log
Instructions:
Each time you go to the doctor or any other health care provider (for
example, midwife or nurse practitioner) or are hospitalized overnight, write
the information about the visit on a new page in the “Health Care Visits
and Overnight Hospital Stays” log.
At the top of the page, write the visit date and also copy the provider number
and provider name from the Health Care Provider Log.
Column 1

Check the box for the reason for the visit. If you were
hospitalized, include the number of nights you stayed at the
hospital. If the reason is not listed, check “Some other reason”
and write in the reason for the visit.

Column 2

Weight

Column 3

Blood pressure

Column 4

If you received any pregnancy care related procedures, check the
box(es) for those procedures. If the procedure is not listed, check
the box “Other tests to check on the health of your baby” and
write in a description.

Column 5

Enter information about any vaccinations (“shots”) you received.

Column 6

List any other tests or procedures (such as a glucose tolerance
test, etc.).

Column 7

If you received any treatments or were told to take any
medications (over-the-counter or prescription medications),
write them here.

Column 8

If you were told that you had a medical condition or diagnosis at
this visit (for example, high blood pressure, diabetes, infection),
write the diagnosis here.

Column 9

Check the box showing whether you or the office staff
completed the log. After you report the visit to the National
Children’s Study staff, write in the date reported.

The National Children’s Study

h

03

18

2010

Visit Date: __ __ / __ __ / __ __ __ __
Month

Day

Year

0

Provider Number from Health Care Provider Log: _______________

Health Care Visits and Overnight Hospital Stays

Dr. Robert Jones

Name of Provider Seen: _______________________________________
Be sure to also write this provider’s contact information in the HEALTH CARE PROVIDER LOG.

Sample Log
1

Reason for visit

☐ Routine
Pregnancy Care

2

Weight

155
lb

3

Blood
Pressure

120

__ __ __

80

/__ __ __

☐ Illness or Injury
☐ Overnight
hospital stay
(Hospitalized)
How many nights?
______
☐ Some other reason
(explain):

☐ Not done/
Don’t know

☐ Not done/
Don’t know

4

Pregnancy Care
Procedures
(Tests to check on
your baby’s health)

(Check all that
apply)
☐ Ultrasound or
Sonogram
☐ Chorionic Villus
Sampling (CVS)
☐ Amniocentesis
☐ Other tests to
check on the
health of your
baby (describe
below):

Triple Screen
Test

5

Vaccination / Shot
/ Immunization

6

7

Other Tests and Procedures
(Tests to check on YOUR
health) For example, lab
tests (blood, urine, etc.)

Medications/
Other
Treatments
(For example,
over-the-counter
or prescribed
medications)

8

Completed by
Office or Self
Diagnoses
Date Reported
to National
Children’s Study

☐ No
☐ Yes (Specify type
below. Check
all that apply).
☐ Influenza
☐ Hepatitis B

☐ Office

Urine Test

Tylenol

Protein in Urine

Glucose tolerance
test

Amoxicillin

Urinary tract
infection

Blood test

☐ Hepatitis A
☐ Tetanus /
Diphtheria (Td)
☐ Tetanus /
Diphtheria
Pertussis (Tdap)
☐ Meningococcal
☐ Pneumococcal
☐ Other:

Bring this log to all health care visits. Use this log for all National Children’s Study telephone calls and visits.
Save all bottles and containers of medications and bring to National Children’s Study visits and have available
for telephone calls:
• Medications (those prescribed by a health care provider and those bought “over-the-counter”)
• Vitamins, minerals, herbs, and any other supplements

9

Ankle x-ray

☐ Self

Folic Acid
Rhogam
Injection
Physical
therapy

Sprained ankle
Date:

4/1/10

The National Children’s Study

h

Visit Date: __ __ / __ __ / __ __ __ __
Month

Day

Year

Provider Number from Health Care Provider Log: _______________

Health Care Visits and Overnight Hospital Stays Log

Name of Provider Seen: _______________________________________
Be sure to also write this provider’s contact information in the HEALTH CARE PROVIDER LOG.

Health Care Visit/Hospital Stay 1
1

Reason for visit

☐ Routine
Pregnancy Care

2

Weight

lb

3

4

Blood
Pressure

Pregnancy Care
Procedures
(Tests to check on
your baby’s health)

__ __ __
/__ __ __

☐ Illness or Injury
☐ Overnight
hospital stay
(Hospitalized)
How many nights?
______
☐ Some other reason
(explain):

☐ Not done/
Don’t know

☐ Not done/
Don’t know

(Check all that
apply)
☐ Ultrasound or
Sonogram
☐ Chorionic Villus
Sampling (CVS)
☐ Amniocentesis
☐ Other tests to
check on the
health of your
baby (describe
below):

5

6

7

Vaccination / Shot
/ Immunization

Other Tests and Procedures
(Tests to check on YOUR
health) For example, lab
tests (blood, urine, etc.)

Medications/Other
Treatments
(For example,
over-the-counter
or prescribed
medications)

8

9
Completed by
Office or Self

Diagnoses
Date Reported
to National
Children’s Study

☐ No

☐ Office

☐ Yes (Specify type
below. Check
all that apply).

☐ Self

☐ Influenza
☐ Hepatitis B
☐ Hepatitis A
☐ Tetanus /
Diphtheria (Td)
☐ Tetanus /
Diphtheria
Pertussis (Tdap)
☐ Meningococcal
☐ Pneumococcal
☐ Other:

Bring this log to all health care visits. Use this log for all National Children’s Study telephone calls and visits.
Save all bottles and containers of medications and bring to National Children’s Study visits and have available
for telephone calls:
• Medications (those prescribed by a health care provider and those bought “over-the-counter”)
• Vitamins, minerals, herbs, and any other supplements

Date:

The National Children’s Study

h

Visit Date: __ __ / __ __ / __ __ __ __
Month

Day

Year

Provider Number from Health Care Provider Log: _______________

Health Care Visits and Overnight Hospital Stays Log

Name of Provider Seen: _______________________________________
Be sure to also write this provider’s contact information in the HEALTH CARE PROVIDER LOG.

Health Care Visit/Hospital Stay 2
1

Reason for visit

☐ Routine
Pregnancy Care

2

Weight

lb

3

4

Blood
Pressure

Pregnancy Care
Procedures
(Tests to check on
your baby’s health)

__ __ __
/__ __ __

☐ Illness or Injury
☐ Overnight
hospital stay
(Hospitalized)
How many nights?
______
☐ Some other reason
(explain):

☐ Not done/
Don’t know

☐ Not done/
Don’t know

(Check all that
apply)
☐ Ultrasound or
Sonogram
☐ Chorionic Villus
Sampling (CVS)
☐ Amniocentesis
☐ Other tests to
check on the
health of your
baby (describe
below):

5

6

7

Vaccination / Shot
/ Immunization

Other Tests and Procedures
(Tests to check on YOUR
health) For example, lab
tests (blood, urine, etc.)

Medications/Other
Treatments
(For example,
over-the-counter
or prescribed
medications)

8

9
Completed by
Office or Self

Diagnoses
Date Reported
to National
Children’s Study

☐ No

☐ Office

☐ Yes (Specify type
below. Check
all that apply).

☐ Self

☐ Influenza
☐ Hepatitis B
☐ Hepatitis A
☐ Tetanus /
Diphtheria (Td)
☐ Tetanus /
Diphtheria
Pertussis (Tdap)
☐ Meningococcal
☐ Pneumococcal
☐ Other:

Bring this log to all health care visits. Use this log for all National Children’s Study telephone calls and visits.
Save all bottles and containers of medications and bring to National Children’s Study visits and have available
for telephone calls:
• Medications (those prescribed by a health care provider and those bought “over-the-counter”)
• Vitamins, minerals, herbs, and any other supplements

Date:

The National Children’s Study

h

Visit Date: __ __ / __ __ / __ __ __ __
Month

Day

Year

Provider Number from Health Care Provider Log: _______________

Health Care Visits and Overnight Hospital Stays Log

Name of Provider Seen: _______________________________________
Be sure to also write this provider’s contact information in the HEALTH CARE PROVIDER LOG.

Health Care Visit/Hospital Stay 3
1

Reason for visit

☐ Routine
Pregnancy Care

2

Weight

lb

3

4

Blood
Pressure

Pregnancy Care
Procedures
(Tests to check on
your baby’s health)

__ __ __
/__ __ __

☐ Illness or Injury
☐ Overnight
hospital stay
(Hospitalized)
How many nights?
______
☐ Some other reason
(explain):

☐ Not done/
Don’t know

☐ Not done/
Don’t know

(Check all that
apply)
☐ Ultrasound or
Sonogram
☐ Chorionic Villus
Sampling (CVS)
☐ Amniocentesis
☐ Other tests to
check on the
health of your
baby (describe
below):

5

6

7

Vaccination / Shot
/ Immunization

Other Tests and Procedures
(Tests to check on YOUR
health) For example, lab
tests (blood, urine, etc.)

Medications/Other
Treatments
(For example,
over-the-counter
or prescribed
medications)

8

9
Completed by
Office or Self

Diagnoses
Date Reported
to National
Children’s Study

☐ No

☐ Office

☐ Yes (Specify type
below. Check
all that apply).

☐ Self

☐ Influenza
☐ Hepatitis B
☐ Hepatitis A
☐ Tetanus /
Diphtheria (Td)
☐ Tetanus /
Diphtheria
Pertussis (Tdap)
☐ Meningococcal
☐ Pneumococcal
☐ Other:

Bring this log to all health care visits. Use this log for all National Children’s Study telephone calls and visits.
Save all bottles and containers of medications and bring to National Children’s Study visits and have available
for telephone calls:
• Medications (those prescribed by a health care provider and those bought “over-the-counter”)
• Vitamins, minerals, herbs, and any other supplements

Date:

The National Children’s Study

h

Visit Date: __ __ / __ __ / __ __ __ __
Month

Day

Year

Provider Number from Health Care Provider Log: _______________

Health Care Visits and Overnight Hospital Stays Log

Name of Provider Seen: _______________________________________
Be sure to also write this provider’s contact information in the HEALTH CARE PROVIDER LOG.

Health Care Visit/Hospital Stay 4
1

Reason for visit

☐ Routine
Pregnancy Care

2

Weight

lb

3

4

Blood
Pressure

Pregnancy Care
Procedures
(Tests to check on
your baby’s health)

__ __ __
/__ __ __

☐ Illness or Injury
☐ Overnight
hospital stay
(Hospitalized)
How many nights?
______
☐ Some other reason
(explain):

☐ Not done/
Don’t know

☐ Not done/
Don’t know

(Check all that
apply)
☐ Ultrasound or
Sonogram
☐ Chorionic Villus
Sampling (CVS)
☐ Amniocentesis
☐ Other tests to
check on the
health of your
baby (describe
below):

5

6

7

Vaccination / Shot
/ Immunization

Other Tests and Procedures
(Tests to check on YOUR
health) For example, lab
tests (blood, urine, etc.)

Medications/Other
Treatments
(For example,
over-the-counter
or prescribed
medications)

8

9
Completed by
Office or Self

Diagnoses
Date Reported
to National
Children’s Study

☐ No

☐ Office

☐ Yes (Specify type
below. Check
all that apply).

☐ Self

☐ Influenza
☐ Hepatitis B
☐ Hepatitis A
☐ Tetanus /
Diphtheria (Td)
☐ Tetanus /
Diphtheria
Pertussis (Tdap)
☐ Meningococcal
☐ Pneumococcal
☐ Other:

Bring this log to all health care visits. Use this log for all National Children’s Study telephone calls and visits.
Save all bottles and containers of medications and bring to National Children’s Study visits and have available
for telephone calls:
• Medications (those prescribed by a health care provider and those bought “over-the-counter”)
• Vitamins, minerals, herbs, and any other supplements

Date:

The National Children’s Study

h

Visit Date: __ __ / __ __ / __ __ __ __
Month

Day

Year

Provider Number from Health Care Provider Log: _______________

Health Care Visits and Overnight Hospital Stays Log

Name of Provider Seen: _______________________________________
Be sure to also write this provider’s contact information in the HEALTH CARE PROVIDER LOG.

Health Care Visit/Hospital Stay 5
1

Reason for visit

☐ Routine
Pregnancy Care

2

Weight

lb

3

4

Blood
Pressure

Pregnancy Care
Procedures
(Tests to check on
your baby’s health)

__ __ __
/__ __ __

☐ Illness or Injury
☐ Overnight
hospital stay
(Hospitalized)
How many nights?
______
☐ Some other reason
(explain):

☐ Not done/
Don’t know

☐ Not done/
Don’t know

(Check all that
apply)
☐ Ultrasound or
Sonogram
☐ Chorionic Villus
Sampling (CVS)
☐ Amniocentesis
☐ Other tests to
check on the
health of your
baby (describe
below):

5

6

7

Vaccination / Shot
/ Immunization

Other Tests and Procedures
(Tests to check on YOUR
health) For example, lab
tests (blood, urine, etc.)

Medications/Other
Treatments
(For example,
over-the-counter
or prescribed
medications)

8

9
Completed by
Office or Self

Diagnoses
Date Reported
to National
Children’s Study

☐ No

☐ Office

☐ Yes (Specify type
below. Check
all that apply).

☐ Self

☐ Influenza
☐ Hepatitis B
☐ Hepatitis A
☐ Tetanus /
Diphtheria (Td)
☐ Tetanus /
Diphtheria
Pertussis (Tdap)
☐ Meningococcal
☐ Pneumococcal
☐ Other:

Bring this log to all health care visits. Use this log for all National Children’s Study telephone calls and visits.
Save all bottles and containers of medications and bring to National Children’s Study visits and have available
for telephone calls:
• Medications (those prescribed by a health care provider and those bought “over-the-counter”)
• Vitamins, minerals, herbs, and any other supplements

Date:

The National Children’s Study

h

Visit Date: __ __ / __ __ / __ __ __ __
Month

Day

Year

Provider Number from Health Care Provider Log: _______________

Health Care Visits and Overnight Hospital Stays Log

Name of Provider Seen: _______________________________________
Be sure to also write this provider’s contact information in the HEALTH CARE PROVIDER LOG.

Health Care Visit/Hospital Stay 6
1

Reason for visit

☐ Routine
Pregnancy Care

2

Weight

lb

3

4

Blood
Pressure

Pregnancy Care
Procedures
(Tests to check on
your baby’s health)

__ __ __
/__ __ __

☐ Illness or Injury
☐ Overnight
hospital stay
(Hospitalized)
How many nights?
______
☐ Some other reason
(explain):

☐ Not done/
Don’t know

☐ Not done/
Don’t know

(Check all that
apply)
☐ Ultrasound or
Sonogram
☐ Chorionic Villus
Sampling (CVS)
☐ Amniocentesis
☐ Other tests to
check on the
health of your
baby (describe
below):

5

6

7

Vaccination / Shot
/ Immunization

Other Tests and Procedures
(Tests to check on YOUR
health) For example, lab
tests (blood, urine, etc.)

Medications/Other
Treatments
(For example,
over-the-counter
or prescribed
medications)

8

9
Completed by
Office or Self

Diagnoses
Date Reported
to National
Children’s Study

☐ No

☐ Office

☐ Yes (Specify type
below. Check
all that apply).

☐ Self

☐ Influenza
☐ Hepatitis B
☐ Hepatitis A
☐ Tetanus /
Diphtheria (Td)
☐ Tetanus /
Diphtheria
Pertussis (Tdap)
☐ Meningococcal
☐ Pneumococcal
☐ Other:

Bring this log to all health care visits. Use this log for all National Children’s Study telephone calls and visits.
Save all bottles and containers of medications and bring to National Children’s Study visits and have available
for telephone calls:
• Medications (those prescribed by a health care provider and those bought “over-the-counter”)
• Vitamins, minerals, herbs, and any other supplements

Date:

The National Children’s Study

h

Visit Date: __ __ / __ __ / __ __ __ __
Month

Day

Year

Provider Number from Health Care Provider Log: _______________

Health Care Visits and Overnight Hospital Stays Log

Name of Provider Seen: _______________________________________
Be sure to also write this provider’s contact information in the HEALTH CARE PROVIDER LOG.

Health Care Visit/Hospital Stay 7
1

Reason for visit

☐ Routine
Pregnancy Care

2

Weight

lb

3

4

Blood
Pressure

Pregnancy Care
Procedures
(Tests to check on
your baby’s health)

__ __ __
/__ __ __

☐ Illness or Injury
☐ Overnight
hospital stay
(Hospitalized)
How many nights?
______
☐ Some other reason
(explain):

☐ Not done/
Don’t know

☐ Not done/
Don’t know

(Check all that
apply)
☐ Ultrasound or
Sonogram
☐ Chorionic Villus
Sampling (CVS)
☐ Amniocentesis
☐ Other tests to
check on the
health of your
baby (describe
below):

5

6

7

Vaccination / Shot
/ Immunization

Other Tests and Procedures
(Tests to check on YOUR
health) For example, lab
tests (blood, urine, etc.)

Medications/Other
Treatments
(For example,
over-the-counter
or prescribed
medications)

8

9
Completed by
Office or Self

Diagnoses
Date Reported
to National
Children’s Study

☐ No

☐ Office

☐ Yes (Specify type
below. Check
all that apply).

☐ Self

☐ Influenza
☐ Hepatitis B
☐ Hepatitis A
☐ Tetanus /
Diphtheria (Td)
☐ Tetanus /
Diphtheria
Pertussis (Tdap)
☐ Meningococcal
☐ Pneumococcal
☐ Other:

Bring this log to all health care visits. Use this log for all National Children’s Study telephone calls and visits.
Save all bottles and containers of medications and bring to National Children’s Study visits and have available
for telephone calls:
• Medications (those prescribed by a health care provider and those bought “over-the-counter”)
• Vitamins, minerals, herbs, and any other supplements

Date:

The National Children’s Study

h

Visit Date: __ __ / __ __ / __ __ __ __
Month

Day

Year

Provider Number from Health Care Provider Log: _______________

Health Care Visits and Overnight Hospital Stays Log

Name of Provider Seen: _______________________________________
Be sure to also write this provider’s contact information in the HEALTH CARE PROVIDER LOG.

Health Care Visit/Hospital Stay 8
1

Reason for visit

☐ Routine
Pregnancy Care

2

Weight

lb

3

4

Blood
Pressure

Pregnancy Care
Procedures
(Tests to check on
your baby’s health)

__ __ __
/__ __ __

☐ Illness or Injury
☐ Overnight
hospital stay
(Hospitalized)
How many nights?
______
☐ Some other reason
(explain):

☐ Not done/
Don’t know

☐ Not done/
Don’t know

(Check all that
apply)
☐ Ultrasound or
Sonogram
☐ Chorionic Villus
Sampling (CVS)
☐ Amniocentesis
☐ Other tests to
check on the
health of your
baby (describe
below):

5

6

7

Vaccination / Shot
/ Immunization

Other Tests and Procedures
(Tests to check on YOUR
health) For example, lab
tests (blood, urine, etc.)

Medications/Other
Treatments
(For example,
over-the-counter
or prescribed
medications)

8

9
Completed by
Office or Self

Diagnoses
Date Reported
to National
Children’s Study

☐ No

☐ Office

☐ Yes (Specify type
below. Check
all that apply).

☐ Self

☐ Influenza
☐ Hepatitis B
☐ Hepatitis A
☐ Tetanus /
Diphtheria (Td)
☐ Tetanus /
Diphtheria
Pertussis (Tdap)
☐ Meningococcal
☐ Pneumococcal
☐ Other:

Bring this log to all health care visits. Use this log for all National Children’s Study telephone calls and visits.
Save all bottles and containers of medications and bring to National Children’s Study visits and have available
for telephone calls:
• Medications (those prescribed by a health care provider and those bought “over-the-counter”)
• Vitamins, minerals, herbs, and any other supplements

Date:

The National Children’s Study

h

Visit Date: __ __ / __ __ / __ __ __ __
Month

Day

Year

Provider Number from Health Care Provider Log: _______________

Health Care Visits and Overnight Hospital Stays Log

Name of Provider Seen: _______________________________________
Be sure to also write this provider’s contact information in the HEALTH CARE PROVIDER LOG.

Health Care Visit/Hospital Stay 9
1

Reason for visit

☐ Routine
Pregnancy Care

2

Weight

lb

3

4

Blood
Pressure

Pregnancy Care
Procedures
(Tests to check on
your baby’s health)

__ __ __
/__ __ __

☐ Illness or Injury
☐ Overnight
hospital stay
(Hospitalized)
How many nights?
______
☐ Some other reason
(explain):

☐ Not done/
Don’t know

☐ Not done/
Don’t know

(Check all that
apply)
☐ Ultrasound or
Sonogram
☐ Chorionic Villus
Sampling (CVS)
☐ Amniocentesis
☐ Other tests to
check on the
health of your
baby (describe
below):

5

6

7

Vaccination / Shot
/ Immunization

Other Tests and Procedures
(Tests to check on YOUR
health) For example, lab
tests (blood, urine, etc.)

Medications/Other
Treatments
(For example,
over-the-counter
or prescribed
medications)

8

9
Completed by
Office or Self

Diagnoses
Date Reported
to National
Children’s Study

☐ No

☐ Office

☐ Yes (Specify type
below. Check
all that apply).

☐ Self

☐ Influenza
☐ Hepatitis B
☐ Hepatitis A
☐ Tetanus /
Diphtheria (Td)
☐ Tetanus /
Diphtheria
Pertussis (Tdap)
☐ Meningococcal
☐ Pneumococcal
☐ Other:

Bring this log to all health care visits. Use this log for all National Children’s Study telephone calls and visits.
Save all bottles and containers of medications and bring to National Children’s Study visits and have available
for telephone calls:
• Medications (those prescribed by a health care provider and those bought “over-the-counter”)
• Vitamins, minerals, herbs, and any other supplements

Date:

The National Children’s Study

h

Visit Date: __ __ / __ __ / __ __ __ __
Month

Day

Year

Provider Number from Health Care Provider Log: _______________

Health Care Visits and Overnight Hospital Stays Log

Name of Provider Seen: _______________________________________
Be sure to also write this provider’s contact information in the HEALTH CARE PROVIDER LOG.

Health Care Visit/Hospital Stay 10
1

Reason for visit

☐ Routine
Pregnancy Care

2

Weight

lb

3

4

Blood
Pressure

Pregnancy Care
Procedures
(Tests to check on
your baby’s health)

__ __ __
/__ __ __

☐ Illness or Injury
☐ Overnight
hospital stay
(Hospitalized)
How many nights?
______
☐ Some other reason
(explain):

☐ Not done/
Don’t know

☐ Not done/
Don’t know

(Check all that
apply)
☐ Ultrasound or
Sonogram
☐ Chorionic Villus
Sampling (CVS)
☐ Amniocentesis
☐ Other tests to
check on the
health of your
baby (describe
below):

5

6

7

Vaccination / Shot
/ Immunization

Other Tests and Procedures
(Tests to check on YOUR
health) For example, lab
tests (blood, urine, etc.)

Medications/Other
Treatments
(For example,
over-the-counter
or prescribed
medications)

8

9
Completed by
Office or Self

Diagnoses
Date Reported
to National
Children’s Study

☐ No

☐ Office

☐ Yes (Specify type
below. Check
all that apply).

☐ Self

☐ Influenza
☐ Hepatitis B
☐ Hepatitis A
☐ Tetanus /
Diphtheria (Td)
☐ Tetanus /
Diphtheria
Pertussis (Tdap)
☐ Meningococcal
☐ Pneumococcal
☐ Other:

Bring this log to all health care visits. Use this log for all National Children’s Study telephone calls and visits.
Save all bottles and containers of medications and bring to National Children’s Study visits and have available
for telephone calls:
• Medications (those prescribed by a health care provider and those bought “over-the-counter”)
• Vitamins, minerals, herbs, and any other supplements

Date:

The National Children’s Study

h

Visit Date: __ __ / __ __ / __ __ __ __
Month

Day

Year

Provider Number from Health Care Provider Log: _______________

Health Care Visits and Overnight Hospital Stays Log

Name of Provider Seen: _______________________________________
Be sure to also write this provider’s contact information in the HEALTH CARE PROVIDER LOG.

Health Care Visit/Hospital Stay 11
1

Reason for visit

☐ Routine
Pregnancy Care

2

Weight

lb

3

4

Blood
Pressure

Pregnancy Care
Procedures
(Tests to check on
your baby’s health)

__ __ __
/__ __ __

☐ Illness or Injury
☐ Overnight
hospital stay
(Hospitalized)
How many nights?
______
☐ Some other reason
(explain):

☐ Not done/
Don’t know

☐ Not done/
Don’t know

(Check all that
apply)
☐ Ultrasound or
Sonogram
☐ Chorionic Villus
Sampling (CVS)
☐ Amniocentesis
☐ Other tests to
check on the
health of your
baby (describe
below):

5

6

7

Vaccination / Shot
/ Immunization

Other Tests and Procedures
(Tests to check on YOUR
health) For example, lab
tests (blood, urine, etc.)

Medications/Other
Treatments
(For example,
over-the-counter
or prescribed
medications)

8

9
Completed by
Office or Self

Diagnoses
Date Reported
to National
Children’s Study

☐ No

☐ Office

☐ Yes (Specify type
below. Check
all that apply).

☐ Self

☐ Influenza
☐ Hepatitis B
☐ Hepatitis A
☐ Tetanus /
Diphtheria (Td)
☐ Tetanus /
Diphtheria
Pertussis (Tdap)
☐ Meningococcal
☐ Pneumococcal
☐ Other:

Bring this log to all health care visits. Use this log for all National Children’s Study telephone calls and visits.
Save all bottles and containers of medications and bring to National Children’s Study visits and have available
for telephone calls:
• Medications (those prescribed by a health care provider and those bought “over-the-counter”)
• Vitamins, minerals, herbs, and any other supplements

Date:

The National Children’s Study

h

Visit Date: __ __ / __ __ / __ __ __ __
Month

Day

Year

Provider Number from Health Care Provider Log: _______________

Health Care Visits and Overnight Hospital Stays Log

Name of Provider Seen: _______________________________________
Be sure to also write this provider’s contact information in the HEALTH CARE PROVIDER LOG.

Health Care Visit/Hospital Stay 12
1

Reason for visit

☐ Routine
Pregnancy Care

2

Weight

lb

3

4

Blood
Pressure

Pregnancy Care
Procedures
(Tests to check on
your baby’s health)

__ __ __
/__ __ __

☐ Illness or Injury
☐ Overnight
hospital stay
(Hospitalized)
How many nights?
______
☐ Some other reason
(explain):

☐ Not done/
Don’t know

☐ Not done/
Don’t know

(Check all that
apply)
☐ Ultrasound or
Sonogram
☐ Chorionic Villus
Sampling (CVS)
☐ Amniocentesis
☐ Other tests to
check on the
health of your
baby (describe
below):

5

6

7

Vaccination / Shot
/ Immunization

Other Tests and Procedures
(Tests to check on YOUR
health) For example, lab
tests (blood, urine, etc.)

Medications/Other
Treatments
(For example,
over-the-counter
or prescribed
medications)

8

9
Completed by
Office or Self

Diagnoses
Date Reported
to National
Children’s Study

☐ No

☐ Office

☐ Yes (Specify type
below. Check
all that apply).

☐ Self

☐ Influenza
☐ Hepatitis B
☐ Hepatitis A
☐ Tetanus /
Diphtheria (Td)
☐ Tetanus /
Diphtheria
Pertussis (Tdap)
☐ Meningococcal
☐ Pneumococcal
☐ Other:

Bring this log to all health care visits. Use this log for all National Children’s Study telephone calls and visits.
Save all bottles and containers of medications and bring to National Children’s Study visits and have available
for telephone calls:
• Medications (those prescribed by a health care provider and those bought “over-the-counter”)
• Vitamins, minerals, herbs, and any other supplements

Date:

The National Children’s Study

h

Visit Date: __ __ / __ __ / __ __ __ __
Month

Day

Year

Provider Number from Health Care Provider Log: _______________

Health Care Visits and Overnight Hospital Stays Log

Name of Provider Seen: _______________________________________
Be sure to also write this provider’s contact information in the HEALTH CARE PROVIDER LOG.

Health Care Visit/Hospital Stay 13
1

Reason for visit

☐ Routine
Pregnancy Care

2

Weight

lb

3

4

Blood
Pressure

Pregnancy Care
Procedures
(Tests to check on
your baby’s health)

__ __ __
/__ __ __

☐ Illness or Injury
☐ Overnight
hospital stay
(Hospitalized)
How many nights?
______
☐ Some other reason
(explain):

☐ Not done/
Don’t know

☐ Not done/
Don’t know

(Check all that
apply)
☐ Ultrasound or
Sonogram
☐ Chorionic Villus
Sampling (CVS)
☐ Amniocentesis
☐ Other tests to
check on the
health of your
baby (describe
below):

5

6

7

Vaccination / Shot
/ Immunization

Other Tests and Procedures
(Tests to check on YOUR
health) For example, lab
tests (blood, urine, etc.)

Medications/Other
Treatments
(For example,
over-the-counter
or prescribed
medications)

8

9
Completed by
Office or Self

Diagnoses
Date Reported
to National
Children’s Study

☐ No

☐ Office

☐ Yes (Specify type
below. Check
all that apply).

☐ Self

☐ Influenza
☐ Hepatitis B
☐ Hepatitis A
☐ Tetanus /
Diphtheria (Td)
☐ Tetanus /
Diphtheria
Pertussis (Tdap)
☐ Meningococcal
☐ Pneumococcal
☐ Other:

Bring this log to all health care visits. Use this log for all National Children’s Study telephone calls and visits.
Save all bottles and containers of medications and bring to National Children’s Study visits and have available
for telephone calls:
• Medications (those prescribed by a health care provider and those bought “over-the-counter”)
• Vitamins, minerals, herbs, and any other supplements

Date:

The National Children’s Study

h

Visit Date: __ __ / __ __ / __ __ __ __
Month

Day

Year

Provider Number from Health Care Provider Log: _______________

Health Care Visits and Overnight Hospital Stays Log

Name of Provider Seen: _______________________________________
Be sure to also write this provider’s contact information in the HEALTH CARE PROVIDER LOG.

Health Care Visit/Hospital Stay 14
1

Reason for visit

☐ Routine
Pregnancy Care

2

Weight

lb

3

4

Blood
Pressure

Pregnancy Care
Procedures
(Tests to check on
your baby’s health)

__ __ __
/__ __ __

☐ Illness or Injury
☐ Overnight
hospital stay
(Hospitalized)
How many nights?
______
☐ Some other reason
(explain):

☐ Not done/
Don’t know

☐ Not done/
Don’t know

(Check all that
apply)
☐ Ultrasound or
Sonogram
☐ Chorionic Villus
Sampling (CVS)
☐ Amniocentesis
☐ Other tests to
check on the
health of your
baby (describe
below):

5

6

7

Vaccination / Shot
/ Immunization

Other Tests and Procedures
(Tests to check on YOUR
health) For example, lab
tests (blood, urine, etc.)

Medications/Other
Treatments
(For example,
over-the-counter
or prescribed
medications)

8

9
Completed by
Office or Self

Diagnoses
Date Reported
to National
Children’s Study

☐ No

☐ Office

☐ Yes (Specify type
below. Check
all that apply).

☐ Self

☐ Influenza
☐ Hepatitis B
☐ Hepatitis A
☐ Tetanus /
Diphtheria (Td)
☐ Tetanus /
Diphtheria
Pertussis (Tdap)
☐ Meningococcal
☐ Pneumococcal
☐ Other:

Bring this log to all health care visits. Use this log for all National Children’s Study telephone calls and visits.
Save all bottles and containers of medications and bring to National Children’s Study visits and have available
for telephone calls:
• Medications (those prescribed by a health care provider and those bought “over-the-counter”)
• Vitamins, minerals, herbs, and any other supplements

Date:

The National Children’s Study

h

Visit Date: __ __ / __ __ / __ __ __ __
Month

Day

Year

Provider Number from Health Care Provider Log: _______________

Health Care Visits and Overnight Hospital Stays Log

Name of Provider Seen: _______________________________________
Be sure to also write this provider’s contact information in the HEALTH CARE PROVIDER LOG.

Health Care Visit/Hospital Stay 15
1

Reason for visit

☐ Routine
Pregnancy Care

2

Weight

lb

3

4

Blood
Pressure

Pregnancy Care
Procedures
(Tests to check on
your baby’s health)

__ __ __
/__ __ __

☐ Illness or Injury
☐ Overnight
hospital stay
(Hospitalized)
How many nights?
______
☐ Some other reason
(explain):

☐ Not done/
Don’t know

☐ Not done/
Don’t know

(Check all that
apply)
☐ Ultrasound or
Sonogram
☐ Chorionic Villus
Sampling (CVS)
☐ Amniocentesis
☐ Other tests to
check on the
health of your
baby (describe
below):

5

6

7

Vaccination / Shot
/ Immunization

Other Tests and Procedures
(Tests to check on YOUR
health) For example, lab
tests (blood, urine, etc.)

Medications/Other
Treatments
(For example,
over-the-counter
or prescribed
medications)

8

9
Completed by
Office or Self

Diagnoses
Date Reported
to National
Children’s Study

☐ No

☐ Office

☐ Yes (Specify type
below. Check
all that apply).

☐ Self

☐ Influenza
☐ Hepatitis B
☐ Hepatitis A
☐ Tetanus /
Diphtheria (Td)
☐ Tetanus /
Diphtheria
Pertussis (Tdap)
☐ Meningococcal
☐ Pneumococcal
☐ Other:

Bring this log to all health care visits. Use this log for all National Children’s Study telephone calls and visits.
Save all bottles and containers of medications and bring to National Children’s Study visits and have available
for telephone calls:
• Medications (those prescribed by a health care provider and those bought “over-the-counter”)
• Vitamins, minerals, herbs, and any other supplements

Date:

The National Children’s Study

h

Visit Date: __ __ / __ __ / __ __ __ __
Month

Day

Year

Provider Number from Health Care Provider Log: _______________

Health Care Visits and Overnight Hospital Stays Log

Name of Provider Seen: _______________________________________
Be sure to also write this provider’s contact information in the HEALTH CARE PROVIDER LOG.

Health Care Visit/Hospital Stay 16
1

Reason for visit

☐ Routine
Pregnancy Care

2

Weight

lb

3

4

Blood
Pressure

Pregnancy Care
Procedures
(Tests to check on
your baby’s health)

__ __ __
/__ __ __

☐ Illness or Injury
☐ Overnight
hospital stay
(Hospitalized)
How many nights?
______
☐ Some other reason
(explain):

☐ Not done/
Don’t know

☐ Not done/
Don’t know

(Check all that
apply)
☐ Ultrasound or
Sonogram
☐ Chorionic Villus
Sampling (CVS)
☐ Amniocentesis
☐ Other tests to
check on the
health of your
baby (describe
below):

5

6

7

Vaccination / Shot
/ Immunization

Other Tests and Procedures
(Tests to check on YOUR
health) For example, lab
tests (blood, urine, etc.)

Medications/Other
Treatments
(For example,
over-the-counter
or prescribed
medications)

8

9
Completed by
Office or Self

Diagnoses
Date Reported
to National
Children’s Study

☐ No

☐ Office

☐ Yes (Specify type
below. Check
all that apply).

☐ Self

☐ Influenza
☐ Hepatitis B
☐ Hepatitis A
☐ Tetanus /
Diphtheria (Td)
☐ Tetanus /
Diphtheria
Pertussis (Tdap)
☐ Meningococcal
☐ Pneumococcal
☐ Other:

Bring this log to all health care visits. Use this log for all National Children’s Study telephone calls and visits.
Save all bottles and containers of medications and bring to National Children’s Study visits and have available
for telephone calls:
• Medications (those prescribed by a health care provider and those bought “over-the-counter”)
• Vitamins, minerals, herbs, and any other supplements

Date:

The National Children’s Study

h

Visit Date: __ __ / __ __ / __ __ __ __
Month

Day

Year

Provider Number from Health Care Provider Log: _______________

Health Care Visits and Overnight Hospital Stays Log

Name of Provider Seen: _______________________________________
Be sure to also write this provider’s contact information in the HEALTH CARE PROVIDER LOG.

Health Care Visit/Hospital Stay 17
1

Reason for visit

☐ Routine
Pregnancy Care

2

Weight

lb

3

4

Blood
Pressure

Pregnancy Care
Procedures
(Tests to check on
your baby’s health)

__ __ __
/__ __ __

☐ Illness or Injury
☐ Overnight
hospital stay
(Hospitalized)
How many nights?
______
☐ Some other reason
(explain):

☐ Not done/
Don’t know

☐ Not done/
Don’t know

(Check all that
apply)
☐ Ultrasound or
Sonogram
☐ Chorionic Villus
Sampling (CVS)
☐ Amniocentesis
☐ Other tests to
check on the
health of your
baby (describe
below):

5

6

7

Vaccination / Shot
/ Immunization

Other Tests and Procedures
(Tests to check on YOUR
health) For example, lab
tests (blood, urine, etc.)

Medications/Other
Treatments
(For example,
over-the-counter
or prescribed
medications)

8

9
Completed by
Office or Self

Diagnoses
Date Reported
to National
Children’s Study

☐ No

☐ Office

☐ Yes (Specify type
below. Check
all that apply).

☐ Self

☐ Influenza
☐ Hepatitis B
☐ Hepatitis A
☐ Tetanus /
Diphtheria (Td)
☐ Tetanus /
Diphtheria
Pertussis (Tdap)
☐ Meningococcal
☐ Pneumococcal
☐ Other:

Bring this log to all health care visits. Use this log for all National Children’s Study telephone calls and visits.
Save all bottles and containers of medications and bring to National Children’s Study visits and have available
for telephone calls:
• Medications (those prescribed by a health care provider and those bought “over-the-counter”)
• Vitamins, minerals, herbs, and any other supplements

Date:

U.S. DEPARTMENT OF HEALTH AND HUMAN SERVICES
National Institutes of Health
Centers for Disease Control and Prevention
U.S. ENVIRONMENTAL PROTECTION AGENCY

PMCLOG01.01EN