Enrollment Medical Record Abstraction Form

ATTACHMENT 5 EXEMPLAR MEDICAL RECORD ABSTRACTION FORM OMB NUMBER: 0925-XXXX

EXPIRATION DATE: XX/XX/XXXX

Stress and Cortisol Measurement Substudy

Enrollment Medical Record Abstraction Form

1. Study ID #: _____________________________

Screen these items from the participant’s prenatal chart:

2. Current gestational age: _______ weeks _______ days

2. EDC or Due Date: __________

2. Gestational age at first prenatal visit: _______ weeks _______ days

2. Weight at first prenatal visit: _______ pounds

2. Height: _______ feet _______ inches