Pregnancy and Zika Virus Disease Surveillance Form

Form Approved

OMB Control No.: 0920-XXXX

Expiration date: XX/XX/XXXX

P regnancy and Zika virus disease surveillance form These data are considered confidential and will be stored in a secure database at the Centers for Disease Control and Prevention Please return completed form by fax to (970) 266-3568 or email [email protected] Contacts (1): (970) 221-6400
Mother’s Zika virus infection (ADB follow-up)
Mother’s name: ________________________________	DOB: _____/_____/_____
State of residence: ______________________________	County of residence: ______________________
Ethnicity (Please ask the patient to self-identify as):  Hispanic or Latino  Not Hispanic or Latino
Race (Please ask the patient to self-identify as one or more of the following):  American Indian or Alaska Native  Asian  Black or African-American  Native Hawaiian or other Pacific Islander  White
Indication for maternal serum Zika virus testing: ____________________________________________________
Date of Zika virus disease onset: _____/_____/_____	-OR-  Asymptomatic
Symptoms of mother’s Zika virus disease: (check all that apply)  Fever _____oF  Rash  Arthralgia  Conjunctivitis  Other Clinical Presentation____________________
Gestational age at onset:________weeks
Countr(ies) of exposure:___________________________	Date of travel1:_______________________________
____________________________________________	Date of travel2: _______________________________
________________________________________________  Mother agrees to participate in the Pregnancy Register	Date of travel3: _______________________________
Mother’s pregnancy (DRH/DBDDD follow-up)
Last menstrual period: _____/_____/_____	Estimated delivery date: _____/_____/_____
Gestation history: Gravida _____ Para _____ SAB _____ TAB _____
Current gestation:  Single  Twins  Triplets
Underlying maternal illness: Diabetes  No  Yes  Maternal PKU  No  Yes Hypothyroidism  No  Yes Hypertension  No  Yes Alcohol use  No  Yes Other underlying illness:  _________________________________________________________________
Complications of pregnancy: TORCH infection  No  Yes  Gestational diabetes  No  Yes  Death of a monozygote twin  No  Yes  Pregnancy-related HTN  No  Yes Other  No  Yes ____________________________________________________________________________________________
Medications during pregnancy:  No  Yes (please list:)______________________________________ _______________________________________________________________________________________ _______________________________________________________________________________________
Did this pregnancy end in miscarriage or intrauterine fetal demise (IUFD)?  No  Yes (date: _____/_____/_____ ) (approximate gestational age: ________weeks)
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