Maternal Health History Form

US Zika Pregnancy Registry

ATT_A_USZPR_Maternal_Health-History_Form_Revised 21SEP2016

Maternal Health History Form

OMB: 0920-1143

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Registry ID _____________ State/Territory ID ___________________________ Approved

OMB No. 0920-1101

Exp. 08/31/2016


U.S. Zika Pregnancy Registry and Birth Defects Surveillance — Integrated

Maternal Health History Form

These data are c confidential and will be stored in a secure database at the Centers for Disease Control and Prevention.


Please return completed form via SAMS or secure FTP—request access from [email protected]

The form can also be sent by encrypted email to this address or by secure fax to 404-718-1013 or 404-718-2200




MHH.1. State/Territory ID:

___________________________

MHH.2. Maternal Age at Diagnosis: _____

MHH.3. State/Territory reporting: ________________

MHH.4. County reporting: _______________________


MHH.5. Ethnicity: Hispanic or Latino Not Hispanic or Latino


MHH.6. Race (check all that apply):

American Indian or Alaskan Native Asian Black or African-American Unknown/Not Specified

Native Hawaiian or other Pacific Islander White Other, specify______________________


MHH.7. Indication for maternal Zika virus testing: Exposure history only, no known fetal abnormalities

Exposure history and fetal abnormalities

No known exposure (skip to MHH.37)


Maternal Zika Virus History


MHH.8. Date of Zika virus symptom onset: _____/_____/_____ OR MHH.9. Asymptomatic

MHH.10. If symptomatic, gestational age at onset: ___________________(weeks, days)

MHH.11. If gestational age or date not known, trimester of symptom onset _________________ (1st, 2nd, 3rd)


MHH.12. Symptoms of mother’s Zika virus disease: (check all that apply)

Fever (if measured) _____oF or _____oC Arthralgia Conjunctivitis Rash

Other clinical presentation_____________________________________________________________________

MHH.13. If rash, check all that apply Maculopapular Petechial Purpuric Pruritic

Describe rash distribution__________________________________________________________


MHH.14. Hospitalized for Zika virus disease No Yes Unknown


MHH.15. Maternal Death No Yes Unknown MHH.16. If yes, cause of death_____________________

MHH.17. If yes, date of death _____/_____/_____ _________________________________


MHH.18. What was the suspected mode of Zika virus transmission?

Human-mosquito-human (vector) Sexual Other, please specify______________________ Unknown


MHH.19. Did the woman spend time in any areas outside the US states or US territories where there was active Zika virus transmission during the periconceptional period or during pregnancy? (http://www.cdc.gov/zika/geo/active-countries.html)

No Yes Unknown (If ‘no’ or ‘unknown’, skip to MHH 26)

MHH.20. If yes, please characterize the type of travel:

Incoming travel (one way travel to US states from an area with active Zika virus transmission)

Incoming travel (one way travel to US territories from an area with active Zika virus transmission)

Outgoing and incoming travel (roundtrip from US states to an area with active Zika virus transmission)

Outgoing and incoming travel (roundtrip from US territories to an area with active Zika virus transmission)



If incoming or outgoing travel, please list location and dates of travel:


MHH.21. Country of exposure (1)

_____________________________

MHH.22. Start Date ____/_____/_____

Start date is same as LMP

End Date ____/_____/_____


MHH.23. Country of exposure (2)

_____________________________

MHH.24. Start Date ____/_____/_____

Start date is same as LMP

End Date ____/_____/_____


MHH.25. Country of exposure (3)

_____________________________

MHH.26. Start Date ____/_____/_____

Start date is same as LMP

End Date ____/_____/_____


MHH.27. Was the Zika virus exposure within the 50 states, DC, or territories? No Yes Unknown


If yes, separately list each state or territory where Zika virus exposure occurred, and dates of possible exposure:


MHH.28. State or territory 1

______________________________

MHH.29. Start Date _____/_____/_____

Start date is same as LMP

End Date _____/_____/_____

Still at location


MHH.30. State or territory 2

______________________________

MHH.31. Start Date _____/_____/_____

Start date is same as LMP

End Date _____/_____/_____

Still at location


MHH.32. State or territory 3

______________________________

MHH.33. Start Date _____/_____/_____

Start date is same as LMP

End Date _____/_____/_____

Still at location


MHH.34. If suspected mode of transmission is sexual, was the pregnant woman’s sexual partner(s):

Male Female Please check all that apply


MHH.35. Did any sexual partner(s) have an illness that included fever, rash, joint pain, or pink eye during or within 2 weeks of spending any time in an area with active Zika virus transmission?

No Yes Unknown


MHH.36. If yes, was there unprotected sexual contact while partner(s) had this illness?

No Yes Unknown


MHH.37. Did partner have a test that demonstrated laboratory evidence of Zika virus infection? No Yes Unknown


Maternal Health History (Underlying maternal illness)


MHH.38. Diabetes No Yes Unknown

MHH.39. Maternal Phenylketonuria (PKU) No Yes Unknown

MHH.40. Hypothyroidism No Yes Unknown

MHH.41. High Blood Pressure or Hypertension No Yes Unknown

MHH.42. Other underlying illness(es): No Yes Unknown

MHH.43. If yes, specify: ____________________________________________________


Pregnancy Information


MHH.44. Last menstrual period (LMP): _____/_____/_____

MHH.45. Estimated delivery date (EDD): _____/_____/_____


MHH.46. Estimated delivery date based on (check all that apply):

LMP 1st trimester ultrasound 2nd trimester ultrasound 3rd trimester ultrasound

Other, specify ______________________________________


OB History:

MHH.47. # pregnancies (including current pregnancy) _____ MHH.49. # miscarriages _____

MHH.48. # living children _____

MHH.50. # elective terminations _____


MHH.51. Prior fetus/infant with microcephaly: No Yes Unknown

MHH.52. If yes, cause genetic?: No Yes  Unknown


MHH.53. Gestation: Single Twins Triplets+


Substance use during this pregnancy:

MHH.54. Alcohol use:

MHH.55. Cocaine use:

MHH.56. Smoking:

No Yes Unknown

No Yes Unknown

No Yes Unknown


Complications during current pregnancy


MHH.57.

Toxoplasmosis infection:

No Yes Unknown


MHH.58.

Cytomegalovirus infection:

No Yes Unknown


MHH.59.

Herpes Simplex infection:

No Yes Unknown


MHH.60.

Rubella infection:

No Yes Unknown


MHH.61.

Lymphocytic choriomeningitis virus infection:

No Yes Unknown


MHH.62.

Syphilis infection:

No Yes Unknown


MHH.63. If yes for infection testing during current pregnancy, please describe results:





MHH.64.

Fetal genetic abnormality:

No Yes, describe __________

Unknown


MHH.65.

Gestational diabetes:

No Yes Unknown


MHH.66.

Pregnancy-related hypertension:

No Yes Unknown


MHH.67.

Intrauterine death of a twin:

No Yes Unknown


MHH.68.

Other: No Yes Unknown

MHH.67. If yes, please specify ____________________________________________________





MHH.69. Medications during pregnancy: No Yes Unknown

MHH.70. If yes, specify (please specify type and see guide for further instructions):




Pregnancy Losses: Please also complete pertinent sections of neonatal assessment form


MHH.71. Did this pregnancy end in miscarriage (<20 weeks of gestation)?

No Yes Unknown MHH.72. Date: _____/_____/_____ OR gestational age_______ weeks

MHH.73. Please describe any abnormalities noted ____________________________________________________


MHH.74. Did this pregnancy end in stillbirth (intrauterine fetal demise) (≥20 weeks of gestation)?

No Yes Unknown MHH.75. Date: _____/_____/_____ OR gestational age_______ weeks

MHH.76. Please describe any abnormalities noted_____________________________________________________


MHH.77. Was this pregnancy terminated?

No Yes Unknown MHH.78. Date: _____/_____/_____ OR gestational age ______ weeks

MHH.79. Please describe any abnormalities noted_____________________________________________________


Maternal Prenatal Imaging and Diagnostics


MHH.80. Date(s) of ultrasound(s):


___/___/___

MHH.81. Check if date approximated


MHH.82. If date not known, Gestational age ____________ (weeks, days)



MHH.83. Overall fetal ultrasound results: Normal Abnormal


MHH.84. Reported by patient/healthcare provider Ultrasound report


MHH.85. Head circumference (HC) _______cm

MHH.86. Normal Abnormal (by physician report)


MHH.87. Biparietal diameter (BPD) ______cm

MHH.88. Femur length (FL) _____cm

MHH.89. Abdominal circumference (AC) _____cm


MHH.90. Symmetric intrauterine growth restriction (IUGR)

Asymmetric IUGR (HC>AC or HC>FL)


MHH.91. Microcephaly

No Yes

MHH.92. Intracranial calcifications

No Yes


MHH.93. Cerebral /cortical atrophy

No Yes

MHH.94. Abnormal cortical gyral patterns (e.g., polymicrogyria, lissencephaly, pachygyria, schizencephaly, gray matter heterotopia)

No Yes


MHH.95. Corpus callosum abnormalities

No Yes

MHH.96. Cerebellar abnormalities

No Yes


MHH.97. Porencephaly

No Yes

MHH.98. Hydranencephaly

No Yes


MHH.99. Moderate or severe ventriculomegaly /

hydrocephaly

No Yes

MHH.100. Fetal brain disruption sequence (collapsed skull, overlapping sutures, prominent occipital bone, scalp rugae)

No Yes


MHH.101. Other major brain abnormalities

No Yes

MHH.102. Anencephaly / acrania

No Yes


MHH.103. Encephalocele

No Yes

MHH.104. Spina bifida

No Yes


MHH.105. Holoprosencephaly /

arhinencephaly

No Yes

MHH.106. Structural eye abnormalities / dysplasia

No Yes


MHH.107. Arthrogryposis

No Yes

MHH.108. Clubfoot

No Yes


MHH.109. Hydrops

No Yes

MHH.110. Ascites

No Yes


MHH.111. Other

No Yes If yes, describe:



MHH.112. Description of abnormal ultrasound findings:






MHH.113. Date(s) of Ultrasound(s):

____/____/____

MHH.114. check

if date approximated


MHH.115.

if date not known, gestational age ____________ (weeks, days)






MHH.116. Overall fetal ultrasound results: Normal Abnormal


MHH.117. Reported by patient/healthcare provider Ultrasound report


MHH.118. Head circumference (HC) _______cm

MHH.119. Normal Abnormal (by physician report)


MHH.120. Biparietal diameter (BPD) ______cm

MHH.121. Femur length (FL) _____cm

MHH.122. Abdominal circumference (AC) _____cm


MHH.123. Symmetric IUGR Asymmetric IUGR (HC>AC or HC>FL)


MHH.124. Microcephaly

No Yes

MHH.125. Intracranial calcifications

No Yes


MHH.126. Cerebral / cortical atrophy

No Yes

MHH.127. Abnormal cortical gyral patterns (e.g., polymicrogyria, lissencephaly, pachygyria, schizencephaly, gray matter heterotopia)

No Yes


MHH.128. Corpus callosum abnormalities

No Yes

MHH.129. Cerebellar abnormalities

No Yes


MHH.130. Porencephaly

No Yes

MHH.131. Hydranencephaly

No Yes


MHH.132. Moderate or severe ventriculomegaly /

hydrocephaly

No Yes

MHH.133. Fetal brain disruption sequence (collapsed skull, overlapping sutures, prominent occipital bone, scalp rugae)

No Yes


MHH.134. Other major brain abnormalities

No Yes

MHH.135. Anencephaly / acrania

No Yes


MHH.136. Encephalocele

No Yes

MHH.137. Spina bifida

No Yes


MHH.138. Holoprosencephaly /

arhinencephaly

No Yes

MHH.139. Structural eye abnormalities / dysplasia

No Yes


MHH.140. Arthrogryposis

No Yes

MHH.141. Clubfoot

No Yes


MHH.142. Hydrops

No Yes

MHH.143. Ascites

No Yes


MHH.144. Other

No Yes If yes, describe:



MHH.145. Description of abnormal ultrasound findings:



MHH.146. Date(s) of Ultrasound(s):

____/____/____

MHH.147. check if date approximated


MHH.148. if date not known, gestational age ____________ (weeks, days)



MHH.149. Overall fetal ultrasound results: Normal Abnormal


MHH.150. Reported by patient/healthcare provider Ultrasound report


MHH.151. Head circumference (HC)_______cm

MHH.152. Normal Abnormal (by physician report)


MHH.153. Biparietal diameter (BPD) ______cm

MHH.154. Femur length (FL) _____cm

MHH.155.Abdominal circumference (AC) _____cm


MHH.156. Symmetric IUGR Asymmetric IUGR (HC>AC or HC>FL)


MHH.157. Microcephaly

No Yes

MHH.158. Intracranial calcifications

No Yes


MHH.159. Cerebral / cortical atrophy

No Yes

MHH.160. Abnormal cortical gyral patterns (e.g., polymicrogyria, lissencephaly, pachygyria, schizencephaly, gray matter heterotopia)

No Yes


MHH.161. Corpus callosum abnormalities

No Yes

MHH.162. Cerebellar abnormalities

No Yes


MHH.163. Porencephaly

No Yes

MHH.164. Hydranencephaly

No Yes


MHH.165. Moderate or severe ventriculomegaly /

hydrocephaly

No Yes

MHH.166. Fetal brain disruption sequence (collapsed skull, overlapping sutures, prominent occipital bone, scalp rugae)

No Yes


MHH.167. Other major brain abnormalities

No Yes

MHH.168. Anencephaly / Acrania

No Yes


MHH.169. Encephalocele

No Yes

MHH.170. Spina bifida

No Yes


MHH.171. Holoprosencephaly /

arhinencephaly

No Yes

MHH.172. Structural eye abnormalities / dysplasia

No Yes


MHH.173. Arthrogryposis

No Yes

MHH.174. Clubfoot

No Yes


MHH.175. Hydrops

No Yes

MHH.176. Ascites

No Yes



MHH.177. Other

No Yes If yes, describe:



MHH.178. Description of abnormal ultrasound findings:




**For additional ultrasounds or MRIs, please request a supplementary imaging form**


MHH.179. Fetal MRI performed: No Yes (If yes, please answer questions below)


MHH.180. Date(s) of MRI(s):


___/___/___


MHH.181. check if date is approximated


MHH.183. Overall fetal MRI results: Normal Abnormal


MHH.184. Reported by patient/healthcare provider MRI report


MHH.185. Head circumference (HC) ___cm

MHH.186. Normal Abnormal (by physician report)


MHH.187. Biparietal diameter (BPD) _____cm

MHH.188. Femur length (FL) _____cm

MHH.189. Abdominal circumference (AC) _____cm


MHH.190. Symmetric IUGR Asymmetric IUGR (HC>AC or HC>FL)


MHH.182. if date not known, gestational age ____________ (weeks, days)



MHH.191. Microcephaly

No Yes

MHH.192. Intracranial calcifications

No Yes


MHH.193. Cerebral / cortical atrophy

No Yes

MHH.194. Abnormal cortical gyral patterns (e.g., polymicrogyria, lissencephaly, pachygyria, schizencephaly, gray matter heterotopia)

No Yes


MHH.195. Corpus callosum abnormalities

No Yes

MHH.196. Cerebellar abnormalities

No Yes


MHH.197. Porencephaly

No Yes

MHH.198. Hydranencephaly

No Yes


MHH.199. Moderate or severe ventriculomegaly /

hydrocephaly

No Yes

MHH.200. Fetal brain disruption sequence (collapsed skull, overlapping sutures, prominent occipital bone, scalp rugae)

No Yes


MHH.201. Other major brain abnormalities

No Yes

MHH.202. Anencephaly / acrania

No Yes


MHH.203. Encephalocele

No Yes

MHH.204. Spina bifida

No Yes


MHH.205. Holoprosencephaly /

arhinencephaly

No Yes

MHH.206. Structural eye abnormalities / dysplasia

No Yes


MHH.207. Arthrogryposis

No Yes

MHH.208. Clubfoot

No Yes


MHH.209. Hydrops

No Yes

MHH.210. Ascites

No Yes



MHH.211. Other

No Yes If yes, describe:


MHH.212. Description of abnormal MRI findings:





MHH.213. Amniocentesis performed: No Yes

If Zika virus testing performed on amniotic fluid, please enter in Laboratory Results Form.

If cytogenetic testing performed on amniotic fluid, please enter below.



Prenatal (Fetal) Cytogenetic Testing


MHH.214. Prenatal (fetal) cytogenetic testing performed: No Yes (If yes, please answer questions below)



MHH.215. Cytogenetic Tests

Karyotype

FISH

CGH microarray

Cell-free DNA

Other, specify ____________________


MHH.216. Date of test:

_____/_____/______

MHH.217. Gestational Age: __________ (weeks, days) or

Trimester: 1st 2nd 3rd


MHH.218. Specimen type:

Amniocentesis

Chorionic Villus Sampling (CVS)

Maternal Serum

Other, specify ____________________

MHH.219. Test Result

Normal

Abnormal

Unknown



MHH.220. Description of abnormal cytogenetic testing findings:



Prenatal (Fetal) Cytogenetic Testing


MHH.221. Prenatal (fetal) cytogenetic testing performed: No Yes (If yes, please answer questions below)



MHH.222. Cytogenetic Tests

Karyotype

FISH

CGH microarray

Cell-free DNA

Other, specify ____________________


MHH.223. Date of test

_____/_____/______

MHH.224. Gestational Age: __________ (weeks, days) or

Trimester: 1st 2nd 3rd


MHH.225. Specimen type:

Amniocentesis

Chorionic Villus Sampling (CVS)

Maternal Serum

Other, specify ____________________

MHH.226. Test Result

Normal

Abnormal

Unknown



MHH.227. Description of abnormal cytogenetic testing findings:







Health Department Information


MHH.228. Name of person completing form: _____________________________________________________

MHH.229. Phone: _______________ MHH.230. Email: _________________________

MHH.231. Date form completed ____/____/____


Internal use only


Date entered____/_____/_____

Data Entry POC Initials: _______

Data Entry Notes:


Public reporting burden of this collection of information is estimated to average 15 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 CDC/ATSDR Reports Clearance Officer; 1600 Clifton Road NE, MS E-11, Atlanta, Georgia 30333; ATTN: PRA (0920-1101).



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