Maternal Health History Form

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).

Version 08/31/2016