Neonate Assessment at Delivery Form

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

Neonate Assessment 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 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

Contact Pregnancy & Birth Defects Task Force phone number: 770-488-7100

NAD.1. Infant’s State/Territory ID ________________

NAD.2. Mother’s State/Territory ID ________________

NAD.3. DOB:

_____/_____/______

Live birth

Stillbirth ≥20 weeks

NAD.4. Sex:

 Male  Female

 Ambiguous/undetermined

NAD.5. Gestational age at delivery:

______ weeks ______ days

NAD.6. Based on: (check all that apply)

 LMP ___/___/___  1^st trimester ultrasound  2^nd trimester ultrasound  3^rd trimester ultrasound  Other_______________

NAD.7. Maternal age at delivery ____ years

NAD.8. State/Territory reporting: _______________

NAD.9. County reporting: __________________

NAD.10. Delivery type:

 Vaginal  Caesarean section

NAD.11. Delivery complication:  No  Yes

NAD.12. If yes, please describe: _______________________________________

NAD.13. Arterial cord blood pH (if performed): _________

NAD.14. Venous cord blood pH (if performed): _________

NAD.15. Placental exam (based on path report):  No  Yes

NAD.16. If yes,  Normal  Abruption  Inflammation  Other abnormality (please describe)

NAD.17. Apgar score:

1 min _______ / 5 min ________

NAD.18. Infant temp (if abnormal): _______ ^oF or ______ ^oC

Physical Examination (record earliest measurements taken)

NAD.19. Birth head circumference:

_______ cm ________ in

NAD.20.  Molding present

NAD.21. Physican report:  Normal  Abnormal

NAD.22. HC percentile:_______

NAD.23. Birth weight:

_________ grams

_________ lbs/oz

NAD.24. Birth weight percentile: ________

NAD.25. Birth length:

_________  cm

_________  in

NAD.26. Birth length percentile:________

NAD.27. Repeat head circumference: _______ cm _______ in

NAD.28. Date performed ___ /____ /____ or

Age _______ day(s)

NAD.29. Physican report:  Normal  Abnormal

NAD.30. HC percentile:________

NAD.31. Admitted to Neonatal Intensive Care Unit:

 No  Yes If yes, reason: ____________________________________________

NAD.32. Neonatal death:  No  Yes

NAD.33. Date __/__/____ or Age at death_____ days

NAD.34. Cause of death: _______________________

NAD.35. Microcephaly (head circumference <3%ile):  No  Yes

NAD.36. Seizures:  No  Yes

NAD.37. Neurologic exam: (check all that apply)
 Not performed  Unknown  Normal  Hypertonia/Spasticity  Hyperreflexia  Irritability

 Tremors  Other neurologic abnormalities NAD.38. (please describe below)

NAD.39. Splenomegaly by physical exam:
 No  Yes  Unknown
NAD.40. (please describe)

NAD.41. Hepatomegaly by physical exam:
 No  Yes  Unknown
NAD.42. (please describe)

NAD.43. Skin rash by physical exam:

 No  Yes  Unknown
NAD.44. (please describe)

NAD.45. Other abnormalities identified: please check all that apply

 Fetal Brain Disruption Sequence (collapsed skull, overlapping sutures, prominent occipital bone, scalp rugae)

 Encephalocele  Anencephaly/ Acrania  Spina bifida  Holoprosencephaly/arhinencephaly

 Microphthalmia/Anophthalmia  Arthrogryposis (congenital joint contractures)

 Congenital Talipes Equinovarus (clubfoot)  Congenital hip dislocation/developmental dysplasia of the hip

 Other abnormalities

NAD.46. (please describe below)

Neonate Imaging and Diagnostics

NAD.47. Hearing screening : (date:____/_____/_____) or Age _______ day(s)

NAD.48.  Pass  Fail  Inconclusive/Needs retest  Not performed

NAD.49. Please describe

NAD.50. Audiological evaluation:  Not performed  Auditory brainstem response (ABR) test performed

 Otoacoustic emisions (OAE) test performed  Acoustic stapedius reflex (ASR) test performed

 Unknown

NAD.51. If performed: Date: ___/___/___ NAD.52.  Normal  Abnormal,

NAD.53. Please describe

NAD.54. Retinal exam (with dilation):  Not Performed  Performed  Unknown

NAD.55. If performed: (date: _____/_____/_____) or Age _______ day(s)

NAD.56. please check all that apply:  Normal

 Microphthalmia/Anophthalmia  Coloboma  Cataract  Intraocular calcifications

 Chorioretinal atrophy, scarring, macular pallor, gross pigmentary mottling, or retinal hemorrhage, excluding retinopathy of prematurity  Other retinal abnormalities

 Optic nerve atrophy, pallor  Other optic nerve abnormalities

NAD.57. (please describe below)

NAD.58. Imaging study:  Cranial ultrasound  MRI  CT  Not Performed

NAD.59. (date: _____/_____/_____) or Age _______ day(s)
NAD.60. Findings: check all that apply  Normal

 Microcephaly  Intracranial calcification  Cerebral / cortical atrophy

 Abnormal cortical gyral patterns (lissencephaly, pachygyria, agyria, microgyria, polymicrogyria, schizencephaly)

 Corpus callosum abnormalities  Cerebellar abnormalities  Porencephaly

 Hydranencephaly  Moderate or severe ventriculomegaly/hydrocephaly

 Fetal Brain Disruption Sequence (collapsed skull, overlapping sutures, prominent occipital bone, scalp rugae)  Other major brain abnormalities

 Encephalocele  Holoprosencephaly/ Arhinencephaly

 Other abnormalities

NAD.61. (please describe below)

NAD.62. Imaging study:  Cranial ultrasound  MRI  CT  Not Performed

NAD.63. (date: _____/_____/_____) or Age _______ day(s)
NAD.64. Findings: check all that apply  Normal

 Microcephaly  Intracranial calcification  Cerebral / cortical atrophy

 Abnormal cortical gyral patterns (lissencephaly, pachygyria, agyria, microgyria, polymicrogyria, schizencephaly)

 Corpus callosum abnormalities  Cerebellar abnormalities  Porencephaly

 Hydranencephaly  Moderate or severe ventriculomegaly/hydrocephaly

 Fetal Brain Disruption Sequence (collapsed skull, overlapping sutures, prominent occipital bone, scalp rugae)  Other major brain abnormalities

 Encephalocele  Holoprosencephaly/ Arhinencephaly

 Other abnormalities

NAD.65. (please describe below)

NAD.66. Imaging study:  Cranial ultrasound  MRI  CT  Not Performed

NAD.67. (date: _____/_____/_____) or Age _______ day(s)

NAD.68. Findings: check all that apply  Normal

 Microcephaly  Intracranial calcification  Cerebral / cortical atrophy

 Abnormal cortical gyral patterns (lissencephaly, pachygyria, agyria, microgyria, polymicrogyria, schizencephaly)

 Corpus callosum abnormalities  Cerebellar abnormalities  Porencephaly

 Hydranencephaly  Moderate or severe ventriculomegaly/hydrocephaly

 Fetal Brain Disruption Sequence (collapsed skull, overlapping sutures, prominent occipital bone, scalp rugae)  Other major brain abnormalities

 Encephalocele  Holoprosencephaly/ Arhinencephaly

 Other abnormalities

NAD.69. (please describe below)

NAD.70. Was a lumbar puncture performed:  Yes  No  Unknown NAD.71. (date: _____/_____/_____) or Age _______ day(s)

Postnatal Infection Testing (includes urine culture for CMV)

NAD.72.

Toxoplasmosis infection:

 No  Yes  Unknown

NAD.73.

Cytomegalovirus infection:

 No  Yes  Unknown

NAD.74.

Herpes Simplex infection:

 No  Yes  Unknown

NAD.75.

Rubella infection:

 No  Yes  Unknown

NAD.76.

Lymphocytic choriomeningitis virus infection:

 No  Yes  Unknown

NAD.77.

Syphilis infection:

 No  Yes  Unknown

NAD.78. If yes for any postnatal infection testing, please describe results:

Postnatal (Infant) Cytogenetic Testing

NAD.79. Cytogenetic Test  Karyotype  FISH  CGH microarray  Other, specify ____________________	NAD.80. Date: _____/_____/______ NAD.81. Infant Age: _____ months	NAD.82. Specimen  Cord blood  Peripheral blood  Tissue  Other, specify ____________________	NAD.83. Test Result  Normal  Abnormal  Unknown
NAD.84. Description of cytogenetic test findings (verbatim):

NAD.85. Other tests/results/diagnosis (include dates):

Birth Defects Diagnosed or Suspected (Include Chromosomal Abnormalities and Syndromes)

Diagnostic Code

Certainty

Verbatim Description

Definite

Possible/Probable

Definite

Possible/Probable

Definite

Possible/Probable

Definite

Possible/Probable

Definite

Possible/Probable

Definite

Possible/Probable

Health Department Information

NAD.86. Name of person completing form: ________________________________________________

NAD.87. Phone: _______________

NAD.88. Email: ________________________ NAD.89. Date of form completion _____/_____/____

FOR INTERNAL CDC USE ONLY

Mother ID: State/territory ID:

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Version 8/31/2016