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
XXXX@cdc.gov
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)
|
-flip to back page -
|