Pregnancy and Zika Virus Disease Surveillance Form

CDC Emergency Operations Center Zika Related Clinical Inquiries and Surveillance

Att E -- Maternal Health History Form 17FEB2016

Maternal Health History Form

OMB: 0920-1101

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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 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)

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