Pregnancy and Zika Virus Disease Surveillance Form

CDC Emergency Operations Center Zika Related Clinical Inquiries and Surveillance

Att. E -- Maternal Health History Form 31MAR2016

Maternal Health History Form

OMB: 0920-1101

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State/Territory ID ___________________________ Approved

OMB No. 0920-1101

Exp. 08/31/2016

Pregnancy 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 sending an encrypted email to ZIKApregnancy@cdc.gov or by fax to the secure number: 404-718-2200. Pregnancy & Birth Defects Task Force phone number: 770-488-7100

Mother’s Zika virus infection (ADB follow-up)


Mother’s name:

________________________________________________________________ Last First MI


____________________ Maiden name (if applicable)

State/Territory ID: ________________________________

DOB: _______/_______/________

State/Territory of residence: _______________________

County of residence: ______________________

Ethnicity: Hispanic or Latino Not Hispanic or Latino

Race (check all that apply): American Indian or Alaska Native Asian Black or African-American

Native Hawaiian or other Pacific Islander White

Indication for maternal Zika virus testing: Exposure history, no known fetal concerns

Exposure history and fetal concerns

Date of Zika virus symptom onset: _____/_____/_____ OR- Asymptomatic

If date not known, trimester of symptom onset _________________ Hospitalized for Zika virus disease No Yes Maternal Death No Yes

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

Fever _____oF (if measured) Rash Arthralgia Conjunctivitis

Other Clinical Presentation_________________________________________________________________________

If symptomatic, gestational age at onset: ___________________weeks

If gestational age not known ,trimester of symptom onset _________________

Travel history: No Yes

Was Zika virus infection acquired in place of residence No Yes, if yes, skip to the section on Mother’s pregnancy

If TRAVEL DURING PREGNANCY, answer questions below. If not, skip to non-traveling woman

Country(s) of exposure (1)_________________

Travel start _____/_____/_____

Travel end____/_____/_____

Mother’s sexual partner(s)? please check all that apply Male Female


Did any male sexual partner(s) travel on this trip? No Yes Unknown

If yes, did any male partner(s) have an illness that included fever, rash, arthralgia, or conjunctivitis during or within 2 weeks of travel? No Yes Unknown

If yes, was there unprotected sexual contact while male partner(s) had illness? No Yes Unknown

If male partner(s) traveled, did he have a test that showed lab evidence of Zika? No Yes Unknown

Country(s) of exposure (2)_________________

Travel start _____/_____/_____

Travel end____/_____/_____

Mother’s sexual partner(s)? please check all that apply Male Female


Did any male sexual partner(s) travel on this trip? No Yes Unknown

If yes, did any male partner(s) have an illness that included fever, rash, joint pain, or pink eye during or within 2 weeks of travel? No Yes Unknown

If yes, was there unprotected sexual contact while male partner(s) had illness? No Yes Unknown

If male partner(s) traveled, did he have a test that showed lab evidence of Zika? No Yes Unknown

Country(s) of exposure (3)_________________

Travel start _____/_____/_____

Travel end____/_____/_____

Mother’s sexual partner(s)? please check all that apply Male Female

Did any male sexual partner(s) travel on this trip? No Yes Unknown

If yes, did any male partner(s) have an illness that included fever, rash, joint pain, or pink eye during or within 2 weeks of travel? No Yes Unknown

If yes, was there unprotected sexual contact while male partner(s) had illness? No Yes Unknown

If male partner(s) traveled, did he have a test that showed lab evidence of Zika? No Yes Unknown

NON-TRAVELLING WOMAN: other possible exposures?

Sexual partner w/travel history, symptomatic, lab evidence of Zika

Sexual partner w/travel history, symptomatic, no test results  

Sexual partner w/travel history, asymptomatic, lab evidence Zika

Other, please describe_____________________________________________________________________________

Unknown exposure history

Mother’s pregnancy (DRH/DBDDD follow-up)

Last menstrual period (LMP): _____/_____/_____

Estimated delivery date: _____/_____/_____

Estimated delivery date based on (check all that apply): LMP ___/___/___ U/S (1st trimester)

U/S (2nd trimester) U/S (3rd trimester)

History: # pregnancies _____ # living children _____ # miscarriages _____ # elective terminations _____

Prior fetus/infant with microcephaly: No Yes If yes, genetic cause: No Yes 

Gestation: Single Twins Triplets+

Underlying maternal illness:

Diabetes No Yes  Maternal PKU No Yes Hypothyroidism No Yes Hypertension No Yes Substance use during this pregnancy: Alcohol use No Yes Cocaine use No Yes Smoking No Yes

Other underlying illness:  ___________________________________________________

Complications of pregnancy:

Toxoplasmosis Negative Positive Unknown Cytomegalovirus Negative Positive Unknown Herpes Simplex Negative Positive Unknown Rubella Negative Positive Unknown

Syphilis Negative Positive Unknown


Fetal genetic abnormality No Yes, diagnosis __________________________ Unknown

Gestational diabetes No Yes

Pregnancy-related HTN No Yes

Intrauterine death of a twin No Yes

Other _________________________________________________________________________________



Medications during pregnancy: No Yes (please list type and see guide for further instructions)



Did this pregnancy end in miscarriage or intrauterine fetal demise (IUFD)? No Yes Date: _____/_____/_____

Gestational age_______ weeks

Was this pregnancy terminated?

No Yes Date: _____/_____/_____ Gestational age______ weeks

Maternal Prenatal Imaging and Diagnostics

Date(s) of Ultrasound(s):




____/____/____ check if date approximated if date not known, gestational age ______ weeks



Overall Fetal Ultrasound Results: Normal Abnormal

reported by patient/healthcare provider ultrasound report


Head Circumference _______cm Normal Abnormal (by physician report)

Biparietal diameter ______cm Femur Length _____cm Abdominal circumference _____cm Symmetrical intrauterine growth restriction (IUGR) (<5% EFW)

Asymmetrical IUGR (HC<FL or HC <AC)

Intracranial calcifications No Yes Ventriculomegaly No Yes

Cerebral atrophy No Yes Ocular anomalies No Yes

Cerebellar abnormalities No Yes Arthrogryposis No Yes

Lissencephaly No Yes Pachygyria No Yes Hydranencephaly No Yes Porencephaly No Yes Corpus callosum abnormalities No Yes Hydrops No Yes

Ascites No Yes Other No Yes, describe

Description of abnormal ultrasound findings:







____/____/____

check if date is approximated if date not known, gestational age ______ weeks


Overall Fetal Ultrasound Results: Normal Abnormal

reported by patient/healthcare provider ultrasound report


Head Circumference _____cm Normal Abnormal (by physician report)

Biparietal diameter ______cm Femur Length _____cm Abdominal circumference _____cm Symmetrical IUGR (<5% EFW) Asymmetrical IUGR (HC<FL or HC <AC)

Intracranial calcifications No Yes Ventriculomegaly No Yes

Cerebral atrophy No Yes Ocular anomalies No Yes

Cerebellar abnormalities No Yes Arthrogryposis No Yes

Lissencephaly No Yes Pachygyria No Yes Hydranencephaly No Yes Porencephaly No Yes Corpus callosum abnormalities No Yes Hydrops No Yes

Ascites No Yes Other No Yes, describe

Description of abnormal ultrasound findings:






____/____/____

check if date is approximated if date not known, gestational age ______ weeks


Overall Fetal Ultrasound Results: Normal Abnormal

reported by patient/healthcare provider ultrasound report


Head Circumference _____cm Normal Abnormal (by physician report)

Biparietal diameter ______cm Femur Length _____cm Abdominal circumference _____cm Symmetrical IUGR (<5% EFW) Asymmetrical IUGR (HC<FL or HC <AC)

Intracranial calcifications No Yes Ventriculomegaly No Yes

Cerebral atrophy No Yes Ocular anomalies No Yes

Cerebellar abnormalities No Yes Arthrogryposis No Yes

Lissencephaly No Yes Pachygyria No Yes Hydranencephaly No Yes Porencephaly No Yes Corpus callosum abnormalities No Yes Hydrops No Yes

Ascites No Yes Other No Yes, describe

Description of abnormal ultrasound findings:




For additional ultrasounds, please request a supplementary ultrasound form

Fetal MRI performed: No Yes (please answer questions below)

____/____/____

check if date is approximated


if date not known, gestational age ______ weeks



Overall Fetal MRI Results: Normal Abnormal

reported by patient/healthcare provider ultrasound report


Head Circumference ___cm Normal Abnormal (by physician report)

Biparietal diameter ______cm Femur Length _____cm Abdominal circumference _____cm Symmetrical IUGR (<5% EFW) Asymmetrical IUGR (HC<FL or HC <AC)

Intracranial calcifications No Yes Ventriculomegaly No Yes

Cerebral atrophy No Yes Ocular anomalies No Yes

Cerebellar abnormalities No Yes Arthrogryposis No Yes

Lissencephaly No Yes Pachygyria No Yes Hydranencephaly No Yes Porencephaly No Yes Corpus callosum abnormalities No Yes Hydrops No Yes

Ascites No Yes Other No Yes, describe

Description of abnormal MRI findings:




Amniocentesis performed: No Yes (date: _____/_____/_____ )

Zika virus testing: Not performed Yes, if yes test results: negative for Zika lab evidence of Zika Non-Zika infection detected No Yes if yes, what infection(s) detected_____________________________ Genetic abnormality detected No Yes Please Describe:



Provider Information

Provider name: Dr. PA RN Mr. Ms. _____________________________________________________

Last First MI

Phone: _______________ Email: ________________________ Date of form completion _____/_____/____

Name of person completing form: (if different from provider) _____________________________________________

Last First MI

Hospital/facility:____________________________________________________________________________________

Phone: _______________ Email: ________________________ Date of form completion _____/_____/____

Health Department Information

Name of person completing form: _____________________________________________________________________

Phone: _______________ Email: ________________________ Date of form completion _____/_____/____

FOR INTERNAL CDC USE ONLY

Mother ID: State/Territory ID: Zika T ID:

R number: _____________ Mother infection type: Confirmed Probable Possible

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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File TitleA TULANE UNIVERSITY HEALTH SCIENCES CENTER RESEARCH STUDY
AuthorCDC User
Last Modified ByZirger, Jeffrey (CDC/OD/OADS)
File Modified2016-03-31
File Created2016-03-29

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