Demography
Subject ID Number
integer
Race
text
Age
integer
Date of Birth
date
Weight (kilogram)
float
Weight (pounds)
float
Height (centimeters)
float
Height (inches)
float
Was the mother using a method of contraception?
boolean
If Yes, specify
text
select one
text
e.g., ultrasound, amniocentesis, chronic villi sampling, including dates of test and procedures
text
Known allergies
boolean
If Yes, specify
text
Alcohol intake
boolean
If Yes, specify
text
Other significant prior or co-existent medical conditions or history
boolean
If Yes, specify
text
Pregnancy Information
Start date of last menstrual period
date
Date of positive pregnancy test
date
Date of last negative pregnancy test
date
Was pregnancy terminated?
boolean
If Yes, record the date
date
If Yes, clarify if elective or spontaneous termination?
text
Date of expected delivery
date
If none, enter a zero
integer
If none, enter a zero
integer
Has subject experienced complications during this or previous pregnancies?
boolean
If Yes, specify
text
Important Note