Reporter name
Item
Reporter name
text
C2826892 (UMLS CUI [1])
Investigators Title
Item
Investigators Title
text
C3888414 (UMLS CUI [1,1])
C0008961 (UMLS CUI [1,2])
Investigators Address
Item
Investigators Address
text
C1442065 (UMLS CUI [1,1])
C0008961 (UMLS CUI [1,2])
Telephone No.
Item
Telephone No.
integer
C1515258 (UMLS CUI [1,1])
C0008961 (UMLS CUI [1,2])
Fax No.
Item
Fax No.
integer
C1549619 (UMLS CUI [1,1])
C0008961 (UMLS CUI [1,2])
City, State/Province
Item
City, State/Province
text
C0008848 (UMLS CUI [1,1])
C0008961 (UMLS CUI [1,2])
C1547742 (UMLS CUI [2,1])
C0008961 (UMLS CUI [2,2])
Postal Code
Item
Postal Code
text
C1514254 (UMLS CUI [1,1])
C0008961 (UMLS CUI [1,2])
Country
Item
Country
text
C0454664 (UMLS CUI [1,1])
C0008961 (UMLS CUI [1,2])
Mother's relevant medical/family history
Item
Mother's relevant medical/family history
text
C0026591 (UMLS CUI [1,1])
C0262926 (UMLS CUI [1,2])
C0026591 (UMLS CUI [2,1])
C0241889 (UMLS CUI [2,2])
Full term pregnancies
Item
Full term pregnancies
integer
C3814420 (UMLS CUI [1])
Pre term pregnancies
Item
Pre term pregnancies
integer
C0151526 (UMLS CUI [1])
Item
Birth Termination
integer
C1283212 (UMLS CUI [1,1])
C0005615 (UMLS CUI [1,2])
Code List
Birth Termination
CL Item
Spontaneous abortion (1)
CL Item
Therapeutics abortion (2)
CL Item
Children born with defects (5)
CL Item
Normal Births (6)
CL Item
Outcome unknown (7)
Item
Information provided
integer
C1533716 (UMLS CUI [1,1])
C1709908 (UMLS CUI [1,2])
Code List
Information provided
Information reported, other
Item
If other, please specify
text
C1533716 (UMLS CUI [1,1])
C1709908 (UMLS CUI [1,2])
C0205394 (UMLS CUI [1,3])
Father's relevant medical/family history
Item
Father's relevant medical/family history
text
C0015671 (UMLS CUI [1,1])
C0262926 (UMLS CUI [1,2])
C0015671 (UMLS CUI [2,1])
C0241889 (UMLS CUI [2,2])
Father Unknown
Item
Tick if Father Unknown
boolean
C0015671 (UMLS CUI [1,1])
C0439673 (UMLS CUI [1,2])
Number of children
Item
Number of children
integer
C2229974 (UMLS CUI [1])
Fathers Age
Item
Fathers Age
integer
C0015671 (UMLS CUI [1,1])
C0001779 (UMLS CUI [1,2])
Fathers Race
Item
Fathers Race
text
C0015671 (UMLS CUI [1,1])
C0034510 (UMLS CUI [1,2])
Drug/Vaccine/OTC Name
Item
Reported Drug / Vaccine / OTC Name (generic or trade name)
text
C0013227 (UMLS CUI [1,1])
C0027365 (UMLS CUI [1,2])
C0042210 (UMLS CUI [2,1])
C0027365 (UMLS CUI [2,2])
C0013231 (UMLS CUI [3,1])
C0027365 (UMLS CUI [3,2])
Dosing Regimen and Frequency of Dosing
Item
Dosing Regimen and Frequency of Dosing
text
C0040808 (UMLS CUI [1,1])
C0678766 (UMLS CUI [1,2])
C2982514 (UMLS CUI [2])
Start Date
Item
Start Date
date
C0808070 (UMLS CUI [1])
End Date
Item
End Date or Check Box if Continuing
date
C0806020 (UMLS CUI [1])
Check Box if Continuing
Item
Check Box if Continuing
boolean
C1553904 (UMLS CUI [1])
Indication
Item
Indication
text
C3146298 (UMLS CUI [1])
Date of last menstrual period
Item
Date of last menstrual period or check box if last period unknown
date
C0425932 (UMLS CUI [1])
Last Period Unknown
Item
Last Period Unknown
boolean
C0425932 (UMLS CUI [1,1])
C0439673 (UMLS CUI [1,2])
Estimated date of delivery
Item
Estimated date of delivery
date
C2825543 (UMLS CUI [1])
Item
Pregnancy status
integer
C0552579 (UMLS CUI [1])
Code List
Pregnancy status
CL Item
Pregnancy Ongoing (1)
CL Item
Delivery Method (3)
CL Item
Early Termination (5)
Delivery Method
Item
If Delivery Method, please specify
text
C0565867 (UMLS CUI [1])
Item
If Early Termination, please specify
integer
C0156543 (UMLS CUI [1])
Code List
If Early Termination, please specify
CL Item
Spontaneous abortion (1)
CL Item
Therapeutic abortion (2)
Other early termination
Item
If other early termination, please specify
text
C0156543 (UMLS CUI [1,1])
C0205394 (UMLS CUI [1,2])
Item
Fetal/Neonatal Status
integer
C3503749 (UMLS CUI [1])
C4042838 (UMLS CUI [2])
Code List
Fetal/Neonatal Status
CL Item
Birth defect (structural/chromosomal disorder) (2)
CL Item
Other disorder (non-structmal, premature birth, intrauterine death/stillbirth) (3)
Multiple births
Item
If multiple births (e.g., twins), indicate number
integer
C2015861 (UMLS CUI [1,1])
C2229974 (UMLS CUI [1,2])
Birth Order
Item
Birth Order
integer
C0005607 (UMLS CUI [1])
Discharge summary notes
Item
Discharge summary notes
text
C0242482 (UMLS CUI [1])
Additional details
Item
Additional details on current pregnancy, labor/delivery, fetus and/or infant
text
C1546922 (UMLS CUI [1,1])
C0747843 (UMLS CUI [1,2])
C1546922 (UMLS CUI [2,1])
C0022864 (UMLS CUI [2,2])
C1546922 (UMLS CUI [3,1])
C0005615 (UMLS CUI [3,2])
C1546922 (UMLS CUI [4,1])
C0015965 (UMLS CUI [4,2])
C1546922 (UMLS CUI [5,1])
C0021270 (UMLS CUI [5,2])
Gestational weeks at birth/miscarriage/termination
Item
Gestational weeks at birth/miscarriage/termination
integer
C0439671 (UMLS CUI [1,1])
C0439230 (UMLS CUI [1,2])
C0005615 (UMLS CUI [1,3])
C0439671 (UMLS CUI [2,1])
C0439230 (UMLS CUI [2,2])
C0000786 (UMLS CUI [2,3])
C0439671 (UMLS CUI [3,1])
C0439230 (UMLS CUI [3,2])
C0156543 (UMLS CUI [3,3])
Date of birth/miscarriage/termination
Item
Date of birth/miscarriage/termination
date
C0011008 (UMLS CUI [1,1])
C0005615 (UMLS CUI [1,2])
C0011008 (UMLS CUI [2,1])
C0000786 (UMLS CUI [2,2])
C0011008 (UMLS CUI [3,1])
C0156543 (UMLS CUI [3,2])
Item
Sex
text
C0079399 (UMLS CUI [1])
Date of Discharge
Item
Date of Discharge
date
C2361123 (UMLS CUI [1])
Length of infant
Item
Length of infant
float
C1444754 (UMLS CUI [1,1])
C0021270 (UMLS CUI [1,2])
Item
Unit Length
integer
C0439148 (UMLS CUI [1,1])
C1444754 (UMLS CUI [1,2])
Weight of infant
Item
Weight of infant
float
C0745274 (UMLS CUI [1])
Item
Unit Weight
integer
C0439148 (UMLS CUI [1,1])
C0043100 (UMLS CUI [1,2])
Apgar score
Item
Apgar score or check box if unknown
integer
C0003533 (UMLS CUI [1])
Apgar Score unknown
Item
Apgar Score unknown
boolean
C0003533 (UMLS CUI [1,1])
C0439673 (UMLS CUI [1,2])
Abnormal evolution/outcome
Item
Abnormal evolution/outcome
boolean
C0205161 (UMLS CUI [1,1])
C0085415 (UMLS CUI [1,2])
Item
If any problems occurred, do you believe they may be drug (or vaccine) related?
text
C0013227 (UMLS CUI [1,1])
C0033213 (UMLS CUI [1,2])
C0042210 (UMLS CUI [2,1])
C2347852 (UMLS CUI [2,2])
C0033213 (UMLS CUI [2,3])
Code List
If any problems occurred, do you believe they may be drug (or vaccine) related?
Reporter's signature
Item
Reporter's signature
text
C2346576 (UMLS CUI [1])
Date of signature
Item
Date of signature
date
C2346576 (UMLS CUI [1,1])
C0011008 (UMLS CUI [1,2])
Investigator Name
Item
Investigator Name
text
C2826892 (UMLS CUI [1])