REPORTER INFORMATION
Reporter name
text
Title of reporter
text
Address
text
Telephone No
integer
Fax No
integer
City
text
Postal Code
integer
Country
text
MOTHER’S RELEVANT MEDICAL/FAMILY HISTORY
(i.e. Include alcohol/tobacco and substance abuse, complications of past pregnancy, labor/delivery, fetus/baby, illness during this pregnancy, assisted conception: specify, other disorders including familial birth defects/genetic/chromosomal disorders, methods of diagnosis consanguinity etc)
text
Number of spontaneous abortion
integer
Number of therapeutic abortion
integer
Number of previous Pregnancies Terminations- Other
integer
Full term birth
integer
Pre term delivery
integer
Stillbirths
integer
Deliveries
integer
provide details under mother’s history
integer
Normal Births
integer
Birth, Outcome Unknown
integer
FATHER’S RELEVANT MEDICAL/FAMILY HISTORY
Information provided by
integer
Information provided by Other
text
(i.e. Include chronic illnesses: specify, familial birth defects/genetic/chromosomal disorders, habitual exposure: specify, alcohol/tobacco, drug exposure: specify, substance abuse and medication use)
text
Father Unknown
boolean
Number of children
integer
Age of father
integer
Race of father
text
GLAXOSMITHKLINE DRUG/VACCINE INFORMATION AND CONCOMITANT MEDICATIONS
Concomitant Medication
text
Regimen Dosing
text
day month year
date
day month year
date
Continuing therapy Concomitant Medication
boolean
Indication
text
CURRENT PREGNANCY INFORMATION
day month year
date
Last menstruation Unknown
boolean
day month year
date
Pregnancy status
integer
Delivery Method
text
If you tick other, please note details in "Additional details" section below.
integer
If you tick Birth defect, please note details in "Additional details" below.
integer
INFANT INFORMATION
Gestational weeks
integer
day month year
date
Sex
text
day month year
date
Length of infant, cm
float
Length of infant, inches
float
Weight of infant, kg
float
Weight of infant, lb
float
Apgar score
integer
Multiple births
integer
(1,2,3,etc) send separate form for each child.
integer
Discharge summary notes
text
Additional details
text
RELEVANT LABORATORY TESTS & PROCEDURES
(e.g., ultrasound, amniocentesis, chorionic villi sampling, autopsy on products of gestation) In case of an abnormal evolution or outcome, please send a copy of all relevant laboratory tests and procedures and complete the AE or SAE form as appropriate.
text
Causations
text
(if not the same as reporter)
text
Reporter’s signature
text
day month year
date