form for reporting exposure to the drug during pregnancy

1) MEDICATION(S) USED DURING THE PREGNANCY

Name of the medication or active substance*

Indication(s)

Serial no.

Expiry date

Start date of administration

End date of administration

Dosage, route of administration, pharmaceutical form

Any actions taken

2) CONTACT INFORMATION FOR THE PERSON SUBMITTING

Please state full name and telephone number or email address of the person submitting the form.

First name, last name*

Address (street, city/town, country)*

Telephone no.*

E-mail

Qualifications of the person submitting

Reported to drug-control authorities?

3) MOTHER INFORMATION

Initials

Date of birth or age*

Body weight (kg)*

Height (cm)

Is the mother still pregnant?

Gestational age (weeks)

Expected date of confinement

Date of delivery

Pregnancy confirmed by

General medical and obstetric history

Were there any medical events during the pregnancy?

Please describe any complications, infections and illnesses experienced during the pregnancy, along with the mother’s exposure to medication:

*any health problems of the mother, used medication, smoking, alcohol use, allergies, information on previous pregnancies, number of children

4) HOW DID THE PREGNANCY END?

gestation age (in weeks):

Jeśli poród przed czasem - proszę podać wiek ciążowy (w tygodniach)

Was the pregnancy termination advised by the doctor?

If yes, please explain

Please describe any complications, infections and illnesses experienced during/after birth, along with the mother’s exposure to medication:

5) CHILD INFORMATION

Apgar score:

In the 1st minute of life:

In the 5th minute of life:

In the 10th minute of life:

Additional information on the child’s health

If there were any medical events noted (for the mother/foetus/newborn), is there any possibility for them to be caused by the medication(s) used during the pregnancy?

If yes, please state medication name and reason for using: