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Cause of death
?
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|
|
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Autopsy performed
|
|
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Autopsy result
?
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|
|
|
Age at delivery Mother
|
|
a
|
|
Attend fam plan prior conception Mother
?
|
|
|
|
Prenatal care indicator:Arb:Pt:^Mother:Ord:CDC
|
|
|
|
Date first prenatal visit:Date:Pt:^Mother:Qn:
|
|
{mm/dd/yyyy}
|
|
Prenatal care location Mother
?
|
|
|
|
Rubella-like illness dur preg Mother
|
|
|
|
Mo preg rubella symp Mother
|
|
mo
|
|
Mother Rubella sero confirm dur illness
?
|
|
|
|
Mother Knows loc expose illness
?
|
|
|
|
Country exp to illness
?
|
|
|
|
St or Prov exposure to illness
?
|
|
|
|
Co. of exposure to illness
?
|
|
|
|
City of exposure to illness
?
|
|
|
|
Travel outside US dur 1st tri Mother
?
|
|
|
|
Trav country outside U.S. 2Y
?
|
|
|
|
Exposed to confirmed case Mother
?
|
|
|
|
Mother Rel to indiv w conf illness
|
|
|
|
Mother Date exposure to illness
?
|
|
{mm/dd/yyyy}
|
|
Num in house under 18 dur preg
|
|
{#}
|
|
Rubella vac rcvd by under 18
|
|
|
|
Num in house under 18 rubella vac
|
|
{#}
|
|
Maculopapular rash Mother
|
|
|
|
Date of rash onset Mother
|
|
{mm/dd/yyyy}
|
|
Rash duration Mother
|
|
d
|
|
Fever Mother
|
|
|
|
Date of fever onset Mother
|
|
{mm/dd/yyyy}
|
|
Fever duration Mother
|
|
d
|
|
Lymphadenopathy Mother
|
|
|
|
Other maternal symp of illness
?
|
|
|
|
Mother Recvd vaccine for illness
?
|
|
|
|
Source of info
?
|
|
|
|
Serologic tx pre pregnancy Mother
|
|
|
|
Date serology test pre pregnancy Mother
|
|
{mm/dd/yyyy}
|
|
Serologic tx result pre pregnancy Mother
|
|
|
|
Specimen type
?
E
|
|
|
|
Collect Date
|
|
|
|
Performing lab name
?
E
|
|
|
|
Lab test method
?
|
|
|
|
Congenital rubella syndrome case classification:Imp:Pt:^Patient:Nom:
?
|
|
|