Pediatric Hiv Exposure Reporting (Pher) - U.s. Department Of Health & Human Services Page 2

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8. Was substance use during pregnancy noted in the medical or social work records?
Yes
No (Go to 10.)
Record not available (Go to 9.)
Unknown
8a. If yes, indicate which substances were used during pregnancy.
(Check all that apply.)
Alcohol
Cocaine
Marijuana (cannabis, THC, cannabinoids)
Opiates
Amphetamines
Crack cocaine
Methadone
Other (Specify.) _________________
Barbiturates
Hallucinogens
Methamphetamines
Specific drug(s) not documented
Benzodiazepines
Heroin
Nicotine (any tobacco product)
_____________________
8b. If substances used, were any injected?
Yes
No
Not documented
Unknown
Specify injected substance(s). _____________________
9. Was a toxicology screen done on the mother (either during pregnancy or at the time of delivery)?
Yes, positive result (Check all that apply.)
Alcohol
Cocaine
Marijuana (cannabis, THC, cannabinoids)
Opiates
Amphetamines
Crack cocaine
Methadone
Other (Specify.) _________________
Barbiturates
Hallucinogens
Methamphetamines
Specific drug(s) not documented
Benzodiazepines
Heroin
Nicotine (any tobacco product)
_____________________
Yes, negative result
No
Toxicology screen not documented
10. Was a toxicology screen done on the infant at birth?
Yes, positive result (Check all that apply.)
Alcohol
Cocaine
Marijuana (cannabis, THC, cannabinoids)
Opiates
Amphetamines
Crack cocaine
Methadone
Other (Specify.) _________________
Barbiturates
Hallucinogens
Methamphetamines
Specific drug(s) not documented
Benzodiazepines
Heroin
Nicotine (any tobacco product)
_____________________
Yes, negative result
No
Toxicology screen not documented
11. Was the mother’s HIV serostatus noted in her prenatal care medical records?
Yes, HIV-positive
Yes, HIV-negative
No
No prenatal care
Record not available
Unknown
12. Were antiretroviral drugs prescribed for the mother during this pregnancy?
Yes (Complete table.)
No (Go to 12a.)
Not documented (Go to 13.)
Record not available (Go to 13.)
Unknown
Drug name
Other
Drug
Date drug started
Gestational age
Drug stopped
Date stopped
Stop codes
(See list on p. 8.)
(specify)
refused
(mm/dd/yyyy)
drug started
Yes No ND
(if yes in preceding
(See list on
(weeks; round down)
column) (mm/dd/yyyy)
p. 8.)
□ □ □
i. ____________
_____________
__ __/__ __/__ __ __ __
______________
__ __/__ __/__ __ __ __
__________
□ □ □
ii. ____________
_____________
__ __/__ __/__ __ __ __
______________
__ __/__ __/__ __ __ __
__________
□ □ □
iii. ____________
_____________
__ __/__ __/__ __ __ __
______________
__ __/__ __/__ __ __ __
__________
□ □ □
iv. ____________
_____________
__ __/__ __/__ __ __ __
______________
__ __/__ __/__ __ __ __
__________
□ □ □
v. ____________
_____________
__ __/__ __/__ __ __ __
______________
__ __/__ __/__ __ __ __
__________
□ □ □
vi. ____________
_____________
__ __/__ __/__ __ __ __
______________
__ __/__ __/__ __ __ __
__________
(After completing table, go to 13.)
12a. If no antiretroviral drug was prescribed during pregnancy, check reason.
No prenatal care
Mother known to be HIV-negative during pregnancy
Not documented
Unknown
HIV serostatus of mother unknown
Mother refused
Other (Specify.) ________________
13. Was mother’s HIV serostatus noted in her labor and delivery records?
Yes, HIV-positive
Yes, HIV-negative
No
Record not available
Unknown
14. Did mother receive antiretroviral drugs during labor and delivery?
Yes (Complete table.)
No (Go to 14a.)
Not documented (Go to 15.)
Record not available (Go to 15.)
Unknown
Drug name
Other
Drug
Date received
Time received
Type of administration
(See list.)
(specify)
refused
(mm/dd/yyyy)
(See military time.)
Oral
IV
Not documented
i. ____________
_____________
__ __/__ __/__ __ __ __
_______ : _______
ii. ____________
_____________
__ __/__ __/__ __ __ __
_______ : _______
iii. ____________
_____________
__ __/__ __/__ __ __ __
_______ : _______
iv. ____________
_____________
__ __/__ __/__ __ __ __
_______ : _______
v. ____________
_____________
__ __/__ __/__ __ __ __
_______ : _______
vi. ____________
_____________
__ __/__ __/__ __ __ __
_______ : _______
(After completing table, go to 15.)
Military time: noon = 12:00; midnight = 00:00

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