Form for reporting exposure to the drug during pregnancy

* required fields

  • 1) MEDICATION(S) USED DURING THE PREGNANCY

  • 2) CONTACT INFORMATION FOR THE PERSON SUBMITTING

    Please state full name and telephone number or email address of the person submitting the form.
  • 3) MOTHER INFORMATION

  • *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?

  • 5) CHILD INFORMATION