InitialPregnancy Questionnaire - SINGULAIR (montelukast sodium) Merck & Co., Inc. is committed to the CONFIDENTIAL collection of patient information. In order to allow for the collection of pregnancy outcome data, minimize duplicate reporting, and prevent loss to follow-up, please COMPLETE ALL SECTIONS below. Please correct any inaccurate pre-filled information. Physician Information Office Contact Patient Information Office Chart Number: ____________________________ Date of birth ____/____/____
Patient name: (last, first, middle) ____________________________________________________________________
Address _________________________________________________________________________________________
City ____________________________________
Race/ethnicity: Caucasian Black Asian Hispanic Native American Multiracial
SINGULAIR Use This Pregnancy Other Medication Use This Pregnancy Date(s) of use Strength (mg) Number of Date(s) Strength Number of From: To: doses taken doses taken Current Pregnancy Date of last menstrual period _____/_____/_____ Estimated delivery date _____/_____/_____ PRENATAL TESTING Date(s) of test Results of test Reason for test Comments Pregnancy History (may attach copy of ACOG Antepartum Record [Form A] or equivalent from patient’s chart) Number of previous pregnancies ______ full-term deliveries ______ pre-term births ______ Did a birth defect occur in any previous pregnancy?
specify __________________________________________________________________________________
Did a stillbirth or miscarriage occur in any previous pregnancy?
If yes, in what week of pregnancy did the stillbirth or miscarriage occur? ___________________________________ Questionnaire was completed by:___________________________________ Date: ____________________________ Merck Use Only WAES Number Return form to: Merck Pregnancy Registries, Worldwide Product Safety/Clinical Risk Management & Safety Surveillance, P.O. Box 4, WP97A-285, West Point, PA 19486 or Fax to: (215) 993-1220 Outcome Pregnancy Questionnaire - SINGULAIR (montelukast sodium) Merck & Co., Inc. is committed to the CONFIDENTIAL collection of patient information. In order to allow for the collection of pregnancy outcome data, minimize duplicate reporting, and prevent loss to follow-up, please COMPLETE ALL SECTIONS below. Please correct any inaccurate pre-filled information. Patient name: ____________________ Pregnancy Outcome (If multiple birth, please photocopy and complete a form for each infant.)
ª Liveborn infant: Birthdate ___/___/___ Sex _____ Weight _________ Weeks from LMP__________ Was the infant normal? yes no Were there congenital anomalies? If so, describe_____________________________________________________ Were there other complications or abnormalities? If so, describe ________________________________________ ____________________________________________________________________________________________ ª Elective termination Spontaneous abortion (< 20 weeks) Fetal death/stillbirth (> 20 weeks) Date ____/____/____
Were the products of conception examined? yes no unknown Was the fetus normal? yes no unknown
If no, describe ____________________________________________________________________________
Obstetric Information yes no Complication during pregnancy, specify _____________________________________________________ yes no Complication during labor/delivery, specify __________________________________________________ yes no Diagnostic test during pregnancy. If yes, dates and test results:____________________________________ ________________________________________________________________________________________________ yes no Infections or illnesses during pregnancy, specify _______________________________________________ yes no Concurrent medical conditions, specify ______________________________________________________ ________________________________________________________________________________________________ SINGULAIR use during this pregnancy Other medication use during this pregnancy Date(s) of use Strength (mg) Number of Date(s) Strength Number of doses From: To: doses taken ª Describe any additional information that might help in interpreting the outcome of this pregnancy: __________________________________________________________________________________________________ __________________________________________________________________________________________________ __________________________________________________________________________________________________ Pediatrician Name Address Office contact
Questionnaire was completed by:___________________________________ Date: _______________________________ Merck Use Only WAES Number Return form to: Merck Pregnancy Registries, Worldwide Product Safety/Clinical Risk Management & Safety Surveillance, P.O. Box 4, WP97A-285, West Point, PA 19486 or Fax to: (215) 993-1220
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Initial Pregnancy Questionnaire - SINGULAIR (montelukast sodium) 
Outcome Pregnancy Questionnaire - SINGULAIR (montelukast sodium)