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initial pregnancy questionnaire - singulairÒ

Initial 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.

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

Source: http://www.merckpregnancyregistries.com/forms/singulair/singulair_enroll.pdf

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