attach PID label here II CHILD MEDICAL HISTORY

attach PID label here II CHILD MEDICAL HISTORY (Abstracted) - Patient ID: - Clinical Unit: Form Date: Month Day Year Coordinator Code: This information should be obtained from the child's medical records. 1. Head circumference at birth: . 2. Apgar scores: centimeters 10 minute 3. Peak serum bilirubin . 15 minute 20 minute mg/d. L: 4. Did the child undergo a double volume exchange transfusion for hyperbilirubinemia? 1 Yes 2 No 5. Did the child have an intraventricular hemorrhage? 1 Yes 2 No 5 a. Grade 1 2 I 3 II 4 III IV 5 b. Was there post-hemorrhagic hydrocephalus? 1 Yes 1 2 3 Left Right Bilateral 2 No 6. Was this a premature infant born with respiratory distress syndrome, requiring ventilator support? 1 Yes 2 No 6 a. Did the child require oxygen at 28 days of 1 age? Yes 2 No 7. Did the child require steroids during the first hospitalization? 1 Yes 2 No 7 a. Steroids were required for: 1 Management of lung disease (bronchopulmonary dysplasia, pulmonary conditions) 2 Other reason, specify: _______________________ 8. Did the child have retinopathy of prematurity? 1 Yes 8 a. Zone of involvement: 1 2 No 8 b. Stage: 1 1 2 8 c. Plus disease 1 Yes 9. Was the child prescribed indomethacin? 1 Yes 2 No OPT Form 95 9 a. 1 2 V 1 (1 -2) Prophylactic Treatment AUG 06 1 2 2 3 2 No 2 3 3 4

II - Patient ID: 10. Was there a positive blood culture? 1 Yes 2 No 3 Not done 11. Was the cord gas p. H less than 7. 00? 1 Yes 2 No 3 Not measured 12. Was the child on a ventilator? 1 Yes 2 No 13. Were surfactants used on the child? 1 Yes 2 No - 14. Did the child have any birth defects? 1 Yes 2 No 14 a. Describe: ________________________________ 15. Did the child have Necrotizing Enterocolitis? 1 Yes 2 No 1 Yes 15 a. Was surgery required? 2 No 16. Did the child have periventricular leukomalacia? 1 Yes 2 No 17. HIV status of the child: 1 3 HIV testing not done Positive 2 Negative 18. Was there a diagnosis of hypoxic ischemic encephalopathy? 1 Yes 2 No 19. Was there a diagnosis of meningitis (a positive CF culture)? 1 Yes 2 No 20. Did the child have seizures during the first hospitalization? 1 Yes 2 No 21. Was there a serum glucose measure of less than 45 mg/d. L? 1 Yes 2 No 22. Was the child ever noted to be hypotensive? 1 Yes 2 No 23. Was there a positive toxicity screen? 1 Yes 2 No 3 Not measured 24. Data Abstractor: __________________________ OPT Form 95 V 1 (2 -2) AUG 06