Pregnancy Reporting Form (Clinical Trials)
Trial Protocol Number
Subject ID
Site Number / Name
Date of Report
Reporter Name
Reporter Role
Date of Last Study Drug Administration
Date of Last Menstrual Period (LMP)
Estimated Date of Conception
Estimated Gestational Age at Discovery
Description of Pregnancy Exposure (including dates of exposure, if known)
Current Study Drug Use
Discontinued
Ongoing
Date Study Drug Stopped (if applicable)
Relevant Medical History/Concomitant Medications
Outcome of Pregnancy (if known; submit follow-up forms as necessary)
Ongoing
Live Birth
Spontaneous Abortion
Induced Abortion
Still Birth
Other
Comments/Additional Relevant Information