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Illinois Teratogen Information Service - Ask Us a Question!

If you are a resident of Illinois, please fill in your information below.
If you are a resident of another state, please contact us by phone at 1-866-626-6847.

* required field

*Name:	Date of Birth:
Address:	City:	*State:
*Zip Code:	County:	*Phone Number:
Email:

*Person requesting information:	Mother or prospective mother Physician or Nurse Genetic Counselor Friend / Other Family Member Father of the baby Other

*How were you referred?	Self referred/referred by a friend Found information online Referred by a Physician or Nurse Referred by a Genetic Counselor Referred by Poison Control Other

*What is the pregnancy status?	Planning a pregnancy Currently pregnant Recently had a baby Breastfeeding Other

What was the first day of your last menstrual period?
How many weeks pregnant are you?
What is your due date?

For the following section, please give as much information as possible about the exposure. For instance, if it is a medication, include the brand name or generic name, dose, and how often you take the medication. If it is an environmental or work exposure, please include how you were exposed, what chemicals you were exposed to, and for how long. It is also very important to include when the exposure occurred, including specific dates if possible.

1. Exposure:
2. Exposure:

If there is other information that you believe is important for this assessment, please explain:

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