TERATOGEN SERVICE INFORMATION FORM

Please fill in all of the requested information...

All of the following information is important in providing you with a correct risk assessment; inquiries without complete information will be returned unanswered.

 

Illinois Teratogen Information Service


Full Name: Date and Year of Birth:
Email Address:
Telephone: County:
Mailing Address:
City: State: Zip:

Race: 		Are you requesting this assessment for a patient?
    Yes No
If YES, what is your relationship to the patient?
Are you or the patient pregnant?
    Yes No
Are you or the patient planning pregnancy?
    Yes No
Are you or the patient breastfeeding?
    YesNo


When was the first day of last menstrual period?month/day/year

When is the due date?

What were you exposed to? [Give brand name OR generic name; ingredients, if known]

  1. How much were you exposed to? (dose)
    When were you exposed? (dates)


  2. How much were you exposed to? (dose)
    When were you exposed? (dates)


  3. How much were you exposed to? (dose)
    When were you exposed? (dates)


Is there other information you believe is important to this assessment?
How did you learn about our Internet site?


Please be aware that the information in this form will be transmitted by email; we can insure confidentiality of the information only when it reaches our office.

You may also print this form and fax it to: 312/981-4366