ellaOne Pregnancy Registry
Patient ID: Initials ________ Date of Birth ____ / ____ / ________
PREGNANCY OUTCOME FORM
Please return this form by fax to HRA Pharma at +33 1 42 77 03 52
Please specify the pregnancy outcome here. Instructions on the completion of additional forms are
provided according to pregnancy outcome.
Pregnancy outcome Additional information requested Instructions
Elective abortion
Thank you for completing this
(no medical reason –
Date of procedure ____/____/________ pregnancy registry. No further
patient’s elective
information is requested.
choice)
Healthy child(ren)
Pregnancy term (weeks) ____
Number of children born ____ Thank you for completing this
For each child, please specify: pregnancy registry. No further
Sex F M Birth weight (kg) ____ information is requested.
Sex F M Birth weight (kg) ____
Live birth Sex F M Birth weight (kg) ____
Please click here to complete the
Congenital anomaly follow-up form 1:
‘Congenital anomaly’
Please click here to complete the
Neonatal death follow-up form 2:
‘Neonatal death
Thank you for completing this
pregnancy registry.
Maternal death
You will be contacted very soon
for further information.
Induced therapeutic abortion (in case of anomaly discovered
during a prenatal diagnosis)
Spontaneous abortion ( 28 weeks of pregnancy)
Ectopic pregnancy
HEALTH CARE PROVIDER INFORMATION
Last name: First name:
Date: Signature:
As per the EU Directive 95/46/EC requirements on data protection, you have the right to access and amend the information
collected processed by HRA Pharma in the framework of the ellaOne Pregnancy Registry.
To exercise this right, please:
Send an email to cil@hra-pharma.com or
Send a fax to +33 1 40 33 12 31 or
Contact us by phone + 33 1 40 33 83 82
ellaOne Pregnancy Registry
Patient ID: Initials ________ Date of Birth ____ / ____ / ________
FOLLOW UP FORM 1
Congenital anomaly (page 1/4)
Please return this form by fax to HRA Pharma at +33 1 42 77 03 52
Pregnancy term (in weeks) _________
Number of children born _________
Delivery method Vaginal Caesarean
CHILD LIST OF CONGENITAL ANOMALIES
1
2
3
RELATIONSHIP TO ellaONE INTAKE* POSSIBLE CAUSES
1=MATERNAL AGE
CHILD
2=UNKNOWN
3=OTHER, SPECIFY
1
2
3
* certain / probable / possible / unlikely / not related / unknown
Apgar scores
APGAR
CHILD
1 MIN 5 MIN
1
2
3
Other comments:
Date: Signature:
As per the EU Directive 95/46/EC requirements on data protection, you have the right to access and amend the information
collected processed by HRA Pharma in the framework of the ellaOne Pregnancy Registry.
To exercise this right, please:
Send an email to cil@hra-pharma.com or
Send a fax to +33 1 40 33 12 31 or
Contact us by phone + 33 1 40 33 83 82
ellaOne Pregnancy Registry
Patient ID: Initials ________ Date of Birth ____ / ____ / ________
FOLLOW UP FORM 1
Congenital anomaly (page 2/4)
MATERNAL HISTORY
no
History of pregnancy
yes, how many? ___ If yes, number of live infants _____
History of spontaneous no History of foetal no
abortion (miscarriage) yes, how many? ___ death? yes, how many? ___
History of elective no History of therapeutic no
abortion? yes, how many? ___ abortion? yes, how many? ___
no
yes, how many? ___
History of birth defect?
If yes, please specify the defect
Please describe below any maternal family history of birth defects
Please describe below any other significant family history
Date: Signature:
As per the EU Directive 95/46/EC requirements on data protection, you have the right to access and amend the information
collected processed by HRA Pharma in the framework of the ellaOne Pregnancy Registry.
To exercise this right, please:
Send an email to cil@hra-pharma.com or
Send a fax to +33 1 40 33 12 31 or
Contact us by phone + 33 1 40 33 83 82