Boston University Medical Campus
Documentation of Pregnancy Testing -or- Determination that Pregnancy Testing Is Not RequiredParticipant ID #:_________________Participant Age:_________________Study Visit:_________________Pregnancy Test Completed: FORMCHECKBOX Yes FORMCHECKBOX NoIf Yes, complete the following: Date of test:___________________ Time:_______________Type of Test FORMCHECKBOX Urine FORMCHECKBOX BloodTest Result FORMCHECKBOX Negative FORMCHECKBOX Positive Tests Results Located: FORMCHECKBOX Attached FORMCHECKBOX EMR FORMCHECKBOX Other, Specify___________________If No Pregnancy Test, Reason FORMCHECKBOX Hysterectomy Date of hysterectomy:______________ FORMCHECKBOX Post-Menopausal Date last menstrual period: ____________ Post-Menopausal(non-surgical) is at least 12 months after a woman's last period. FORMCHECKBOX Other Reason, specify: ________________________________ Notes/Comments:Study Staff Name: ________________________________Signature: ______________________________________ Date: _______________(signature is required even if pregnancy test not done) ................
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