It t of lYpanaeat Coarfilt! .aUh Perinatal Hepatitis B Intake Form Fax to S17/335‐ 9855 or ca■ 517/335-8122 or 800/964‐ 4487 or in Southeast Michigan Fax to 313′ 456-0639 or cal1 313/456-4432 Mom's name Date of binh Para Grav Zip City Address County Emergency contact name & # Telephone # Race: L Asian/PI L B lack Ethniciり : ]HiSpanic ! White ! Amer Indian - Non-Hispanic Alaska tr Unknown Mom's Country of Birth Native L Unknown - Vaginal ! Method of Delivery Needed Y Interpreler If Yes, WhaI Language Other Cesarean N Crandmother of Infant's Country of Birth Mom's Insurance -Privatc *Medicaid LUninsured -County Health Plan -Medicare LMilitary (Tricare) lUnknown H BsAg / ノ e=Positive/Reactive;N=Ncgative′ Non‐ Reactivc;NT=Not Tested;U=Unknown) P iN Date HBsAg Reported HBeAg Anti‐ / HBclgM HBV DNA _J_J_ / / ノ / INT / U ノ Lab How Reported: Electronic Paper 日P l,N □P N P N 「 Repeat HBsAg NT IU 「 □ NT U NT IU 「 HBeAb / Anti― HBc / OB / / 1 P _N U Hospital Other P 「 / NT ]P N 「 NT l U N ENT H BV Viral Load 「]U Genotype ions(HCV,HIV,Syph‖ is,Other STIs,ctc) LHD Rcfcr Mom for Carc7Evaluation?EY IN EU Mom BOing MOn■ Ored for HBV?二 Y IN]U Other Matcrnal infectons/Cond■ Mom Being Treated for HBV? Y !N U If yes, Treatment Slart Physician Monitoring/Providing Treatment Mom Cet Tdap rraお ′7FgFα 〃ψ′ lY□ N Datc / Dale I Brand/Dose Telephone # / / Flu r力 お′′ α `g″ "り IY IIN Datc / / Doscsin MCIR「 IY IN Prenatal Care Provider (PCP) Information: EDC Date PCP/Facni,Nainc Address / / TelephOne# Zip Ciサ Reporting lnfolJlation Sentto PCP ttY ON Date Hospital to Deliver / / Household/Sexual Contact Information: First/Lasl Name (relationship) HBsAg,anti‐ HBs DOB HBIC Hep B CD Nurse DCH‐ 1398 AUTHORITY:PA 368 of1978 as anmded Hep B #2 Hep B #3 and/or anti― Test HBc Date Reミ ::l,s ′ ′ ′ ′ ′ ′ ′ ′ ′ ′ ′ ′ ′ ′ ′ ′ ′ ′ ′ ′ ′ ′ / ′ / / ′ ′ ′ ′ ′ ′ ′ ′ ′ ′ Contact's Provider Name Ciり #l Address Zip Telephone # Telephone # Re,01′ 11′ 11
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