First Trimester Singleton Pregnancy
This form is to be filled in for first trimester pregnant women with Singleton Fetus to identify pregnant women at risk for preterm PE and FGR. The form utilizes risk prediction data based on the online FMF calculators for PE and FGR. Data submitted through this form will be stored electronically in a dedicated folder and used to develop and inform policy and for education or research purposes only.

Note: PE and FGR high risk are defined based on a 1:150 cutoff. Thus, any risk estimate lower than or equal to the cutoff is a high risk. For example, a 1: 120 is a high risk and a 1: 170 is a low risk

Enter only number for variables that have a number entry, do not enter the units. For example, enter height as 100 and not as 100 cms
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Email *
1st trimester Scan ID
Unique ID for each woman, can use same ID for all trimesters
Month *
Year *
State *
District *
Date of Birth
Enter as dd/mm/yyyy
Date of Exam *
Enter as dd/mm/yyyy
GA at exam (weeks) *
Height (cms)
Weight (kgs)
Racial Origin
Smoking
Patient mother had PE
Type of Conception *
Chronic HTN
DM
SLE
APLS
Parity (Nulliparous is no previous pregnancy >=24 wks) *
PE in last delivery (if parous)
Date of last delivery (if parous)
MM
/
DD
/
YYYY
GA last delivery (weeks+days)
Interpregnancy Interval (Years)
Sys BP Left Arm 1
Dias BP Left Arm 1
Sys BP Right arm 1
Dias BP Right arm 1
Sys BP Left Arm 2
Dias BP Left arm 2
Sys BP Right Arm 2
Dias BP Right arm 2
MAP (Digital BP machine) (FMF calculator)
Right Uterine artery PI *
Left Uterine artery PI *
Mean Uterine artery PI (from FMF calculator) *
Fetus 1 CRL (mm) *
Smallest Previous Baby  GA (Weeks)  Enter 0 if none
Smallest Previous Baby Weight (grams) Enter 0 if none
PE risk Digital (from FMF calculator)
PE high risk (1: <=150 as cutoff. E.g. 1: 140, 1: 60 etc) *
FGR risk (from FMF calculator) *
FGR high risk (1:<=150 cutoff. E.g. 1 :120, 1:50 etc) *
Low Dose Aspirin Recommended *
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