| Question | Response |
|---|---|
| Form Not Done | |
| Reason Pregnancy Test Not Done | FEMALE - POST-MENOPAUSAL FEMALE - SURGICALLY STERILE FEMALE - PRE-PUBERTY MALE OTHER |
| If 'OTHER', specify | |
| If Test Performed, | |
| Date sample taken | |
| Specimen | URINE SERUM |
| Result of pregnancy test | POSITIVE NEGATIVE |