VR100 REV 11/89

INFORMATION FOR MEDICAL AND HEALTH USE ONLY

(BASED ON 1989 U.S. STANDARD CERTIFICATE

OF HISPANIC ORGIN?

RACE-American Indian,

26. EDUCATION

27. OCCUPATION AND BUSINESS/INDUSTRY

(Specify No or Yes-If Yes

Black, White, etc.

(Specify only highest grade completed)

(Worked during last year)

specify Cuban, Mexican,

(Specify below)

Elementary/Secondary (0-12)

College (1-4 or 5+)

Occupation

Business/Industry

24.

Puerto Rican, etc.)

25.

No

Yes

MOTHER

24a.

Specify:

25a.

26a.

27a.

27b.

No

Yes

FATHER

24b.

Specify:

25b.

26b.

27c.

27d.

28.  PREGNANCY HISTORY

MULTIPLE BIRTHS Enter State File Number for Mate(s) LIVE BIRTH(S)   FETAL DEATH(S)

(Complete each section)

MOTHER MARRIED? (at delivery, conception or at 

DATE LAST NORMAL MENSES BEGAN

any time between) (Yes or No)

(Month, Day, Year)

29.

30.

LIVE BIRTHS

(Do not include this child)

OTHER TERMINATIONS

(Spontaneous and induced at

any time after conception)

MONTH OF PREGNANCY PRENATAL CARE BEGAN

PRENATAL VISTS

First,   Second,   Third,   Etc.     (Specify)

Total Number (if none, so state)

31.

32.

NOW LIVING

NOW DEAD

BIRTHWEIGHT

CLINICAL ESTIMATE OF GESTATION

Number  ____

Number  ____

Number  _____

(Specify Units)

28a.    None

28b.    None

28d.     None

33.

34.

Weeks

DATE OF LAST LIVE BIRTH

DATE OF LAST OTHER TERMINATION

PLURALITY

IF NOT SINGLE BIRTH - Born

(Month, Year)

(Month, Year)

Single, Twin, Triplet, etc. (Specify)

First, Second, Third, etc.     (Specify)

28c.

28e.

35a.

35b.

36.  APGAR SCORE

MOTHER TRANSFERRED PRIOR TO DELIVERY?     No      Yes     

IF YES, ENTER NAME AND LOCATION OF FACILITY TRANSFERRED FROM

37a.

1 MINUTE

5 MINUTES

INFANT TRANSFERRED?  

   No

   Yes

IF YES, ENTER NAME AND LOCATION OF FACILITY TRANSFERRED TO

36a.

36b.

37b.

38a.

MEDICAL RISK FACTORS FOR THIS PREGNANCY

(Check all that apply)

40.

COMPLICATIONS OF LABOR AND/OR DELIVERY (Check all that apply)

43.

CONGENITAL ANOMALIES OF CHILD

(Check all that apply)

Anemia (Hct.<30/Hgb. <10)...........................................

01

Febrile (>100°F. or 38°C.)......................................

01

Anencephalus............................................

01

Cardiac disease.........................................

02

Meconium, moderate, heavy.................

02

Spina bifida/Meningocele.........

02

Acute or chronic lung disease......................................

03

Premature rupture of membrane (>12 hours).......

03

Hydrocephalus.........................................

03

Diabetes.....................................................

04

Abruptio placenta................................

04

Microcephalus...........................

04

Genital herpes...............................................................

05

Placenta previa.....................................................

05

Other central nervous system anomalies

Hydramnios/Oligohydramnios....................

06

Other excessive bleeding.....................

06

(Specify) ___________________________

05

Hemoglobinopathy.....................................................

07

Seizures during labor............................................

07

Heart malformations..................

06

Hypertension, chronic................................

08

Precipitous labor (<3 hours).................

08

Other circulatory/respiratory anomalies

Hypertension, pregnancy associated............................

09

Prolonged labor (>20 hours)..................................

09

(Specify) ___________________________

07

Eclampsia..................................................

10

Dysfunctional labor..............................

10

Rectal atresia/stenosis.............

08

Incompetent cervix........................................................

11

Breech/Malpresentation........................................

11

Tracheo-esophageal fistula/

Previous infant 4000 + grams....................

12

Cephalopelvic disproportion................

12

Esophageal atresia................................

09

Previous preterm or small-for-gestational-age infant....

13

Cord prolapse........................................................

13

Omphalocele/gastroschisis......

10

Renal disease............................................

14

Anesthetic complications....................

14

Other gastrointestinal anomalies

Rh sensitization............................................................

15

Fetal Distress........................................................

15

(Specify) ___________________________

11

Uterine bleeding.........................................

16

None.....................................................

00

Malformed genitalia...................

12

None..............................................................................

00

Other (specify)_______________________________

16

Renal agenesis........................................

13

Other (specify) ________________________

17

Other urogenital anomalies

41.  METHOD OF DELIVERY (Check all that apply)

(Specify) __________________

14

38b.  OTHER RISK FACTORS FOR THIS

Vaginal..................................................................

01

Cleft lip palate..........................................

15

PREGNANCY (Complete all items)

Vaginal birth after previous C-section..

02

Polydactyly/syndactyly/Adactyly

16

Tobacco use during pregnancy.................

Yes

No

Primary C-section..................................................

03

Club foot...................................................

17

Average number of cigarettes per day ___

Repeat C-section.................................

04