Section 500.APPENDIX A Birth Records

Section 500.ILLUSTRATION B Information for Medical and Health Use Only

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.

Yes

MOTHER

24a.

Specify:

25a.

26a.

27a.

27b.

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 _____

(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)

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?

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)................................................

Febrile (>100°F. or 38°C.)

Anencephalus

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

Meconium, moderate, heavy

Spina bifida/Meningocele

A cute or chronic lung disease...........................................

Premature rupture of membrane (>12 hours)

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

Diabetes

Abruptio placenta

Microcephalus

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

Placenta previa

Other central nervous system anomalies

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

Other excessive bleeding

(Specify) ___________________________

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

Seizures during labor

Heart malformations

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

Precipitous labor (<3 hours)

Other circulatory/respiratory anomalies

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

Prolonged labor (>20 hours)

(Specify) ___________________________

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

Dysfunctional labor

Rectal atresia/stenosis

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

Breech/Malpresentation

Tracheo-esophageal fistula/

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

Cephalopelvic disproportion

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

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

Cord prolapse

Omphalocele/gastroschisis

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

Anesthetic complications

Other gastrointestinal anomalies

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

Fetal Distress

(Specify) ___________________________

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

None

Malformed genitalia

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

Other (specify)_______________________________

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

Other (specify) ________________________

Other urogenital anomalies

41. METHOD OF DELIVERY (Check all that apply)

(Specify) __________________

38b. OTHER RISK FACTORS FOR THIS

Vaginal

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

PREGNANCY (Complete all items)

Vaginal birth after previous C-section

Polydactyly/syndactyly/Adactyly

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

Yes

Primary C-section

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

Average number of cigarettes per day ___

Repeat C-section

Diaphragmatic hernia

Alcohol use during pregnancy............................

Yes

Forceps

Other musculoskeletal/integumental anomalies

Average number drinks per week _____

Vacuum

(Specify) ___________________________

Weight gain during pregnancy _____ lbs.

42. ABNORMAL CONDITIONS OF THE

Down's syndrome

PARENTS REQUEST FOR A SOC. SEC. NO. ISSUANCE
□

NEWBORN (Check all that apply)

Other chromosomal anomalies

39. OBSTETRIC PROCEDURES

Anemia (Hct.<39/Hgb. <13)

(Specify) ___________________________

(Check all that apply)

Birth injury

None

Amniocentesis................................................................

Fetal alcohol syndrome

Other (specify) ______________________

Electronic fetal monitoring.................................

Hyaline membrane disease/RDS

44a. DATE OF MOTHER'S BLOOD TEST FOR SYPHILIS

Induction of labor.............................................................

Meconium aspiration syndrome

(MONTH, DAY, YEAR)

Stimulation of labor...........................................

Assisted ventilation <30 min.

Tocolysis........................................................................

Assisted ventilation ≥30 min.

Ultrasound........................................................

Seizures

44b. LABORATORY DOING THE SEROLOGY

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

None

Other (specify) ________________________

Other (Specify) ____________________

MOTHER

Social Security Number

FATHER

Social Security Number

45.

46.

(Source: Added at 15 Ill. Reg. 11706, effective August 1, 1991)