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VR-110-(11/89)
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INFORMATION FOR HEALTH AND STATISTICAL USE
ONLY
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(BASED ON 1989 U.S.
STANDARD CERTIFICATE)
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OF HISPANIC ORGIN?
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RACE-American Indian,
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19. EDUCATION
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20. OCCUPATION AND BUSINESS/INDUSTRY
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(Specify below No or
Yes-If Yes
specify Cuban, Mexican, Puerto Rican, etc.)
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Black, White, etc.
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(Specify only highest
grade completed)
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(Worked during last
year)
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(Specify below)
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Elementary/Secondary
(0-12)
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College
(1-4 or 5+)
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Occupation
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Business/Industry
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17.
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18.
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No
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Yes
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MOTHER
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17a.
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Specify:
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18a.
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19a.
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20a.
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20b.
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No
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Yes
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FATHER
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17b.
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Specify:
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18b.
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19b.
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20c.
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20d.
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21. PREGNANCY HISTORY
(Complete each
section)
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MOTHER
MARRIED? at delivery, conception or at
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DATE LAST NORMAL MENSES BEGAN
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any
time between (Yes or No)
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(Month, Day, Year)
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22.
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23.
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LIVE BIRTHS
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OTHER TERMINATIONS
(Spontaneous and
induced at
any time after
conception)
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MONTH OF PREGNANCY PRENATAL CARE BEGAN
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PRENATAL VISTS
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First,
Second, Third, Etc. (Specify)
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Total Number (if none so state)
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24.
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25.
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NOW LIVING
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NOW
DEAD
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(Do
Not Include This Fetus)
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WEIGHT
OF FETUS
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CLINICAL ESTIMATE OF GESTATION
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Number
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Number
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Number
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(Specify
Units)
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21a.
None
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21b.
None
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21d.
None
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26.
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27.
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Weeks
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DATE
OF LAST LIVE BIRTH
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DATE OF LAST OTHER TERMINATION
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PLURALITY
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IF NOT SINGLE BIRTH - Born
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(Month,
Year)
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(Month,
Year)
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Single,
Twin, Triplet, etc. (Specify)
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First, Second, Third, etc. (Specify)
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21c.
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21e.
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28a.
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28b.
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DATE
OF MOTHER'S BLOOD TEST FOR SYPHILIS (Month Day Year)
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LABORATORY
DOING THE SEROLOGY
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29a.
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29b.
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30a.
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MEDICAL
RISK FACTORS FOR THIS PREGNANCY
(Check
all that apply)
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32.
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OBSTETRIC
PROCEDURES
(Check
all that apply)
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34.
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CONGENITAL
ANOMALIES OF
FETUS
(Check all that apply)
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Anemia (Hct.<30/Hgb. <10).............................................
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01
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Amniocentesis......................................................
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01
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Anencephalus............................................
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01
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Cardiac
disease.............................................
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02
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Electronic
fetal monitoring......................
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02
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Spina
bifida/Meningocele.............
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02
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Acute
or chronic lung disease.........................................
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03
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Induction
of labor...................................................
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03
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Hydrocephalus..........................................
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03
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Diabetes.......................................................................
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04
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Stimulation
of labor................................
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04
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Microcephalus.............................
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04
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Genital herpes...............................................................
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05
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Tocolysis..............................................................
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05
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Other
central nervous system anomalies
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Hydramnios/Oligohydramnios.......................
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06
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Ultrasound............................................
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06
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(Specify)
___________________________
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05
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Hemoglobinopathy...................................................
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07
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None.....................................................................
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00
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Heart
malformations.....................
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06
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Hypertension,
chronic..................................
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08
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Other
(specify)_____________________
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07
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Other
circulatory/respiratory anomalies
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Hypertension, pregnancy associated..............................
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09
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(Specify)
___________________________
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07
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Eclampsia......................................................
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10
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33. COMPLICATIONS OF LABOR
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Rectal
atresia/stenosis.................
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08
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Incompetent cervix........................................................
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11
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AND/OR DELIVERY (Check all that apply)
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Tracheo-esophageal
fistula/
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Previous
infant 4000 + grams..........................
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12
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Febrile (>100°F. or 38°C.)......................................
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01
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Esophageal
atresia....................................
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09
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Previous preterm or small-for-gestational-age
infant.........
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13
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Meconium, moderate, heavy..................................
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02
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Omphalocele/Gastroschisis..........
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10
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Renal
disease.................................................
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14
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Premature rupture of membrane (>12 hours)
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03
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Other
gastrointestinal anomalies
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Rh sensitization............................................................
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15
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Abruptio placenta..................................
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04
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(Specify)
___________________________
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11
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Uterine
bleeding.............................................
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16
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Placenta previa.....................................................
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05
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Malformed
genitalia......................
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12
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None.............................................................................
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00
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Other excessive bleeding.......................................
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06
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Renal agenesis..........................................
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13
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Other (specify) ________________________
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17
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Seizures
during labor.............................................
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07
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Other
urogenital anomalies
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Precipitous
labor (<3hours)....................................
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08
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(Specify) __________________
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14
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30b. OTHER RISK FACTORS FOR THIS
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Prolonged labor (>20 hours)....................................................
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09
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Cleft lip/palate............................................
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15
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PREGNANCY (Complete all
items)
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Dysfunctional labor................................................
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10
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Polydactyly/Syndactyly/Adactyly...
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16
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Tobacco
use during pregnancy........................
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Yes
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No
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Breech/Malpresentation.........................................
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11
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Club foot....................................................
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17
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Average
number of cigarettes per day ___
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Cephalopelvic
disproportion...................
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12
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Diaphragmatic
hernia...................
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18
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Alcohol
use during pregnancy..........................
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Yes
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No
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Cord prolapse.......................................................
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13
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Other
musculoskeletal/integumental anomalies
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Average
number drinks per week _____
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Anesthetic
complications.......................
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14
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(Specify)
___________________________
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19
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Weight gain during pregnancy _____ lbs.
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Fetal
Distress........................................................
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15
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Down's
syndrome........................
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20
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None.....................................................
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00
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Other
chromosomal anomalies
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31.
METHOD OF DELIVERY (Check all that apply)
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Other (specify)......................................................
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16
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(Specify)
___________________________
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21
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SOCIAL SECURITY NUMBER
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None............................................
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00
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Vaginal.........................................................................
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01
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MOTHER
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Other
(specify) _____________________
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22
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Vaginal
birth after previous C-section...............
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02
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35.
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Primary C-section.........................................................
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03
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SOCIAL SECURITY NUMBER
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Repeat
C-section ...........................................
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04
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FATHER
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Forceps........................................................................
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05
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36.
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Vacuum..........................................................
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06
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Hysterotomy/Hysterectomy............................................
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07
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