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Illinois Administrative Code (Last Updated: March 27, 2024) |
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TITLE77. PUBLIC HEALTH |
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PART500. ILLINOIS VITAL RECORDS CODE |
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Section500.APPENDIX A. Birth Records |
§500.ILLUSTRATION B. Information for Medical and Health Use Only
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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
(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)
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
IF YES, ENTER NAME AND LOCATION OF FACILITY TRANSFERRED FROM
37a.
1 MINUTE
5 MINUTES
INFANT TRANSFERRED?
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
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
Diaphragmatic hernia
18
Alcohol use during pregnancy............................
Yes
No
Forceps
05
Other musculoskeletal/integumental anomalies
Average number drinks per week _____
Vacuum
06
(Specify) ___________________________
19
Weight gain during pregnancy _____ lbs.
42. ABNORMAL CONDITIONS OF THE
Down's syndrome
20
NEWBORN (Check all that apply)
Other chromosomal anomalies
39. OBSTETRIC PROCEDURES
Anemia (Hct.<39/Hgb. <13)
01
(Specify) ___________________________
21
(Check all that apply)
Birth injury
02
None
00
Amniocentesis................................................................
01
Fetal alcohol syndrome
03
Other (specify) ______________________
22
Electronic fetal monitoring.................................
02
Hyaline membrane disease/RDS
04
44a. DATE OF MOTHER'S BLOOD TEST FOR SYPHILIS
Induction of labor.............................................................
03
Meconium aspiration syndrome
05
(MONTH, DAY, YEAR)
Stimulation of labor...........................................
04
Assisted ventilation <30 min.
06
Tocolysis........................................................................
05
Assisted ventilation ≥30 min.
07
Ultrasound........................................................
06
Seizures
08
44b. LABORATORY DOING THE SEROLOGY
None...............................................................................
00
None
00
Other (specify) ________________________
07
Other (Specify) ____________________
09
MOTHER
Social Security Number
FATHER
Social Security Number
45.
46.
(Source: Added at 15 Ill. Reg. 11706, effective August 1, 1991)