TITLE 77: PUBLIC HEALTH
CHAPTER I: DEPARTMENT OF PUBLIC HEALTH
SUBCHAPTER e: VITAL RECORDS
PART 500 ILLINOIS VITAL RECORDS CODE
SECTION 500.APPENDIX A BIRTH RECORDS



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.

 

 

 

 

 

 

 

 

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

 

 

Printed by the Authority of the State of Illinois – Illinois Department of Public Health – Division of Vital RecordsNumber  ____

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

 

 

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

 

 

 

 

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

 

 

 

 

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)