TITLE 77: PUBLIC HEALTH
CHAPTER I: DEPARTMENT OF PUBLIC HEALTH
SUBCHAPTER l: MATERNAL AND CHILD HEALTH
PART 635 FAMILY PLANNING SERVICES CODE
SECTION 635.APPENDIX A ILLINOIS FAMILY PLANNING CLINIC VISIT RECORD



Section 635.APPENDIX A   Illinois Family Planning Clinic Visit Record

 

ILLINOIS FAMILY PLANNING CLINIC VISIT RECORD

 

 

Name

 

 

Pt #

 

 

 

Address

 

 

Phone #

 

 

 

 

 

 

 

 

1. FORM NUMBER

C121002

 

12. SERVICE PROVIDERS/BCRR ENCOUNTERS

SECTION A

ALL VISITS

 

 

Medical (check one)

Counseling (check one)

 

 

 

1. Physician

 

2. SERVICE SITE NUMBER

 

 

 

 

 

 

 

 

2. Mid-Level Pract.

 

 

 

 

 

 

 

 

 

3. Nurse

 

3. PATIENT NUMBER

 

 

 

 

 

 

 

 

4. Ed./Counselor

 

 

 

 

 

 

 

 

 

5. Nutritionist

 

 

 

 

 

 

 

 

 

6. Social Worker

 

4. DATE OF VISIT

MO

DAY

YR

 

13. METHOD AT END OF THIS VISIT (check one)

 

 

 

 

 

 

 

 1. Oral

   7. Natural Method

5. PURPOSE OF VISIT (check one)

 

 2. IUD

   8. Cervical Cap

 

 

 

 

 

 

 

 3. Diaphragm

   9. Sterilization

 1. Initial Visit

 5. Supply Visit

 

 4. Foam & Condom

 10, Sponge

 2. Annual Revisit

 6. Education/Counseling Visit

 

 5. Spermicide

 11. Other

 3. Routine Visit

 7. Non F.P. Visit

 

 6. Condom

 12. None

 4. Problem Visit

 

 

 

 

 

 

 

 

6. DATE OF BIRTH

MO

DAY

YR

 

14. IF NO METHOD, REASON FOR NONE (check one)

 

 

 

 

 

 

 

 1. Pregnant

 4. Other Medical Reasons

7. PRIMARY SOURCE OF PAYMENT (Check One)

 

 2. Infertility

 5. Relying on Partner's Method

 

 3. Seeking Pregnancy

 6. Other

 1. Medicaid Only

 4. Full Fee

 

15. REFERRALS MADE (check up to two codes)

 2. No Fee (0-100%)

 5. FWF Only

 

 1. Sterilization

   7. STD

 3. Part Fee (101%-250%)

 6. Medicaid and FWF

 

 2. Gynecology

   8. Other Medical

8. BILLABLE MEDICAL SERVICES

 

 3. Prenatal

   9. Other F.P. Clinic

 1. Minimal Service

 13. Misc. Culture

 

 4. Other Pregnancy

 10. Infertility

 

 2. Brief/Int. Exam

 

 14. Sickle Cell

 

 5. Social Service

 11. Nutrition

 3. Extended Exam

 15. PP Blood Gluc.

 

 6. Contraception

 12. Other

 

 4. IUD Insertion

 

 16. Cholesterol Level

 

SECTION B

INITIAL, ANNUALS

 5. Diaphragm Fit

 17. SMA-12

 

 

ZIP CODE

FIPS

 

 6. HGB/HCT

 

 18. Colposcopy

 

16. RESIDENCE CODES

 

 

 

 

 

 

 

 

 

 

 7. U/A

 19. Colposcopy & Biopsy

 

17. ETHNIC ORGIN/RACE (check one)

 

 8. Pregnancy Test

 

 20. Sonography/Lost IUD

 

 1. White

 4. Asian or Pacific Islander

 9. VDRL

 21. X-Rays/Lost IUD

 

 2. Black

 5. Hispanic

 

 10. PAP Smear

 

 22. Chlamydia Test

 

 3. Native American

 

 11. Gonococcal

 23. Cervical Cap Fit

 

18. SEX (check one)

 

 12. Wet Mount

 

 24. None

 

 1. Female

 2. Male

9. BILLABLE COUNSELING SERVICES

 

19. EMPLOYMENT STATUS (check one)

 1. Indepth/l Hr.

 2. Counseling/15 min. to 1 Hr.

 

 1. Employed

 3. Not In The Work Force

10. ROUTINE COUNSELING SERVICES

 

 2. Unemployed

 

 1. Sterilization

 4. Pregnancy

 

20. GROSS WEEKLY INCOME

 2. Contraception

 5. STD

 

21. FAMILY SIZE

 

 3. Infertility

 6. Natural Family Planning

 

22. SOURCE OF REFERRAL (check one)

11. BILLABLE CONTRACEPTIVE SUPPLIES

 

 1. Other F.P. Clinic

 6. Other Patient

 

Qty

Brand

 

Qty

Brand

 

 

 2. Hospital/Health Agency

 7. Family/Friend

 

 

 

1. Orals

 

 

8. Basal T&C

 

 3. Private Doctor

 8. Media

 

 

 

2. Creams

 

 

9. Contraceptive Sponges

 

 4. Social/Church Agency

 9. Hotline

 

 

 

3. Jellies

 

 

10. Condoms

 

 5. School

 10. Phonebook

 

 

 

4. Suppositories

 

 

11. Meds/Vag Inf

 

LOCAL USE SECTION

 

 

 

5. Foams

 

 

12. Meds/STD

 

 

 

 

6. Diaphragms

 

 

13. VC-Foam

 

A

B

C

D

 

 

 

7. IUD

 

 

14. Cervical Cap