Ill. Admin. Code tit. 77, pt. 640, app I
1. Child's First Name
2. Child's Middle Name
3. Child's Last Name
4. Child's Suffix
5. AKA
6. Child's Date of Birth
7. Child's Time of Birth
8. Sex
A. Male
B. Female
C. Ambiguous
9. Child of Hispanic Origin
A. Yes
Cuban
Mexican
Puerto Rican
B. No
10. Race
A. Asian
B. Black
C. Caucasian
D. Native American
E. Other
11. Place of Birth
12. City of Birth
13. County of Birth
14. Mother's First Name
15. Mother's Middle Name
16. Mother's Last Name
17. Mother's Maiden Name
18. Mother's Social Security Number
19. Mother's Date of Birth
20. Mother's Street Number
21. Mother's Street Name
22. Mother's Street Direction
23. Mother's Street Type
24. Mother's Street Location
25. Mother's City
26. Mother's County
27. Mother's Zip Code
28. Mother's State
29. Mother's Telephone
30. Mother's Age
31. Mother's Birthplace
A. ________State
B. ________County
32. Mother of Hispanic Origin
A. Yes
Cuban
Mexican
Puerto Rican
B. No
33. Mother's Race
A. Asian
B. Black
C. Caucasian
D. Native American
E. Other
34. Mother's Education (specify highest grade completed)
35. Mother's Occupation
_________________
36. Mother's Business/Industry
37. Mother Employed During Pregnancy
A. Yes
B. No
C. Record Not Available (N/A)
D. Not Stated
38. Marital Status
A. Married
B. Not Married
39. Father's Last Name
40. Father's Middle Name
41. Father's First Name
42. Father of Hispanic Origin
A. Yes
Cuban
Mexican
Puerto Rican
B. No
43. Father's Race
A. Asian
B. Black
C. Caucasian
D. Native American
E. Other
44. Father's Education (specify highest grade completed)
45. Father's Age
46. Father's Occupation
_________________
47. Father's Business/Industry
_________________
48. Father Employed
A. Yes
B. No
C. Record N/A
D. Not Stated
49. Pregnancy History
50. Plurality (# this Birth)
If greater than 1, Birth Order of this Birth
51. Previous Live Births
52. Number Live Births Now Living
53. Number Live Births Now Dead
54. Date of Last Live Birth
55. Previous Terminations
56. Number of Other Terminations
57. Date of Last Other Termination
58. Date of Last Normal Menses
59. Month Prenatal Care Began
60. Number of Prenatal Care Visits
61. 1 Minute Apgar Score
62. 5 Minute Apgar Score
63. Estimate of Number of Gestation Weeks
64. Mother Transferred In Prior to Delivery
A. Yes
B. Name of Hospital ______________
Location of Hospital ______________
C. No
65. Infant Transferred (Out)
A. Yes
B. Name of Hospital _____________
Location of Hospital _____________
C. Transfer Code
D. No
66. Reporting Hospital
67. Reporting Hospital City
68. Tobacco Use During Pregnancy
A. Smoked during pregnancy
Average cigarettes per day _____________
B. Stopped smoking during pregnancy
C. Does not smoke
D. Record N/A
E. Not Stated
69. Alcohol Use During Pregnancy
A. Yes
Average number drinks per day ______
B. No
C. Record N/A
D. Not Stated
70. Mother's Weight Gain
A. Yes
Pounds ______
B. No
C. Record N/A
D. Not Stated
71. Mother's Weight Loss
A. Yes
Pounds ______
B. No
C. Record N/A
D. Not Stated
72. Medical Risk Factors for this Pregnancy
A. Anemia
B. Cardiac Disease
C. Acute or Chronic Lung Disease
D. Diabetes
E. Genital Herpes
F. Hydramnios/Oligohydramnios
G. Hemoglobinapathy
H. Hypertension, Chronic
I. Hypertension, Pregnancy-related
J. Eclampsia
K. Incompetent Cervix
L. Previous Infant 4000 + Grams
M. Previous Preterm or Small-for-Gestational-Age (SGA) Infant
N. Renal Disease
O. Rh Sensitization
P. Uterine Bleeding
Q. None
R. Other, Specify
73. Obstetric Procedures
A. Amniocentesis
B. Electronic Fetal Monitoring
Internal
External
Both
Neither
Record N/A
Not Stated
C. Induction of Labor
D. Stimulation of Labor
Yes
Pitocin ________
Oxytocin ______
No
Record N/A
Not Stated
E. Tocolysis
F. Ultrasound
G. None
H. Other, Specify
74. Complications of Labor and/or Delivery
A. Febrile
B. Meconium
C. Premature Rupture
D. Abruptio Placenta
E. Placenta Previa
F. Other Excessive Bleeding
G. Seizures During Labor
H. Precipitous Labor
I. Prolonged Labor
J. Dysfunctional Labor
K. Breech/Malpresentation
L. Cephalopelvic Disportion
M. Cord Prolapse
N. Anesthetic Complications
O. Fetal Distress
P. None
Q. Other, Specify
75. Method of Delivery
A. Spontaneous Vaginal
B. Mid - Low Forceps
C. Vacuum Extraction
D. Vaginal Breech
E. Caesarean Section Primary
F. Caesarean Section Repeat
G. Other Type
H. Record N/A
I. Not Stated
J. Vaginal Birth After Previous Caesarean Section (VBAC)
K. Other Caesarean Section
76. Abnormal Conditions of Newborn
77. Anemia
78. Birth Injury
79. Fetal Alcohol Syndrome
80. Hyaline Membrane Disease
81. Meconium Aspiration Syndrome
82. Assisted Ventilation > 30 min.
83. Assisted Ventilation = 30 min.
84. Seizures
85. Human Immunodeficiency Virus (HIV)
86. Other, Specify
87. Congenital Anomolies of Newborn
88. Anencephalous
89. Congenital Syphilis
90. Hypothyroidism
91. Adrenogenital Syndrome
92. Inborn Errors of Metabolism
93. Cystic Fibrosis
94. Immune Deficiency Disorder
95. Retinopathy of Prematurity
96. Chorioretinitis
97. Strabismus
98. Intrauterine Growth Restriction
99. Cerebral Lipidoses
100. Spina Bifida/Meningocele
101. Hydrocephalus
102. Microcephalus
103. Other CNS Anomalies, Specify _______________________
104. Heart Malformations, Specify _________________________
105. Other Circulatory/Respiratory Anomalies, Specify _____________________________
106. Rectal Atresia/Stenosis
107. Tracheoesophageal Fistula/Esophageal Atresia
108. Omphalocele/Gastrochisis
109. Other Gastrointestinal Anomaly
110. Malformed Genitalia
111. Renal Agenesis
112. Other Urogenital Anomaly, Specify ____________
113. Cleft Lip/Palate, Specify _____________________
114. Polydactyly/Syndactyly/Adactyly
115. Club Foot
116. Diaphragmatic Hernia
117. Other Musculoskeletal/Integumental Anomaly
118. Down's Syndrome
119. Other Chromosomal Anomaly, Specify _______________________
120. None
121. Other, Specify ________________________
122. Transfusion
123. Anesthesia
A. Local/Pudenal
B. Regional
C. General
124. Umbilical Cord Blood Gases Tested
A. Yes
B. No
125. Small-for-Gestational-Age (SGA)
126. Infection of Newborn Acquired Before Birth
127. Infection of Newborn Acquired During Birth
128. Infection of Newborn Acquired After Birth
129. Hereditary Hemolytic Anemias
130. Hemolytic Diseases of the Newborn
131. Due to Rh Incompatibility Only
132. Due to ABO Incompatibility
133. Due to Other Causes
134. Drug Toxicity or Withdrawal
A. Yes, Specify ___________________
B. No
135. Highest Bilirubin, Total ________________
136. Admit to Designated Patient Unit
A. Yes
B. No
137. Genetic Screenings Conducted
138. Rh Determination
A. Mother's Blood Type ________ Rh Factor________
Immune Globulin Given
B. Yes
C. No
139. Hepatitis B - Surface Antigen
A. Positive
B. Negative
140. Non-Obstetrical Infections
A. Syphilis
B. Gonorrhea
C. Rubella
D. Other
141. Obstetrical Infections
A. Antepartum
Amnionitis/Chioramnionitis
Urinary Tract Infection
B. Postpartum
Endometritis
Infection of Wound
Urinary Tract Infection
142. Mother admitted within 72 hours after delivery
A. Precipitous Delivery
B. Planned Home Birth
143. Drug Use During Pregnancy
A. Cocaine
B. Heroin
C. Marijuana
D. Other Street Drugs
E. None
F. Record N/A
G. Not Stated
144. Transfusion
145. Prenatal Screening Conducted for
A. Gestational Diabetes
(Blood Glucose Tolerance Test)
B. Congenital/Birth Defects
A. Maternal Alpha Feta Protein
B. Chromosomal
C. Other
146. Number of Days Maintained on Ventilation Before Transfer to Level III Center-Days
147. Prenatal Ultrasound
A. Yes
B. No
C. Record N/A
D. Not Stated
148. Chorionic Villus Sampling
149. Were Newborn Screening Tests Conducted?
A. Yes
B. No
150. Mother Transferred Out to Another Hospital After Delivery Destination Hospital Code
151. Mother Transferred From Emergency Room
152. Infant Transferred In Transfer Code
153. Consult Administrative Perinatal Center or Another Level III
154. Infant Maternal
A. A. Yes, with Transfer
B. B. Yes, No Transfer
C. C. No Consultation
D. D. Not Stated
155. Mother Died In Hospital
156. Fetal Death
157. Infant Died in Hospital
158. Extrauterine Pregnancy
159. Ectopic Pregnancy
160. Admission Date - Infant
161. Admission Date - Maternal
162. Discharge Date - Infant
163. Discharge Date - Maternal
164. Payment Method
A. Yes
Medicaid
Medicaid HMO
HMO
Medicare
CHAMPUS
Title V
Health Insurance
Self Pay
Not Stated
Other, Specify ______________
B. No
165. Were prenatal records available prior to delivery?
A. Yes
B. No
166. Maternal Diagnosis (Specify up to 8 Diagnoses)
167. Mother's Medical Record Number _________________
168. Infant Diagnoses (Including Congenital Anomalies); Specify up to 8 Diagnoses
169. Infant Released to:
A. Home
B. Other Hospital Name and Location __________________
C. Long Term Care Name and Location _________________
D. Other Child Care Agency Name and Location _____________
170. Infant Patient ID
171. Infant Medical Record Number _______________________
172. Referrals
A. Community Social Services
B. Division of Specialized Services for Children (DSCC)
C. Department of Healthcare and Family Services (HFS)
D. Department of Children and Family Services (DCFS)
E. Other, Specify _________________
F. None
G. Early Intervention program
H. Other ________________________
173. Feedings
174. Breast Fed
175. Bottle
176. Tube
177. Formula
178. Frequency
179. Amount
180. Infant Medications
181. Birth Weight
182. Birth Head Circumference
183. Birth Length
184. Discharge Weight
185. Discharge Head Circumference
186. Discharge Length
187. Infant Discharge Treatment
188. Other Concerns
189. RN Contact at Hospital - Phone Number
190. Relative/Friend
191. Relationship
192. Address/Phone #
193. Family Informed of Local Health Nurse Visit
A. Yes
B. No
194. Primary Care Physician's Name -
195. Mother Gravida Para F_ P_ A_ L_
196. Signature
197. Title
198. Report Date
Ill. Admin. Code tit. 77, pt. 640, app I