Prenatal Record - National Archives and Records Administration

NINCDS COLLABORATIVE 

PERINATAL PROJECT 

A User's Guide to the Project and Data 

Volume II: Project Study Forms 

and Documentation of Transfer 

to Computerized Data Items 

in Master File 

Part A: Prenatal. Record and 

Medical History 

Qecember 1983 

Prepared for 

the National Institute of Neurological 

and Communicative Disorders and Stroke 

under Contract 2311105150 

Osanelle 

Pacific Northwest Laboratories 

Reproduced at the National Archives

This tt'J)Of1 wOK pr~.:red by B.met&. ~ •n ~ccount of tpemored 

te.t'Jtch "'ivltiti, ~•ther Spomor nor &.neol&. nor •ny penon "'*"~ 

on ll.h•lf of eitht!t: 

MAUS .J\NY WAIIIIANn ott ttiNUIHIAnoN. lZNISS CHI 

IMPUID. with tnpoc!!(:lto th~ «cur.cy, compt...meM, or UHfulNU of 

theo lnform•don c:ont.tint'd in this report. or '"" th~ uw of .,.,. infGftn.t· 

tion• .tpp.N.tlut, proceu. or C:GMf)CKtlion dKdOM!d In rhii repcm may not 

infrlnte Ffv.ttefy ownt'd rishts; or 

~ssumM •n~ lilb4filfM with 'ftf34!

NINCDS COLLABORATIVE PERINATAL PROJECT: 

A USER•s GUIDE TO THE PROJECT AND DATA 

Volume II. Project Study Forms and Documentation 

of Transfer to Computerized Data Items 

in ~1aster File 

Part A. 

NR Hinds 

A Brix 

Prenata 1 Record and 11edi ca1 Hi story 

JS Littlefield 

CR Watson 

December 1983 

Prepared for 

National Institute of Neurological 

and Communicative Disorders and Stroke 

under Contract 2311105150 

Battelle 

Pacific Northwest Laboratories 

Richland, Washington 99352 



INTRODUCTION 

DOCUMENT OBJECTIVES AND READER ASSUMPTIONS 

Volume II, Project Study Forms and Documentation of Transfer to 

Computerized Data Items in Master File, provides researchers with detailed 

documentation for how data were collected, coded and stored on the data base. 

Volume II will help investigators decide: if data were collected in a suitable 

way for addressing particular research questions; if revision of forms 

affected the collection of specific data items; if data were coded on master, 

variable or work files, or are available only on microfilm. The reader is 

assumed to be the principal investigator for a project in which data from the 

data base will be used. 

DOCUMENT STRUCTURE 

Because of its size, this volume is divided into ten separate parts, each 

containing material on a group of forms related by subject. Each part groups 

together similar study forms. Generally, a part covers a single time period. 

The parts do not correspond exactly to the hierarchical classification 

structure described in Volume I. The parts of Volume II include: 

A. Prenatal Record and Medical History 

B. Labor and Delivery 

C. Pathological Exams and Autopsies 

D. Family and Socioeconomic History 

E. Neonatal Exams and Observations 

F. Pediatric and Neurological Exams, Four Months - One Year 

G. Pediatric Neurological Exams, Seven Years 

H. Psychological Exams, Eight Months 

I. Psychological Exams, Four Years and Seven Years 

J. Speech, Language and Hearing Exams, Three Years and Eight Years (Final) 

This part of Volume II contains Part A: Prenatal Record and Medical History 

and includes Forms AR-1, OB-2, OB-3, OB-4, OB-5, OB-6, OB-7, OB-8, OB-9, 

OB-42, OB-43, OB-10, OB-44, OB-45, OB-11, OB-46, OB-12, OB-47, and OB-15. 

Reproduced at the National Archives 

II.A.iii

To allow easy access to the data as they appear on the master file, all 

documentation for each form or form grouping representing a card series on the 

master file is identified by form number appearing at the bottom of each page. 

Forms are arranged in what may appear to be illogical numerical order in some 

cases, but the arrangement presented here ties forms and their revisions 

together and allows an investigator to trace an item through all revision 

cycles. Thus, in Part A of Volume II, OB-42 follows OB-9 and OB-10 appears 

next to OB-44 and OB-45. (For an explanation of how the master file was 

organized to result in this ordering, see the next section of the Introduction.) 

All material related to a form is organized as a single unit within each 

part of Volume II. The material included for each form is given below in the 

order. it appears: 

• Descriptive Summary of Form. Includes purpose of form, history of use, 

revisions and location of records stored on Master File. A table is 

provided for each form {except those on microfilm only) showing the 

number of records available for each revision. 

• Data Items Referencing Form. A list of all data items in computer 

files originating from form. List ordered by data item identification 

with reference to item number on form. 

• Form. Copy of last revision of form. 

• Form item numbers linked to data items. A list organized by form item 

numbers of all computerized data items originating from the form. 

• Definition of codes. Coding instructions detailing the codes assigned 

to each computerized data item from the form. 

• Master File Card Image. 

File card. 

Illustrates transfer of data on form to Master 

• Instructions for Completing Form. The instructions used by study 

personnel to complete the form for each case. 

• Earlier Forms or Manuals. Copies of earlier versions of forms or 

manuals that were used during the study. 

MASTER FILE ORGANIZATION AND REVISION OF FORMS 

Some understanding of how the master file was organized should aid 

investigators who want to trace the entry of data into computerized study 

files. The numbering system used both on forms and cards provides information 

on how data may be retrieved from the master file. 

II.A.iv 


_______________________________________________________________________________ 

- -

Forms 

The first forms used in the study were the OB forms; as a consequence, 

this group of forms underwent the most revision. At first glance, it appears 

that forms disappear from the file and reappear in strange or bewildering 

places. In actuality, revisions were made according to a specific method. 

Two types of revision and subsequent recodes appear in the master file, 

both of which appear in the OB series. In the first type of revision, radical 

changes in the concept of a form created a need for new coding in the computer 

file. Form OB-9, for example, was replaced by forms OB-40 (an optional form 

retained by the institution), OB-42, and OB-43 in April 1962. Data for earlier 

patients were recorded on OB-9 and entered on cards 1309, 2309, 3309 and 4309 

of the master file; after April 1962, data was recorded on OB-42 and OB-43 and 

were entered on cards 0342, 1343 and 2343 of the master file. 

In the second type of revision, the Collaborative Perinatal Task Force 

considered revisions important enough to warrant the distinction of a new form 

number, but considered the data for both forms to be similar enough to allow 

combining of data from both the old and new forms on the same card series. An 

example of this type of revision is form OB-35, replaced by OB-57 in April 

1962. Records for both OB-35 and OB-57 are entered on cards 0357, 1357, 2357, 

3357, 4357, and 5357 in the master file. 

In assigning numbers to forms and their revisions, designers of the study 

followed a plan: prenatal records, history, and summaries of the prenatal 

period received numbers 1 through 15; when revised, these forms were assigned 

numbers in the forties. Labor and hospital records appeared on the 30 series 

of forms. When these forms were revised, they were assigned numbers in the 

fifties. Some OB data in the master file were abstracted by NINCDS staff 

members from forms filled out at the hospital. Cards derived from this 

procedure were designated as coming from forms ADM-49, 50 and 51 (which were 

actually ABSTRACT SHEETS). Autopsy protocol and laboratory exams of the 

placenta were recorded on forms PATH-1, PATH-2 and PATH-3. 

Forms for recording family health history and genetic information during 

pregnancy also received a fair amount of revision. Early records appear on 

forms FHH-1,2,3 and 4. With revisions in April 1963, form SE-1 replaces part 

of FHH-1 and FHH-3; FHH-2, FHH-4 and parts of FHH-1 and FHH-3 were replaced by 


II.A.v

forms GEN-5 through GEN-8 in May 1961. Form FHH-9, initiated in November 1965 

for collection of socioeconomic data at time the child was seven years of age, 

was not replaced or revised. 

The PED series of forms underwent little revision. Records for newborn 

babies appeared in PED-1 through PED-8; records for children up to age one and 

interval records were placed on PED-10 through PED-29. Seven year records were 

included in the series numbered PED-74 and up. Only one pediatrics form was 

radically revised: PED-7 was replaced by PED-8 in March 1963. 

No replacements occur in the PS series, where results of psychological and 

speech, language and hearing tests were recorded. The PS forms are divided 

into distinct groups based on time of testing and subject of testing. 

Psychological testing occurred at 8 months, 4 years and 7 years; speech, 

language and hearing exams were administered at ages 3 and 8. Only the 8 month 

psychological examination underwent substantial revisions. 

Master File Card Number and 

NINDB Case Number Rationale 

Computer cards for each NCPP study form are numbered to reflect their 

origin and possible revisions. Card numbers are assigned to identify the type 

of data (subject), the presence of multiple cards in a series, NCPP study form 

and form revisions. The first five digits of each card on the master file are 

the card number. The study forms and card numbers are given in Figure 1. 

The first fourteen columns of each master file computer card contain the 

master file card number and the NINOB case number. Table 1 identifies the 

function of each of these columns. 

Column 1 identifies multiple cards in a series. It contains a zero for 

cards unique to a particular form (that is, no other cards are present), for 

example OB-3, or for cards where repetitive data are contained. Cards for 

OB-2 are an example of this second type; no new categories of information are 

included on successive cards, but previous births in excess of four must be 

recorded on an add-on card. For card series where data entered are unique to 

11 

a card and more than one card is required to complete the series, a 1 11 

is 

used to designate the first card, for example OB-5. OB-57, PATH-2 and PED-14 

are exceptions to these rules. 


II.A.vi


AR 1 082 083 08-4 085 086 087 08-8 08-9 

(Repl.ced by 08-431 

0810 08-15 08ll 0834 

0835.08 57 0836 08-37 08-38 08-42 08-43 

I Replaced bv 08-451 (Repla:ad by 08-551 

IAO\t491 IAOM-501 IAOMSII 

..... 

.... 

..... CJ 0344 

oa... 

)::o 08... 08-55 0858 08 51 52 0858 0880 

FHH 1. J SE 1 FHH9 

flfn Vtlit IReptKH 08·101 

(RepiiCH 08 341 I Replaced by SE I) (Ritpl~en FHH I, 31 

< ...... 

...... 

GEN 5-8 PATH-I PATH 2 PATH 3 PEO 1 PEO 2 PWJ PE0-4 PED-S PEDS 

PEO 7 PEO 8 PEO 10 PEO 11 PED-12 PEO 14 PED-75 PE0-76 ·peo-n 

•New Card Type1 

• •on DNB copy of the master data file only 

PS-1-5 

PS-10-17 PS-28 PS 20-25 PS l0-38 PS-41J.45 

FIGURE 1. 

Cards on the Master Data File

TABLE 1. 

Derivation of Master File Card Number 

and NINDB Case Number. 

Contents 

Columns 

Master File Card Number 

card identifier 1 

general subject matter 2 

form number 3-4 

revision code 5 

NINDB Case Number 

collaborating institution 6-7 

type of patient selection 8 

gravida identification number 9-12 

order of the pregnancy 13 

identifies child or gravida 14 

The second digit on the card reveals the general subject matter covered by 

data on the card. All cards containing information pertaining to obstetrics, 

for example, are designated by a "3" in column 2; family histories are 

designated by a "5 11 11 

; pathology with a "2"; pediatrics, with a 4 11 ; and 

psychological testing with a "1". 

Columns three and four reveal the form number. In the case of forms where 

old and new forms having different numbers are included together, the number of 

the latest form appears on the master file. This rule does not apply to data 

abstracted from several forms by NINCDS staff (ADM forms). 

Column 5 of the card contains a revision code indicating which form or 

combination of forms was used in arriving at data on a particular car~. A 

typical card will have one to three revision codes, with a zero indicating the 

first version of a form and "1", "2", and "3" indicating later revisions. As a 

rule, revision codes used on cards differ from card to card; investigators 

should check the definition of codes provided in Volume II to determine the 

meaning of revision codes used. 

Each woman and child studied in the project received a unique case number 

(NINDB case number) composed of nine digits, recorded in columns 6 through 14 

of all master file cards. The case number identified the institution, the 

mother and the child. The first two digits represented the collaborating 

institution (see Table 2). The third digit indicated the type of patient 


II.A.viii

selection. A n1n was used for patients selected for the central core study; a 

n5n indicated that a patient had been transferred from one institution to 

another, and a nr indicated that the patient was part of a special study 

undertaken by the collaborating institution. The fourth through seventh digits 

were used to identify the gravida, while the eighth digit identified the order 

of the pregnancy of a given gravida in the project. The ninth digit was used 

to identify the gravida or child of the pregnancy; ngn indicated the gravida, 

non indicated the child of a single birth, n1n indicated the first child of a 

multiple birth, n2 11 indicated the second child of a multiple birth, etc. 

TABLE 2. 

Collaborating Institutions and Their Code Number 

(Columns six and seven of all master file cards.) 

OS - Boston, Massachusetts 

Harvard Medical School 

Boston Lying-In Hospital 

Children's Hospital Medical 

Center 

10 

15 

32 

- Buffalo 1 

New York 

Univers1ty of Buffalo 

Children's Hospital 

- New Orleans, Louisiana 

Charity Hospital 

Tulane University School of 

Medicine Medical Center 

Louisiana State University 

- New York, New York 

Columbia University College 

of Physicians &Surgeons 

Columbia-Presbyterian 

Medical Center 

37 - Baltimore, Mar~land 

The Johns Hopk1ns University 

School of Medicine 

The Johns Hopkins Hospital 

45 - Richmond, Virginia 

Virginia Commonwealth 

University 

Medical College of Virginia 

50 

55 

60 

66 

71 

-Minneapolis, Minnesota 

University of Minnesota Hospital 

Health Sciences Center 

- New York, New York 

New York Medical College 

Metropolitan Hospital 

- Portland, Oregon 

University of Oregon 

Medical School 

- Philadelphia# Pennsylvania 

University o Pennsylvania 

Pennsylvania Hospital 

The Children's Hospital of 

Philadelphia 

-Providence, Rhode Island 

Brown University 

Child Study Center 

82 - Memphis 1 

Tennessee 

Univers1ty of Tennessee 

College of Medicine 

Gailor Hospital 

II.A.ix 


Data Item Identification and Naming 

The NCPP data base contains over 6700 different data items and blank 

filler locations on computer files. We have assigned each of these a unique 

identification and a terse, stylized name. Because names were chosen to 

facilitate use of this guide, they do not duplicate names used by NINDB during 

the active phase of the project. Users should consult appropriate 

documentation before using data items from the master, variable or work files 

(Volumes II, III and IV). 

The data item identifiers consist of 11 characters. At the far left are 

four unique numbers that were assigned sequentially. The next character is 

always a period and is followed by up to six characters. For data items on 

the master file, these characters describe the data collection form from which 

a data item was derived; for data items on the variable (VAR) or work (WXX) 

files, these characters indicate the appropriate file. If the right side is 

less than six characters, periods are inserted as shown in these examples: 

850 ..OB-34 an item from OB-34; on the master file 

3650.PATH-3 an item from PATH-3; on the master file 

5223 .... VAR an item on the variable file 

6340 ...W-10 an item on work file 10, Rupture of Membranes 

We assigned the numbers sequentially as they appear in Volume V. For the 

master file, we followed the order in which the cards would be found within an 

NINDB case. All card columns are accounted for by one of our data item 

identifications. For the variable and wor-k files, the numbers were assigned 

in the order that data items appear within a case. 

We categorized each data item according to the person to whom the data 

refer, by the time of measurement and/or the time to which the item applies and 

by general type or subject area (Table 3). Then we assigned names to the data 

items using the following guidelines: 

1 The name and the three associated categories had to stand alone 

they must describe the data item out of context. 

• The first word in the data item name had to be an important or key 

word when all names were listed alphabetically as in Volumes VI and VII. 

Thus 11 cry, abnormal 11 was used rather than 11 abnormal cry 11 because a 


II.A.x

, 

researcher is more likely to look for this item under "C" than under 

"A" in an alphabetic list. 

• Secondary key words were preceded with a semicolon to facilitate 

preparation of the permuted index. For example, "abruptio; placenta" 

will be found under both the "A" and "P 11 

portion of Volume VI. 

• Qualifying words are delimited by commas and will not appear as 

keywords in Volume VI. Thus 11 abruptio; placenta, degree" will not be 

11 

found in the 0 11 

section. 

• If medical terminology or usage has changed since the study was 

conducted, modern terms may be included and will be enclosed in 

brackets. Thus 11 mongolism; [Down•s syndrome] 11 will appear under both 

11 

the 11 M" and portions of Volume VI. 

011 

• If measurement units are associated with a data item name, they are 

enclosed in parentheses and placed at the end of the name as in 

"Birthdate (yr). 11 

• The categories (person, time and subject) are appended to the right of 

the data item name. 

Definitions for each category used in naming data items are given in 

Table 4 at the end of this introduction. Additional information is found in 

Chapter 4 of Volume I. 

Data item names thus assigned are terse and highly stylized; as we have 

already indicated, they are not the names used by NINDB during the active phase 

of the project. Our aim was to develop standardized names that would stand 

alone. These names are intended to facilitate a user•s search for data items 

potentially useful in a research project. Before an item is used, a researcher 

should consult its complete description. For a data item from the master 

files, e.g., 850 .• 08-34, the data item should be traced to the appropriate 

study form, e.g., OB-34, located in Volume II. A variable file data item, 

e.g., 5223 ...• VAR, is traced to Volume III, where it is defined and its 

original source given. A data item from a work file is traced to Volume IV for 

its description. 

Some data items contained in the indexes may include the notation 11 00 NOT 

USE. 11 

These items are either inaccurate or an alternative data item is 

available that gives better information. Users will find more appropriate 

data items by consulting one of the indexes to the data items (Volumes, V, VI 

and VII). 


II.A.xi

Tables of Data Items: 

Column Headings 

For each form, two sets of computer generated pages list all data items in 

either the master, variable or work files derived from this form. These lists 

enable a user to track form items to computerized data items listed in other 

volumes of the User's Guide and vice versa. The computer listings have the 

following information. 

Column Heading 

DATA ITEM ID 

Description 

A unique identifier for this data item. 

See Data Item Identification and Naming 

above for details. 

ITEM ON FORM An identifier used on the NCPP study form to 

identify the question or group of questions 

which was used to generate this data item. 

CARD NUM 

FROM 

TO 

DATA ITEM NAME 

ASSOCIATED DOCUMENTS 

Identifies the master file card on which 

this data item is located. See Master File 

Card Number and NINDB Case Number Rationale 

above for a description of card number. 

Beginning card column for this data item. 

Ending card column for this data item. 

Terse stylized name for this data item. 

See Data Item Identification. and Naming 

above for details. 

By examining the tables provided for each, investigators will be able to 

determine which computer files contain data of interest. For data contained in 

the variable file, see Volume III of this guide; for data contained in work 

files, see Volume IV. 


II.A.xii

TABLE 3. 

Abbreviations for Person, Time and Subject Categories 

Person 

Mother 

Father 

Placenta 

Fetus 

Child 

M Surrogate 

Family 

Sibship 

Time 

General 

Preconception 

Registration 

Prenatal 

Admission 

Intrapartum 

Delivery 

Post Partum 

Neonatal 

Four month 

Eight month 

·One year 

Three year 

Four year 

Seven year 

Eight year 

Subject 

Administrative 

Anesthesia 

Clin. Impression 

Clinical Lab 

Current Pregnancy 

Environ. Exposure 

Events 

Heari'ng 

Hospitalizations 

Language 

Linkage 

Ma lformati ens 

Diag. & Cond. 

Med. History 

Medications 

Neurological Exam 

Observations 

Pathology 

Physical Exam 

Procedure 

Psych. Exam 

Reproductive Hist. 

Serology 

Sod oecon. Info 

Speech 

Vhion 

Work History 

X-ray 

Surrmary 

Gyn. History 

Sped a 1 Studies 

Fam/Cenetic Hist. 

SLH Exam 


II.A.xiii

TABLE 4. 

Definition of Person, Time 

and Subject Categories 

PERSON 

Mother 

Father 

Placenta 

Fetus 

Child 

DEFINITION 

Study registrant bearing the "study pregnancy"; biologic mother of the "study 

chi 1 d"; gravida. 

Biologic father of the study child or study pregnancy; in the case of 

socioeconomic data, thh category may indicate either the "father of baby" (not 

necessarily husband of the mother) or the "husband" (not necessarily related 

biologically to the study child). 

The organ of metabolic and gaseous interchange between the fetus and mother; also 

included in this category are gross and microscopic pathologic data from 

examination of the umbilical cord. 

Conceptus; the product of conception including the embryonic stage, i.e., from 

conception to the moment of birth. 

Product of the study pregnancy from the moment of birth onward; study child. 

r~ Surrogate Person or persons substituting for the mother of a study child, e.g., adoptive 

parents, foster parents or guardian. 

Family 

Sibship 

Person or persons biologically related to the mother or father of the study child. 

Child or children having one or both of the same biologic parents as the study 

child; siblings; half siblings; full siblings. 


II.A.xiv

TABLE 4. 

Definition of Person, Time 

and Subject Categories (Cont.) 

TIME 

Ceneral 

Preconception 

Registration 

Prenatal 

Admission 

Intrapartum 

Delivery 

Post Partum 

Neonatal 

Four Month 

Eight Month 

One Year 

Three Year 

Four Year 

Seven Year 

Eight Year 

DEFINITION 

Data with no pertinent time period or data pertaining to more than one time 

period. 

Data pertaining to the period prior to conception of the study pregnancy. 

Data collected at the time of study mother's registration in the study. 

Data pertaining to the period from conception of the study pregnancy to 

delivery of the study child. 

Data collected at the time of study mother's admission to the hospital for 

delivery of the study child. 

Data pertaining to the period from admission for delivery or onset of labor 

to delivery of the study child. 

Data pertaining to the time period during which delivery of the study child 

occurred. 

Data (pertaining to the study mother) collected during the period immediately 

following birth of the study child. 

Data pertaining to the study child during the period from birth to one month 

of age; the majority of these data were collected prior to or at the time a 

study child was discharged from the hospital. 

Data collected at the time of the four month examination of the study child. 

Data collected at the time of the eight month examination of the study child. 

Data collected at the time of the one year examination of the study child. 

Data collected at the time of the three year examination of the study child. 

Data collected at the time of the four year examination of the study child. 

Data collected at the time of the seven year examination of the study child. 

Data collected at the time of the eight year examination of the study child. 

II.A.xv 


TABLE 4. 


and Subject Categories (Cont.) 

SUBJECT 

Administrative 

Anesthesia 

Clin. Impression 

Clinical Lab 

Current Pregnancy 

Environ. 

Exposure 

Events 

Hearing 

Hospitalizations 

Language 

Linkage 

Malformations 

Diag. & Cond. 

Med. History 

Medications 

Neurological 

Exam 

Observations 

Pathology 

Physical 

Exam 

Procedure 

Psych. Exam 

DEFINITION 

Data pertaining to the administrative aspects of the study. 

Data on medications and procedures used to obtain anesthesia. 

Impression of abnormality or dysfunction gained by an examiner 

following evaluation of clinical signs and symptoms and including a 

subjective component. 

Data obtained from laboratory examination of clinical specimens. 

Personal data and medically relevant information pertaining to 

the study pregnancy for which the mother is enrolled. 

Data on exposure to occupational or other environmental entities 

or hazards. 

Data related to a specific event, occurrence or incidence. 

Data obtained from examination and testing of hearing function. 

Data on specific hospital admissions or the number of hospi~alizations. 

Data obtained from examination and testing of language function. 

Data on the genetic relationships of family members to the study 

mother, father or child. 

Data on the conditions in which failure of normal development has 

resulted in abnormal physical traits existing at the time of birth. 

Data on specific diagnoses or conditions obtained from past 

medical history or examination during the study. 

Data obtained from the study participant or medical records relevant to 

past or current medical diagnoses or conditions. 

Data on drugs or medications used. 

Data obtained from observation and physical examination 

of the central nervous system. 

Data obtained from observations not categorized elsewhere. 

Data obtained from clinical and anatomical 

pathological examination. 

Data obtained from physical examination of the 

study participant. 

Data relating to specific procedures performed on the study participant 

prior to or during the period of enrollment in the study. 

Data obtained from the psychological examinations and observations. 

II.A.xvi 


TABLE 4. 


and Subject Categories. (Cont.) 

SUBJECT 

Reproductive 

Hi st. 

Serology 

Socioecon. Info 

Speech 

Work History 

X-Ray 

Summary 

Cyn. History 

Special Studies 

Fam/Cenetic 

Hi st. 

SLH Exam 

DEFINITION 

Data pertaining to the outcome of pregnancies prior to and or during 

the period of enrollment in the study. 

Data obtained from the laboratory examination of serum by specific 

immunologic methods. 

Data related to the social and economic characteristics and environment 

of the study participant. 

Data obtained from examination and observation of speech function. 

Data obtained from examination of the eyes. 

Data pertaining to occupation and employment prior to and during the 

period of enrollment in the study. 

Data on diagnostic x rays and diagnostic or therapeutic radiological 

procedures. 

Data presented as a summary of data collected and recorded elsewhere. 

Medical history specifically related to the female genital tract, 

reproductive physiology and endocrinology. 

Data pertaining to participation in other special organized studies 

conducted during the period of enrollment in the study. 

Data on the medical histories of family members genetically 

related to the study child. 

Data obtained from the speech, language and hearing examinations not 

specifically or exclusively related to one of these areas. 


II.A.xvii


CONTENTS 

AR-1/0B-1 

OB-2 

OB-3 

OB-4 

OB-5 

OB-6 

OB-7 

OB-8 

OB-9 

OB-42 

OB-43 

OB-10 

OB-44 

OB-45 

OB-11 

OB-46 

OB-12 

OB-47 

OB-15 

Obstetrical Administrative Records 

Reproductive History 

History Since Last Menstrual Period 

Gynecological History 

Recent t1edical History 

Past Medical History 

Infectious Disease and System Review 

Repeat Prenatal History 

Prenatal Record 


Initial Prenatal Exam 

Return Visit and Laboratory Record 

Prenatal Observations 

Laboratory Record 

Record of Current Pregnancy 

Physician•s Clinic Record 

Summary of Hospitalization for Any 

Antepartum Condition 

Summary of Antepartum Hospitalization 

Drugs in Pregnancy 

II.A.1 

II.A.21 

II.A.37 

II. A. 55 

II.A.69 

I I. A. 91 

II.A.113 

I I.A.131 

II.A.147 

II.A.195 

I I. A. 209 

I I. A. 237 

II.A.259 

II.A.275 

I I. A. 319 

II.A.327 

II.A.333 

I I. A. 341 

I I.A.347 


II.A.xix


AR-1 

Obstetrical Administrative Record 

Form OB-1 (changed to AR-1 in July 1960) was designed for use as the 

opening record for any gravida registered in the study. Used to notify NINDB 

of a new case, this form was submitted as soon as possible after registration. 

First implemented into the study in January 1959 as OB-1, the form was revised 

once in July of 1959 and then redesignated as AR-1 under the same title in 

July 1960. The January 1959 version is not itemized and is worded differently 

than the July 1959 version, where items were itemized. The July 1960 revision 

did not result in any changes to the form. Codes 1,2, and 3 in column 5 of the 

master file cards indicate that data came from the 1/59, 7/59 and 7/60 versions 

of the form, respectively. Patient status, from item 20 on the form, was 

included on revisions 2 and 3 only. 

Originally coded on card 0301 (AR-1: OB Administrative Record), these 

cards were used as input when the master data file was created and renumbered 

(0001) on the master file. At that time, information for columns 76 and 80 was 

added to the data tape. One card record exists for each study patient, 

yielding a total of 58,760 records (Table OB-1.1). 

TABLE AR-1.1 

Cards and Data Records by Revision for Form AR-1 

CARD REV. NUMBER 

CARD NAME NUMBER NO. RECORDS 

AR-1: OB Administrative Record 

0001 

1 3, 781 

2 8,094 

3 46,885 

58,760 

total for form 58,760 

II.A.l 

AR-1 


II.A.2 

AR-1 



H 

H 

0 

> 0 

w 

~ 

r.;., 

nata lte'IIS RetPrf'ncin~ form IIR-1, nbstPtrical ldmtntstr::~t:tve RPcorr1 

DUA 

TrF'14 

IT€_. )N CAkl'l 

TO FJPI4 Nll!ol FR014 T" :>Afll T TF:'I U'IE 

1 ••••••• 

ono1 1 5 Car"! number CseC'luence, for11 tVOf', for"' nu'llber, revision number) 

2 ••••••• 

onot ,; 14 NTNOB c~s~ number 

3 ••• AR•1 2 0001 1'i ::!8 Nllme, last 

4 ••• AR•t 3•4 ooot 2Q 15 Institution ldentlflcatfon 

5 ••• AI:l-t 0001 3fi 36 Tvo~ of instttutiol"' 

6 ••• AA•t b 0001 37 37 N,.me, ffr5t, first letter 

7 ••• AI:l•t 1'2 0001 3fl 19 Re~tstratfol"' date (1110) 

8. • .AR•t 1'2 0001 40 41 Heqtstrlltfon date (1!Vl 

9 ••• AR•1 17 

ooot 42 43 Reqlstr11tton date Cvrl 

to ••• AR•\ 13 

onot 44 45 Forlft AR•1 tnttiate:i, 'tate 

11 ••• AP•1 1J 

onot 46 47 Form IIR•t inltiate:t, 1ate (mol 

(d;w) 

t2 ••• AQ•1 1J 0001 4~ 49 For111 AR•1 lnitiate:t, 1ate Cvrl 

13. • .AR•t 14 0001 50 'i1 LMP, first riav (110) 

t4 ••• AR•t 14 

onot 52 51 LMP, first riav f:iliV) 

tS ••• AR•1 14 

onot 54 55 L-.P, first riav Cv,r> 

t& ••• AR•t 15 

0001 s,; '57 Birth date fmo) 

t7 ••• AR•1 1!' 

0001 SA '59 !'trth dati" {diiV) 

t8.ooAR•t l"i 

0001 bO 1'\l Birth datf' Cvr> 

t9 ••• AR•t 17 

onot &'2 62 14Arttal status 

20 ••• AR•\ 1fl onot 61 63 RI'ICP. 

?t ••• AR•t 20 0001 64 64 P11ttent status, clinic or ortvate 

?2 ••• AR•t 21 ooot 6!' 65 Sli~Plfnq frame oatient, 00 Nell' IJSF 

?.3 ••• Aq•t 1t 

0001 6fi fi7 F.:OC, estimated 

?4 ••• AI:l•t 11 

ono1 &A 69 El'lC, estimate-t date 

riate of conftnP~I"nt 

of conff ne'llf'nt 

Cmo) 

fdiiVl 

?5••• AR•1 1t 0001 70 71 EOC, esttmated date of conttnP'IIPnt Cvr> 

26 ••• AR•1 lfi 

0001 72 73 Aae at reatstration (VrS) 

?7 ••• AR•1 tQ 

onot 74 75 Gestation at re~tstratlon (WKS) 

?8 ••• AR•t 0001 7fi 76 WlllK/tn pattent 

?9••••••• onot 77 79 Alank 

'lO ••• AR-1 onot AO AO Plltf ent, tvoe of 

4974 •••• VAR 16 31 32 Aae Cvrs> 

4975 •••• VAR 

31 33 Aae, arouoeri In 5 vear tntervats 

4976 •••• VAR lQ 

34 35 Gestatiol"' at reqistratlon (WI(S) 

4977 •••• VAQ 

36 36 ~~rft~tl statu~ 

4978 •••• VAR tQ 37 37 TrllllestPr at re~lstratlon 

49A7 •••• VAR 1'2 

55 56 Prenatal visits, total nu'IIOPr 

49A9 •••• VAR 14 

5Q 64 MPnstrual perto~: L14P, first ~av 

'HQ4 •••• VAR 12 

297 302 Reqtstratfon ~ate (lfto/davtvr> 

519S •••• VAR lA 

303 303 R11ce 

'HQ6•••• VAR 20 304 304 Plltlent status, cllntc or ortvate 

63'54 •• w-1111 

01193x 20 1.5 

fi377 •• W-tlA 

OA912 21l 25 L14P, from 

L14P, from AR-t, ftrst 

AR-1, ffrst riate 

dlltP 

( 110/rhvtvr) 

C11o/rt•wtvr) 

Cmo/~ay/yr)

cOL.R-aooa.l 

"lEv. 7-eo 

!Ol 

I. PATIKNT IDKNTIII'ICATION 

OBSTETRICAL ADMINISTRATIVE RECORD 

2.. L.AaT NAMIE I. OPD NO, .to HOIPITAL. NO. !1. SPECIAL NO • 

e .... I..IT NAWIE 

I'· WIDDL.Il 

: 

a. WAIOKN 

I 

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I 

I 

COMPLETE ONLY 

IF NEEOED BY 

HOSPITAL 

I. AOOJII 11:11 (St,..t ..d l'ftllllber) (City, • ..,• .,, Stele) 10. TIEL.I:~HONIE NO. 11. EDC 

12. OATil: RKGIITK .. IED 11. DATa "0RM INITIAT.D I.a. I'IIIIIT DAY LMP II. OATC: a, atiiiiTH 11. AGC 

I I I I I 

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I 

v... Mo. Do,. I 

Yur 

: 

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WIESTATION 

os OM OCL ow oo CJSII'. ow ON OOR CJPR CJOther 

1 I 

• • • • • , 

• • • 

oa ...... n 

20. PATIIENT STATUI 21. IAWIILINQ P'IIIAM& ~ATICNT 

O Booed on 

OCIIntc CJPrtvoto SI!L.I!CTI!I) I"Oft t s,..-,. s-plint NOT SI!L.I!CTI!D 7 Sampling Design 

1 STUDY 1"0" STUDY 

1 Spoclol s-pllng (Sped,.) I (Spec~"' below) 

• CJBu... on O For Other Reasons 

I 

Collaborative Reaearch 

Perinatal Reeeotch Br..,ch, NINOB, NIH 

Bath..cia 1.t&, Md. 

(AR-1) 

II.A.4 

AR-1 



H 

Ḥ 

• > 

U1 

~or~ Ite~ Mumb~rs linked to nata Items on ftR-1, ObstPtrical Administrative Kecor1 

ITE~ 

nATA 

ON TrF.M CARO 

F'ORM HI NIIM F'ROIC T'1 I> AlA T fF.M NAr4F: 

4 1 H 67 EOC, 11sti~ate1 date of continP~ent (mo) 

11 2"i ••• IIK-1 0001 7() 71 EOC, Pstlmate1 date of conffnflment Cyr) 

12 8 ••• AR•1 ono1 40 41 Reqfstration date (day) 

12 

7 ••• AR•1 onot 3A 39 Rectistrl'ltion date {mol . 

12 

5194 •••• VAR 297 302 Reqistrl'ltfon date (mo/davtvr> 

12 

Q••• AR•1 0001 42 43 Reqlstratton date (yr> 

13 

11 ••• AR•1 0001 46 47 ~orm AR-1 initi~tte::l, date {day) 

I 3 

10 ••• AR-1 ooot 44 45 For~ AH-1 initiated, 1ate (mol 

lJ 12 ••• AR•l ono1 4R 49 Form '"~-1 initiated, :iate

OOTE: 

FIELD 

MASTER ~ ~ LAYOUT 

DEFINITION OF CODES 


FORM AR-1 CARD 0001 

Use f'or specifications. 

CARD 

COI1JMN 

1. Card Number 

Code: 0 

.., 

2. Form Number 2-4 

Code: 001 

3· Revision Number * 5 

Code: 1 - OB-l Form Dated : 1/59 

2 - OB-1 Form Dated : Rev. 7/59 

3 - AR-1 Form Dated: Rev. 7/6o 

4. NINDB Number 6-14 

Item 1 

Nine-digit number tor Patient Identification 

Code: As given 

Last Name 15-28 

Item 2 


6. Institution Identification 

Item 3 or li 

29-35 


0000000 - Unknow. 

1 

1· Type of Institution Number Used 

Item 3 or li 

Code: 0 - OPD B'umber 

1 - B'either Item 3 or 4 reported 

9 - Hospital Number 

8. First Letter First Name 37 

Item 6 

Code: As given 

9· Date Registered 

Item 12 

Six-digit code tor Month (cols. 38-39), 

Day (cols. 40-41) and Year (cola. 42-43) 


* Item numbers refer to Form Dated: Rev. 7/6o 

II.A.6 

AR-1 



{Continued) 

FORM A·.mon Law 

4 - Widow 

5 - Divorce 

6 - Separated 

9 - Unknown 

1 - White 

2 - Negro 

3 - Oriental 

4 - Puerto Rican 

8 - Other 

9 - Unknown 

15. Patient Status 

Item 20 . 

Code: Blank - Item not on Rev. "1" 

1 - Clinic 

2 - Private 

44-49 

50-55 

56-61 

62 

64 

II.A. 7 

AR-1 


DEFINITION OF CODES (Contimled) 

FIELD 

FORM AR-l 

Card 0001 

CARD 

COWMN 

1.6. Sampling Frame Patient - DO NO!' USE 65 

17. EDC 66-71 

Item ll 

Six-digit code for MOnth (cols. 66-67), 

Day ( cols. 68-69) and Year ( cols. 70-71) 


99 - Month, day and/or year unknown 

18. ~ 72-73 

Item 1.6 

Code: 10-58 - As given 

99 - UnknOWD 

19. Weeks of Gestation 74-75 

Item 19 

Code: 01-50 - As given 

99 -Unknown 

20. Walk-In 

Code: Blank., 0 = Ito~ 

1 .- Yes 

- 

21. Type of Patient 80 

Code: 1 1 2 = Core 

1 ,. liln-core 

II.A.S 

AR-1 


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II.A.9 

AR-1 


PHS-3003-1, Obstetrical Adminiatrativ~ 

A.IMIN!8l'RATIVE RECORD MANUAL 

.,:, ..,. 

Record 

AR-1 

Rev. 7-6o 

A. PURPOSE. This form provides for the registering, and notifying NINDE of 

the registration; of each gravida in the sampling frame. The sampling 

frame includes all patients who are eligible for inclusion in the study, 

based on the sampling procedures approved for each institution. It also 

provides the information needed for opening the case records of women 

selected as study cases. In addition,. it provides for the reporting of 

comparable administrative data for gravida in the sampling frame of the 

institution, but who were not selected as study cases. 

B. INTERVIEWER. The interviewer who completes the .form AR-1 may be any staff 

member of the hospital trained to obtain and record the required information. 

c. uriLIZATION. This form supersedes Form OB-1 (R~v. 7/59) which will not be 

used after receipt of sqpplies of Form AR-1. 

D. INSTRUCTIONS FOR COMPLETING FORM AR-1. 

Item 1, Patient Identification. Patient NINDE study number is entered here 

for all study cases. It may be entered by Addressograph, other stamp or 

written. The number must be completely legible on the copy sent to NINDE. 

This item is left blank for patients in the sampling frame who are not 

selected for the study. 

Item 2, Last Name. 

Item 3, OPD Number. 

Last name of patient. 

OUt-patient Department number if assigned to patient. 

Item 4, Hospital Number. 

Regular hospital number if assigned to patient. 

Item 5, Special Number. Any special identifying number assigned by the 

hospital to the patient. If none, leave blank. 

Item 6, First Name. 

Item 7, Middle Name. 

Self-explanatory. 

If none, leave blank or write the code "NMI". 

Item 8, Maiden Name. As reported. If patient is single (Item 17 coded "S"), 

malden name will be reported in Item 2 (Last Name); therefore place an 

"X" in Item 8 (Maiden Neme). If a patient with other marital status is 

using her maiden name as her last name place an "X" in Item 8 and indicate 

reason, if known in item 8. 

Department of Health, EducatiOn, and Welfare 

Pub~ic Hea~th Service 

October 1, 1960 

II.A.lO 

AR-1 


ADMINISTRATIVE RECORD MANUAL 

PHS-3003-1, Obstetrical Administrative Record 

AR-1 

Rev. 7-6o 

Item 9, Address. 

Self-explanatory. 

Item 10, Telephone Number. Self-explanatory. If none, state "none" or 

leave blank. 

Item 11, EDC. Expected date of confinement. This item is to be completed 

only if needed by hospital. 

Item 12, Date Registered. Date patient was first seen in the clinic whether 

or not Form AR-1 is started on this date. Record all dates numerically, 

in the order month-day-year as 9-15-59· This item should also be completed 

for non-study sampling frame patie~ts {i.e., not selected for study). 

Item 13, Date Form Initiated. Date that this form is started, which may 

be prior or subsequent to the date of registration {Item 12). For many 

hospitals it will- be the same as the date shown in Item 12. 

Item 14, First-Day LMP. Record the date of first day of the last normal 

menstrual period. If unknown, record as "X" and record the best availa:.~e 

estimate of EDC in Item 11. If the date given is obviously not for this 

pregnancy, give the date with an asterisk {*) next to it and in Item 11 

{EDC) record the best known estimate of the date of confinement. If not 

available at time of report submit at a later date as a correction to the 

form. 

Item 15, Date of Birth. 

help of patient. 

If unknown, attempt to estimate year of birth with 

Item 16, Age. Age at last birthday. This item is to be completed only if 

needed by hospital. 

Item 17, Marital Status ..This item is to be used to record, where possible, 

the legal marital status of gravida and non-legal relationships should 

be ignored. Check appropriate box. The abbreviations on the form represent 

the following classifications: 

S - Single {never married) 

M - Married 

CL - Common Law ?-!arriage - Use this category if it is 

in general use in your institution and it is a 

legal marital status in your community. 

W - Widowed 

SEP - Married but separated. Include all patients who 

are married but not living with husband whether or 

not the separation is legally recognized. 

Department of Health, Education and Welfare October 1, 1960 

Public Health Service 

II.A.ll 

AR-1 


ADMINifn'RATIVE RECORD MANUAL 

PHS-3003-1, Obstetrical Administrative Record 

AR-1 

Rev. 7-60 

Item 18, Race. Check appropriate box. The abbreviations on the form represent 

the following classifications: 

W - White, exclusive of Puerto Ricans 

N - Negro, exclusive of Puerto Ricans 

OR - Oriental 

PR - Puerto Ricans. A Puerto Rican is defined as a gravida 

born in PUerto Rico; or if born elsewhere, is classified 

as Puerto Rican if either or both of her parents 

were born in Puerto Rico. If the gravida and both her 

parents were not born in Puerto Rico, race is to be 

assigned to White or Negro as the case may be. 

Other - Include all other groups (such as American Indian, 

Polynesian, etc.) 

Item 19, Weeks of Gestation. Number of weeks between first day of last normal 

menstrual period (Item 14) and date of registration (Item 12), (corrected 

to the nearest whole week). This item is to be completed only if needed 

by hospitaL 

Item 20, Patient Status. Check appropriate box. 

Item 21, ~ling Frame Patient. Classify each patient by the reason patient 

was or was not selected for registration in the study. 

Selected for stu based on s stematic s ling. If the patient is 

selected using the sy ematic sampling method or. other method used 

to select basic core study patients approved for your institution, 

i.e., without regard tor ~cial characteristics of the patient, 

check this box. For ~la, an institution taking 100~ of its cases 

would check this box tor all accepted cases. In the same manner an 

institution selecting every tenth case, every fourth case or a case 

whose hospital number ended in a specified digit would check here for 

cases chosen in this manner. 

Selected for study based ~ special sa.m,pllng. This box should be checked 

for all patients registered who are selected on the basis of some 

characteristics of the gravida herself, but who have not otherwise been 

selected in the syste~ic sample. No special selection procedure of this 

type should be used wi · ftt prior approval. This would include approved 

selection of the first triaester patients, selection by age, parity, etc. 

The reason for such selection must be specified. 

Department of Health, Education, and Welfare October 1, 1960 


II.A.l2 

AR-1 


ADMI!liSTRATIVE RECORD ;fl.A.TI.TUAL 

PHS-3003-1. Obstetrical Administrative Record 

AR-1 

Rev. 7-60 

Not selected for study based on sampling design. This should be 

checked for all patients in the sampling frame approved for the 

institution (i.e. all patients coming to the institution from 

which selection for study could be made) but which are not selected 

for study using an approved procedure of the types described above. 

Not selected for study for other reasons. This should be checked 

for all patients which should have been selected for study under 

the procedures described above but were not selected. Refusal 

to cooperate in the study is an example of the kind of explana~ 

ti6n expected when this item is checked. The reason for checking 

this entry must be specified. 

Department of Health, Education, and Welfare October 1, 1960 


II.A.l3 

AR-1 


IIICV. 7-•• 

Ill 

OBSTETRICAL ADMINISTRATIVE RICORD 

1 1 ... TICNT IQCNTifi'ICATIOI'II 

)Pi" AL AK-1 r~ ..-· L 

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PK>- ·~..., ~ -f 

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e. II'UIIIT NAMC 7 ....DDI.C a.MAIDIIN 

1 1 C:OIIIPL!TI 0111.Y 

I 

 

I 

IP ,_IDID IY 

I I HOSPITAL 

O. AODIIIIII (-·-10-1 ICily,;~;--•-• 10. TCLC~HONC NO. 11. KDC 

••• DATK IIIIIIITKIIIID I"· OATil I'OIIM tNITIATJ ........T DAY ...... 18. DATC OP' .IIIlTH ....... 

I 

~ :-~~ ~~-~~ ~~-~~ ~ I Dey : Y•• I 

I I I I I I I I 

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17. MAfiiiiTAL ITATUI ......c. te. W'C&Ka 0~ 

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20. ~ATICNT ITATUI 21 ..........." .............,.....,. 

0 •.,.._.s-.1... 7 0..11• 

STUDY 

1'0.-ITUOY 

' • ....... s-.11..cs.-ilr) 0 (Specify .... Otloe< Mlowl ·-· 

• ....... 

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QUTATION I 

I 

ADDII~IAPH PLATI 

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..,..,. ...... 

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aLuc CltOaa eltOUII NUM8CJt 

IB.UC ..II&LD ... CJ ICJ 

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P..WI• "-ltlt S..l.. 

(AR·l) 

II.A.l4 

AR-1 


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OBSTITRICAL ADMINISTRATIVI a!CORD 

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II.A.l5 

AR-1 


,.... 

~Ha.!IOOS•I 


os-a 

..J....f'M' Jc./ 1 ~~~" j 7-51 

OAT TH S ,-O,_M INITIA HO.ITAL I~I:C:IAL 

NAMC 

ADOtiiCSS (SIHel & No.I 

OATil 011' 81 .. TH ( 

::::JOR 

QPR ~Ott... 

lir!IIA"ITAL STATUS OAT& OP' L AT&ST HI.HC•T IC:HOOL 

MA..RtA•K 

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occ:u~ AT ION 

-..~.oveR 

OUTI!TRICAL CLINIC PATIENTS 

OATit ~lfltST SCIIlN IN CLINIC IO:X .....NINe "'NY.CIAN 

OTHI!R PATII!NTS 

NA"''C AND AOD.. US 011' 0.8TCT,_ICIAN I OAT I: .. ATII:NT ~I"ST SIECN 

SPOUSE 

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HI.HCST SCHOOf. 

QfltAOil locc""A'ftON IINOU8T..Y JGI:NI:.. A&. HI:ALTH 

co..-L.CTCD 

N-0: 

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JWO:IGHT 

FATHER JHO:ICIHT JWI:IGHT 

OF CHILD 

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o.,..,._, of H..tth, Eduutl.,. ..... W.II 

Pu .. lic H.eltt. S..•ice 

(OB-1) 

II.A.l6 

AR-1 


OB-1: 

OBSTETRICAL· ADMINISTRATIVE RECORD 

Instructions for Use 

par. 1 

par. 2 

This record was designed as the opening record for any gravida 

registered in the study. It notifies NINDB of a new study 

case, and should be submitted as soon after registration as 

is possible. 

It may also serve as a hospital form, and therefore includes 

items which are not needed for study use. Additional infor 

mation required locally may be recorded at the· bottom of the 

sheet. The.items listed below are needed for study use and 

must be completed before the form-is submitted. Other items 

are optional. 

1 - Date this form initiated 

2 - First day LMP 

3 - Record numbers (including NINDB study number) 

~ - Name (including mai~en name) 

5 - Address 

6 - Date of Birth 

1 - Present Age 

I 

; 

'• 

8 - Race 

9 -Marital Status 

10 - Religion 

11 - Date first seen by clinic or private obstetrician 

Par. 3 

Comments concerning each of the above items are enumerated 

below: 

1 - This date should be the date on which the gravida is 

selected as a study case. For many hospitals it will 

be the same as the date shown in item 11 (date first 

seen). All dates should be recorded.n~rically~ in 

the order month/day/year. 

II.A.l7 

AR-1 


Par. 3 

(Cont.) 

2 - Record the first day of the last menstrual period. 

If the date given is obviously not for this pregnancy, 

record it 1 place an asterisk (*) next to 

the date, and at the bottom of the page record the 

patient's estimate of the date of confinement. 

3 - Record number. If the addressograph plate is not 

yet available, write the NINDB namber for this 

patient in the blank box above the record number 

space and also record the outpatient number and 

hospital or unit number (if known). 

4 - Name - Be sure to include maiden name if gravida is 

married. If she is not married, place an "X" in 

the space for maiden name. 

5 - and 6 -Address R~d date of birth -- These items are 

self-explanatory. 

7 - Present age - should be age as of last birthday. 

8 - Race. Record as follows: 

W - White, exclusive of Puerto Ricans 

N - Negro, exclusive of Pue~to 

Ricans 

OR - Oriental 

PR - 

Puerto Ricans, regardless of racial group 

Other - Include all other groups, such as American 

Indian and Polynesian. 

9 - Marital Status 

S - Single (never married) 

M - Married 

CL - Common Law Marriage. Use this category if 

it is in common use in your institution. 

W - Widowed 

D. -···.nivorced 

SEP·- Separated. Include here all patients who are 

married but have separated, whether or not 

the separation is legally recognized. 

II.A.l8 

AR-1 


Par. 3 10 - Religion. Record as Catholic, Protestant, 

(Cont.) 

Jewish (Hebrew), or Other. 

11 - Date First Seen. Record the date the patient 

is first examined by her private obstetrician 

or an obstetrician in clinic. 

II.A.l9 

.AR-1 



II.A.20

OB-2 

Reproductive History 

Form OB-2 was used to record information about the previous pregnancies of 

each gravida. Data were obtained through interviews with the gravida herself. 

Used first in January of 1959, the form was revised once in January of 1961. 

Revisions did not affect items or order of items on the form. Card numbers 

from the master file and the number of records generated for each of these 

cards appear in Table OB-2.1. An 0302 card indicates the gravida had four or 

fewer prior pregnancies; for women with more than four prior pregnancies, 

cards 1302, 2302, etc., were used as required. 

TABLE OB-2.1 

Cards and Data Records by Revision for Form OB-2 

Card Rev. Number 

Card Name Number No. Records 

OB-2: Four or Fewer Prior Pregnancies 0302 0 47,655 

OB-2: More Than Four Prior Pregnancies with 1302 0 9,020 

First Through Fourth Recorded 

OB-2: Fifth Through Eighth Prior Pregnancies 2302 0 9,040 

OB-2: Ninth Through Twelfth Prior Pregnancies 3302 0 1,417 

OB-2: Thirteenth Through Sixteenth Prior 4302 0 159 

Pregnancies 

OB-2: Seventeenth Through Twentieth Prior 5302 0 15 

Pregnancies 

OB-2: Twenty-first Through Twenty-fourth 6302 0 2 

Prior Pregnancies 

OB-2: Twenty-fifth Through Twenty-sixth 7302 0 1 

Prior Pregnancies 



II.A.21 

OB-2

II.A.22 

OB-2 



H 

Ḥ 

. :'J:II 

N 

w 

nata Items Referencin~ rnrm n~-2, ReProductive Htstorv 

oau 

ITEiol 

TO 

TTF:I4 

J" 

F")QI4 

CAHil 

Nlll4 FR0'4 TO !>HII l fF:Iol UIIIF: 

lAS ••••••• 030? t 5 c~rd number (5eCIUI'!nce, torn tvoe, form nu'llber, revll ion nu111ber> 

1A6 ••••••• 0302 6 14 NTNOB c~se numoer 

1A7 ••• o~-? 

0302 

16 Pro~ucts nf orinr oreqn~tncies, total nu111ber 

1AB ••• OR•?. 

OJO? 17 ·~ 18 Preananr.ies, tot :~1 number orior to study 

tA9 ••• 0A•? t 

OJO? 1Q ?.0 Pre~nancv termination 1ate ( 110 >: or1or oroduct, nth (n • 1•4) 

1QO ••• OA•2 1 

030?. 21 22 

1Q1 ••• 0A•'2 2 

030?. 21 ?4 Gestation PreCin~tncv termination d~te ( vr >: orfor 

(WkS): orlor orn:Juct, nth (n oro::luct, nth 

: t-4) 

1q2 ••• o~-1 l 

0302 25 ?5 Liveborn: prior oro~uct, nth (n = 1•41 

1Q3 ••• oA-2 5 

030? 2fi ?6 Sex: Prior PrCI::Iuct, nth (n = 1•4> 

1Q4 ••• oA-? 10 

030? 27 ?1 Oellvery type: orior oro::lu::t, nth (n s 1•4) 

11 

030? 211 29 Bfrthwe1qht (1 bS )r prtor oro:Juct, nth (n : 1-4> 

11 

010? ]I) 11 Bfrthwe1.qt-!t (ozl: or lor or:>duct, nth (n z 1•4) 

010? 32 32 Aae at ~e111th: orior prortuct, nth fn = 1•41 

1QB ••• OA•2 12 

0302 3l H Blrtholace; orior product, 

199 ••• oA-? 1-12 030? 34 78 Prior product, nth, repeat nth 

1Q5 ••• oq-? 

1Q6 ••• oA-? 

1Q7 ••• oA-? 

213 ••• 0R•2 

2t4 ••• ofl-2 

2t5 ••• 0A•2 

12 

I 

1302 

110? 

130? 

32 

33 

34 

12 

H 

78 

Btrthnlace; prior oro1uct, nth Cn = 1•28) 

Prior pro~uct, nth Cn = 1•28), rePeat of colu~ns 19•33 

for n • 

2,3,4 

216 ••••••• 1302 Jq 80 Blanle 

2t7 ••• oR-2 1•12 2302 t 80 Prior 

218 ••• 0R•? t -1'2 3302 1 ~0 Prior product, 

orortuct, nth 

nth Cn 

1•29), 


nata Ite~s RPterPn~in~ for~ ns-2, Penrndo~ttvP Hfstorv 

01\TII 

Tfl"''l 

ITEM JN CARO 

TO F'JRI4 NIIM fROM TO DATA TfFM NA"'f: 

49112 •••• "AR t-2 46 47 P~rttv, oreqn~n~i~s, total nu~bPr of nrfor non abortion of 20 wks 

aestAtfon or ~reatPr 

49A3 •••• VAR 2 4R 49 Deaths, tot~l nu~her nf orior orenatal 

49114 •••• VI\P 2 50 51 Lfvebfrtns, total nu~ber of Prior 

5248 •••• VAR t 1 l8R JAB Premature: hirtns, total numoer Prior to current ore~nancv 

5249 •••• VAR 2 ~~q 3A9 F'Pt~l dP~th~: (~borttonl At less th~n 20 wee~s aestAtlon, total 

nu~bP.r orior tn currP~t orPqnancv 

52r;O •••• VAR ~90 ]QO Prean~n~lP.s, ~ultlple, tot!l number orlor to current oreanancv 

'52'5l •••• VAR 2 391 ]Qt sttllhirths: deat~s at 20 •ee~s ~Pstatlon or areater: fetal ~eat~ 

orfor to current orea~anev 

!§252 •••• YAR 2 19? ]Ql oeatns: nP.onatal an~: stlllhlrths, total nu•ber prior to current 

nreanancv 

52Sl •••• YAR 394 JQS Preanancv, last orlor: aest~tfon £wks) 

H 

H 

> •N 

olio> 

@ 

I 

IV

COLIII:•IOoa-& 

,.., 

REPRODUCTIVE HISTORY 

(lra~~n~i...,.r) 

""".". 'DATI: (llo.D•·Yr) I 

RECORD PREGNANCIES IN CHRONOLOGICAL ORDER 

PREGNANCY ORDER: I 2 3 s 

I. DATE OF TERMINATION 

OF PREGNANCY 

2. GESTATION ('Wul&~) 

3. LIVEBORN (Yu or No) 

4.. D & C AFTER 

MISCARRIAGE 

s. SEX (M or F) 

6. NAME OF CHILD 

" 

COMPLICATIONS OF 

7. PREGNANCY 

8. INDUCED LABOR 

(Yu or No) 

9. DURATION OF LABOR 

(Hour~) 

Vaginal 

TYPE c.... 

10. OF .,.,.,. 

DELIVERY BrHch 

~=~~·- 

II. BIRTH WEIGHT 

(U.~.- Os.) 

12. PLACE OF BIRTH RI!CORD CITY AND NAME Of HOSPITAL IN SPACE BELOW 

13• ~r~~~~LITIES 

14. NA~ OF FATHER 

IS. RACE OF FATHER 

DATE OF DEATH 

16. OF CHILD 

17. PLACE OF DEATH 

18. CAUSE OF DI!ATH 

- 

INFORMANT ('Wbne ~owe• 

19. 

i~ b~pital -.cord~. 

iMicat• by •n• J 

12. PLACE OF BIRTH IR•corti Citv arui Na- o/ Host>ital) 

I. 

2. 

3. 

"· 

5. 

IF MORE THAN 5 PREGNANCIES, USE ANOTHER FORM. 

C.II.......... R..... 

Pwtn.... Re................ HINDI, NIH 

.......... 14,MII. 

(DI-2) (Je•. 1-41) 

II.A.25 

OB-2 



H 

H 

> •N 

0\ 

@ 

I 

"' 

Form Item ~u~bers linked to ~ata Items on nR-2, ReorodiiCttve Htst:>ry 

I 

1 

1 

1 

1 

1-2 

1•2 

1-3 

1•11 

1-t 2 

1•12 

1•12 

1•12 

1·12 

1•12 

1•12 

2 

2 

IT~!ol 

nATA 

ON Tlf::IC CARO 

FORM ID Nil"' FROliC TO DAfl TTF:M NAME 

= 1•28) 

= 1•4) 

211 ••• oa-2 

197 ••• ns-2 o1o2 

130?. l2 32 Aqe at 

l2 32 A~e at ~eath: prior 

~eath: prior pro~uct, nth 

pro~uct, nth fn 

Cn 

49At •••• YAR 44 45 Gravidity, ore~nanctes, total nu~ber of prior 

5250 •••• YAR 390 390 PreqnanctPs, multiple, tot~l number prior to current preqnancv 

18R ••• OB•2 0302 17 t 8 Pre~nanries, total number orior to study 

204 ••• oa-2 uo2 17 18 Preananc1Ps, total numoPr orior to studv 

4980 •••• YAR 

40 43 Preanancy, last Prior: hirth wet~ht 

5?.S3 •••• YAR 194 395 Preanancv, last prior: qestatton Cwksl 

4979 •••• YAR ll' 19 Preanancy, last priori survival 

187 •••1"18•2 0302 15 16 Products of prior preqnanctPs, total number 

201 •••DB•2 

2os ••• na-2 

189••• D8•2 

206 ••• 08•2 

190 ••• 08•2 

215 ••• ns-2 

4982 •••• YAR 

5253 •••• VAR 

497CJ •••• VAR 

4980 •••• YAR 

219 ••• 08•2 

220o •• 08•2 

221 ••• 08•2 

222 ••• 08•2 

217 ••• 08•2 

2t8 ••• n8-2 

19CJ ••• na-2 

4CJ83 •••• YAR 

S25? •••• YAR 

ll02 

1102 

0302 

ll02 

030? 

tlo?. 

4302 

510?. 

&302 

7302 

B02 

3307 

0102 

1CJ '" 

19 

21 

21 

l4 

46 

394 

3A 

40 

I 

1 

1 

t 

1 

I 

34 

4R 

]92 

16 

?.0 

1.0 

22 

22 

78 

2 5249 •••• YAR 389 389 

2 

2 

2 

2 

3 

] 

5 

201 ••• ns-2 

19t ••• ns-2 

4Q84 •••• YAR 

52St •••• YAR 

2on ••• ns-2 

t9? ••• ns-2 

20Q ••• na-2 

t3o7 

olo? 

tJO? 

0102 

1101 

23 

23 

50 

391 

2S 

2S 

26 

47 

Products of prior preanancles, total nuMber 

Preanancv termination datP C•n>: orfor oroduct, nth (n 

Preanancv termination dAte c~o>: orlor orod~ct, nth (n 

Pre~nancv tPrmination date Cvr>: orlor product, ntn (n 

Preanancv termination date Cvr>: prtor orojuct, nth (n 

Prior product, nth Cn = 1•2R), reoeat of columns 19•33 

2,1,4 

Parftv, preanancles, total number of nrtor 

~estatlon or Qreater 

Preananev, last prlorr aestatton (wksl 

1•28) 

t -4) 

1•28) 

= t-4) 

for n • 

non abortion of 20 wks 

395 

39 PreQnancv, last prior: survtval 

43 Preanancv, last prior: birth wel~ht 

RO Prior pro~uct, nth (n 1•28), reoeat of card 1302 for n w 13 to 16 

RO Prior product, nth Cn l•2R), re~eat of card 1302 for n • 17 to 20 

80 Prior product, nth Cn 1•28), re~eat of card 1102 for n c 21 to 24 

RO Prior pro~uct, nth Cn 1•28), rereat of card 1102 for n • 25 to 28 

80 Prior product, nth Cn 1•28), repeat of card 1302 for n • 5 to 8 

AO Prtor product, nth Cn = 1•28), repeat of card 1102 for n c CJ to 12 

78 Prior pro~uct, nth, repeat of columns 19·33 for n = 2,3,4 

49 Deaths, total number of prior prenatal 

393 D~aths: neonatal and: stillbirths, total number prior to current 

oregnancv 

FPtal dPaths; [abortion) at less than 20 weeks aestatlon, total 

numbPr orior to current ore~nancv 

24 

?4 

~1 

JQJ 

25 

25 

?b 

GPstation (wk~); Prior oro1uct, nth (n ~ 1•28) 

Gestation (wks); Prtor orodnct, nth (n = 1•4) 

LlVPbfrtns, tot~l number of prior 

Stillhlrths: rteAths at ?n weeks ~estation or qreater: fetal death· 

orlor to current preqnancv 

Liveborn: prior product, nth Cn = 1·28) 

Liveborn: prior product, nth Cn = 1·41 

Sex: Prfor oroduct, nth (n = t•?Bl


Porm Item ~umu~rs llnKPd to nata Items on nn-2, Reorn::tucttve Hlst:>rv 

'5 

10 

10 

1l 

11 

11 

tl 

11 

12 

12 

ITE!Iol 

OATA 

ON 1 rF:~l CARn 

FOR!Iol 10 NUM FROIC TO DATA JTF:M NAMr;: 

193 ••• 08•2 

210 ••• ns-2 

t94 ••• nB-2 

211 ••• 0B•2 

19!'i ••• nB-2 

212 ••• ns-2 

196 ••• 08-2 

0302 

l]O? 

o3o7. 

1301 

o3o? 

llo? 

030? 

5249 •••• VAR 

214 ••• 08•2 

19B ••• n8-2 no2 

0102 

26 

27 

27 

211 

21l 

30 

30 

1811 

33 

H 

26 

1.1 

27 

?9 

19 

11 

H 

31!11 

13 

13 

SeK: r'lrfor oro::tnct, nth (n = 1•4) 

OPltv~rv tyne: nrtor oroctuc::t, nth (n = 1•281 

UPllvPrV tyoe: r'lrtor proctu:;t, nth (n = 1•4) 

IHrthwelqht (lbs); prtor oro::tuct, nth (n = 1•28) 

Ktrthwetaht (lbs); ortor Product, nth (n = 1•4) 

Bfrthwefqht (oz>: orior or:>fiuct, nth Cn = 1•2R) 

Htrthwetqht (Cizl: orlor orot1uct, nth fn = 1-~) 

Premature: hlrths, total nllmbPr ortor to current 

Ht rthPlftce; prlor product, nth Cn = 1•28) 

B1rthPl ... CP; orior oroc!uct, nth Cn = 1•41 

pregnancy 

H 

H 

.;,. 

~ 

@ 

~

DEl!'INITION OF CODES 


-Font·~ ·. card· 0302 or 1302 

FIELD 

CARD 

COLUMN 


1 

Code: 0 - 4 or less Prior Products 

1 - More than 4 Prior Products 

with first through fourth 

recorded 

2 - Fifth through eighth prcduct 

3 - Ninth through twelfth product 

4 - Thirteenth through sixteenth 

product 

5 - Seventeenth through twentieth 

product 

6 - Twenty-first through twenty-fourth 

._%UUOt 

T - TW~-fifth through twenty-sixth 

produot 


Code: 302 

3· Revision Number * 5 

Code: 0 - Form Dated: 1/59 or Rev. 1/61 

4. NINDB Number 6-14 

Nine-digit numaer for Patient Identification 


5. Total Number of Products of Conception 15-16 

Code: 00 - ito prLir pregna.my 

oo.-26 - As given 

99-U~ 

6. Total Number of Pregnancies 17-18 

Code: Same aa in Fie~d 5, except 

01-28 -As given 

r. FIRST PRODUCT 19-33 

Date of Termination of Pregeancr (cols. 19-22) 

Item 1 

Four-digit co4e_ for Month 

( coa. 19-20) and tear (co~s. 21-22) 

Code: As givem . _ 

99 - Meath anii/or. year unlmawn 

* Item numbers refer to F

DEFTIITTION OF CODES (Continued) 

FIELD 

FORM OB-2 

Card 0302-l3C2 

CARD 

COIDMN 

7· 

FJRST PRODUCT (continued) 19-33 

Weeks of Gestation (cols. 23-24) 

Item 2 

Code: 01-50 - As given 

40 - Term 

99 -Unknown 

Liveborn (col. 25) 

Item3 

Code: 0 - No, Single' (includes unknow. plurality) 

l - Yes, Single (includes unknown plurality) 

2 - No, Multiple 

3 - Yes, Multiple 

7 - Unknown if Liveborn, single 

8 - Unknown if Liveborn, IID.lltiple 

Sex (col. 26) 

Item 5 

Code: l - Male 

2 - Female 

3 - Undetermined, Unknown, (Abortion - 

Gestation 20 or more weeks) 

8 - Not applicable, (Abortion - Gestation 

less than 20 weeks) 

Type of Delivery (col. 27) 

Item lO 

Code: l - Vaginal. (Abortion) 

2 - Caesarean 

3 - Ectopic delivery, delivery of mole 

9 -Unknown 

Birthweight (eels. 28-31) 

Item ll 

Four-digit code for pounds (eels • 28-29) and 

ounces (eels. 30-31) 

Code: 0001-1515 - As given _. _ 

99 -.Unknown pounds arid/or ounce.E 

Child's Age at Death (col. 32) 

Item 16 

Code: 

0 - Child still living 

l - Less than 24 hours 

2 - Lived one day through 6 days 

II.A.29 

OB-2 


DEFJNITION OF CODES (Continued) 

FOBM OB-2 

Card 0302-1302 

CARD 

COIDMN 

1· FIRST PRODUCT (continued) 19-33 

Child's .Age at Death (continued) col. 32 

Code: 3 - 7 through 27 day-s 

4 - 28 days through 1 year 

5 - Arter 1 year 

6 - Unable to classifY, but death 

occurred in the same month a.nd year 

as the date of termination of pregnancy 

7 - Unable to classify, but death 

occurred in same year as date of 

termination of pregnancy 

8 - Unable to classify, but known to be 

dee.d 

9- UDknown 

Place of Birth (col. 33) 

Item 1.2 

Code: 0 - Stuey- Hospital 

l - other Hospital 

2 -Home 

8 - Other place 

9 - Uuknown 

8. SECOND PRomCT 34-48 

Code: Same as in Field 7 

THIRD PR

1 


l:TeM.. 

- ,0,., -fOki&A. 

I • 

----- 

REPRODUCTIVE HISTORY 

FOR-t OB-2 

I 12 13161-i II I U IJIS II p~ I IZ. 1315~GI II 'Bl5 1/ 

X~ liT4 16 --,--.-,liJITf"ITI••-s16lu 1 •t»JITtii'it'itli.~,"iil9lii11•i'A :iilflil7 1 liD~•i"-.2'41«~,•.-t,a 9lfili'Arrlit~·~l~6t, ~~liiiiillfUfs-,i.-ftiilii"..-- 

-- 

I 

-- 

1 

·- 

0 

bj 

I 

.I\) - 

I 

FIRST PRODUCT ISECOUD PRbDUCT ITHIRD PROOOCT IFWIUH PROOOCT 

z 

~ ; Dllff MilllWEI II liM lllbltlEI IIIIB'JTIIIOOTEI IIIIB\JT 

l 

~ I-. 

1-1 "g ~ 

1-1 -F 4 

• ~ARO 4 

~IJ.)Q6 

1 ~ 1111 I LII&IJII~ 

>• 

w 

o;l··~. 

~{ 1 ~ ~ li i 

* 

: o ~ u I~ ~~~ ~ d ~ • ~ ~ ; ~ •' ~ d ~ 

...... 1-5- ~ &l 1:: ~ ~ ~ ~ I! I~ l: ~ 

-' &lOt ~ ~~ 6;:,. ,,. ~ ~~:II 

7 "" ;:,.0 ' (b ~ • 

~ I .._ .,_ 

1- 

I :- ~ ~ o ~~ "' .~ ~«. ~ '" o 

~ ~ ... 

"' "' :- "' ~ ~ ..,

REPRODUCTIVE HISTORY 

(For Form OB-2, Dated 1-59) 

Instructions for Interviewer 

On this form is to be recorded what the gravida knows about her previous 

pregnancies. The only source of information for OB-2 is to be an interview 

with the gravida. 

All information about previous pregnancies that you may obtain from 

hospital records, abstracts, etc., should be made available to the 

obstetrician, who will record it on OB-9. 

Disregard item #19, "Informant," since in all cases the informant will be the 

gravida herself. 

If the gravida has had more than 5 pregnancies, use additional sheets. 

Note this at the bottom of the first sheet and renumber the pregnancies on 

the next. 

With the exception of item #19, for each pregnancy all items should have 

some notation. This notation should consist of the answer called for, or 

one of the following: 

None - if no complications or abnormalities. 

UNK - if the answer cannot be determined. 

NA - if the item is not applicable. 

Unless otherwise instructed, write all dates numerically in the order month, 

day, and year, such as 2/24/59. 

Iwin Pregnancies: 

Use a separate column for each child. Correct the pregnancy numbers printed 

at the top. For the seeond child, leave blank items # 2, 4, 7, a, 9, 12, 

14, and 15. 

Item #1. "Date of Termination G!t' Pregnancy" 

Record the month, day amd year. If the gravida is in doubt about the exact 

date, record the most prebable date. 

Item #2. "Gestation" 

The length of gestation should be given in weeks from the LMP to the termination 

of pregnancy (corrected to the nearest whole week). The average as 

determined in this mannw is 40 weeks. 

If the gravida reports a duration in months, multiply the number of months by 

4 1/3 to get the number of weeks. Thus, a 4 month gestation is equal to 

17 1/3 weeks, which should be recorded as 17. (If, however, the gravida 

reports "9 months," she probably means term, or 40 weeks.) 

If the gravida reports a delivery as "three weeks early" or 11 2 weeks late," 

add or subtract this nuaber or weeks from 40. 


II.A.32 

February 1959 

(For Forms in Use April 1961) 

OB-2

R~PRODUCTI\~ HISTORY (Con't.) C3-2 

1/59 

Item #3. "Liveborn" 

If a pregnancy lasted less than 20 weeks, there is little probability that the 

child was born alive. For pregnancies of this or longer duration, however, 

you should make special effort to distinguish between cases in which the 

gravida was told that the child was stillborn, those in which it was born 

alive but immediately expired, and those cases in which the gravida was not 

told or cannot recall whether the child was l~ve born or not. 

Item #4. "D & C" 

Make sure the gravida understands the question and write "yes" or "no" in the 

space. 

Item #5. "Sex" 

Attempt to determine the sex for all children, whether live or stillborn, 

at any gestational age. 

Item #6. "Name of Child" 

For all children born alive, record the first name. 

Item #7. "Comolications of Pregnancy" 

The following types of complications should be noted: 

1. Difficulties during pregnancy, such as chronic or infectious disease, 

bleeding, high blood pressure, and albumin in the urine. 

2. Difficulties during labor, such as bleeding, prolonged or difficult labor, 

or retained placenta. 

J, Difficulties after labor, such as post-partum infection or excessive 

bleeding. 

If the patient reports any such complications, record her answer as 

completely as possible. If there were difficulties during pregnancy, attempt 

to date them as "early" (first trimester) 1 ''middle" (second trimester) 1 or 

"late" (third trimester). 

Item #8. "Induced Labor" 

Write "yes" in this box if labor was induced by the patient, a physician, 

or by arr,y other person, using any drug or procedure. Write "no", if labor 

started without any interference. If labor was induced, ask "why?" and see 

t::,at the answe:r: is noted under i tern #7 • 

Item #9. "Duration of Labor" 

This should not inclu~~ the third stage. It is expected that the duration 

of "labor" as reported by the gravida will, in nearly all cases, approximate 

the duration of the tirst two stages. 

February 1959 


II.A.33 

OB-2 


REPRODUCTIVE HISTORY {Can't.) 

Item #10. "Type of Delivery" 

OB-2 

l/59 

Make sure that the gravida understands the terms you use in asking this 

question. 

Choose the correct term and write the abbreviation in the box. Abbreviate 

vaginal as "VAG", Cesarean as "CES", Vertex as "VTX", Breech as "BR", 

Operative as "OP", and Spontaneous as "SPON". 

The term "Operative delivery" as commonly used includes procedures that 

the gravida will not necessarily regard as operative. To guarantee 

uniformity, ask the gravida "were forceps used.when this child was born?" 

If the answer is yes, write "OP," if no write "SPON," if unknown write 

"UNK". 

Item #11. "Birth \tleight" 

Record this to the nearest ounce. If there is doubt about the exact weight, 

select ~he most probable weight and record it in pounds and ounces. 

Item #12. "Place of Birth" 

If at home, write "home". If in a hospital, name the hospitaL In all cases 

give the location - city or town and when necessary, state or country. 

Item #13. "Abnormalities at Birth" 

For pregnancies of less than 20 weeks gestation write "NA" in this space 

and go on to item #14. 

For all other children live or stillborn, ask the patient if there was any 

thing about the child that "wasn't formed right", and record her answer. 

For a live born child, ask if it had any difriculty in breathing, need for 

blood transfusion, etc. 

Item #14. "Name of Father" 

Record the father's (not necessarily the husband's) first name. 

Item #15. "Race of Father" 

Record as W, N, OR, PR, or "Other" 1 

as on .t\R-1. 

Item #16. "Date of Death" 

If the child was stillborn, or i~ the pregnancy terminated with a miscarriage, 

or if the child is now alive, write "NA" in the box. 

If the child was born alive but is now dead, record the exact date if this is 

known. 

Item #17. "Place of Death" 

Write "NA" in this box if it appears ror item #16. Otherwise, record the city 

and if necessary, state in which the death occurred. 

February 1959 


II.A.34 

OB-2 


REPRODUCTIVE HISTORY (Con•t.) C3-2 

l/59 

Item #18, "Cause of Death 11 

If "NA 11 appears in items #16 and #17 1 write it here also. Otherwise, ask ~he 

gravida what caused the child's death. If it was an accident of any sort, 

record "accident 11 • For other cases attempt to determine the specific cause. 

February 1959 


II.A.35 

OB-2 


.-...a..JOo... a 

,.... 

..: 


(t,,."';,..,.,) .4• 'fh· c.AA' 1; 

/-~/~. 

'-~·N D I OATil c-..D..Yr) l 

- 

RICORD PRI!GNAMCII!S IN CHRONOLOGICAL ORD.R 

PREGNANCY ORDER: I 2 3 4 s 

I. DATE OF TERMINATION 

OF PREGNANCY 

2. GESTATION (W••i&s) 

3. LIVEBORN (Yu '"No) 

4. D & C AFTER 

MISCARRIAGE 

5. SEX (M or F) 

6. NAME OF CHILD 

COMPLICATIONS OF 

7. PREGNANCY 

8. INDUCED LABOR 

(Y•• or No) 

c.-- 

9. DURATION OF LABOR 

(How•) 

Vaginal 

TYPE 

10. 

DELIVERY OF Snech ·-• 

fc~·- 

II. BIRTH WEIGHT .. 

(U.•• - 0..) 

12. PLACI! OF BIRTH IIKOIID CITY AND MAMa 0, HOSPITAL IN SPACI! II!LOW 

ll. !-rg~~~LITIES 

. ' 

14. NAME OF FATHER ~· 

15. RACE OF FATHER 

DATE OF DEATH 

16. .. 

OF CHILD 

17. PLACE OF DEATH 

18. CAUSE OF DEATH 

19. 

INFORMANT (lrhrw •.....:• 

;. o-pi,., ,.cora. 

i..lictU• lty .,.J 

12. PLACE OF BIRTH (R«or;! Cux llllll N-o( ,.pil!ll 

I. ,I 

2. 

3. 

4. 

5. 

IF MORE THAN S PREGNANCIES, USE ANOTH!tt FORM. 

o._. o1 H-'"'· e•-•- _. w.,,... 

Public Heelth Sw.ice 

II.A.36 

OB-2 


OB-3 

History Since Last Menstrual Period 

Form OB-3 was used to provide details about early pregnancy. Data were 

obtained through interviews with the gravida. First implemented in January 

1959, the form was revised once in November of that year. The order of item 

numbers was changed and some of the wording was altered during revision. Only 

one card (number 0303) was used to record the 56,771 records obtained during 

the study (Table OB-3.1}. Titles and items on the card refer to the last 

revision. For cards coded from the form dated January 1959, item numbers may 

differ slightly. 

TABLE OB-3.1 




OB-3: History Since Last Menstrual 

Period 

0303 

0 8,851 

1 47,920 

56,771 



II.A.37 

OB-3

II.A.38 

OB-3 



H 

H 

.;.. 

w 

\0 

~ 

w 

nata Items Ref~rPnci~q Form Oli•l, Hlstorv Since l.ast Nel"'strual Perf o1 

OAr• 

TTF"M 

ITE14 :llf CARll 

TO FJPI4 NIIM FR014 TD OA rA T fF:I4 NAI4F: 

22l ••••••• 0103 1 5 carrt number (s~qu~nce, torn tvoe, form nu~b~r. revision numb~r) 

2'4 ••••••• 0301 I; 14 NTNilB cftse numb~r 

2?S ••• OR•1 4 0'303 1'5 16 For~ ~a-3 d~te Cno) 

2?6 ••• 0R•'J 4 0301 17 t8 Form 08•3 d~te (jayl 

217 ••• 08•3 4 0301 1q 20 For~ ns-3 d~t~ fyr) 

2?H ••• OR·3 6 0103 21 21 Sfc~ fn any wav 

219 ••• OR•'J 7 010'3 2?. ?2 He~~ache 

210 ••• 0A•l 8 0303 21 73 Vtsual ~isturhanc~ 

211 ••• oR-3 9 0101 24 ?4 wea~ness: numhness: dtz~iness 

212 ••• OR•3 10 

0101 2~ ?5 Vonltlnq 

213 ••• 0R•3 11 

0301 2f; ?6 Paln, andomen, oelvts, ~ac~ 

214 ••• oR-1 1? 0303 27 ?7 Urt"arv urqency: 1vsurta 

215 ••• OR•] 13 

0301 2P 28 Olarrhea 

236 ••• 01\•3 14 

0303 2q ?9 Cnld: sore throat: cou~h 

2H ••• OR·3 15 0'301 30 30 Fever 

23B ••• OR•3 16 

0'303 31 31 Eye lnflammatlon 

219 ••• OR•] t 7 

0101 32 12 Rash: s~ln condftton 

240eoe0R•] 18 

0303 H 33 J~undtce 

241 ••• oA-J 1q 

0301 34 34 swollPn ~lands 

242 ••• 0R•] 20 

0303 3'5 35 Colrt sores 

24l ••• UR•3 21 030] 36 16 Bnlls: abcessPd teeth 

244 ••• 01~-1 22 0301 31 17 Earache 

24S ••• OR•3 23 0101 ]A 38 Swellfn~ of teet or le~s 

246 ••• 0R•3 24 030'3 3Q 19 Swellfnq ot han1s or f~ce 

247 ••• 01\•3 2o; 0301 41) 40 Va~ln~l bleedtno 

24B ••• OR•'J 26 0101 41 41 F~lnttnq 

249 ••• 0R•3 27 0301 4?. 42 Convulsions 

2'50 ••• 01\•1 28 0101 41 43 Accident; ootson: ln1urv 

2'51 ••• 0R•'J 29 0101 44 44 Oneratlon: sur~erv 

2'52 ••• 01\-3 30 0301 4'5 45 R~dt~tlon: x-r~v 

2'53 ••• 01\•l 31 0301 46 46 ~tr travel 

2'54 ••• oR-'3 n 0303 47 47 In1ection: vaccination 

25S, •• OR•'J 3'3 0101 48 48 InfPctinus 11sease at ho~~ 

2~6 ••• 0R•1 )4 0301 49 49 Pet tn hom~, sic~ 

2S7 ••• oA-1 3o; 0301 so ~o 

2o;H •• ,OR•1 )6 

0101 51 52 

wnr~s outsi1e ho~e 

2o;9 ••• 0R•1 37 

0101 51 ~3 

260 ••• 0R•1 39 

0301 54 54 

Intercourse frequ~ncy 

s~okinq hfstory, ever smo~ert 

s~o~lnq hlstorv, at l~ast 5 oacks 

2t;l.,.OR•3 H 0303 so; 56 ~moklnq htstorv, tot91 vears 

2fi2 ••• 0R•3 40 0101 57 ~8 S~o~inq hlstorv, ~1~ St8rtert 

263.,.oR-J 41 0]01 sq fiO Smo~lnq history, ~~e stooped 

264 ••• 0R•3 4?. 0101 61 f;2 smokll"'q history, lar~est rt~flY anount


nata Ite~s RPfPrenclnq fnr~ nB-3, HistorY ~ince ~ast ~PnStruat Perf~~ 

DATA 

Tr~!4 

ITEM JN CIIRO 

TO F'JIUI NIIM FROIC TI'J DA rA TTF.M IU14F.: 

2,;s ••• o~-1 4l 0101 61 64 Smo~inq history, nu~oPr s~~l 65 Phy~ici~n vfsftej 

2ft7 ••••••• 0303 66 ~0 BlanK 

49A5 •••• VAR 43 5? ~3 s~o~inq htstorv: cl :uret tes ol"r :H1y now, nu111ber 

49R7 •••• VAR 4 5'> ~6 Prenatal visits, tot a 1 nu'lloer 

49R8 •••• VA~ H 57 c;a smol • 

~ 

0 

@ 

I 

w

eoL"-aooa.a 

ACV. n-et 

• 

HISTORY SINCE LAST 

MENSTRUAL PERIOD 

(lnteme...rJ 

2. HISTORY TAKEN BY 3. 

I. PATtENT IDENTIFICATION 

•• DATE 

5. NEXT SCHEDULED VISIT 

I I I 

; 

I 

I 

I 

I I 

I I 

Mo. 

I 

D•l' 

I 

Y••r Mo. 

I 

Day I y ... 

•• 

CHECK 

APPROPRIATE 

COt..UMN 

NO YES 

0 1 

S. FELT SICK IN ANY WAY X X XX 

: 

7. HEADACHE 

8. VISUAL DISTURBANCE 

9, WEAKNESS, NUMBNESS, DIZZINESS 

10, VOMITING 

11. PAIN: ABDOMEN, PELVIS, BACK 

12. URINARY URGENCY, DYSURIA 

i 

13. DIARRHEA ' 

1•• COLO, SORE THROAT, COUGH 

1!, FEVER 

18. EYE INI"LAMMATION 

17. RASH OR SKIN TROUBLE 

18. JAUNDICE 

.7. LIST BY NUMBf:R AND DESCRIBE ANY CONDITION NOTED 

PRESENT AT LEFT WITH APPROXIMATE DATE OF ONSET, 

DURATION AND SEVERITY. 

11. SWOLLEN GLANDS 

20. COLO SORES 

21, BOILS OR ABSCESSED TEETH . 

22. EARACHE I 

23. SWELLING 01" I"EET OR LEGS i 

2., SWELLING 01" HANOI OR I" ACE 

ZS. VAGINAL BLEEDING 

Zl. I"AINTING 

27. CONVULSIONS 

28. ACCIDENT, POISON, INJURY 

21. OfOERATION 

30. RADIATION, X-RAY 

31. AIR TRAVEL 

32. INJECTION, VACCINATION 

33, INI"ECTIOUI DISEASE IN HOME 

3•• SICK PET IN HOME 

31. WORKS OUTSIDE HOME 

3~ INTERCOURSE FREQUENCY 

(Total nYDNr ot tlrnee ~ laat _.Ill) 

.. 

37. EVER SMOKED 38. SMOKED AT 31. TOTAL YEARS 

LEAST 5 PACKS SMOKED 

0YO:S QNo Qyu ONo 

' 

' 

.0. AGE STARTED • •• AGE STOPPED U. LARGEST 

REGULAR DAILY 

AMOUNT 

U. NO. 01" CIGARETTES SMOKED PER DAY NOW 

••· PHYSICIAN VISITED !Mual k c..uaolecO 0 NO 

• 

G. NAME 01" PHYSICIAN 

QYU 

I 

••• ADDRESS 

COL.LAaO.. ATIVIE JIIII:IEAJIICH (RII:V. ,..91 

~IEfUNATAL JIICS&AftCH 8JIIANCH, NINa•• NIH 

08-3 

81ETHIESOA 1., MO. 

II.A.41 

OB-3 



1-1 

1-1 

• 

15 

15 

16 

> • 

Form Ite~ numbPrs tin~Pd to nata Items on nB-3, Hl!torv Since r.ast MPnstrulll Perlo1 

ITEM 

OATA 

ON T rF~Iil CAHO 

FORM Ill Nlllil FROM TO DATA TIFM NAME 

4 226 ••• ne-l o3o3 17 18 Form oo-3 dAtP CdAVl 

4 225 ••• 08-3 0301 15 16 Form ne-3 date ('110) 

4 227 ••• os-3 oJoJ 19 20 Form OR-3 date cvr> 

4 4987 •••• VAR 5'5 56 Prenatal visits, total number 

6 22A ••• o8-3 o1o1 21 71 stele tn anv w11v 

7 ?.2q ••• 08•3 0303 27 22 He!!!dache 

R 230 ••• n8-3 0101 21 23 Visual disturbance 

9 231 •••08-3 0103 24 24 weaknf'ss: nu111t-oness; dlzf.iness 

to 232 ••• 08•3 0103 25 25 Vodtfnq 

10 

5t9CJ •••• VAR 107 1n1 

11 

233 ••• n8-3 olol 26 26 

t2 234 ••• 08•3 0101 27 27 Urinary urgencvr 1ysur1'1 

I) 235 ••• n8-3 0101 2R ?8 Diarrhea 

l4 236 ••• 08-3 0303 2q 29 COld; sore throau cough 

17 

~ 

!)..) 18 

@ 

I 

w 

237 ••• oa-3 

519A •••• VAR 

23A •••'l8•l 

23q ••• o8-3 

0101 30 

306 

0301 31 

0101 32 

0101 H 

309 

10 

306 

11 

32 

vo•ttfnq by tri•ester of report 

Pllin, abdoiiU!n, netvts, bolCI( 

f'ever 

r~ver 

bV trimester of 

Eve tnflaiiiM&tton 

Rash; slrin condition 

report 

33 

308 Jl'llundtce 

Jaundice by trimester of report 

240 ••• 08•3 

18 

5200 •••• VAR 

19 241 ••• 08•3 0303 34 14 swollen Qlands 

20 242 ••• 08-3 0301 35 35 Cold sores 

21 ?41 ••• OH•3 0103 36 36 Boil SJ l!!lbcessPd teeth 

22 244 ••• n8-3 o1o1 37 H t::arl!!lche 

23 

245 ••• 08-l 0301 39 lll swellfnq of fPet or 

24 

520t •••• VAR 3oq 309 t::dema hl!!lnds or face leQs 

bV tri11ester of report 

24 246 ••• 08•3 0303 39 39 swellfnq of hands or face 

25 5197 •••• VAR 305 305 IHemorrhaqeJ; vaginl!!ll bleP11nq bV trimest@r of reoort 

25 247 ••• oe-3 0101 40 40 V;;tgtn"'l bleedinq 

26 248 ••• 08•3 0303 41 41 Fllintina 

27 249 ••• oa-3 0101 41. 42 Convulsions 

27 5202 •••• VAR 310 310 Convulsions by trl~ester of rPport 

28 250 ••• 08•3 0301 43 43 Accident: poison; injury 

29 251 ••• 08•3 0303 44 44 OPeration: surgerv 

30 

31 

32 

252 ••• 08-3 

253 ••• nl:l-3 

254 ••• 08-l 

0301 

0101 

0303 

4'5 

4fi 

47 

45 

46 

47 

Rattlation: 

Air travel 

In1Pction: 

x-rav 

vaccinAtion 

33 2ss ••• os-1 0101 4R 48 Infectious ~isease at home 

34 256 ••• ns-3 o3o3 4'l 49 Pet in home, si~l< 

35 257 ••• n8-3 0101 so 50 wor~s outsi~e home 

16 258 ••• 08-3 0301 51 ~2 Inter~ourse fre~uencv 

n 259 ••• nB-3 OJo3 51 ~l Smo~inQ htstorv, ever smolceri


F'OrAI Item 

38 

l9 

l9 

40 

41 

42 

43 

4J 

44 

I TEN 

ON 

FOR Iii 

1'4umbers linked 

OUA 

IrF.14 

10 

2&o ••• ns-3 

26i ••• 08•3 

49B8 •••• VAR 

2&2 ••• 08•3 

2&3 ••• 08•3 

2&4 ••• ns-3 

2&'5 ••• 08•3 

4911S •••• VAR 

266 ••• na-3 

to ~ata 

Items on 

CARO 

Nlll4 FRO Iii rn 

o3o3 54 54 

0303 5'5 '56 

57 ~8 

0303 57 58 

0303 59 60 

0101 61 62 

0303 61 64 

5? 53 

o3o1 6'5 65 

OB-3, Historv 

Since Last liiP.nstrul'll Periot1 

DArA JfF.M NAME 

srno~inQ history, !!It least S oacks 

smo~ing history, tot~ 1 veers 

smoking history; Vel!lrs smolee::l at reqistration 

Smoking history, I!ICJI! started 

Srno~lng history, I!I:JI! stopped 

Srnokln:, history, ll!lrQest daJlv l!lmount 

smoking history, number smoket1 now 

Smoking nfstory; ciqarettes Pf'r ::lay now, number 

PhysiciAn visited 

H 

H 

),. 

. 

~ 

w 

~

DEP'INITION OF CODES 

HISTORY SINCE LAST MENSTRUAL PERIOD 

FORM OB-3 

CARD 0303 

FIELD 

1. 

2. 

3· 

4. 

5· 

6. 

7 

8. 

Card Number 

Code: 0 

Form Number 

Code: 303 

Revision Number * 

Code: 0 - Form Dated: 1/59 

1 - Form Dated: Rev. 11/59 

NINDB Number 

Nine-digit number for Patient Identification 


Date Form Ccmpl.eted 

Item 4 

Six-digit code for month (cola. 15-16), 

day (cola. lT-18) and year (cola. 19-20) 



Felt Sick in A& Way 

Item 6 

Code: 0 -No 

1 - Yea 

7 - Bot reported on Rev. "1" 

8 - Questionable 

9 -Unknown 

Headache 

Item 7 

Code: 0 -No 

1 - Yes 

8 - Questionable 

9 - Unknown 

Visual Distu:bance 

Item 8 


CARD 

COLUMN 

1 

2-4 

5 

6-14 

15-20 

21 

22 

23 

* Item numbers refer to Form dated ll/59 


II.A.44 

OB-3

DEFINITION OF CODES (Continued) FORM OB-3 

Card 0303 

FIELD 

CARD 

- COLUMN 

20. Cold Sores 

Item 20 


21.. Boils or Abscessed Teeth 36 

Item 2l 

Code: Same as in Field 7 

22. Earache 37 

Item 22 


23· Swelli!!§ of Feet or Less 38 

Item 23 


24. Swelli~ of Hands or Face 39 

Item 2 


25. Vaginal Bleeding 4o 

Item 25 


26. Fainti~ 

27· 

Item 2 


Convulsions 

Item 27 


28. Accident z Poison z I~ury 43 

Item 28 


29. Operation 44 

Item 29 


30. Radiation, X-Ray 45 

Item 30 


31.. Air Travel 

Item 3l 


35 

41 

42 

46 

II.A.45 

OB-3 



Card 0303 

FIELD 

CARD 

COLUMN 

9· Weakness, Numbness, Dizziness 

Item 9 


10. Vomitin5 

Item 10 


11. Pain: Abdcimen z Pelvis, Back 

Item ll 


24 

25 

26 

12. Urinary Urgency, Dysuria 

Item 12 


13. Diarrhea 

Item 13 


14. Cold, Sore Throat, Cough 

Item 14 


15. Fever 

Item 15 


16. . Eye In:f'lammation 

Item 16 


17. Rash or Skin Trouble 

Item 17 


18. Jaundice 

Item 18 


28 

29 

30 

31 

32 

33 

19. Swollen Glands 

Item 19 

Code: Same as in Fie1d 7 


II.A.46 

OB-3

DEFJNITION OF CODES (Continued) FORM C3-3 

Card 0303 

FIELD 

32. 

33· 

34. 

35· 

Injection, Vaccination 

Item 32 


Infectious Disease in Home 

Item 33 

Code: Se..me as in Field 7 

Sick Pet in Home 

Item 34 


Works Outside Home 

Item 35 


Intercourse Freauency 

Item 36 

Code for Rev. "O": 

00 - N'one 

01-98 - Number of times per week as given 

99 - Unknown 

Code for Rev. "1": 

00 - None 

01-78 - Number of times per month as given 

79 - 79 or more 

8o.- Les~ than once·a-morith - 

88-- Frequently, innumerable 

. 99 - Unbiown 

CARD 

COI.UMIT 

47 

48 

50 

51-52 

Note: Rev. 1 - Use codes 89-98 as 79 or more in tabulations. 

Frequencies fo·r- "Ou a.J?-d "1"' revi-sion cannot .?~. ~onil;>ined. 

37. 

38. 

Ever Smoked 53 

Item 37 

Code: 0 - No 

1- Yes 

9 -Unknown 

Smoked at Least 5 Packs 54 

Item 38 

Code: 0 - No, never smoked 

1 - Yes 

9 -Unknown 

II.A.47 

OB-3 


DEF:rniTION OF CODES (Continued) 

FIELD 

39· Total Years Smoked 

Item 39 

Code: 

00 - Never smoked 

01-50 - As given 

8o - Smoked less than 6 months 

88 - Duration unknown (started and stopped 

in same year and smoked less than 

5 packs) 

99 -Unknown 

4o. Age Started Smoking 

Item 4o 

Code: 00 - Never smoked 


99 - Unknown 

41. Age Stowed. 

Item 41 

Code: 

00 - Never smoked 


88 - Still smoking 

99 -Unknown 

42. Largest Regular Dail,y .AIDmt 

Item 42 

Code: 

00 - Never smoked, none 

01-60 - Number ot cigarettes smoked 

per day' as given 

61 - 61 cigarettes or more per day 

70 - Regular IIIIDker but less than 1 

cigarette per day' 

8o - Irregular smoker, less than 4 

cigarettes per month 

99 -Unknown 

Number Per Day Now 

Item 43 


FORM OB-3 

Card 0303 

CARD 

COWMN 

55-56 

57-58 

59-60 

61-62 

63-64 

44. Physician Visited 

Item 44 

Code: 0 - No 

1 - Yes 

9 -Unknown 


II.A.48 

OB-3

"' 

1: : 

~~ 

:; "':J. 

!~ 

~ 

~ 

:~ ~ ; : 

1: ; 

I~ ; 

1:2 

i~ f"''QI'I 11J1)1QWS 113"-""' ; 

'tfr I; ../.! ·v-v -f{71e1~ -.·- •....,. ; 

\0:7" 

2~ 

i; Z9/:l ~ 

·~ -o 

~ .... A=> ' _..'.. ~ill:l ~ 

o+ I' ~~ 

S~/(. 7fU.OJ. ~ 

'r ' 

I~ f/)";1! 

.n: s )/'""" , ~~ . ..u:l ., 

fLrrr -:;: 

" 1:;: ~:1· ........ .Ia 

' 

~ 

; 

~ 

~fi~ ~fl r-N 2 o 9 

f(il 

_,_. q-~ rs ~':I #Of/~ 

!II"" 

lffl 

s~-s 

·~Jt'" 

'"'"' 

:r ''"'ll 

,.,., 

•.r 

C\ 

IJ"\ 

'-... 

~ 

~ 

7flf7 '" 

~ 

IX: 

.. 

'i 

!! +> 

-; 

a:S 

'0 

-~ 

~ 

,.,.. 

; 0 

0 

:: 

= +> 

!! lot 

ilJ 

Oo 

.. 

~ 

,.,.. 

... 

OJ 

... 

~ 

ilJ 

ilJ 

~ 

~ 

- ~ 

S! 

..~ 

ilJ 

+> 

1-1 

j 

* 

II.A.49 

OB-3 


HISTORY SINCE LAST MENSTRUAL PERIOD 

(For Form OB-3, Revised 11-59) 


The period of early pregnancy is one of great importance in determining the 

fate of the child. Infectious disease, radiation, and conditions that interfere 

with maternal oxygenation such as anesthesia, shock and poisoning may 

damage the fetus. Recent studies indicate that mere exposure to certain 

diseases of humans pr animals may also be significant, even though the mother 

has no symptoms of illness herself. 

It is important, therefore, to discover as much about the period of early 

pregnancy as is possible.. The information that you obtain on this form 

should be as complete and accurate as the gravida's memory and your skill as 

an interviewer can make it. 

Dates of events in early pregnancy are especially meaningful, since these can 

be correlated with certain types of damage to the developing child. You 

should make every attempt to fix the dates of symptoms and unusual events 

with accuracy. For every symptom that the gravida reports, give the date of 

onset, if it is known. U the gravida is in doubt, give the earliest and 

latest dates on which it is probable that the onset occurred. Thus, your 

comments might be: 

15. Fever. Onset 5-14-59. Duration 2 days. 

"not high." With cough. 

Patient states 

or 

15. Fever. 

days. 

Onset between 5-12 and 5-16-59. 

Morning and evening only. 

Duration 2 or 3 

Since all times of events will be treated as dates, you should not report 

symptom as occurring in the "first week of March" or "4th week of pregnancy." 

Instead, consult a calendar and record the dates as "Between 3-01-59 and 

3-07-59," etc. 

This form is substantially the same as OB-8 (Repeat Prenatal History). 

General comments on OB-3 a~ply also to OB-8. 

The form has two purposes: To serve as a primary source of coded data and 

to furnish the obstetrician with the information that will help him 

evaluate the patient's medical experience. Therefore, you should make every 

attempt to include all details that may be important to the physician, yet at 

the same time follow closely the instructions regarding the way in which 

data are to be recorded. 

Identify yourself by placing your first and last name in the box headed 

"This History Taken By." Record the date of this interview and of the next 

scheduled visit. Throughout, all dates must be written using numbers in the 

order month-day-year, (as for example 10-21-59 or 4-07-60). 

Every item from 6 to 35 must be checked either "yes" or "no". Each item 

that is checked "yes" shol1ld have a description on the right hand side of 

the page. Each of these descriptions should be preceded by the item number 

to which it applies. Be sure to date the onset as accurately as possible. 


II.A.SO 

February 1959 


OB-3

HISTORY SINCE LAST 1-ENSTRUAL PERIOD (Con't.) 

Item #6 "Felt Sick in .t..:ny Way" 

This is a general probing question which will elicit symptoms of illness 

that have not been anticipated in items 7 through 27. If the patient reports 

that she has felt sick, place a check (v') in the ''Yes" column and have her 

describe her symptoms in detail. If she mentions any symptom listed, place 

a check in the "yes" column opposite that symptom. If she mentions other 

symptoms, list them on the right hand side of the paper. 

Continue down the list asking about each symptom or event that you have not 

checked in the "yes" column. 

If the patient reports that she has not felt sick, place a check in the 

"no" column, and continue down the list asking about each symptom in turn. 

Item #15 "Fever" 

If the patient states that she had fever, with or without other symptoms, 

inquire carefully into this. Fix the dates of onset and duration as 

closely as y~u can. Record the maximum temperature reached, if the patient 

knows this, or describe the fever as "rr.ild", "moderate" or "high". Note 

any unusual feature, such as intermittent fever. 

Item #23 "Swelling of Feet or Legs" 

Item #24 "Swelling of Hands or Face" 

Swelling or edema is an early sign of possible pregnancy complication. If 

the patient gives a positive history, note the extent and severity as well 

as the date of onset, whether still present, etc. 

Item #25 "Vaeinal Bleeding" 

If the patient has had any vaginal bleeding since the last normal menstrual 

period (this is the date that appears on form AR-1 and in Item #11 on OB-4) 

have her describe it fully. In addition to the comment required for all 

positive items, record bleeding as "show" or "free". "Show" is slight and 

intermittent bleeding, also known as "Spotting", and should require no more 

than one pad per day. "Free" bleeding is any amount in excess of this, or 

any continuous bleeding. "Free" bleeding is not necessarily profuse. 

Items #26 and #27 "Fainting" and "Convulsions" 

If present, inquire also about associated symptoms and the duration of the 

attack. Attempt to find out if the attack br·ought about any physical injury, 

such as a fall or blow on the head. If so, check "yes" for the next item, 

#28. 

Item #28 

"Accident. Poison. Injury" 

If an accident, note the type of accident as well as the kind of injuries 

that resulted. Give all possible detail that will help to establish the 

importance of the accident as far as the pregnancy is concerned. 

Poisons include such toxic substances as carbon tetrachloride, dusts, and 

fumes, as well as the more usual ingested substances. Describe the symptoms 


II.A.Sl 

February 1959 


OB-3

HISTORY SINCE LAST MENSTRUAL PERIOD {Con't.) 

carefully. 

If the patient has suffered an injury, give the site and extent. Note any 

complications of the healing process. 

Item #29 "Operation" 

Attempt to provide answers to the following questions, in addition to date: 

1. Hospital in which performed (if not in hospital, so note). 

2. What was the condition necessitating the operation? 

J. What operative procedure was done? 

4· 'Was anesthesia given? If so, was -it local or general? 

Item #30 "Radiation. X-R§y 11 

If an examination, note the type of examination and attempt to determine 

why it was done. If the patient has had therapeutic x-ray, record the site 

and reason if this can be determined. Also note the hospital in which such 

treatment was received or the physician who gave it (see Item #44). 

Item #31 "Air Travel" 

Do not record any air travel that occurred prior to the last normal menstrual 

period. If the patient has traveled by air since that time, give the dates 

of all flights and the points of departure and destinations. 

Item #32 "Injection. vaccination" 

Record the date, the suhatance (if known) and the reason for the injection 

or vaccination as best determined by you. 

Item #33 "Infectious Disease in lfpme 11 

·.This item .attempts to establish any close contact that the gravida may have 

had with acute infectioue diseases, particularly those of virus etiology. 

Inquire about any illneu of anyone in the gravida's household. Attempt to 

answer the following q~tians: 

1. What is the relationship of persons ill? 

2. 'Was a doctor consulted? 

J. If he made a diagnosis, what was it? Otherwise, what does the gravida 

think it was? 

4· 'What were the principal symptoms? 

5. 'What was the date of onset and duration for each person ill? 

Item #34 "Sick Pet in Home" 

Exposure to diseases of animals may be of significance in the etiology of 

pregnancy wastage. It is desirable to have a record of all close contact 

by the gravida with warm-blooded animals (i.e. birds and mammals). Do not 


II.A.52 

February 1959 


OB-3

HISTORY SINCE ~T MENSTRQ~ P~RIOD 

{Con't.) 

record contact with reptiles, amphibians, or fish. 

At this interview, list all types of warm-blooded animals that are kept in 

the gravida's home as pets, or on the premises as farm animals. 

Ask if any household pet has shown any signs of illness since the gravida's 

last menstrual period. If so, check "yes" and record the symptoms, date of 

onset and duration, as you would for a member of the family. If no pet has 

been sick, check "no". 

Item #35 "Works Outside Horne" 

If the patient has done any work other than at home, whether paid or 

voluntary, check "yes". Attempt to answer the following questions: 

1. What is the industry? 

2. What is the gravida's specific job? 

J. Are there any special occuptional hazards, such as fumes, noise, 

infection? (Do not record hazards that may only cause accidents). 

4· If the gravida was not working when she became pregnant, when did she 

start? 

5. If she is not now working, when did she stop? 

Item #36 "Intercourse Frequency" 

Ask the gravida how many times during the last month she (at the time of 

this interview) has had intercourse and record this number. 

Items #37 through #43 "Smoking History" 

Ask the patient if she has ever smoked. If she has not, check "no" in 

item #37 and place a 0 {zero) in item #43· Items #38 through #42 need not 

be filled in. 

• 

If the gravida has ever smoked, check "yes" in item #37 and ask all the 

questions on smoking. 

Item #38 should be checked "yes" if the gravida has during her lifetime 

smoked a total of five packs of cigarettes. 

Items #44 and #45 "Physician Visited" 

If the gravida has seen a physician since her last menstrual period, the 

name and address s~ould be given. Try to identify each physician so that 

he may be contacted by letter or telephone. 

If the patient has attended a clinic, the name and address of the clinic 

is sufficient. 

February 1959 



II.A.53 

OB-3

•H•MO••• .... HISTORY SINCE LAST 

MENSTRUAL PERIOD 

(lllt.rvi•w.,.) 

Al•f"...... &-IL..J 1/-5'1 ~~ 

HISTORY TAKEN BY 

~ 

06-3 

DATE (Mo-D"Y"YrJ 

IDATE NEXT $CHEDUI.ID VISIT 

1. FELT SICK IN ANY WAY 

2. HEADACHE 

3- VISUAL DISTURBANCE 

~. WEAKNESS NUMBNESS DIZZINESS 

5. NAUSEA OR VOMITING 

6. PAIN: ABDOMEN, PELVIS, SJ

OB-4 

Gynecological History 

Form OB-4 was used to record information about the gravida's menstrual 

history, including unusual features, pain and sterility. The form was first 

implemented in January 1959; revisions to the form occurred once in November 

1959. Revision affected the form by altering itemization only. 

TABLE OB-4.1 


Card Rev. Number 

Card Name Number No. Records 

OB-4: Gynecological History 0304 1 56,798 


II.A.55 

OB-4 


II.A.56 

OB-4 



. )II 

1-1 

1-1 

~ 

~ 

nata Ite~s RPferencin~ for~ 0R•4, ~ynecoloqical History 

011!11 TTF:14 

ITEM JN CIIRn 

TO F'JP14 Nil~ fROI4 TO DllrA TlF:14 NAI4E 

2ft& ••••••• 

0104 1 5 car~ numbPr (sequence, for~ tVoP, for~ numoer, revision nu~berl 

21\9 ••••••• 

0104 6 14 NTN~B C8SP number 

27o ••• oR-4 4 0304 1~ 16 Form 08•4 d~tP (~O) 

271 ••• 01\-~ 4 0304 17 18 rnrm OB-4 datP C1ay) 

272 ••• oR-4 4 0)04 1Q ~0 Form OB•4 d~tP (yr) 

273 ••• 0R·4 b 0104 21 22 ~enarche; aqe at onset of ~enstruatfon 

274 ••• oR-4 1 0104 21 ?4 14enstru~l pertoi duration 

275 ••• 0R•4 8 0304 25 ?6 Menstru~l p~rtod usu~l tnterval, mlni~u• 

276 ••• 0R•4 8 ()304 27 ?8 MPnstrual oPrtod usual tnterv8l, maximum 

277 ••• ofl-4 9 0304 2Q ?9 MenstruAl period, amount of flow 

278 ••• oR-4 10 

0~04 30 10 Menstrual htstory, unusual features 

279 ••• uR-4 11 

0104 31 11 ~Pnstrual history; L14P, tyoe of entry 

2AO ••• OR•4 11 

0104 3?. 13 14enstru~l hfstory; LMP, ttrst 1ay (~o) 

2Rl ••• OR•4 11 

0104 34 35 MPnstru8l history: LMP, first 1ay (day) 

2A2ooo0R•4 11 

0104 36 37 Menstrual history; LMP, first day (yr> 

2Al ••• OR·4 12 

0304 3R 39 Menstrual htstory; PMP, first 1ay (mo) 

2R4 ••• 0R•4 12 

0304 4n ~~ Menstru~l history; P14P, first day (1av> 

2A5 ••• 0R•4 12 

0104 4? 43 Menstrual htstory: P14P, ftrst day


Data Ite~s RPfPrP.nctn~ For~ na-4, ~vnecolo~lcal H1stnrv 

DATA 

Trf::lll 

ITE:14 J"4 CAR!"' 

TO FJRIC Nlllll FROio! rn ()ArA trF.H NUF: 

'i20S •••• VAR Jt4 lt4 M~nstrural cvclP, unusu~l lntPrV!l 

'59?0 •••• VAR 0 ttot 1102 GPstation at 1ellverv (wKsl 

1-1 

• 

>. 

1-1 

U1 

Q) 

~ 

.co.

COL.,.-aaaa-4 

RIEV. tt-11 

• 

GYNECOLOGICAL HISTORY 

I. PATIENT IDENTII"ICATION 

Z. HISTORY TAKEN DY 

3, TIT L.E OR POSIT ION ··DATE 

I 

s. MENSTRUAL HISTORY 

Mo. 

v... 

IS. FERTILITY 

5. AGE AT ONSET 

16. HAVE YOU BEEN TRYING TO BECOME PREGNANT? 

7. DURATION 

I. USUAL. INTERVAL. 

I. AMOUNT AS DESCRIBED BY GRAVIDA 

OHtAV'I' 

I 

17. Ill' YES, HOW LONG DID IT TAKE YOU TO 

BECOME PREGNANTT 

OMt:DIUM 

• 

O•lnT 

• 

10. UNUSUAL. I"EATURES 01" MENSTRUAl. PERIOD 

0•••• 

Q 

Ona(Deocrlh) 

I 

__MONTHS 

18. IF NO, DO YOU USUAI.I.Y USE A CDNTRACEPTIVET 

0HO 

Q 

Ons 

I 

II. WERE YOU USING A CONTRACEPTIVE AT THE 

TIME YOU BECAME PREGNANT? 

ONo 

0 

Ons 

1 

ZO. Ill' YES, WHAT CONTRACEPTIVE WIERE YOU 

USINGT (Clloclr ell eppllceble) 

OotAIIMitAeM 

I 

0• ·~··" 

II. I"IRST DAY 01" I.AST NORMAL. MENSTRUAL. PERIOD 

12. I"IRST DAY 01" PREVIOUS MENSTRUAL. PERIOD 

0 v•••••11. .u.... o.rTOIIT 

• 

0 COI1'U. IIIITIIIUtU•Tu• (lrlehd.--1) 

I 

0oTN.. (DeeMh) 

I 

13. EXPECTED DATE 011' CONII'INEMENT 

1•• DYSMENORRHEA 

0 MONK (II no dlecomlort notHJ 

a 

0 •l.leMT (11 dleCODtfort noted but no mHicatlon 

1 fa requiNCO 

D MODIIRATI: at dlecomloft ,..,,,.. m.dlcatlan but 

a p.tlent oew~tlnuee ...ula ueual actffttlee) 

Zl. STERII.ITY INVESTIGATION 

0•••• 

Q 

Ona(DNcrlh) 

I 

0 8&VCR& (It ,_,..,, llae to be In bed or..,.,. 

a lraat 'alnA.d emplo,...nt for ane da,.) 

COLLA80JitATIVIE R ..SIEARCH 

(RCV. U.aa» 

PIE ..INATAL R&IIIARCH aRANCH. NINO., NIH 

BCTHEIOA U, MCI• 

08-4 

II.A.59 

OB-4 



H 

H 

>• 

0\ 

0 

@ 

I 

ol=>o 

For~ Item ~umbers linked to nata Items on 08•4, Gynecoloqical History 

ITEM 

OUA 

ON HEM CARD 

FORM 10 NUM FROM TO o~u JTF14 Nl14t 

520"i •••• VAR )14 314 M~nstrura1 cycle, unusu~l tnt~rval 

0 5CJ20 •••• VIIR 1101 1102 G~station at delivery (wks) 

4 

271 ••• 08•4 0304 17 18 For~ 08•4 date 

4 

no ••. ns-4 o1o4 1'i 16 for~ 08•4 date (dey) 

(~o) 

4 212 ••• oe-4 0304 1CJ 20 for~ OB-4 d~te Cyr) 

211 ••• n8-4 01o4 21 22 Menarche: aoe at onset of ~enstruatfon 

6 " 

51.04 •••• VAR ]12 313 Menarche: aqe at onset of ~enstruatlon CyrsJ 

7 274 ••• 08•4 0104 23 24 Menstrual p~riod duration 

A 276 ••• 08•4 0104 27 28 Menstrual period usual Interval, maximum 

A 275 •••08•4 0104 25 26 Menstrual perto~ usual interval, ~ini•um 

9 277 ••• 08•4 0104 29 29 Menstru~l period, a•onnt Of flow 

to 2711 ••• 08-4 0304 30 10 Menstrual hfstory, unusual fe~tures 

tl 281 ••• 08•4 0104 34 15 Menstrual hfstory: L~P, first day (~ay) 

11 280 ••• 08-4 0304 32 13 M~nstrual history: L~P, ffrst d~y (~ol 

t1 

28?. ••• 08•4 0304 36 17 MPnstru~l history: 

11 

?.7CJ ••• ns-4 H04 31 11 MPnstru~l history: LMP, 

LMP, first d~y Cvr> 

tyoP of entry 

tl 

49RCJ •••• VAR 

SCJ 64 Menstrual oP.rio~: L~P, first ~av (mo/day/yrl 

'2 

284 ••• na-4 0104 40 41 Menstru~l hfstorv: PMP, ffrst day C~ay) 

12 

281 ••• 08•4 0)04 JA Jq Menstru~l history: PMP, first ~~Y (mol 

12 

7.8.....08•4 0104 4? 43 M~nstrual htstoryr PNP, first day •••"'8•4 0304 44 44 Menstrual history: PMP, tyoe of entry 

I 2 4990 •••• V11R 6"i 70 Menstru~l pPrto~: PMP, first dav Cmolday/yr> 

14 287 •••013-4 0104 4"i ~5 ovsmenorrhe~ 

t4 520~ •••• VAR 111 311 ovs~e~orrhe~ 

1& 28A ••• D8•4 0104 4fi 46 Fertility, PatiPnt trytnQ to become preqnant 

17 4CJ91 •••• VAR 71 72 Fertility, len~th of time to beco~e oreqnant 

17 2BCJ ••• ns-4 o1o4 47 48 Fertility, months to hecome oreqnant 

tB 290 ••• 08•4 0304 40 49 fertility: ~ontraceotlv~ use, usu8l 

19 

?91 ••• 08•4 0)04 50 ~0 Fertility: ~ontraceotlve use at conception 

20 

?96•••08•4 

0104 so; o;s F~rtility: contracePtive type used. coitus tnterruotus 

?0 293 ••• 08•4 0)04 52 ~2 Fertility: contraceotfve tyoe U5ed, condom 

20 292 ••• 08•4 0104 51 ~1 Fertility: contraceptive type use~, diaphragm 

?0 ?97••• 08-4 0304 56 ~6 fPrtilitv: contraceotive tvoe use~. douche 

20 Joo ••• o8-4 o3o4 so 59 Fertility: contracePtive tvoe used, intrauterine rtn~ 

20 

294 ••• 08-4 0104 5] 53 F~rtility; contraceptive type used, jelly 

?0 

29o ••• DB•4 0)04 58 58 F~rtillty; contracePtive tyoe used, oral contraceptives 

20 

301 ••• 08•4 0304 bO 60 Fertility: contraceotlve tvpe used, other contraceptives 

20 29A ••• 08•4 0304 57 57 Fertility: contraceottve type used, rhythm 

?0 29'i ••• 08•4 0304 54 54 FPrtility: contraceottve tyoe userl, V8gtn~l suppository 

21 302 ••• 08•4 0304 61 61 Fertility; sterfltty tnvPsttqatfon 

21 4Q9? •••• VAR 73 73 Sterility tnvestiqation


GYNECOLOGICAL HISTORY 

FORM OB-4 

CARD 03o41 

FIELD 

1. 

Card Number 

Code: 0 

CARD 

COIDMN 

1 

2. 

3· 

4. 

5 

6. 

7. 

Form Number 2-4 

Code: 364 

Revision Number* 5 

Code: 1 - Form Dated: 1/59 or Rev. ll/59 

NINDB Number 6-14 



Date Form Completed 15-20 

Item 4 

Su-digit code for month (cola. 15-16), 

day (cola. 17-18) and year (cola. 19-20) 


99 - Month, day a.rJd/or year unknown 

Age At Onset 21-22 

Item 6 

Code: **00 - Never menstruated 

o8-25 - As given 

99 -Unknown 

**.Add.itio~ codes reviewed and approved: 04-o7, 26 

Duration of Menses 23-24 

Item 7 

Two-digit code for IDwest (col. 23) and 

Highest (col. 24) 

Code for es:clt coll.u!m.: 

o - N..rer metlS"!;ruat·aa· 

1-7 - Number -Q.~·day& as gives 

8 - 8 0!1:"· more -«ays, irregular 

9 - Unknown 

l'rot:~ 

00 - Never menstruated; 89 - Irregular; 99 - Unknown 

* Item numbers refer to Form Dated 11/59 


II.A.61 

OB-4

DEFINITION OF CODES (Continued) 

FORM OB-4 

Card 03041 

FIELD 

CARD 

COWMN 

8. Usua1 Interval 25-28 

Item 8 

Four-digit code ~or 

Lowest (eels. 25-26) and 

Highest (eels. 27-28) 

Code for each colUlllD.: 

00 - Never menstruated 

01-86 - Number o~ days as given 

87 - 87 days or more 

88 - Irregular 

99 -Unknown 

9. .A..mount o~ Flow 29 

Item 9 

Code: l - Heavy 

2 - Medium 

3 - Light 

8 - Irregular 

9 -Unknown 

10. Unusual Features 30 

Item 10 

Code: 0 - None 

l - ~-fore than one period a month 

2 - Skipped or IDissed one or more 

menstrual periods regularly 

3 - Coribination o~ codes l and 2 

4 - Irregular 

5 - Combination o~ codes l and 4 

6 - Combination o~ codes 2 and 4 

7 - Amenorrhea 

8 - Spotting or staining between 

menstrual periods 

9 -Unknown 

11. Type o~ Entry: IMP 31 

Code: 0 - One speci~ic day reported for n~ 

l - Day o~ LMP reported as a range o~ 

7 days or less 

2 - Day o~ LMP reported as a range o~ 

8 or more days 

3 - Any portion o~ or entire date ~uestioned 

4 - Two LMP dates reported by gravida 

5 - Two IMP dates reported - one by gravida 

and one by hospital editor 

6 - Non-numericaL entries 

7 - Termination of last 

pregnancy 

9 -Unknown 


II.A.62 

OB-4


FIELD 

- 

12. IMP, First Day 

Item 11 

Six-digit code for Month (cols. 32-33), Day 

(cols. i:-3!) and Year (cols. 36-37) 

Code: 

~RX~ Never Menstruated 

fTTT77 - None since last delivery 


Suwlemental code for day: 

o4 - Early, beginning of month, first week 

11 - Second week 

16 -Middle 

20 - Third week 

27 - Last week, end of month, late 

13. Bfi', First Day 

Item l2 


(cols. 40-41) and Year (cols. 42-43) 


FORM OB-4 

Card 03o41 

CARD 

COIDMN 

32-37 

38-43 

14. Type of Entry: Bfi' 

Code: Same as in Fie J.d. 11 

15. Dysmenorrhea 

Item 14 

Code: 0 - None 

1 - Slight 

2 - Moderate 

3 - Severe 

8 - Irregular 

9 -Unknown 

1.6. Trying to Become Prepnt 

Iteml6 

Code: 0 -No 

1 - Yes 

2 - Unconcerned 

9 -Unknown 

17. Months to Become Pregna.nt 

Item 17 

Code: 00 - Not applicable, n~t trying 

01-97 - As given. 

98 - 98 months or more 

99 - Unknown 

45 

46 

47-48 

II.A.63 

OB-4 



FCRI-1 OB-h 

Card 030h1 

CARD 

corm-m 

18. Usual Contracentive Use 

Item 18 

Code: 0 - No 

1 - Yes 

2 - Occasionally 

9 - Unkno'Wll 

19. Contracentive Used at Concention 

Item 19 

Code: 0 - No, not applicable 

l - Yes 

9 - Unkno'Wll 

20. Type of Contracentive 

I~em 20 

Ten-digit code for: 

DiapPxa~ (col. 51) 

Condom (col. 52) 

Jel1y (col. 53) 

Vagi~al Sunnository (col. 54) 

Coitus Interruntus (col. 55) 

Douche (col. 56) 

~hm (col. 57) 

Oral Contracentive (col. 58) 

I~tra-Uterine Ring (col. 59) 

Other (col. 60) 

Code for each column: 

0 - Not used 

1 - Used 

9 - Unkno-wn 

21. Sterility Investigation 

Item 21 


49 

50 

51-60 

61 


II.A.64 

OB-4

'? 

I~ 

1: :1\ 

j; t:: 

t; ....J 

7 ,.,_ 

t::Et::~·~l . . l ~ ~"'· [,.,., 

8'1 ......, 

'rn .il 

'""'~ 

-· p.. .!/ff/IQ;Jfff t1-' ;a ~"""Ill 

(N,IW9~1JI.J •L.•,,ttlf...l. 

.. 

~ 

~ 

- ..... v 

• ! =ti 

:-:_______ 

~ 

i 

GYNECOLOGICAL HISTORY 

(For Form OB-4, Revised ll-59) 


In Item #2 "History Taken By 11 1 record your first and last name. Do not write 

in the small box following. In Item #3 11 Title or Position" record your 

official title, such as "lay interviewer 11 1 "Nurse interviewer", "socia:l 

worker", etc. In Item #4 labeled 11 Date", record the date this information 

was obtained in the manner designated: month, day, and year (ll/22/59). 

Item #5 MENSTRUAL HISTORY 

Item #6 "Me at Onset" 

Record Ghe age (at her last birthday) at which the patient's menstrual periods 

began. 

Item #7 11 Duration" 

Record the average number of days the patient's menstrual peri~ds 

last. 

usually 

Item #8 "Usual Interval" 

Record the average number of days from the first day of one menstrual period 

to the first day of the next period. 

Item #9 11 Amount as Described by Gravida 11 

It is assumed that most women are aware whether the amount of their menstrual 

bleeding is greater or less than that of most other women. Ask the patient 

whether in her opinion she bleeds more than most other women at the time of 

her periods, less than other women, or about the same. If she states she 

bleeds more, record as "heavy 11 ; if she bleeds about the same, record as 

11 

medium"; if she bleeds less, record 11 light 11 • 

Item #10 "Unusual Features of tfcnttruil Period" 

Do not include dysmenorrhea (pain or discomfort ~h the menstrual period) 

under unusual features. This will be considered under Item #14. Unusual 

features of the menstruai period should include gross variations in the 

duration of flow and in the interval between periods, or any other feature 

which the patient thinB& is unusual. 

Item #11 "First Day of 1ast Ng:rmal Menstrual Period 11 

Record the first day of the last normal period in the order month, day, and 

year (9/22/59). 

Item #12 "First Day of PrevioUI M!nstrual Period 11 

I 

Record the first day of the menstrual period prior to the last normal period 

in the order month, day, and year (9/22/59). 

February 1959 



II.A.66 

OB-4

GY1~F..COLOGICAL HISTORY (Con't.) OB-4 

Rev. 11/59 

Item #13 "Exoected Date of Confinement" 

Record the expected date of confinement (in the order month, day, and year) 

obtained by adding seven days to the first day of the last normal menstrual 

period, adding one year, and counting back three months. If this is 

obviously not correct, record the obstetrician's estimate instead. 

Item #14 "Dysmenorrhea" 

Ask the patient if she has any discomfort with her periods. If she has 

none, check "None 11 • If the patient notes some discomfort, but takes no 

medication (not even aspirin), check "Slight". If the patient has discomfort 

which requires medication but is able to continue with her usual 

·activities, check "Moderate". If the patient's discomfort is such that 

she must remain in bed or away from gainful employment for at least one day, 

check "Severe". 

Item #15 FERTILITY 

Item #16 "Have you been Trying to Become Pregnant?" 

Ask the patient if she has been trying to become pregnant. If she says 

"yes", ask question #17, "How long did it take you to become pregnant?" 

The answer is to be determined in months. If the patient says "no" to 

Item #16 1 

ask Item #18, "If no, do you usually use a contraceptive?" 

Record "yes" or "no". 

Item #19 "Were you Using a Contraceptive at the Time You Became Pregnant?" 

This must be asked of all patients. This refers to the actual exposure 

at which the patient believes she conceived. Record "yes" or "no 11 • If 

the patient does not know whether a contraceptive was used at the actual 

time she conceived, write "UNK" in the space to the right. If the patient 

answers "no", omit Item #20. If the answer is "yes" ask what contraceptive 

the patient was using, and check more than one contraceptive if 

more than one was used at the same time. 

Item #21 "Sterility Investigation" 

Inquire whether the patient has ever been examined to determine why she did 

not become pregnant. If the patient did not go to the doctor specifically 

for this, check "no". If she has gone to the doctor to see why she did not 

become pregnant, check "yes" and obtain all information possible regarding 

what the doctor did in the way of investigation. 

II.A.67 

February 1959 


OB-4 


.... 

(lflt.rvj-.,-) 0 

•H•.a..4 


GYNECOLOGICAL HISTORY ..•cJ# 

TITLE OR POSITION 

-rYr) 

I. MENSTRUAL HISTORY 

1. AGE AT ONSET 

l. DURATION 

3. USUAL INTERVAL 

4. AMOUNT AS DESCRIBED 8-Y GRAVIDA 

Qttn.y 

0 ,...,u.. 

QLitht 

5. UNUSUAL FEATURES OJI MENSTRUAL Pl!RIOD 

ON 

0 Yea (D••eril>d 

•. 

-.'~ .... 

L PlntLITY 

1. HAVI YOU BEEN TRYING TO BECOME PREGNANT? 

0" 

0Y.. 

2.. IP YIS, HOW LONG OlD IT TAKE YOU TO 

BECOME PREGNANT? 

___MONTHS 

S. II" NO, DO YOU USUALLY USE A CONTRACEPTIVEr 

DNa 

OY• 

.4 watl! YOU USING A CONTRACEPTIVE AT THE 

n•·YOU BECAME PREGNANT? 

a•· 

OY 

~· 

:-....·.· 

... . .... ··._.,.. 

. .:. ~ "I: . 

t. IWSMENORRHEA 

0 ~(If-..__,_.-.i) _ 

ost..-{lf .. d ..,......... :: ... 

.............. ·;_.;• ~- 

,...................... 

,....._..........~ 

. ...... 

,_,..,..... ; ,_.-_.,}._ 

o..........a, ... 

QS....llf,.._........ -~·:..,. . 

.... - ~- . 

·. ••.•• ! • ..... 

.r ,. ;: • .• ... ~' . ,, 

c~ ..._,.,._

08-5 Recent Medical History 

Form 08-5 was used to obtain medica1 hi story for the 12 month period 

preceding the date the history was taken. The form was first used in January 

1959; it was revised in November 1959. The revised form was renumbered and the 

information on medications was made more specific. 

Two cards were used in keypunching data records (Table 08-5.1). Cards 

punched from the January 1959 version of the form contain information on 

medications taken in columns 66 to 78 of card 2305; this information is found 

in columns 50 to 65 of card 2305 for the November 1959 revision. All other 

columns on the cards contain data from both the January 1959 version and the 

November 1959 revision. Item numbers refer to the November 1959 revision. 

TABLE 08-5.1 Card~ and Data Records by Revision for Form 08-5 


CAro NAME NUMBER NO. RECOroS 

OB-5: II lness or Dfsabll lty 1305 

OB-5: Non-Confining II lness or 

Dlsabl I lty 2305 

0 8,676 

1 47,289 

------ 

55,965 

0 8,654 

1 47,043 

------ 

55,697 


II.A.69 

OB-5 


II.A. 70 

OB-5 



Data Items Referf'rtcin:J rorm OB-5, Recent 14eclfc~tl Htstorv 

D~U 

TrF:It 

ITEIII Jill C~HD 

10 F'JQM NIIM FROM TO oara rrr.111 NUF: 

)04••••••• 

1305 t 5 car-1 numbf'r (se11uence, forn tvoe, form number, revlslon numher) 

Jns ••••••• 

110"i 6 14 NTNOB case number 

3n& ••• oq-o; 5 130'5 1'5 16 Fnr~ na-s d~te ('10) 

307 ••• oR-o; 5 130'5 17 18 Fnrm na-5 date ( :ja vl 

309 ••• 0R-I\ 5 noo; tCI ?0 Fnrm 0B•5 dAte rvrl 

309 ••• oR-5 130'5 2t 21 Illness or dlsabilltv, rea~frlna confinement, number 

310 ••• 0R•"i 7 00'5 21. ?3 Illness or ~tsabllltv, rea~lrfna conffnf'ment, tvoe 

31l ••• OR•'\ A llOI\ 24 15 Illness or ~lsabllltv, rea~lrtna conffnement, davs In bed 

3t2 ••• oR-5 9 1305 26 27 Illness or t11sahllltv, rea~trtna ronftnement, date onset ('10) 

3t1 ••• oR-'5 9 

1'0'5 

2~ 19 Illness or dtsabilltv, rea~tr!na confinement, date OF\Set (day) 

314 ••• 01'\-"i 9 

110'5 31'1 31 Illness or iisahllitv, reauirlna confinement, date onset (yr) 

315 ••• 01\-"i tO 

DO"i 31 l2 Illness or ~tsabllttv, renutrtna confinement: ohvstclan consulted 

or nosoltaliz:ed 

316 ••• 0R•"i 7 130'5 33 34 Illness or ilsanllltv, re11utrtna confinement, tVPf! 

1-t 

317 ••• oR-'5 9 

130'5 l"i 16 Illness or dlsahllttv, reautrtn11 conflnf'ment, 

1-t 

3t9 ••• 0R·"i 9 nos 37 39 Illness or dlsanlllty, rea~trtna confinement, 

. )' 

319 ••• oR-o; 9 

130'5 H 40 Illness or dlsahllltv, reaufrtna confinement, 

..... 

-..1 

320 ••• 01"-'5 9 

1305 41 42 Illness or dlsahllttv, reaulrtnn confinement, 

31l ••• OP•"i tO 

110'5 4l 43 Illness or ~tsabilitv, rea~irtna confineme'lt: 

or hosP1tal1ze1 

322 ••• 0R•S 7 

1l05 44 45 Illness or disability, re11uirin11 confinement, 

311 ••• 01\-'5 8 

00'5 46 47 Ill"ess or ~isabllitv, reautrtn1 confinement, 

3?4 ••• oR-o; 9 

110'5 4A 49 Illness or ~lsahilltv, reautrinq confinement, 

325. o •')R•'i 9 no or; so "it Illness or rtlsabllitv, rea~irfnq conflnemf'nt, 

J?6 ••• oR-5 9 

1105 5? '5) Illness or "lsanilitv, reaulrtna confinement, 

@ 

days ln bed 

date onset (110) 

date onset (dav> 

date onset (yr) 

onvsician consulted 

type 

days ln bed 

dat~ onset (:110) 

:jate onset Cdavl 

:late onset cvr> 

3?7 ••• oR-5 10 130'i 54 54 Illness or ~~~abllttv, re1ufrtna confinement: ohvslcian consulte~ 

or noso1ta11Zed 

)?9••• 0R•5 1 

1305 55 56 Illness 

3?9 ••• oR-5 8 

1305 57 58 Illness or 

or disabilltv, requtrina confineMent, type 

t1isabllitv, reaulrtn1 confinement, davs In bed 

330 ••• 0R•'5 9 1305 SCJ 60 Illness or t1lsahilitv, reautrtna confinement, datf! onset (MO) 

31t ••• oR-"i 9 130'5 6f 62 Illness or dlsabllttv, reaufrlna confinement, date onset Cdav> 

J32 ••• oR-'5 9 1305 63 64 Illness or t11sabilitv, reauirlna confinement, date_ onset cvn 

313 ••• oR-5 10 00'5 6'5 65 Illness or rtisabiltty, reauirina confinement' ohvslcian consulted 

or hosoltal1ze


1-1 

1-1 

>• -..J 

~ 

@ 

I 

tTl 

Data Ite~s Refere~cln~ For~ ns-s, Recent Medtcal Htstorv 

OAf A 

lTF::fl4 

ITE14 Jllf CARO 

YO FJR14 NUM FROM TO OA U IrF.M NAMF. 

342 ••• oR-"i 13 2305 25 ?6 Illness or rttsabilltv, non conft~tnq, date onset C•o> 

343 ••• oR-"i tJ 230'5 27 28 Illness or rtisah111ty, non contt~tna, date onset (day) 

344 ••• oR-"' 11 2305 29 10 Illness or rtlsabllity, non conft~fna, date onset (yr> 

345. • .OR•5 14 2305 )t Jt Illness or rt1sab111ty, non contintna; ohysician consulted 

346 ••• 01'1•5 12 

2305 32 33 Illness 

347 ••• 01'\-~ 12 

230'5 34 15 Illness or or 

rtlsahllitv, ~isahillty, non 

non conftntng, 

conftnfna, date tyoe 

onset (mo) 

34B ••• OR·'i 12 2305 ]fi 37 Illness or rttsabllltv, non conttntna, d~te onset (day) 

349 ••• oR-" 12 

2]0'5 lA J9 Illness or rtlsablltty, non conftntna, date onset (yr) 

)SO. • .OA•5 12 

2305 40 40 Illness or rtlsabllltv, non conttnlna; ohvslclan consulted 

3'5l ••• DR•"i 12 

230'5 41 42 Illness or dlsabllltv, non eontintng, tvoe 

)'§2••• DA•5 11 

2305 41 44 Illness 

3'5l ••• DA•tll 11 

2105 4"i 46 Illness or 

or disability, 

disahilitv, non 

non conttnfna, 

contfntna, date 

datP onset 

onset (dey) 

C•o> 

3'54 ••• DR•5 11 230'5 47 48 Illness or ~tsablllty, non conftntna, date onset Cyr) 

3'55. • .OR•"i 14 2305 4~ 49 Illness or rttsahlllty, non conflntn~l phystcien consulted 

3'§6 ••• DR•"i 16 

230"i so 50 I~~untzatfon, ore/oost L~P. preceding t2 months 

3'57 ••• DR•S 

1"'B ••• DR·"i 

3'59 ••• oR-"i 

3~o ••• oR-"i 

16l ••• DR•5 

17 

tll 

29 

20 

21 

2305 

2305 

210'5 

'230S 

2305 

51 

52 

53 

54 

55 

51 Anttbtotir fn1ectfon, pre/oost L~P, precedina 12 •onths 

~2 Antfbtotlcs, ~ther, ore/oost L~P, orecedlnq 12 months 

53 In1ection, other, ore/post L~P, orecedlnq 12 Montha 

~4 In1ection, un~nown, ore/oost f,MP, orece~lng 12 •onths 

~5 Sle~otno ollls, ore/oost r.~P, orecedlna 12 •onths 

lfi2 ••• DR•5 22 2305 56 56 Tranquilizers, ore/oost LMP, orecedln~ 12 •onths 

363 ••• o~'~-5 21 230'5 57 57 Otet or "oep• pills, ore/o,st LMP, precedina 12 •onths 

364 ••• DR•'5 24 230"i SA 58 Antihistamines, ore/oost r.~P. orecedtng 12 Months 

36S ••• DR•"i 21\ 230'5 5~ '59 Jnsulfn, ~re/oost LMP, orecedtna 12 months 

Jfo6 ••• oR-"i 2" HO"i 60 ~o Thyroid or anti•thvrotd, ore/nost LMP, orecedfna 12 months 

367 ••• o~'~-5 21 230"i 61 61 Cortisone, nre/oost LMP, orecP.1fnq 12 months 

36B ••• DR•5 2P 230'5 62 62 HorMones, other, ore/post LMP, orecedlna 12 months 

)fo9••• DR•'5 

)70••• DR•"i 

371 ••• DR•5 

30 

31 

37. 

HO"i 

2JO"i 

Hoc; 

61 

64 

6"i 

63 

64 

65 

Laxat1ves, nre/oost LMP, 

He~dache oills, oowders, 

Medication or fn1ect1on, 

orecedfno 12 months 

ore/nost LMP, orecedlnQ 12 aonths 

other, ore/oost LMP, orecertinq 12 months 

372 ••• 01'1-"\ 2JO"\ 6fi 66 I•muntzatton, ves/no, orecedtnq 12 months 

37l ••• OR•"i 230"i 67 67 Antfbfotics, ves/no, orece1tno 12 months 

374 ••• oR-5 2105 6A 68 In1ection, ves/no, other, orece~ina 12 months 

)75••• 01'\•5 

l76 ••• oR-I\ 

377 ••• oA-"i 

)78 ••• 0"--"i 

379 ••• 0~'~•" 

lPO ••• OR•"i 

)Rl ••• OR•"i 

3A2 ••• DR-~ 

)R)••• U"~•"i 

)R4••• 0R·5 

230"i 

230"i 

230"i 

2305 

2]05 

230'5 

2J05 

2JO'l 

2305 

2105 

69 

70 

71 

77. 

73 

74 

'"' 76 

77 

7A 

69 

70 

71 

72 

73 

74 

75 

76 

77 

78 

Injection, ves/no, unknown, orece~ing 12 

Ant1blot.ics, ves/no, other, orecertinq 1? months 

months 

L~xattves, ves/no, orecedl~a 12 months 

Sleeotna pills, ves/~o. orece11n~ 12 months 

Tranquilizers, yes/no, nrecedfn~ 12 months 

Dtet or "nen" otlls, yes/n,, nrecedino 12 months 

Headache nills, yes/no, oowrters, orecedlna 

Nose droos; inhalers, yes/no, orece11nq 12 

Antthtstamlnes, yes/no, orecedinq 12 

Medlc~t1on, ves/no, other, nrecedfno months 

12 months 

12 months 

months


nata Ite•s R~fer~nclng Form ns-5, Recent ~~dfc~l H1storv 

DITA 

trF'!t 

ITEM ON CARO 

TO FJIHII NIIM FROM TO DATA TTF.M NAME 

JAS ••••••• 230"i 7q 110 Blanlt 

520& •••• YAP 6 315 315 Illness cnnfinin~, orecedf,~ 12 ~onths, totBl number 

H 

H 

).. 

. 

....,J 

w 

@ 

I 

01

C:OL,.-3003•1 

,. .. v. 11 .eo 

2 

RECENT MEDICAL HISTORY 

II. PATIENT IDENTIFICATION 

2. HISTORY RECORDED BY 

4. TITLE OR POSITION 1•• DATE 

i 

I 

••· I Day 

YHr 

6 IL.I.NESS OR DISABII.ITY REQUIRING CONFINEMENT TO BED DURING PRECEDING 12 MONTHS 

I. DAYS IN 

I. DATE 10. PHYSICIAN CONSULTED AND HOSPITAL 

7. ILLNESS 0 .. DISABILITY OF ONSET IF HOSPITALIZED 

BED 

/tlo. '.O.y ~ Year 

{I) 0 HOSP. 

I 

I I 

I 0PHYS. 

I 

I 

~NO 

0 

{21 

I I iYHOSP. 

I I 

I IOPHYS. 

I I I I • 

I 

I iONo 

I 

(3) 

I I IQHOSP. 

I I 

I 

:0PHYS. 

I 

I 

I 

I 'oNo 

I I 

':I 

(4) I IOHOSP. 

! I 

I I :QPHYS. 

I I 

I I 19NO 

I 

II NON.CONFINING II.I.NESS OR DISABII.ITY PRESENT DURING PRECEDING 12 MONTHS 

U. DATE 

12. ILLNESS 0 .. DIIABII.ITY OF ONSET 14. PHYSICIAN CONSULTED 

llo.'Day i r ...r 

{1) I IL,.lNONE 

I • 

I 

I 

I 

{2) I 

0NONE 

I 

I • 

I 

I 

I 

{3) I 0NONE 

I 

I • 

I 

I 

15. MEDICATION OR INJI!CTIONS TAKEN DURING PRECEDING 12 MONTHS 

Y&a Y&a 

33. LIST BY BOX NUMBER AND DESCRIBE ANY POSITIVE 

.. •&,..II ...... UM• ANSWERS INDICATING SPECIFIC DRUG IF KNOWN • 

...~ '"a:- 

..... 

REASON FOR TAKING. AND FRI!:OUENCYOR NUMBI!:FI OF 

• TIMI!:S TAKEN. GIVE LATEST DATE PATIENT HAS 

16. IMMUNIZATIONS 

TAKEN EACH DRUG FIEPOFITED. 

17. ANTII!IIOTICS (I>J' ltljeetlan) 

11. ANTII!IIOTICS (orl!er rl!~ l>ylnleetlorU 

II. OTHER INJECTION (opecl,.,) 

20. UNKNOWN TYPE OF INJECTION 

21. SLEEPING PILLS 

22. TRANOUILIZI!:RS 

23. ''PEP.. OR OIET PILLS 

24. ANT IHIST A MINES 

21. INSULIN 

Zl. THYROID OR ANTI•THYROID 

27. CORTISONE 

Zl. OTHER HORMONES 

21. g:.~'iyT~~....~~.:.Eg.lf,!,T,:Z~ II,_,__,.,,..,. 

moN olten, M II pNecftbH by • pltyelcl-. 

30. LAXATIVES I I I 

Jt. HEADACHE PILLS OR POWDERS 

I I 

12. OTH~R 

_l 

COL..LABO,.ATIYII: "I::SitA,.CH 

PE.. INATAL. Jlltii.SII:AftCH .fltANCH, NINaa, NIH 

•&THilSDA 14, MD. 

l"&v. 11481 

08-5 


II.A. 74 

OB-5


H 

H 

~ 

• ....,J 

l11 

~ 

l11 

~orm Item Numbers linKed to Oata Items on o~-5, Re~ent ~e~tc&l Hfstorv 

5 

5 

5 

'5 

5 

o; 

(\ 

7 

1 

7 

7 

(I 

8 

1!1 

8 

A 

9 

9 

q 

9 

Q 

9 

9 

q 

9 

9 

9 

ITE114 

flAT A 

ON TrFIII CARD 

FOR"' IO NUM FROM TO OIITII TfF"' NAMF.: 

376 ••• oa-5 

111 ••• oa-s 

383 ••• oa-5 

nn••• os-5 

381 ••• n~-s 

HO ••• na-5 

3o9 ••• os-5 

372 ••• os-5 

374 ••• ns-5 

Hs ••• ns-5 

377 ••• oa-s 

384 ••• ns-5 

n2 ••• ns-s 

378 ••• os-s 

379 ••• os-5 

339 ••• ns-5 

l07 ••• 0B•5 

337 ••• os-5 

2305 

230'5 

230"i 

230"i 

nos 

nos 

1305 

2301\ 

2305 

2305 

2305 

230'5 

230'5 

2305 

2305 

2305 

130"i 

230'5 

130'5 

l06 ••• na-s 

30R ••• ~B-5 1305 

339 ••• ~8-5 2305 

5206 •••• VIIR 

310 ••• ns-s 

328 ••• ns-5 

322 ••• nB-5 

316 ••• oa-5 

330 ••• 08-5 

323 ••• 08•5 

311 ••• 08•5 

329 ••• os-5 

317 ••• 08•5 

319 ••• ns-5 

313 ••• os-5 

32"i ••• ns-s 

Ht ••• na-5 

324 ••• 08•5 

) 1' ••• 118•5 

HA ••• os-5 

314 ••• oa-5 

326. • .llB•5 

33?. ••• os-s 

120 ••• na-5 

130"' 

1301\ 

tJoo; 

1305 

1305 

1305 

1305 

1305 

130'i 

nos 

1305 

no5 

nos 

1305 

130'i 

1305 

1 1os 

1305 

1305 

uoo; 

1n 

67 

77 

74 

7'5 

21 

21 

66 

6A 

69 

7t 

7A 

7(, 

7?. 

7l 

17 

17 

15 

'"' 

19 

19 

H"i 

27 

so; 

44 

3l 

59 

46 

24 

57 

35 

)9 

2A 

5n 

6t 

4A 

26 

37 

30 

52 

6) 

41 

70 Antfbfotir.s, ves/no, other, ore~edinq 12 months 

67 Antlbfotir.s, Ve5/no, orecejfna 12 months 

77 Antlhtsta~tnes, ves/no, orecedinl 12 months 

74 Diet nr •oeo• pflts, ves/no, orecedina 12 months 

75 HPadache oill5, yes/no, oo•~ers, orecedtnq 12 months 

12 Illness or ~tsability, non conttntna, numher 

21 Illness or ~isah111ty, re~ufrfna confinement, number 

66 Im~untz~tton, yes/no, nrecejlna 12 months 

68 In1Pction, ves/no, other, orece~tnq 12 months 

~9 Injection, ves/no, u~~nown, orecedtn~ 11 ~o~ths 

71 L~xatfves, yes/no, orecedfna 12 ~nntns 

78 MP~tc~tlon, yPs/no, other, precedtng 12 months 

76 Nnse ~roos: inh8lers, yes/no, orece11nq 12 ~onths 

72 Sleeplna Dills, yes/no, orecedina 12 months 

73 TranauiJizers, yes/no, precedlna 12 months 

t8 form OR•5 datP (day) 

tH Form OR•S d~tP (18y) 

16 Fnrm ns-5 d~te f•o> 

lb rnrm nB-5 d~tP C•n> 

10 Form nH-5 dAte Cyr) 

10 Form OR•5 d8tP (yr) 

315 Illne5s c~nftninq, orecedtno 12 months, tot&l number 

?3 lllne5s or ~tsa~ilitv, reoutrfn~ conflnPmPnt, type 

56 Illness or dls8bilitv, reaulrtnQ conffnPment, type 

45 Illness or ~1sah111ty, reautrfna confinement, type 

l4 Illness or dlsablllty, reautrtna conttnement, type 

60 Illness or ~isabllity, reoutrtnq confinement, date onset Cmo) 

47 Illness or disahility, reautrtno confinement, d8yS ln bed 

?5 Illness or ~isahiltty, reautrtna confinement, d&ys tn bPd 

'58 Illness or ~1san111ty, reouirfnQ confinement, days ln bed 

1b Illness or rtisah11ity, reautrtna confinement, days in bPd 

40 Illness or disability, reautrlna confinement, date onset fd8Vl 

?.9 Illness or ~isahllity, reautrlna confine~ent, date onset (day) 

51 Illness or disability, reautrtno confinement, date onset (day) 

62 Illness or disability, reaufrfna confinement, date Dnset (day) 

49 Illness or disahility, reautrtno confinement, date onset (Mo) 

27 illness or ~isah111ty, reauirtn~ confinement, date onset (mo) 

18 Illness or rtisabilitv, reaulrlno confinement, date onset (~o) 

31 Illness or disability, requtrfna confinement, date onset (yr) 

53 Illness or disability, reoulrino confinement, date onset (yr) 

64 Illne5s or dtsahillty, reaufrfna confinement, date onset (yr) 

42 Illness or ~tsahillty, reauirina confinement, date onset Cyr)


H 

H 

> • ..... 

0\ 

@ 

I 

U1 

ForM Ite~ Nu~bers Ji~~ed to Oata Ite~s on ~tl-5, Recent ~edfcal ~fstorv 

ITEM 

DATA 

ON TrF:" CARD 

FORM In NIIM FROio! TO DAfA TTFM NAMF. 

to 121 ••• os-~ noc; H 43 Illness or ~lsabllltv, re~uirlno conflne~ent: ohvstclan consulted 

or hosoltallze~ 

to 327 ••• ns-5 13o"i 54 54 Illness or dlsablllty, re~utrtna cont1ne~ent: ohvslclan consulted 

or hosoitallze1 

to 333 ••• na-5 1305 6"i 65 Illness or ~isabilttv, requtrfna confinement: ohvslclan consulted 

or hosottalize1 

t 0 lts ••• na-5 130'5 32 32 Illness or ~i~abllitv, re~ulrtna confinement: ohvsieian consulted 

or hosoltalize~ 

12 

348 ••• oa-5 2305 36 37 Illness or dlsahlllty, non conflnJn~, date 

12 

347 •••ns-5 210'5 34 35 Illness or dtsabllttv, non contlnlna, date 

12 

J4~ ••• ns-5 210~ 31' 19 Illness or ~tsahlllty, non eonflntna, date 

12 151 ...!'JB-5 230'5 41 42 Illne5S or dtsabllttv, non contlnlna, tvoe 

12 

12 

12 

t1 

11 

11 

13 

u 

13 

346 ...'l8•5 

141 •••no-s 

1so ••• oo-s 

2~0"i 

2J05 

2lO"i 

32 

23 

40 

33 

24 

40 

Illne5s 

Illness 

Illness 

or 

or 

or 

~tsablltty, non 

~lsabllitv, non 

dtsablltty, non 

disability, non 

~1sab111ty, non 

~isab111ty, non 

~tsabllttv, non 

dlsabllttv, non 

disahlltty, non 

conflntna, 

eonttnlnq, 

conflnlna: 

onset 

onset 

onset 

(day) 

(mo) 

Cyr) 

tyoe 

type 

physician consulted 

353 ••• 08-5 230'5 4'5 46 Illness or 

conflnfna, date onset (day) 

343 ••• na-s 2305 27 78 Illness or 

contlnJna, date onset (day) 

1s2 ••• na-s 2J05 

44 Illness or 

conffnfna, date onset (Mo) 

H2 ••• IJB-~ 230'5 25 ·~ ?b Illness or 

conftnlna, date onset C•o) 

354 ••• ns-5 noo; 47 48 Illness or 

eont1ntna, d8te onset (yr) 

144 •••'lB-5 

2JO"i 2Q 10 Jllne5s or 

conftntna, d8te onset (yr) 

t4 355 ••• 08-5 2~0"i 4q 49 Illness or ~isablllty, non conttntn~; physician consulted 

1 4 H'i ••• ns-s 23o"i 31 31 Illness or dtsah111tv, non conttnlna; p~vsician consulted 

16 

356 ••• ns-s nos; 50 50 I~muntzatton, pre/oost LMP, precedlnq 17 months 

1 7 

357 ••• ns-5 210"i 51 ~1 Antlolotic fn1ertton, oretoost f,~P, orecedin~ i2 months 

tl:l 

JSP ••• ns-5 noc; 52 ~2 Antfbfotlrs, other, pre/onst r,MP, orece~in~ 12 months 

20 

3&0 •••na-s noc; 54 "i4 Jn1Pctton, un~nn•n, ore/onst LMP, orecedln~ 12 ~ont~s 

21 

36t ••• na-s 230"i 5'5 "iS SlePofn~ ollls, ore/oost r.~P, orecedina 12 months 

?2 

1&2 ••• ns-5 230"i 56 '5& Tranquilizers, or~/oost LMP, orecedina t2 nonths 

23 

163 ••• os-5 230'5 51 11)7 otet or •nep" ollls, orP/o,st LMP, orecedlna 12 months 

24 364 ••• os-s 2305 5R ~8 Antfhlstamines, pre/oost L~P, orece~lng 12 months 

75 

16"i ••• na-5 23oo; 5Q ~9 Jnsultn, ore/oost LMP, rreceilno 12 ~nnths 

?6 

3&6 ••• '18-5 210'5 6fl 60 Thvrotrl or anti-thyroid, ore/oost LMP, Drecedlna t2 nonths 

'11 367 ••• 08-5 230"i bt 61 Cortisone, pre/oost LMP, orecPdfna 12 months 

'18 

36fl ••• oa-5 21oo; &2 62 Hormones, other, nre/oost LMP, orecedlno 12 months 

79 

l5Q ••• oa-5 2305 51 "i3 tn1ectJon, other, orelpnst J.MP, preee~lna 12 months 

10 

J&Q ••• no-5 230"i f>J 63 L~xatfvPs, orP/oost LMP, orPcedtna 12 months 

lt 

370 ••• na-5 210'5 &4 64 Headache ollls, oo•ders, ore/oost LMP, orecedtna 12 ~onths 

32 

111 ••• os-5 230'5 &"i 65 MedicAtion or injection, other, oreloost LMP, orecedina 12 months



FORM OB-5 CARD 1305 

CARD 

COWMN 


Code: 1 

2. Form Number 

Code: 305 

3· Revision Number * 

Code: 0 - Form Dated: 

1 - Form Dated: 

1/59 

Rev. 11/59 

1 

2-4 

5 

4. NINDB Number 

Nine-digit number for Patient Identification. 


5· Date Form Completed 

Item 5 

Six-digit code for month (eels. 15-16), 

day (eels. 17-18) and year (eels. 19-20) 



6-14 

15-20 

6. Number of Illnesses or Disabilities Requiring 

Confinement to Bed 

Rem b 

Code: 

0 - None 

1-7 - As reported 

8 - 8 or more reported 

.9 -Unknown 

1· IliL1mSS


FORM OB-5 

Card 1305 

CARD 

COWMN 

7. ILLNESS OR DISABILITY I (continued) 22-32 

Item 9 

Date of Onset (cols. 26-31) 

Six-digit code for Month (cols. 26-27), 

Day (cols. 28-29), and Year (cols. 30-31) 


000000 - None 


Supplemental code for day: 

04 - Early, beginning of month, first week 

ll - Second week 

16 -Middle 



Physician Consulted or Hospitalized (col. 32) 

Item 10 

Code: 0 - No 

1 - Hospitalized 

2 - Physician consulted 

3 - Hospitalized and physician consulted 

9 - Unknown 

Note: No illness ::a "O's" for entire field 

8. ILLNESS OR DISABILITY II 33-43 


9· lLLJ."1ESS OR DISABIL.J..""'TY III 44-54 


10. ILLNESS OR DISABILITY IV 55-65 


Note: 

An ill.ness or disability may be recorded in any of the 

four lie~E; therefore, aJl fields ~ust be cnecked fur 

data. 


II.A. 78 

OB-5

DEl!'INITION OF CODES (Continued) 

FORM OB-5 

Card 2305 

l. 

2. 

3· 

4. 

Card Number 

Code: 2 

:Basic Data * 

Code: Same as in colllmns 2-20 of Card l 

Non-cont'ining Illness or Disability During 

1 

Preeeding l2 Months 

Item ll 

Two-digit code for: 

Total Number Reported (col. 21) 

Total Illnesses for Which Physician, Hospital 

or Clinic was Visited (col. 22) 

Code for each column: · 

a·.;. .None 

l-1 - As given 

8 - 8 or more 

9 -Unknown 

NON-cONOB'lNING ILim!SS OR DISABILITY I 

Illness or Disability - Type (cols. 23-24) 

Item l2 

Code: See Attachment "Illness or Disability Codes" 

page O:B 5 - lO-ll 

CARD 

COIZJMN 

l 

2-20 

21-22 

23-31 

* 

Date of Onset (cols. 25-30) 

Item 13 

Si%-digit code for ~nth ( cols. 25-26) 1 

Day 

(cols. 27-28), a.IId Year (cols. 29-30) 


000000 - None. 

99 -Month,. day azul/or. year unknown 

~lemental code for day: 

- Earl¥, beginning of month, first week 

ll - Second week 

1.6 -Middle 



UnJ.ess specified, Fields, Codes azul Card Colllmns refer to Revisions 

"O" azul "l". ItE!Il mmibers refer to Form Dated: ll/59· 


II.A.79 

OB-5

DEFINITION OF CODES {ContiiiUed) 

FORM OB-5 

Card 2305 

CARD 

corm.m 

4. NON-CONli'INING' ILLNESS OR DISABILITY I *: 23-31 

(contiiiUed) 

Physician Consulted (col. 31) 

Item 14 

Code: 0 - No 

l .. Yes 

9 - Unkno"Wn 

Note: No ill.ness = "O' s" for entire field 

5· NON-CONli'INING ILL."'IiESS OR DISABILITY II* 32-4o 


6. NON-CONFINING :cr..nrESS OR DISABILITY ~ 41-49 


ImrmlDi zation {Revision "1" only) 50 

Item 16 

Code: 0 - No 

l - Yes, before LMP 

2 - Yes, since LMP 

3 - Combination of codes l and 2 

8 - Unknown · 

9 - Not evaluat~d, not on I.=v-. "-0" 

8. Antibiotic Injection {Revision. "1" only) 51 

Item 17 


9· 

ection 52 

Coo e: Ss..me as in Field 7 

10. Other Injection (Revision "1" only) 53 

Item 19 


ll. UP..knoYm Type of Injection (Revision "1" only) 54 

Item 20 

Code: Same as in Field .7 

* An i].lness or disability rr,ay be recorded in .xn.y of the three f:.elds 

(4-6); therefore, all fie~ds must be checked for data. 


II.A.80 

OB-5


Card 2305 

FIELD 

12. Sleeping Pills 

Item 21 

Coder Same as 

13. Tranquilizers 

Item 22 

Code: Same as 

(Revision "1" only) 

in Field 7 


in Field 7 

CARD 

COLUMN 

55 

56 

14. "Pep" or Diet Pills (Revision "1" only) 

Item 23 


57 

15. Antihistamines 

Item 24 

Code: Same as 


in Field 7 

58 

16. Insulin (Revision "1" only) 

Item 25 


17. Thy'roi!i or Anti-Thy'roid (Revision "1" only) 

Item 26 


18. Cortisone (Revision "1" only) 

Item 27 

Coder Same as in Field 7 

59 

6o 

61 

19. Other Hormones 

Item 28 

Coder Same as 


in Field 7 

62 

20. Laxatives (Revision "1" only) 

Item 30 


21. Headache Pilla 

Item 31 

Code: Same as 

or Powders 

in Field 7 

(Revision "1" only) 64 

22. Other (Rev-ision "1" only) 

Item 32 



II.A.81 

OB-5

DEFINITION OF CODES {Continued) FORM OB-5 

Card 2305 

FIELD 

23. Immunization (Revision "o" only) 

Item 1, Section III 

Cede: 0 - No 

1 .. Yes 

9 - u~..k.nown 

Blank - Not on Revision "1" 

CARD 

COLUMN 

66 

24. Antibiotics (Revision "o" only) 



25. other Injection (Revision "O" only) 


Cede: Same as in Field 23 

68 

26. Unknown Type of Injection (Revision "o" only) 



27. Antibiotic - Other (Revision "O" only) 



28. Laxatives {Revision "o" only) 



29. Sleeping PiD.s (Revision "O" only) 



30. .Tranquilizer (Revision "o" o~~y) 



31. "Pep" or Diet Pills (Rev:!.sion "o" only) 



32. Headache Pills or Powders (Revision "0" only) 

Item 10 , Section lli 


70 

71 

72 

73 

74 

75 


II.A.82 

OB-5


Card 2305 

FIELD 

CARD 

COLUMN 

33. Nose Dro'Ps or Inhalers (Revision "O" only-) . 76 

I-eem ll, Section lli 


34. Antihistamines (Revision "O" only-) 

Item 12, Section III 


35. Other Ty-pe of Medication (Revision "O" only-) 

Item 13, Section III 


NOTE: 

WHEN OCCURRANCE OF CONFINING OR NON-CONFINING IS DUE TO 

MORE THAN ONE ILLNESS, THE MOST MEDICALLY SIGNIFICANT CAUSE 

IS NOT CODED. THE HIGHEST NUMERIC CODE FOR THAT OCCURRANCE 

IS CODED. 


II.A.83 

OB-5

ILLNESS OR DISABILITY CODES 

OB-5 

00 None 

Cardiovascular and Blood 

Systems 

01 Cardiovascular (general) 

02 Rheumatic Fever 

03 Thrombophlebitis 

04 Anemia 

05 Cardiovascular Surgery 

06 Leukemia and Lymphomas 

07 Pericarditis 

o8 Purpura (all types) 

09 Combination of codes Ol-o8 

Pulmonary Systems 

10 Respiratory Diseases (general) 

ll Tuberculosis (all sites and 

procedures) 

12 Pneumona and Pneumonitis 

13 Bronchial As~hma 

14 Pulmonary Surgery 

15 Hemoptysis and Pulmonary Embolism 

16 Sarcoidosis (all sites and 

procedures) 

19 Combination of codes 10-16 

Metabolic System 

20 Metabolic Diseases (general) 

21 Glucose Metabolism Disorders 

22 Thyroid Diseases 

23 Endocrine Surgery 

24 Glycosuria (nbt specified as 

diabetes) 


genito-Urinary System 

30 Genitourinary (general) 

31 Glomerulonephritis 

32 Genito-Urinary Infection 

33 Genito-Urinary Surgery 

34 Hematuria 

35 Genito-Urinary Stones 

36 Nephrosis 

37 Genito-Urinary Tumors 


Gynecological System 

401 Gynecological (general) 

Gynecological Tumors 

Infertility and Sterility 

41 

42 

43 Venereal Diseases 

44 Gynecological Surgery 

45 Complications of Pregnancy 

46 Termination of Pregnancy ( =xcept 

ectopic and mole) 

47 

48 

49 

Ectopic Pr,egna.ncy 

Trophoblastic Tumors 

Combination of codes 40-48 

Neurological Surgery 

Neuroses and Psychiatric 

Disorders, n.o.s. 

55 Psychoses 

56 Alcoholism 

57 Drug Addiction 

58 Cerebral Palsy 


chiatric 

Gastro-Intestinal Systems 

60 Abdominal and Gastrointestinal 

Diseases (general) 

61 Jaundice and Hepatitis 

62 Gallbladder and Pancreatic Dis :?..ses 

63 Gastrointestinal Diseases 

64 Hernia (Hiatal only) 

65 Abdominal and Gastro-intestinal 

Tumors (not elsewhere specified) 

66 Abdominal and Gastro-intestinal 

Surgery 

67 Hematemesis and Melena 

68 ~plenic Diseases and Surgery 


II.A.84 

OB-5 


ILL..'1ESS OR DISABILITY CODES 

(Continued) 

Skin, Breast and Alrendages 

70 Skin Diseases (General. 

71 Burns 

72 Breast Diseases 

73 Diseases of the Head and NeCk 

74 General Diseases of Extremities 

(including :fractures) 

75 Breast Surger,y 

76 Surgery of skin, head, neck and 

extremities 

77 Bone inf'ections and tumors (any site) 

79 Combination of codes 79~~;-··- 

Inf'ectious Diseases 

"80 Infections (site and type not 

specified) 

81 Viral Infections 

82 Bactex:ial Infections 

83 Intestinal Parasitic Infections 

84 Fungal. Infections 

85 Scabies 

86 RiCkettsial Infections 

88 Immunization Procedures and 

.Antitoxin Adm1 ni stration 

89 Cemoination of codes 80 ...88· 

other Diseases and Conditions 

90 Other Diseases and Procedures (General and 

Unspecified site) not elsewhere specified 

91 Observation and Diagnostic Procedures 

92 Diseases ami Procedures of Back and Side 

93 Poisoning 1 chemical (All types except 

alcohol) 

94 Trauma and Fractures ot Pelvis 

98 !~Jgpbinatien of codes 90-.94 

99 Unknown 


II.A.85 

OB-5

------- 


·x:re~ # 

_.:_ 0~ fOilkto if 

R 

RIDENT MEDICAL HISTORY 

FORM OB-5 

1. 5"' ') 8 q jill ') 6 'J '} 8 9 1 8 lj 

~· ' 

X f--- 121. ~ 

1 • ' 10 II 12-f:i"l• tilililiTt1ii \ jfjj 20S ,,,-~lO:ill21JlO$li 1Jtlt~-· ~ ''.ru••-..~,-~ ~II~ lt6i6fifif6! 

U61 6Ut li71if1l14JS-i6 1111,10 

0 

Ill 

J. 

I 

1 

1 

1 

1 ) 

z 

4"' 

I 

H -- tARO 

H ()) 

5 • 

• 

• 

> ~ ~ 

ClO 

en 

I--; 

1- 

I 

~- 

•·llllJ).B. :-: 

i ~ 

~ !t 

~~ 

l>RTE lllNE~S OR \)lSA81UT~ REQUlRltl6 CONFUlE~Et-tT 

FORM 

t.OMPWI 

r n -:m: D[. 

J>ATE l)RTE .DATE DRTE 

ONSE'T ONSET OMSEl ONSET 

!! 

• 

.... 

~ ~ ~~ ~ ~ 

~:-: ~ ~}, @ ~~ I~~:.: 

~ ~ ~ ~ ~ ~ ~ "' ~ I; .. ~ ..-; "' I~ tu ~ ~ ~ • 

~~~~~!~~~~!~~~~~~~~~~~! 

~ 

.. 

t 

BlRKK 

I 

: 

i-, I Z J 4 ~ 6 

* Item numbers 

1 I 9 10 II 11 IJ 14 IS k 11 II t :Ill 22 n 4 21 I!_!! ~ ~-~ ll II 1~ IS 16 J1]' lf40 I ~; a· 4 ~~ 1641 I 4• 10 Sl Ul 4 5 56 S1 511 t 6IJ 162 J 64 

refer to form dated: Rev. 11/59 

~ 6J6Ut 10 71JUJ74 7J 71 17 11 1t 10 

@ 

I 

l11


-- I .0 12. lt. ~12. 13 

R 

-- 

·~ ·~ 

--- 

REX:!ENT MEDICAL HISTORY 

FORM OB-5 

rtl?M_I#: . 

Dll FoltM V. 

' 

0 

0 

.. /lEV. -o·' OAILJI 

X f---. f2T4 6Tit_lii_II_I_Hi14 ~ilili11 ltli l2tr. 11 2• 'nliv-11 29-m ii ifl1 1• u 16 li"» ~· .o iio J 44 cs"M" 47-d 49 - Si ~i sJ sc ss ~~iII s9 606162 u6tis 1 a t po i ,~; 4 -s -, 1111· "1110___ 

-- -· 

-I J)RTEI 

NON-CONFINltJG ILNESS Of? .biSABILIT~ MEDICATION OR IN JfCliON 

fORM 

1 

--- tGMMltj) I: li' :m:. 

z 

1 ~TE l>llTE l>I\TE i 

0 l ONSET ONSET ONSET I~ 

- I~ 

~ " 

4 I~ ... 

' 

~ 

--- CRRD ' ~IIJJ).B'~~- ~ It 

~ 

~ ·- ~ ~ 

~ ~- ' ~ 8/.&tiiC 

H \0 5 , I~ 

t ... ... 'll~ ., 1.. q 

H -- 2365" ' ~ " 

1:~ 

~ ~ 1 

.. ~~ .. 

,: ~ :: li 

0 

s ~ 

~ 

~~~ I"~~~ ! " 1~1' > ~ I~ 

1 

'I;~ ~1.... ~ oc. 

~ 

1- " 

0 

~~Iii I~ I~ I~ ._I~ I~ ~ ~ 

Ill 

(X) ' • 

I• I~ ., -~.~~ . , ~~~ I~ I• 1il~ '~"I~ lc 

(J 

...... 

all? 

7 llttl~l~ IG ~ ,




Item #2 "History Recorded By" 

Record your first and last names. 

Item #4 "Title or Position" 

Record your official title, such as "l.ay interviewer", nurse interviewer", 

"social service interviewer", etc. 

Item f/5 "Date" 

Record the date this history was obtained in the order designated: 

day, and year (9/22/59). 

month, 

This "Recent Medical History" covers the period of twelve months preceding 

the date this history was obtained. It is obvious that all items on this 

page will cover that portion of the pregnancy which the patient has 

experienced before reporting for prenatal care, as well as a number of months 

preceding the pregnancy. Therefore, it is especially important to fix dates 

as accurately as possible. 

Item #6 "Illness or Disability ReQUiring Confinement to Bed During Preceding 

(12) Twelve Months" 

Item #7 "Illness or Disability" 

Include any symptom, disorder, illness or disability which resulted in 

confinement to bed for at least one day, whether or not the patient was 

attended by a physician. 

Item #8 "Days in Bed" 

Record the number of days that the patient was confined to bed. 

Item #9 "Date of Onset" 

Record the dates (month, day, year) of onset of the illness or disability. 

Item #10 "Physician Consu1ted aPJI Hospital if Hospitalized" 

If a doctor was consulted, record his full name and address, and if the 

patient was hospitalized, record the name and address of the hospital. 

Have the patient describe the illness or disability and record it as 

described. If she gives a medical diagnosis in addition, record this also. 

Item #11 11 Non-Confining I11n•s or Disabilitv Present During Preceding (12) 

Twelve Months 11 February 1959 


• 

II.A.88 

OB-5 


RECENT MEDICAL HISTORY (Con 1 t) 

OB-5 

Rev. 11/59 

Item #12 "Illness or Disability" 

Item #13 "Date of Onset 

Record the dates (month, day, year) of onset of the illness or disability. 

Item #14 "Physician Consulted 11 

If a doctor was consulted, record his full name and address. 

Items #15 - 32 "Medication or Injections Taken During Preceding Twelve funths" 

This is to include any medication or injection which was taken during the 

twelve months preceding this interview. Since this covers a portion of the 

early pregnancy, there must be a way to distinguish between drugs taken 

during pregnancy and those taken before. Therefore, for each positive item 

check either "Yes"-before "LMP"; or •ryes", since "LMP", and indicate the 

approximate time in the pregnancy if possible, such as "first month", 

"third month", etc. 

Ask the patient specifically about each item listed and record as "yes" or 

"no", or "unknown", if the patient doesn't know if she has taken this medication. 

List each positive answer by box number in item #33 and describe, 

indicating the specific drug (if known), the reason for taking, and the 

frequency or number of times taken. If the patient doesn't know the name of 

the drug, attempt to obtain as detailed a description of the medication as 

possible. 

February 1959 


II.A.89 

OB-5 


........... 

.... 

RECENT MEDICAL HISTORY 

(,..,.,._., 

r) 

1. ILLMIISS Olt OISAaiLITY lt...lltiMG COMPI...MIMT TO UD DURING l"ltiCIDIMG 12 IIIOMTHS 

ILI.NI!SS OR DISABILITY 

DAYS _IN 

BED 

DATIS 

PtiYSICIAN CONSUL TED AND HOSI'IT AL 

IF HOSPITALIZED 

1. 

2. 

3. 

'· 

1L. NGNoalll...lltl. LUIUS - Dllo\8ILITY ..118MT ..... PRI!aDIIIG 12 IIOMTHS . .. 

· , IU.ItUI ~~.· · DATE: JIHYSICJAN CONSULTED 

s. 

.. ·.• 

ltL. ~TIOit·- IUKnCMI· TMIIt DUilttNJ I"RIIaDI... 12 IIIOMTHS 

=""==,.,.,....,..,.TTI.,!,!:· ...~·--.....;---~· :·NO.'~..!!:' U. UST BY. ISOIC NUMIIER' AND DESCRIBE ANY POSITIVE 

IN..;J..;I!C~TI~DN~S=-OR~.-="SH=OTS;::;...'"_·__-.......;··-·-+-~·~·+--'--fi'";,;.''.J.--r-·-"-+ .ANSWERS INDICATING SP£CII'IC DRUG IF ICNOWN, 

- I. I 

........I..•Tt- . . REASON. FOR TAKING, AND FREQUENCY OR NUMBER 

:;....;::_.=.:::::;-:=:-;:,;:=-'="""'~---:---1--~.;.,·..-.J,;·..;;";._-4 .~· TIMU TAKEN. 

2. ANTIBIOTICS (Jfo.Uro;;;i] 

:t. OT~R IMJECT10N (f..a/9} 

.&. UNKNOWN TYPE OJI I 

.S.. AMTIBIOTIC roi-. r'- h 

6. L.UATIV~!!: 

7. SLEEPING. PlLU· 

8. TWANQUILLJZERS 

'f. "P£P" OR DieT PILLS 

ICf. ue.•A ·-u• PILL~ iii 

I\. NOSE DROPS OR INHAL!It$ 

12. ANTIHISTAMINES, 

13. OTHER TYI"!! .,. 

~--------~~==-~-~-==~~=r==~~r=~r=~~~~~==~~----------- 

(Oa-5) 


II.A.90 

OB-5

OB-6 


Form OB-6 was used to record medical history of the gravida from birth 

until the beginning of the year prior to pregnancy. (See form OB-5 for medical 

history 12 months prior to registration.) Form OB-6 also recorded any 

radiological treatments or examinations taken during the last 12 months. Form 

OB-6 was implemented into the study in January 1959 and revised once in 

November 1959. In revision, information was itemized; some items were added 

and items were coded. Two cards were used for keypunching data (Table OB-6.1). 

Additional information on past medical history is available on form OB-42 . 

. 

Form OB-42 includes information on childhood diseases, other diseases 

(respiratory, cardiovascular, digestive, gynecological and venereal, renal, 

endocrine, psychiatric), blood transfusions and other conditions. 

TABLE OB-6.1 




OB-6: Hospitalization 1306 

OB-6: Radiological Exams; Other Exams 2306 

0 8,310 

1 47,627 

55,937 

0 8,303 

1 47,615 

55,918 


II.A.91 

OB-6 



II.A.92 

OB-6


H 

Ḥ 

>. 

nata Ite111s Rl'fPrl'ncln:J Fnrm 

na-&, Past Ml':ltcAl Hfstorv 

DHA 

IrF:"' 

ITE14 J~ CARO 

TO FJQ~ NIIM FROio! rn DAfA TrF.M NAMF: 

3A6••••••• 1106 t 5 Cartt numbl'r (SeCJUl'nCe, for11 tVpf', form nu'lloer, revision number> 

387 ••••••• 1306 6 14 NTNOB C~Sl' number 

3AB ••• OA•6 4 1306 1'5 t6 Fnr"' ne-& d~t"" (110) 

3R9 ••• 0R•6 4 1306 17 18 Form OB•b d~tP C:Javl 

3CJO ••• OR•6 4 1306 1Q 20 ror'll nB-6 dati" (yr) 

3Q1 ••• 0R•6 5 1106 21 2t Hosoltallzat ion, number 

3IJ2ooo0R•'i II 1306 22 73 Hosoital17.at1on, nth, t llness or dlsabilltv 

3Q3 ••• oR-6 6 1306 24 25 Hoso1ta11zat1on, nth, d!ttl' ('110) 

3CJ4 ••• 0R•6 6 1306 21' 27 Hosoltallzatton, nth, d~te Cvr> 

3QS ••• OR•6 8 1306 2R 29 Hnsoltallzattnn, nth, lllness or 1tsab1Jttv 

3CJ6 ••• oR-'i 6 1106 ]I) 31 Hosoltallzation, nth, 1/ttl' {110) 

3CJ7 ••• oR-'i 6 l306 3? 13 Hosoltalization, nth, rlatl" Cvr> 

3CJ8 ••• 0R•6 8 

1306 34 JS Hosnitall7atton, 

JQ9 ••• oJ:~-6 6 

1306 ]I\ 37 Hoso1ta11zat1on, nth, illness or disability 

nth, d!ttP, (litO) 

4no ••• oR-6 6 1306 38 19 Hosoltalization, nth, dati" Cyr) 

40t ••• oR-6 8 

1306 40 41 

cn2 ••• oR-6 6 

1306 4? 43 Hosoitallzatton, 

Hosoltaltzation, nth, lllnpss or rHsah111tv 

nth, dati" (110) 

401 ••• 01\•6 6 

1106 44 45 Hosoitalizatton, nth, 

\0 

404 ••• oR-6 8 

lJOf' 41' 47 Hosoitaltzatton, nth, 

w cos ••• oR-6 6 1306 4A 49 Hnsnitalization, nth, datP {110) 

406ooo0R•6 6 1306 so 'H Hosoitali7.ation, nth, datP rvr> 

407 ••••••• llOf' 52 AO Blank: 

408 ••••••• 2306 t 5 c... r1 nurnbl"r CseCJuence, for11 tv~e, fOr'll nU'IIbl'r, revision number) 

409 ••••••• 2306 6 14 NTNOH CASP nombf'r 

tto ••• oR-6 4 2106 1'; 16 Fnrrn OR•b date ('110) 

@ 

"' 

dAti" (yr) 

lllnl'SS or rltsabllltv 

411 ••• oR-6 4 

2306 t7 18 

412 ••• 0R•6 4 

2106 19 20 Form 

Form nB-6 

ns-& rl~tl" 

dati" ("'ay) 

rvr> 

413ooo0R•6 9 

2306 21 21 

414 ••• oR-6 12-13 2306 22 22 H,.dfolo!lical Pxa:ns or 

Rit:Holoair-al PX't'IIS or treatments, number, orecedlnq 12 months 

treAtment!':, nth, tvoe, oreced1n~ 12 ~onths 

4ts ••• oR-6 10 2306 23 24 Rildfoloatcal f'XA'RS or treAtml'nts, nth, rtate, nreceding 12 months 

(mn) 

416 ••• oR-6 10 H06 25 26 Radtoloaical Pxarns or treatments, nth, date, Preceding 12 months 

(yr) 

417 ••• oR-6 

41B ••• DR-6 

419 ••• DR•6 

420 ••• 0R•6 

4?1 ••• 01'1•6 

12-!3 

10 

10 

1'-•13 

10 

2306 

2301' 

2306 

2306 

2306 

27 

2A 

30 

32 

H 

27 

29 

4?2 ••• 0R•6 10 2306 35 36 

H 

Radfo\oQic:al 

R1'111oloairal 

Cmo) 

Radioloaical 

cvn 

32 

34 R,.dloloaical Radfoloaical 

Pxarns 

PX811S 

I"XAms 

ex a ;as 

ex~t'IIS 

or 

or 

or 

treatments, 

tre1'1t'llents, 

treatments, 

or 

or tre8tments, 

treatments, 

nth, 

nth, 

nth, 

tvol', 

rtat.e, 

rtate, 

orecedinq 

nrecl'dlna 

orl'ced1nq 

12 

12 

12 

months 

months 

months 

nt.ll, 

nth, tvoe, 

rtate, precl'd1ng 

orecedlna 12 

t2 ~onths 

months 

(mo) 

RAdfoloQical exa11s or treatments, nth, date, Prl'cedlnCI 12 months 

Cvr)


l'a~ta Items R~fPrPnc1n~ fnrm ns-6, Past I'IP::tlcal History 

oara 

TrP:N 

ITE14 JN CARn 

TO FJPN NIIM fRO Ill TO DAr II TTEN NUF: 

423 ••• o~-6 

414 ••• oR-6 

4?.s ••• oR-6 

42& ••• oR-6 

417 ••• oR-6 

47& ••• oR-6 

4?.9 ••• oR-6 

4JO ••• OR•6 

4Jt ••• OR•fi 

412 ••• DA•6 

4Jl ••• oR•6 

414 ••• DA•6 

43S ••• DR•6 

416 ••• oR-6 

417 ••• oR·6 

438oooOR•6 

439 ••• 0R•fi 

• 

440 ••• 0R•fi 

441 •••0A•6 

H 

Ḥ 

)I 

• 

"' 

1?.-13 

10 

10 

16 

11 

lit 

20 

tCJ 

20 

Ill 

20 

t«< 

22 

24 

21 

24 

21 

24 

23 

2106 

2)06 

2)06 

2306 

2306 

2306 

2306 

2306 

2106 

210fr 

2106 

2106 

2106 

2306 

2106 

2106 

210fi 

2106 

230fi 

37 

]!I 

40 

42 

44 

41\ 

47 

49 

50 

St 

51 

54 

56 

57 

SA 

60 

61 

61 

64 

442 ••• 0R•6 27 2306 66 66 Transfusions 

441 ••••••• 

2106 67 

49CJl •••• VAR 1?.-13 

14 

!i207 •••• VAR 

'5208 •••• VAR 

52R9 •••• VAR 

27 

12-13 

5 

316 

317 

Hq 

31 R"::tlotoatcal I! X

z 

PAST MEDICAL HISTORY 

(Interviewer) 

Z. HISTORY TAKI!N BY I, 

4. DATI! 

..... 1 o.,•v.... 

I 

I 

I 

I 

I 

I 

S. UST HOSPITALIZATIONS I NOT LISTED ON 0 ..51 

0NONE 

Ill 

IZI 

IJI 

141 

I. DAr~ 

..... I'•• 

I 

I 

I 

I 

I 

I 

I 

I 

(51 I 

! 

7. HOSPITAL (N-• •rl A"*-••J 1. REASON 

t. RADIOLOGIC EXAMINATIONS OR TRIATMINTS DURING PAST 12 MONTHS (l.4ot oedt) ...JNONI! 

ox 

10. DATI! II. 12. II. OTHER TYPE Ofl' EXAMINATION OR 14. 

I •••cc CHEST 

lifo. r- TREATMENT (OI!SCRIBI!I GIVE SITE REASON, RESULT lfl' KNOWN 

~•ceMAIICT X• RAY 

l 

Ill 

I gNo QYIES 

0 0 

I 

QYIES 

I 

I 

IZI I QNO QYIES 

0 0 

I 

9 

QYIES 

l 

I 

QNO L;J YIES 

·~· I 

y 

I 0 0 li1 

I 

OYIES 

I 

141 L:J YIES 

I QNO 

'-; 

I 

0 0 

ovu 

' 

15. OTHIR RADIOLOGIC IXAMINATIOMS OR TRIATMINTS (Prlo••• ,_, 12 _...., 

II, CHI!ST X.RAYS 17. OIENTAL X.RAYS: Clfl' UNUSUAL PROCIEOURIES OR NUMaiER, OIESCRIIIII 

TOTAL NUMaiER 

DURING Llfi'IE 

IIEXCIPT THOSI 

USTID AaOVLI--- 

TOTAL NUMIIER Ofl' 

IEXAMINATIOHS DURING 

Llfl'l IIXCIPT THOll 

LISTID ABOVLI--- 

.. EXAMINATIONS AND TRIATMIMTS OP IXTRIMITIIS (l.4ou 

11. YEAR zo. TYPE OR PROCIEOURIE AND SITE Zl. REASON, fi'INDINOS lfl' KNOWN 

9NONI 

l 

I 

:ZZ. ALL OTHIR EXAMINATIONS AND TRIATMINTS MOT IMUMIRATID AIOVI (l.loC) 

u. YEAR I 24. TYI'IE OR I'ROCIEDURIE AND SITE 

I 

I 

~NONC 

COLLABORATIVC ft.S.AJICH 

.. ERINA TAL RCI.AftCH ... A.NCH, NINDa, NIH IREV. 11-t• (QB-6) PAOI 1 Ofl' Z 

BCTHESDA ,., MO. 

II.A.95 

OB-6 


.. 

• 


(Interviewer) 

~. TNNIII"UIIONI 

ZL DATil & NllAION JO. NllACTION 

lifo. Yr. 

QNONII 

0 

m 

QNONK 

0' 

CJNONE 

121 0 

Ill 

QNONII 

0 

II. •LOOD TUTI TAICIEN 

l2. DATE ILNilAION 34. IIIESULT 

lifo. Yr. 

g_NONE 

Ill 

(ZI 

(JI 

(41 

(II 


H 

H 

• 

• > 

\0 

...... 

@ 

I 

0'1 

~orm Ite~ Numb~rs ltn~Pd to nata Items on nB-&, Past uejtcal H1storv 

ITEU 

I'IATA 

nN TTF:M CARll 

FORM rn ~liM FROM tn DATA TTF.:I4 ~ANF. 

4 

uq•• •na-6 1306 17 18 Form 

4 

411 ••• 08•6 2306 17 18 Form nB-b datP (dayl 

08•6 d~t~ (jay) 

4 3811 •••1J8•6 1306 1S 16 Form ns-6 dAte ('110) 

4 410 ••• 08•6 2306 1'5 16 Form 08•6 dAtP ('110) 

4 390 ••• 08•6 1306 tQ ?.0 Form na-6 datP Cvr> 

4 412 ••• n8-& 2306 19 20 Form na-& date (yr) 

r; 391 ••• ns-6 1306 21 ?I Hnsnitalizatlon, nu~ber 

'5 570Q •••• VAR 318 318 Hosnltalizations 12 months or 'IIOrP prior to study, total nulllber 

6 40'5 ••• 08•6 1306 411 49 Hosoltallr.attnn, nth, d8te (mo) 

6 Hfi ••• 08•6 1306 30 H HosoH all zat lon, nth, date (:n('l) 

6 4o2 ••• n8-& 1306 42 43 Hosoitaltzation, nth, cil'ltP (110) 

6 

3 93 ••• n8-6 1306 24 ?5 Hosottaltzatlon, nth, 

6 

397 ••• na-6 1306 32 33 H~soltattzatlon, nth, date 

dl1te (Tin) 

Cvr> 

6 

406 ••• 08•6 1306 50 51 Hospltaltzatlon, 

6 

403 ••• 08•6 tJo~; 44 45 Hospitalization, nth, nth, 

d&te cl8tP. (yr) 

6 

400 •• • 08•6 1306 3R 19 

6 

394 ••• os-6 1306 26 ?7 Hosottalizatlon, 

Hosottatlzation, nth, 

nth, date d8te Cvr> 

6 39Q ••• 08•& t 306 36 17 Hosottaltzation, nth, date, (mol 

8 404 ••• 08•6 1306 46 47 Hosoltalization, nth, illness or ~isabilitv 

8 401 ••• 08-6 1301; 40 41 Hospitalization, nth, illness or disabllltv 

8 392 ••• o8-& 1306 22 23 Hosoitaltzatlon, nth, iJlne5s or dlsabllity 

8 398 ••• 08-6 1306 34 35 Hosoitalization, nth, illness or disability 

R 39'5 ••• 1JB•6 13011; 2R 1.9 HCisoltallzatton, nth, illness or ~lsabllity 

q 413 ••• 08•6 2306 21 71 Radtolooicat PXa'IIS or tre8tments, nnmher, orecedlnQ 12 months 

to 421 ••• 08•6 2306 H 34 R~tdtolo'llcal Pxa•s or treatments, nth, riate, prececllno t2 months 

(mo) 

10 41A ••• 08-6 2306 211 ?9 Radfoloolcal ex8ms or treatments, nth, date, orecedlna 12 months 

(1110) 

10 4t"i ••• o8-6 2306 2l 74 R~tctfoloatcal exams or tre~tments, nth, date, orecect!nQ 12 months 

(1110) 

tO 424 ••• 08•6 2306 ]R 39 Radlolo~lcal ex&IIIS or treatments, nth, date, precedlna 12 months 

Cmo) 

to 422 ••• 08•6 2306 35 36 Radloloatcal exams or treatments, nth, riate, precedlnq 12 months 

cvr> 

1 0 416 ••• os-& 2106 25 76 Radtoloolcal ex ... ~s or treatments, nth, dlllte, orecedinq t2 months 

cvr> 

to 425 ••• 08•6 2306 40 41 Radfoloatcal exams or treatments, nth, date, precedtna 12 months 

(yr) 

10 4t


F'orm Ite"' ~u'llbPrs llniCPd to nata Items on 01:3-6, Past N~>:lfcel Htst:>rv 

ITE"' 

OATA 

nN TfF'M CARO 

rnR-. 10 NIIM fROII4 TO o~ra 

. 

TfF'M NAMF. 

12-11 417 ••• ns-o 2306 27 11 k~:tlolo~lcal exa~s or treAtments, nth, tyoe, orececH nq t 2 months 

12-B 423 ••• I")S-6 2306 37 l7 ~,.:1folootral f'X~'IIS nr tre,.tments, nth, tvoe, nrPcedlna 12 months 

12-11 4t4 ••• ns-& 2306 2? ?2 Ra:Holocrlcal PXIUIS Of treatments, nth, tyoe, precedina 12 months 

12-11 42n ••• na-& 210fi 3? 12 1-!adfoloolcal Pxams or 

treatments, nth, tvoe, orecedfna 12 months 

16 42fi ••• ns-& 2306 4? 43 1-!AdfoJoolr.al PX,.'IIS or treAtments, other, number of; chest x-r11vs 

17 427 ••• ns-6 2306 44 45 Rl'l:tfoloalcal exa"'s or treatments, other, number of; dental x-ravs 

tB 42A ••• 'lB-6 2306 .. ,. 46 Elftre"'it les, PXA'IIlnattons and treatment, numher 

19 43'2 ••• n8-6 2306 51 c;2 Elftremlt1Ps, P.XIUitnattons and treat111ent, veAr 

19 43() ••• llB•6 2306 4A 49 Extrem1t1Ps, PXa~tnatfons and treatment, vear 

19 414 •••na-& 210" 54 55 ~xtremttles, exa111tnattons and treat•ent, vear 

20 43t •••OB•6 230~ sn ~o Extre-tttea, exa•lnatfons an:l treat•ent, type 

1.0 42q ••• '18•6 2106 47 47 Extre•tttes, PXI!I~f.nattons and treat'llent, tvoe 

10 4H •••OB•b 230fi 53 53 F.lfttelllitlf's, PXI'I~lnatfons and tre111t•ent, t.voe 

72 43'5 ••• 08•6 2306 56 c;6 F.Yaminatinns, other, number 

?3 441 ••• 08•6 2306 64 65 Elfallltnations, other, vear 

H ?.3 437 ••• nB-6 HOt> 5A 59 Examinations, otner, year 

H 7J 439 ••• 08•6 2l0fi 61 62 Examinations, other, vear 

0 

'24 436 ••• nB-6 230fi 57 ">7 Exa~~ttnattons, othPr, tvoe 

)II 

"' 

0 

HR ••• nB-6 2306 &n 60 Exa111tnat1nns, othf'r, tyoP. 

\0 

co '24 441)ooo08•6 2306 61 1>3 Ell'a•Jn~ttlons, other, tvoe 

17 44? ••• 08•6 2106 66 66 Transfusions 

1.1 5'207 ••• oVAR Hli 316 Transfusions 

@ 

~

DEF'll'UTION OF CODES 


FOBM OB-6 CABD 1306 

CABD 

COIDMN 


Code: 1 


Code: 306 

3· Revision Number * 

Code: 0 - Form Dated: 

1 - Form Dated: 

1/59 

Rev. ll/59 

4. :NllmB Number 

Item 1 



5· Date Form Completed 

Item 4 

Six-digit code for month (co:ls. 15-16), 

day (co:ls. 17-18), and year (co:ls. 19-20) 

Code: 

As given 

99 -Month., day and/or year unknown 

6. Number of Hospitalizations 

Item 5 


1-7 - Number reported 

8 - 8 or more 

9 -Unknown 

1 

2-4 

5 

6-14 

15-20 

21 

7- HOSPITALIZATION - I 22-27 

nlness or Disability ( cols. 22-23) 

Item 8 

Code: See Attacbment, "Illness or Disability 

Codes", page OB 5-10 

Date (co1s • 24-27) 

Item 6 - 

Four-digit code for month (cols. 24-25), 

year (cols. 26-27) 


0000 - None 

99 - Month a:o.d/or year unknown 

Note: O's in entire field • no hospita~zation 

* Item numbers refer to Form Dated: ll/59 

and 


II.A.99 

OB-6

DEFINITION OF CODES (Continued) FORM OE-6 

Card 13C6 

FIELD 

CARD 

COLUMN 

8. HOSPITALIZATION - II 28-33 


9· HOSPITALIZATION - III 


34-39 

10. HOSPITALIZATION - IV 4o-45 


ll. HOSPITALIZATION - V 46-51 


Note: 

A hospitalization may be recorded in any of the five 

fields; therefore, all fields must be checked for data. 


II.A.lOO 

OB-6

DEF'INli'ION OF CODES (Continued) 

FIELD 

FORM OB-6 

Card 23o6 

CARD 

COIDMN 

l. Card Number l 

Code: 2 

2. Basic Data* 2-20 

Code: Same as columns 2-20 of Card l 

Number of Radiological Examinations or 21 

Treatments During the Past 12 Months 

Reported on Different Dates 

11 

(Rev. 1 11 only} or 

Number of Radiological Examinations or 

Treatments Reported on Different Dates 

11 

(Rev. 0 11 only} 

Item 9 

Code: 

0 - None 

1.-7 - Number reported 


9 -Unknown 

4. RADIOLOOICAL ElCAMINATION OR TREidMENT - I 22-26 

Chest X-Ray and Other Type of Examinations (col. 22) 

Items 12 and l3 

Code: 

0 - None 

l - ~erapeutic radiation of abdomino-pelvic 

region with or without chest X-Ray 

2 - Diagnostic radiation of abdomina-pelvic 

region With or without chest X-Ray 

3 - Therapeutic radiation of other and 

unspecified regions with or without chest 

X-Ray 

4 - Diagnostic radiation of other and unspecified 

regions with or Without chest X-Ray, chest 

X-Ray only 

5 - Unknown if diagnostic or therapeutic of 

abdomina-pelvic region with or Without 

chest X-Ray 

6,- Unknown if diagnostic or therapeutic of. all 

other and unspecified regions with or without 

chest X-Ray 

9 -UnknoWn. 

* Unless specified, Fields, Codes and Card Columns refer to Revisions "O" 

and "l". Item numbers refer to Form Dated: ll/59 


II.A.lOl 

OB-6

DEFINITION OF CODES (Contiwed) 

FIELD 

Date of Radiological Examinations or 

Treatments During the Past 12 Months 

Item 10 

Four-digit code for month (cols. 23-24) 

and year (cols. 25-26) 


0000 - None 

99 - Month and/or year unknown 

Note: O's in entire fie1d = no treatment 

5- RADIOLOGICAL EXAMINATION OR TREMMENT - II 


6. RADIOLOOICAL EXAMmATION OR TREidMENT - III 


1· RADIOLOOICAL EXAMmATION OR TREMMENT - IV 


FOIM OB-6 

Card 23o6 

CARD 

COIIJMN 

27-31 

32-36 

37-41 

8. Number of Chest X-Rays 

Item i6 


01-97 - NUmber reported 

98 - 98 or more 

99 -Unknown 

g. Number of Dental X-Rays 

Item 17 


10. NUmber of Examinations and Treatments 

11 

of Extremities (Rev. 1 11 only) 

Item 18 

Code: 

0 - None 

1-T - Actual number repoL~ed 

8 - 8 or more reported 

9 - Unknown, not on Revision "O" 

44-45 

46 

OB 6 - 4 


II.A.l02 

OB-6


u. ElCAMINATION AND ~ OF EXTR:EMITIES - I 

(Rev. "1" only) 

Type or Procedllre and Site (col. 47) 

Item 20 

Code: 

0 - None 

1 - Therapeutic radiation of abdominope1vic 

region with or without chest 

X-Ba.y 

2 - Diagnostic radiation of abdominope1vic 


X-Ba.y 


unspecif"ied regions with or without 

chest X-Ba.y 

4 - Diagnostic radiation of" other and 

unspecified regions with or without 

chest X-Ba.y, chest X-Ba.y only 

5 - Unknown if diagnostic or therapeutic 

of abdomino-pe1vic region with or 

without chest X-Ba.y 


of other and unspecified regions with 

or without chest X-Ba.y 

9 - Unknown, not on Rev. "o" 

Year - EXamination and T.reatment of Extremities 

(columns 48=49) 

Item 19 


00 - None 

99 - Unknown, not on Revision "O" 

Note: O's in entire field • no treatment 

12. :J!:XAMINAnON AND TRFA!IMENT OF EX'!'Rl!MITIES - II 

(Revision 11 1" onl.y) 

Code: Same as in Field ll 

13. EXAMINATION AND TBEA!lMENT OF EX'TB!MITIES - III 

(Rev. "i" only) 

Code: Same as in Field ll 

FOIM OB-6 

Card 2306 

CARD 

COIDMN 

47-49 

50-52 

53-55 

II.A.l03 

OB-6 



FIELD 

FORM OB-6 

Card 2306 

CARD 

COIDMN 

14. Number of A~~ Other Examinations and Treatments 

Not Enumerated Above (Rev. 

11 11 

~ only) 

Item 22 

Code: Same as in Field ~0 

15. Other EXaminations and Treatments - I 

(Rev. 11 ~" only) 

57-59 

Type of Procedure and Site (co~. 57) 

Item 24 


~ - Therapeutic radiation of abdominapelvic 


X-Ray 

2 - Diagnostic radiation of abdominapelvic 


X-Ray 


unspecified regions with or without 

chest X-Ray 

4 - Diagnostic radiation of other and 

unspecified regions vith or vithout 

chest X-Ray 


of abdomino-pe~vic 

region with or 

without chest X-Ray 


of other and unspecified regions with 

or 'Without chest X-Ray 

9 - Unknown, not on Revision "o" 

Year - Other Examination and Treatment 

( cou. 58-59) 

Item 23 

Code: A.s given 

00 - None 

99 - Unkno"Wn, not on Rev. "O" 

Note: O' s in entire field = no treatment 

~6. Other Examinations and Treatments - II 

(Rev. "~" only} 

Code: Same as in Field ~5 

60-62 

II.A.l04 

OB-6 


DEFINITION OF CODES (Continued) FOOM OB-6 

Card 2306 

FIELD 

CARD 

COLUMN 

17. Other Examination and Treatment III 

(Rev. 11 1 11 only) 


18. Transfusions 

Item 27 


1 - One or more transfus"ions reported 

9 -Unknown 

66 


II.A.lOS 

OB-6

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... 1::: 

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II.A.l06 

OB-6 



0 

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-- 

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l CRlD /JINDB.:II )fie Dan& Dl1f: )IIi ; 

# ~ ' 

4 

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--- 230(, q,: 

-- 

' 

,_ I 2 l 4 I ' J I 9 10 II 12 ll I 15 I 111 

* Item nwnbers refer to form dated: Rev. ll/59 


FOR-i OB-6 

~ 

01-) 

1.. 

- 

- ~OJ.IIA il 

1 

' 

,, ,, 

1- 

X t--- lil4 - j6TitiOTfiiTllf ~~-16Jr II 1tj I ri :n 24 n ~ 2i 21 29l0ll i2 jj]05]6 11 :ii1t.Oii 4211 u4s 6 ir 4119 111 sTizsJ ~ 16 ~~ 

...,.. 

--- 

5'Cfltii111IITIOII'S a•t 

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- RRIILOGICil EXI\MS DRTR£1\lmJTS 

oF i""TRr.;~aTiiS Uflkl aumo~ 

I 

ttMI'LI1lD 

1- 

R 4 9~ IO 10 /0 ,, I 'I ~ 19 ~ 19 Z3 .:/3 ~ -13 

z :t lL m. -:m: I'Nil 

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liw 60 ffi, n 646 - Tiliilili1Jnu 751611 Ji79i0-- 

u 

BLANK 

6 r o" 10 n n n 74 rs n !!11 '!_~ ____ 

9. 

0'1

PAST MEDICAL HIS'roRY 

(For Form OB-6, Rev. 11-59) 

rnSTRUCTIONS FOR INTERVIEWli 

Item 2. 

"History Taken Bv" Write your first and last name clearly. 

Item J. This space is for Central Office use. 

Item 4. 

"lak" Record the· date this history was obtained. 

Item 5. "List H9spitalizatipns 11 Include here all hospitalizations which were not 

listed on OB-2 or OB-5. This will include all hospitalizations (not for 

previous pregnancy) which occurred more than one year ago. Admissions to 

sanitaria and mental hospitals should be reported here (or on OB-5 if 

occurring during the past year). If there were no such hospitalizations, 

mark the box for ''None. 11 

Item 6. 

Item 7. 

Item 8. 

"~"Record the patient's best approximation or month and year. 

"Hospital" Record the name and address or location or the hospital, with 

sufficient accuracy, it possible,. to establish a mailing address. If at 

this hospital, or a~ associated hospital using the same record room, 

record "Here." 

"Reasgn" Determine the diagnosis or complaint if possible. Inquire 

specifically about any op~ration that may have been performed and note the 

procedure here. 

Item 9. 

"Radiologic EIAm'n•tiOl.,;, .2r Treatments During Past 12 Months" This includes 

the diagnostic use ot radioisotopes. A history or X-ray since L.M.P., noted 

on OB-J, should be reported here also. It need not be described in detail 

on OB-J, but should always be described here. 

X-rays obtained through this obstetric clinic after the patient is 

registered in the Study should ~be reported either here or on OB-J, but 

only on OB-10, 11, ana other appropriate clinical records. 

If the patient reports no radiation exposure in the 12 months preceding 

date of registratiop in the Study, check the box marked "None." 

Item 10. 

Item 11. 

Item 12. 

"~"Record month numerically and year in two digits ('60, 1 61, etc.). 

"Singe Pregnancy" It the exposure was before LMP (or estimated date of conception 

it LMP is not related to onset or pregnancy), mark "No." If after 

LMP, mark ''Yes." 

"Chest X-Ray" Mark. "Yes" if the exposure was a routine chest x-ray (either 

standard or miniature film). In this case items no. lJ and 14 should be 

left blank. 

Mayl961 


II.A.l08 

OB-6

PAST HEDICAL HISTORY (Con't) 

Item 12. "Chest X-Ray" (Con 1 t) 

OB-6 

Rev. 11/59 

For chest X-ray other than a routine plate, mark ''Yes" in item no. 

and complete items 13 and 14. 

12, 

Item 13. 

"Other Type of Examination or Treatment" Mark the box in this item if 

exposure did not consist solely of diagnostic chest films. Describe 

as fully as possible the type of exposure, number of plates, and site. 

Item 14. Reason, Result: Describe these briefly if known to the patient. 

Note: It is important that the record give the location (for mailing) 

of the physician or hospital from which X-rays were obtained during the 

previous year. If this is not specified on OB-3 or OB-5, note it here. 

Item 15. "Other Radiologic Examinations or Treatment~" The rest of this page of 

the form summarizes all radiation in the gravida's lifetime, exclusive 

of the 12 months preceding the interview. 

Item 16. 

Item 17. 

Item 18. 

Item 22. 

"Chest X-Ravs" Record the patient's best estimate of the number of 

examinations. (Not the number of plates.) If none, enter "0." 

"Dental X-Ravs" Record the total number of times the patient has had 

dental X-rays, An unusual type or amount of dental X-ray should be 

described in this space. 

"Examinations and Treatments of Extremities" This includes all diagnostic 

and therapeutic X-rays of hands, feet, arms, and legs. If for fractures, 

type of procedure and findings need not be recorded. If this radiation 

of extremities occurred with radiation of other parts of the body, such 

as the shoulder, hip, etc., record only in item #22. 

All Other Examinations and Treatments This includes fluoroscopy, G.I. 

series, X-rays of head, neck, shoulder, and head of the femur, use of 

radioisotopes, etc., not done during the past 12 months. 

Item 25. Reason, Findings if Known This item number and title does not appear on 

the form. Describe the reason and findings in the right-hand column under 

item #22. 

Item 27. "Transfusions" Includes any transfusion ever given the gravida. Use one 

line for each series of transfusions (i.e., those given over a brief span 

of time for the same season). 

Item 30. 

"Reaction" If the patient reports 

or shock, mark the box "None." 

no acute reaction, such as hives, fever, 

Item 31. 

Item 33. 

"Blood Tests Taken" Do not record tests given in the prenatal clinic after 

the patient is registered in the Study. 

"Reason" If illness was 

the test, if possible. 

"pregnancy," etc. 

suspected, be as specific as possible and identify 

For routine serologies, record simply "marriage," 

February 1959 


II.A.l09 

OB-6

PAST MEDICAL HIS'roRY (Con't) 

Item 34. 

"Result" List such terms as "negative," "positive," "diabetes," etc. 

OB-6 

Rev. 11/59 

Item 35. Series of Injection~, Include aey series of injections or "shots" taken up 

to the time of this interview. 

Item 37. 

"Reason" Record the substance given, if known, such as "triple toxoid," 

"Salk vaccine," "course of penicillin," etc. Also report reasons in such 

terms as "routine inlllunization," "upper respiratory infection," "syphilis," 

etc. 

February 1959 


II.A.llO 

OB-6



(I~) 

-~ ~ 1/-.5"'1 ~- 

DATE (Mo-DrrYrJ 

I. LIST HOSPIT ALIZATIOHS (Not U.t..l 011 08·" • 

u.,. .r..........,. ~.- ,_,..-~,.,__ ,.~ ,,....,••....,. __,.,..,._..... ,.,_,_,, 

~ 

DATE HOSPITAL (N- MJ AM~M..J REASON 

I. 

. 

2. 

3 • 

... 

-- 

. 

- 

- 5. . 

.. 

DATE n"lle fW EXAMINATION OR TREATMeNT RI!ASOM 

1. ; 

2. 

3 • 

... 

5. 

6. 

T • 

•• 

o.-. ollteelth, e..--.......... 

....... H.oolth -.... 

(OW) .,,..11: 1 o" a 


II.A.lll 

OB-6


(llltmli-) 

~ ~ /!-59/l.£y"· 

DA.TE 

lti!AICIM 

1. TRAHSPIISIOMI 

REA.CTION 

1. 

2. 

3. 

DATE 

tiL ILOOD_ TI!ST TA_KII 

RI!SULT 

I. 

2. 

3 • 

.. 

s. 

. ... 

6. 

. ·'·' 

··-~ ·. ·: ·\.:: :.~ "'· 

·- .•' -~-· } .. · • . 

·. '· 

7. 

... ·-·. 

·~·- .... 

DATE 

ReACTION 

1. 

...~· 

. ~ ·... 

.i ~ 

2. 

·.:'- 

:J. 

~ 

...__ :} ·:-' 

..-... 

5 •. 

6. 

7-.. 

--- 

(08-6) "••o: • oor • 


II.A.ll2 

OB-6

OB-7 

Infectious Disease and System Review 

Form OB-7 was designed to collect data on infectious diseases and other 

conditions that might affect the body systems. The physician and interviewer 

worked together to establish as complete a medical history as possible within 

the limits of the study. First used in February 1959, the form was not revised. 

Records generated by the form totaled 53,233 and were keypunched on card 0307 

of the master file (Table OB-7.1). 

TABLE OB-7.1 



CAro NAME NUMBER NO. RECOroS 

OB-7: Childhood Disease, Other 

Infectious Disease and Parasitic 

Diseases 

0307 

0 53,233 

53,233 

tota I for form 53,233 

II.A.ll3 00-7 


II.A.ll4 

OB-7 



H 

H 

• 

>. 

...... 

...... 

l11 

B 

~ 4RO ••• DR•7 

4Rt ••• OR•7 

4R2 ••• 0R•7 

48l ••• uR-7 

tfl4 ••• ol'l-7 

49s ••• oR-7 

Oata Ite'lls RPff!rencinc, For"' nB-7, Tnff!cttous Disease a~1 System Peview 

OAT I\ 

TTF.114 

ITE"' JJI CI\Ril 

TO F'JRM NIIM FROM rn OArA lTF.N NAMF 

444 ••••••• 

0307 t 5 CIHi number (sequf!ncf!, for11 tvpP, for'll number, revision· nullbf!r) 

445 ••••••• 

0307 6 14 NTNOB C~SP numbf!r 

446 ••• oR-7 0307 1"i t6 Form na-7 d~tP (!110) 

447 ••• 01'1-7 0307 17 t8 ~nr111 nR-7 d~te (:t8y) 

448 ••• oR-7 0307 19 ?o ~or"' ns-7 d~te (yr) 

t49 ••• oR-7 1 0107 2t 21 C~ll:t~oo:t dlsP.ases: of!rtussls 

450 ••• 0R•7 l 0307 2' 23 C~il:thoo:t diseases; oertussts, 8:1@ onsf!t 

4~t ••• oR-7 1 0107 24 ?4 C~il~hoo:t dtsf!ases: chicke"' oox 

4o;2 ••• oR-1 1 0307 25 ?6 C~1l:thoo:t diseases: chiCkPn POX, ac,e onset 

to;l ••• oR-7 1 0307 27 11 C~ildhood diseases: 'IIUIIIPS 

4"'i4 ••• oR-7 1 0307 2A ?9 C~il:t~oo:t diseases: 11UIIIOS, a:te onset 

4'55 ••• 01'1-7 1 0307 30 30 Child~oo:t disPases; rubf'll:t: Ger11an rnPaSlf!S 

4'56 ••• oR-7 l 

0307 lt 32 Chil:thoo:t dtsPa~e$; 

4'57 ••• oR-7 1 

0307 33 33 C~ildhoo:t diseases: 'llt"aSlf!S 

rubell!; GPr11an measlP.s, aqe onset 

4'58 ••• 01'1-7 1 

0307 34 35 Childhood diseases: 11eastes, aqe onset 

459 ••• oR-7 1 

0307 36 36 C~il:t~oo:t diseases: diohtherh 

460 ••• 0R-7 1 

.0307 ]7 J8 Chlld~oo:t diseases: :tto~t~eril'l, aqf! onsf!t 

tfit ••• oR-7 1 

0307 H 19 C~il:t~on:t dtsPases; scarlet fPYf!f 

4fi2 ••• oR-7 t 

0307 40 41 Chlld~ood diseases; scarlet fPYf!r, AQe onset 

4fi3 ••• oR-7 2 

0307 4? 42 Infectious ~tseasesr oolio11Vel1 tis 

464 ••• 01'1-7 2 0307 41 44 I~fPctious diseasPs: ootio11velitis, aQf! onset 

4fi5 ••• oR-7 2 0307 4"i 45 Infectious diseases: herof!s stmolex 

466 ••• 01'1-7 2 

0307 46 47 Infectious ~iseases: 

4~7 ••• 01'1-7 2 

0307 411 48 InfPcttnu~ rtiseasPS1 heroPs sl'llolex, 8qe onset 

neroPs zoster 

46B ••• OR•7 2 

0107 4Q so Jnt~ctlous ~iseases: neroes zoster, aqe onset 

4fi9 ••• 0R•7 2 

0307 51 'H Infectious ~lse~s.-s: encer~halltfs 

470 ••• 01'-7 2 0307 5? S3 Infectious ~lse~tses: enceohAlftfs, "Cie onset 

47t ••• oR-7 2 0307 54 ~4 Inff!ctlous 1iseasPs: 111enin~lt ts 

472 ••• 0~-7 2 

0307 

5~ '56 Infectious ~~~eases: 'llentn:::Jttts, aqe onset 

473 ••• DR•7 2 

0)07 57 ~7 Infectiou~ ~iseases: toxoPlAsmosis 

474 ••• oR-7 2 

0307 59 S9 Infectiou~ rti~easPs: tO'IrODlltSIIIO~iS, aqe onset 

475 ••• 0"'•7 2 

0307 60 60 Infectious ~ise~ses, tst other, tvoe 

476 ••• oa-7 2 

0107 61 ~2 Infectious ~iseases, 1st other, !IQe onset 

477 ••• 01"-7 2 

0307 6] 63 IntPctlous ~iseasf!s, 2no1 ot~er, typ@ 

478 ••• DR-7 2 

0307 64 65 Infectious ~lseases, 2no1 ot~er, aqe onset 

479 ••• 01'1-7 2 

0107 66 66 InfPctiou~ ~ise"ses, Jrd other, tvoe 

2 

3 

3 

3 

3 

3 

0107 

OJ07 

0307 

0307 

0307 

0307 

67 

69 

70 

7'2 

n 

75 

68 

69 

71 

72 

74 

75 

Infectious 

Infectious 

Infectious 

Infectinus 

Infectious 

IntPctious 

diseases, 

diseases: 

~iseAses: 

diseases: 

rtiseases: 

111seases: 

3rd other, aqe 

oarasitic 1st, 

oarasttic tst, 

parasitic ?.nrt, 

paraslt.ic 2nd, 

oarasttic 3ro1, 

onset 

tYPP 

ac:te onset 

type 

arJe onset 

tvoe


nata Items Refer@ncin~ fnr~ ns-7, Tnfectlous Ots~ase anj System Review 

Dll'fl\ 

ffEM 

ITE'C :J~ Cl\RO 

TD F'JIU4 NliM fROM TO OA fA Tff.M NAMF. 

4116 ••• oP-7 3 0107 76 71 Infectiou~ ~tse~ses: oarasltlc lrd, a~e onset 

4f'7 ••••••• Ol07 7A PO ~lank: 

H 

H 

>• ..... 

..... 

0\ 

@ 

I 

.....

COLIII.•I00 ..7 

,... 

INFECTIOUS DISEASE AND 

SYSTEM REVIEW 

NAME OF PHYSICIAN 


I 

NAME OF INTER VI EWER I 


DATE HISTORY TAKEN 

DATE HISTORY TAKEN 

PHYSICIANs INQUIRE ABOUT EACH ....~0... AGE DIAGNOSIS 

DISEASE LISTED NO TOI .... ONSET WARRANTED? 

Ill 

w"' 

J: 

"' 

> 

"' w 

I. CHILDHOOD DISIASI!S 

PERTUSSIS 

CHICKEN POX 

MUMPS 

GERMAN MEASLES 

MEASLES 

DIPHTHERIA 

SCARLET FEVER 

~ 

Cl 2. OTHER IMP ECTIOUS DISEASI!S 

w POLIOMYELITIS 

Ill 

HERPES SIMPLEX 

"' w 

. 

HERPES ZOSTER 

ll: 

w ENCEPHALITIS 

MENINGITIS 

.... TOXOPLASMOSIS 

~ OTHER (Specify) 

DESCRIPTION AND COMMENT 

~ 

1 PARASITIC DISI!ASI!S 

(S~ty) 

INTERVIEWER'S SECTION 

CHECK ..,d describe if a positive hiatary Ia obtalnecl. 

... RESPIRATORY SYSTEMa Ever have trouble with Our 0 Chronic Bronchitis 

breathing 0 ? Trouble with ad.,oida or tanaih ? 0 Bronchiecsoaia 

Pn-monia 0 ? Have many colds a y- 0 ? Do you 

have a p•aiatent cough 0 ? 

PATIENT'S COMMENTS: 

PHYSICIAN'S SECTION 

CHECK and describe each diagnosis mode. Establish as closely 

aa pouible the date of onset and duration 

0 Tuberculosis 

0 Pneumonia 

OOther 

5. ALLERGIES. Ever hod hay fever 0? Asthma 0? 0 Asthma 

Hives 0 ? Food allergies 0 ? Drug a.,aitivltiea 0 ? 0 Hay Fever 


0 Hives 

0 Food lntaler..,ce 

0 Drug or Serum S..aitlvity 

OOther 

6. SKIN AND CELLULAR TISSUEs Ever had a rash or akin 0 Chronic Cellulitis 

breaking aut 0 ? s-u.. ,....d. 0 ? s-lllng ...y where 0 Chronic D .....alitia 

else 0? Ecz-o 0? Bolla 0? 

0 Chronic Acne 


0 Psoriasis 

OOther 

COLLA.OIItATtVK "KSIKA..CH 

.II:THIUDA t•• NO. 

I 

l 

I 

(QB.7) ""Gl! , ol' ! 

i 

! 


II.A.ll7 

OB-7

coL,...aoo•? 

•••• 

INFECTIOUS DISEASE AND 

SYSTEM REVIEW 


7. DIGESTIVE SYST!MJ Ever b.., put on o .,eciol diet 0? 0 Ulcer 

Ever hod ulcers 0 ? Stamoch troulllo 0 ? J-dlco 0 ? 

Ever had any trouble with your bo-Is? 0 ? 


0 Chronic Diorrhoo 

0 Ulceroth•o Colitis 

0 Cholecystitis 

0 Cholelithiasis 

OOther 


8. GEMITO.URINARYt Ever had any troulllo with your 0 Syphilis 

bladder 0 ? Buming 0 ? Hurt to empty 0 ? Kidney 0 N!isaerian 

trouble O ? Infections 0 ? Blood In owlno 0 ? GraYOI 0 N.,hritls 

or stanos in uri no 0 ? Evor any infocti.. of your tubes 0 Nephrotic S,ndromo 

or ovarioo 0 ? Inflammation of g.,it..s 0 ? 

0 Hydronophouia 


0 Nephrolithiasis 

0 Recurr.,t Pyolonophrltls 

0 Recurr.,t Cystitis 

0 Chronic S.lpingo-Oophoritis 

0 Other 

I 

9. CIRCULATORY SYSTEMI Ever hove any troulllo with 0 C.,.oatlvo H-rt Failure 

your heart O ? Ever ha¥0 trouble gottt,. ,.ur llreoth whon 0 Rheum•ic Heart Disoose 

your heart boats fost 0 ? Any trouble with hlth bloo.t 0 Myocer

C:OLft-IOOa-7 

1··· 

INFECTIOUS DISEASE AND 

SYSTEM REVIEW 


12, RADIATION: Ever had radium tr-montQ? X·Ray 

treehllantQ? Radto-iaot--0?·-- -- --- -- 


13. ENDOCRINE: Ever had thyroid trouble 0? Evot had a 

thyroid toot 0? Ever talcan thyroid 0? Ever had 

diaboteo 0? Ever telcon harman .. 0? 


0 Radium Therapy 

0 x--Ray Therapy ·-- · · ··· 

0 Radioactive loatope Treat-nt 

0 Hypothyroidiom 

0 Hyper:thyroid iom 

0 Thyroiditlo 

0 Diabetoo Mollituo 

QOther 


I 

14. BONES, JOINTS, MUSCLES: Ever had ooro or owallon 

jainto 0? Rh.......,tiom 0? 


O Arthritio 

QJoint Oiooaso 

QRickoto 

QOther 

I 

15. NEUROLOGICAL: Ever fainted or last consciousness 0? 

Ever had canvuloians 0? Fits or opes111s 0? 

Epilepsy 0? Paralysis 0? Da you have corobral 

palsy Q? Any trouble -i119 or h-int O? 


0 Cerebral Paloy 

0 Convulsive Disorder 

QBIIndnou 

QDeafneso 

QOther 

1 

16. BIRTH AND INFANCY: Old you have any difficulty In tho 

first faw 111antho of lifo 0? Convulsions 0? Jaundica 0? 

How -ch did you woith?___Was there anythint unusual 

about your 111ather's pro1nancy ouch as convulolans 0? 

BIHdint Q? Was there anythint in y- bady that wasn't 

fa,.., ritht whan you w.,. born 0? 


0 Etythroblastoslo 

0 Pro111atutity 

0 Birth Injury 

0 Other condition nat llotod 

CONGENITAL MALFORMATIONS 

0 Cardiac Malfor111ationo 

0 Coarctation of A- 

D Cleft Palate 

QHoro Lip 

0 Othor Co"l-ltel Malfor111atians 

I 

j 

17. ACCIDENTS, POISONS, AND VIOLENCE: Ever bHn in ony 

bad accidants 0? Ever taken any peisons 0? 


0 Liu and describe 

Coll....,atlvo Reoeorch 

Porlnetel Raoeorch Bronch, HIHDB, NIH 

Bethesda 14, Md. 

I 

(oa.n PAGE 30F 3 

II.A.ll9 

OB-7 



H 

H 

• 

> 

.... • 

0 

"' 

@ 

I 

-...! 

For~ Ite~ ~umbers linked to nata Ite~s on OH-7, Tnfer.ttous Ofsease anct svstem Review 

I TE'' 

[lATA 

ON tr~M CARD 

FORM In NIIM FROM TO DAfA TrF.M Nli"'F: 

447 ••• ns-7 0101 17 18 Form ns-7 d~te ( j I'll'/) 

446 ••• 08•7 0107 15 16 Form OB-7 dAtP. {'110) 

449 ••• n8•7 0101 19 10 Form na-7 date fvr> 

45t ••• os-7 0101 24 74 Childhood diseases: chiC"ICen POX 

' t 452 ••• n8-7 0307 2'\ 76 Ch111hood dfsea~es: chicl


nlFECTIOO'S DISEASE AND SYSTEM REV l.:.W' 

FOEM OB-7 CARD 0307 

FIEI.D 

l. Card Number 

Code: 0 


Code: 307 

3. Revision Number * 

Code: 0 - Form Dated: l/59 

4.. NnmE Number 


Code: As g1ven 

5. Date Blstory Taken 

Six-digit code for month (cols. 15-16), 

day (cols. 17-18) and year (cols. 19-20) 


99 - Month and/or day, and/or year u.nlmown 

CARD 

COWMN 

l 

2-4 

5 

6-14. 

15-20 

CRIUlHOOD DISEASE 

6. Pertussis 

Item l 

Three-digit code for response (col. 21), 

and Age of Onset (eels. 22-23) • 

Code-for column 21: 

0 -No 

l- Yes 

2 - Yes (more than one episode) 

9 -Unknown 

21-23 

1· 

Code· for colUZDJ:l.s 22-23: 

00 - Birth to ll months 

Ol-50 • As giyen 

05 - Pre-school 

95 - School age 

99 - Unknown, no disease 

Note: !'or fie:!.d, no disease • 099 

ChiCken Pox 

Item 1 

Cede: Same as in Field 6 

8. ~ 

Item l 


27-29 

II.A.l21 

OB-7 


Da .L:.'i.!.T!CN OF CODES (Ccnt!nued) ?ORM 03-7 

Cari 03.::7 

CARD 

COLUMN 

9· German Measles 

Item 1 


10. ~e9.sles 

Item 1 

Cede: Same as in ?!eld 6 

30-32 

33-35 

11. Diphtherla 

I-:em 1 


Scarlet Fever 

Item 1 


39-41 

CTEER INFECTIOUS DISEASES 

13. Poliomyelitis 

Item 2 

Cede: Same as in F!eld 6 

cerpes Si!:l.plex 

Item 2 


45-47 

15. Her?es 

Item 2 

Code: 

Zoster 

Same as in Field 6 

!.l.S-50 

16. Encephali-tis 

Item 2 


51-53 

17. Me!lingitis 

Item 2 

Cede: Same as in Field 6 

18. Toxoplasmosis 

Item 2 

Cede: Same as i..'"l Field 6 

57-59 

II.A.122 

OB-7 


DEl''ll'IITION OF C:JDES ( Conti::::.ued) FORM OB-7 

·carl 0307 

CABD 

COLUMN 

19. Other - First Disease Re~orted 

Item 2 

60-62 

Three-digit code for Type (col. 6o) 

and Age of Onset (eels. 61-62) 

Code for column 60: 

0 - None 

3 - Rickettsial 

4 - ViraJ. 

5 - Bacterial 

6 - Other, 'I..Ulknown etiology 

9 - Uilknown 

Code for columns 61-62: 

Same as in Field 6 columns 22-23, "Note" also 

applies 

20. Other - Second Disease Reported 

Item 2 


2l. Other - Third Disease Re~orted 66-68 

Item 2 

Code: Same as 1n Field 19 

PARASITIC DISEASES 

22. Parasitic Disease - First Re~orted 69-n 

Item 3 

Three-digit code for ~ne (col. 69) 

and Age of Onset (eels. 70-n) 

Code for Col. 69: 

0 - None 

3 - Malaria 

4 - Rizlgvorm 

5 - Pil:tworm. 

6 -Definite intestinal worms (other 

than pinworm) , and im.lScle infesting 

worms 

7- Protozoans, yeast and other fungi 

9 - Unknown 


II.A.l23 

OB-7

( ~ -.,- .. -••e'" '; ?C?.M OE- 

..,'-..1~-...,~--- - 

Card C3C7 

~,., 

i:.!....::.J.JJ.J 

CA.;uJ 

COL'tJ"Wr 

22. 

23. 

Parasitic ~isease - First Ee~crted 

(continued) 

Code for columns 70-Tl: 

Same as i!l Field 6 columns 22-23, 

a.!..so ap:pli.es 

Parasitic Disease - Seccnd Reported 

Item 3 

Code: Sat:le as i!l Field 22 

"Note" 

72-7!.. 

Parasi~ic Disease - Thi~ Reported 

Item 3 

Code: Sat:le as i.:l Field 22 

75-TI 

II.A.l24 

OB-7 


 

 

i 

i 

:a 

:: 

·• 

1: 

!: ! 

I! 

::: .L*rrto 

.. )&\ "ti -.. 

-· 

-..,n~ 

1=. -w u"' 

1-"' ~1'10 ~ 

('0 ::: H 

~~~ 

I~ 

'" =J 

M J..•srro ~'" 

... 

I. ~lltl Hftl 

~ ... .. 

!~ 

:« 

.USI'Itl Hll 

• 

~ 

)4 

% ..; 

it ... ~ .J.•Sf'ltl Hfl 

!; 0 

; 

~ 

}'4 

o• ... .. 

~ 

~~ - SIS•"'~,. .J.IStr() ~9fl 

~ 

I' 

t ŪU\ --J. 19. :;:; 

.X 

SIJ.I~WIN!W 

I~ ~Vt 

~4E 

- 

.J.Inro 

a.l -~.~~ .J.nrJq !Hill 

... 

SW111M4!:lN3 ~·~~ ':: 

tiC~ tr ~ 

\110. ~ 

: ¥US4Z ~flri'O H4l 

!: 

!~ 

6 

~nH 1'>-~U : 

1: ....,...,, .J.Imtl 

~ 

- e 

~ 

- 

.. 

":: 

.. 

. 

~fl .. 

SN-.iH frillf 

:.. 

• 

su.•,,...... 

.1.3/1(} Ht/ 

•01,... 0 ~ 

llliA!:I ~ntrfl Hfl 

I; ;1 

.un•~ . r • rv¥ 

I= Ylli1H.IJWIQ ~rtrtl ~·~~ 

,. 

~l 

!; 

~Hfl 

I; A 

S!lSlltW 

,... -- 

I; S"" ~Hfl 

...... ... = 

~ II 

!= == 

~"' 

.J.I$/tltl ,.fl 

1: :a SdlllnW 

;j 

,.., 

Col 

li 

- 

.J.I.n'IQ Hfl 

~"~to 

-'l: 

INFECTIOUS DISEASE AND SYSTEM REVIEW 

(For Form OB-7, Dated 1-59) 

PURPOSE OF THIS FORM 

Par. 1 

Par. 2 

Study of the epidemiology of pregnancy wastage is made difficult 

by the fact that important events or conditions may occur only 

once in many thousands of pregnancies. Therefore, analysis .of 

the relationship between supposed causes and the outcome of 

pregnancy often must be based on relatively small numbers of 

cases. 

In such a situation, analysis is particularly vulnerable to the 

haphazard introduction of cases having rare or obscure diseases 

that are undiagnosed. For this reason scrupulous assessment of 

the state of health of each gravida is a fundamental part of this 

or any similar study. 

Par. J 

IN$IRUCTIONS FOR INTERVIEWER 

The Infectious Disease and System Review, OB-7, is designed to 

enable the interviewer and physician, working together, to 

establish as complete a medical history as is possible within 

the limits of this study. To do so requires careful and systematic 

questioning of the patient. This may at times be a 

burdensome task, but it will always be an important one. Poor 

medical histories might render useless other very careful 

observattons of the mother and child. 

Par. 1 

Par. 2 

Par. 3 

Par. 4 

At the top of page 1, record your first and last name and your 

title or position, such as "Lay interviewer", "Nurse interviewer" 

or "Social worker". Beneath this record the date on 

which the history is taken, writing the month, day, and year 

numerically, such as 6/22/59. 

The review is divided into seventeen categories. The first three 

of these are entirely to be done by the physician, so that you 

should befin your interview with category #4, Respiratory System. 

For each category you should attempt to discover all the 

relevant aymptoms that the patient has experienced at any time 

during her life. The questions listed are not necessarily all 

the questions that you may need to ask, nor is the wording the 

best for all patients. Make sure that the patient understands 

the questio~s, before you accept a negative answer. 

For those categories for which the patient gives a negative 

history, write the figure 

11 

0 11 (zero) in the space reserved for 

patient's comments, and make no other mark in the block. If 

the patieot gives a positive history record in the space under 

"Patient's COIIlments" all detail that will be helpful to the 

physician. Ask about dates of onset and duration, and record 

these. If the patient knows any diagnosis that may have been 

made, record this also. 

February 1959 



II.A.l26 

OB-7

l!:i i!;T!IJIJ;: IIJ;;:..f,;:l·: . !IJJ ::Y.STEM REVItVJ (Con't) 

l]:::THUCTIONS FOR INTERVIEWER (Con' t) 

03-7 

:/59 

Par. 5 The small check boxes are only for your convenience. Use thee 

to save writing, by checking questions that the patient has 

answered affirmatively. 

Category #10 "Blood" 

This refers to any actual blood abnormality. If the patient 

states that she has been treated for "bad blood", record this 

fact here and under category #8 (genito-urinary) also, since 

it may indicate previous syphilis. 

Category #12 

"Radiation" 

This category refers only to therapeutic radiation, not 

diagnostic x-ray. 

Category #17 

"Accidents. Poisons. and Violence" 

If the pati~nt has had a serious accident or injury note- the 

type of accident and ask about immediate and long-term effects. 

INSTRUCTIONS FOR PHYSICIANS 

Par. 1 

This form provides the only opportunity in the obstetrical 

protocol for a physician to determine whether or not a 

patient's history of previous illness is valid and complete. 

When it reaches you, it should contain the interviewer's 

notation of positive history. You should add the following 

information: 

1. All warranted current and retrospective diagnoses that 

you are able to make. 

2. For each diagnosis, your estimation of the probability 

. that it is correct. 

J, Any information (in addition to that elicited by the 

interviewer) about the symptoms of or circumstances surrounding 

a disease or event. 

4. Your estimation of the date of onset and duration of each 

diagnosed illness. 

Par. 2 

Base this information on: 


1. Interviewer's notations on this form. 

2. Discussion with the patient of symptoms, treatment, 

physician attendance, circumstances surrounding the illness 

or event, etc. 

J. Any medical records available. 

February 1959 


II.A.l27 00-7

INFEX;TIOUS DISEASE AND SYSTEM REVIEW (Con't) 

Estimating the Reliability of Retrospective Diagnosis 

OB-7 

l/59 

Par. 3 Diagnoses may be classified, according to th3 p bability that 

they are correct, as: 

Definite 

Probable 

Possible 

Remote 

Whenever in the c•1urse of this interview you feel that a 

diagnosis is warranted, indicate your estimate of its reliability 

by writing in parentheses one of the following: 

(DF) - Definite. There is objective evidence to show that the 

disease has existed or does exist. 

(PR) - Probable. The chances that this patient has had this 

disease are greater than the chances that she has not. 

(PS) - Possible. The chances that this patient has had this 

disease are less than the chances that she has not. 

Further, the possibility is not remote. 

Remote possibility should not warrant any specific diagnosis on 

this form. 

Par. 4 

In those instances in which some diagnosis seems warranted, 

but you are unable to specify a particular disease, name a 

group of diseases or type of disease if this is possible. 

All diagnostic information will be coded according to the 

International List of Causes o~ Morbidity and Mortality, 1957 

revision. 

Identifying Data (Page 1) 

Par. 5 

At the top of the page fill in your first and last name. 

Record your title or position, such as "project obstetrician", 

"intern", "medical student", or "resident". Record the date 

numerically in the order month, day, and year. 

Infectious and Parasitic Diseases 

(Page 1; Categories 1 1 2, and 3) 

Par. 6 

The interviewer will not ask the patient about these diseases. 

The list includes only the more common or important diseases, 

and does not pretend to be complete. You should make every 

effort to add to it other infectious or parasitic diseases 

that the patient has had. (Note that tuberculosis, pneumonia, 

and venereal diseases are covered in other categories, and need 

not be mentioned here.) In adding to this list, bear in mind 

the prevalent diseases in regions in which the patient has lived. 

In the southern states, for example, malaria, amebiasis, and 

February 1959 



II.A.l28 

OB-7

INF~TIOUS DIS~S~ ;~D SYSTEM REVIEW {Con't) C3-7 

:/59 

Infectious and Parasitic Diseases (Con't) 

hookworm should be considered. Patients from Puerto Rico 

should be questioned about these and ascariasis trichuriasis 

and schistosomiasis, among others. ' ' 

Par. 7 

Par. 8 

Ask the patient if she has had each disease listed, and other 

diseases that you think it prudent to inquire about. When 

necessary, recite the symptoms in addition to naming the disease. 

Record her answer as "no", "yes", or "unknown", by 

placing an X in the appropriate box. If "yes", note the 

approximate age at onset (to the nearest year, even though 

this may be uncertain). 

If you have checked "yes" in the response column, in the 

column headed "Diagnosis Warranted?" write either "yes" or 

"no". If a diagnosis is warranted, qualify it by recording 

under "Description" and "Comment" either DF, PR, or PS, for 

definite, probable, or possible. Also record any unusual 

or severe complications. If there were none, write "normal 

course" or "mild", etc. 

System Review 

{Pages 1, 2, and 3; Categories 4 through 17) 

Par. 9 

Par. 10 

By asking questions such as those listed on the left, the 

interviewer will attempt to furnish "clues" to past and 

present illness. Follow them up and attempt to establish 

diagnoses. When you are able to do this, name the disease 

by checking it, if it is listed, or by checking the box marked 

"other" and writing it in the space provided. Qualify each 

diagnosis by using the symbols DF, PR, or PS. Record the date 

of onset to the nearest year {except to the nearest month for 

diseases occurring within the last year), and estimate the 

duration in days, months, or years, whichever seems most 

suitable. 

Also note in each category any symptoms, events, etc., that the 

patient relates to you if these have not been noted by the 

interviewer. You should ask probing questions in each category 

in which the interviewer has recorded no symptoms, in order to 

confirm this. If you have nothing to record for a particular 

category, place a "0" {zero) in that space. 

February 1959 



II.A.l29 

OB-7


II.A.l30

OB-8 

Repeat Prenatal History 

Form OB-8 was used to record prenatal history between visits. It was 

fi 11 ed out at each repeat prenata 1 vis it and at the time the patient was 

admitted to the hospital for delivery. The form was first used in January 

1959; it was revised in July 1959. Items were renumbered and reworded in the 

July 1959 revision. Coding differs between the January 1959 form and the July 

1959 revision on items 6 (sickness in any way) and 36 (frequency of 

intercourse). Information from form OB-8 was recorded on card 0308 (Table 

OB-8.1). 

TABLE OB-8.1 




08-8: II lness, Disturbances Since Last 

Cl lnfc VIsit 0308 

0 29,596 

1 347,652 

377,248 



II.A.l31 

OB-8

II.A.l32 

OB-8 



H 

H 

• )II 

. 

..... 

w 

@ 

I 

co 

Oat a Ite~s Referenetnq For~ na-o, ReDe~t Prer'lataJ •Hstnrv 

OAf A 

Tr~-. 

ITEM Olf CIIRO 

TO F'JR" NIIM FROM TO ()A fA TrF.M I'UJIIIIE 

4A8••••••• 03011 t 5 Cl'lrd nu111ber (sequt"nee, for11 tvoe, for"' nu'llber, revlslon nu111ber> 

t99 ••••••• 0108 6 14 NTN08 CI'ISt" numbt"r 

4qO ••• oA-II 4 OlOA 1'5 16 Form OB-8 d~tP ('110) 

4CJ1 ••• 0R-A 4 

0)09 17 t8 ror111 na-11 dl'ltt" (18y) 

4CJ2 ••• 0R-II 4 

0308 19 ?.0 For• ~B-8 date Cvr> 

4CJ3 ••• 0R-II 6 03011 21 '21 stele fn any wav 

4CJ4 ••• 0R-A 7 O~OA 22 ?2 H~'.ldachf' 

4CJS ••• OR-A 8 03011 23 ?3 VIsual ,.lst•Jrhance 

4Q6 ••• oR-A 9 03011 24 ?4 Wt>akness: numhnPss: :Hzztne!ls 

4CJ7 ••• oR-fl 10 Q10A 25 ?5 Vl'l11ltfnq 

4CJB ••• OR-P 11 03011 2fi ?6 Pain, ah:tomen, oelvts, bac< 

4CJ9 ••• 0R-A 1?. 

03011 27 ?1 Urlnarv urqen~v: 1ysurl"' 

500 ••• oR-" 13 

03011 2A ?A Ot'lrrhe~t 

sol ••• oR-11 14 01011 2CJ ?9 Cold: sou• throat: COIJQh 

S02 ••• 0R-II 15 

OlOA ]0 JO revt>r 

SOl ••• OR-11 16 

03011 lt H E:ve lnflam111at1on 

sn4 ••• oR-A 17 

OJOA 32 32 Rash: skln r.on:Ht1on 

sos ••• oA-11 1(1 

03011 H 'B J111un:tf ct" 

sn6 ••• oR-II ICJ 

03011 ]4 34 Swollen qlan:ts 

so7 ••• oR-A 20 

01011 3"\ 15 Co\1 sores 

SOB ••• oR-A 21 0308 36 36 Bolls: ab!:cesse:t teeth 

509 ••• 0A-A 2?. OlOA J7 37 E~trache 

sto ••• oR-A 23 

03011 ]A 18 

Stt ••• OA-A 24 

03()11 )Q 39 Swellfnn swellfntJ of tf'et or lf'qs 

nf h"'n1s or face 

512 ••• 01\-A 25 

0301! 40 40 Vaqtn"'l olefl'dfn1 

Sfl ••• OR-8 26 

01011 41 41 FllinttntJ 

514 ••• 0R-A 27 03011 4? 42 Convulsions 

sts ••• oR-11 211 OJOA 41 43 AecfdPnt: polson: ln1urv 

516 ••• 0R-A 29 030A 44 44 OPeration: surqerv 

517 ••• 0R-II )0 01011 4S 45 Radiation: x-rav 

51B ••• OA-R 31 01011 46 4b At r travel 

519 ••• 0~-A 3?. 0308 47 47 In1ectlonJ var.clnl'ltt on 

5?o ••• oJt-8 H 03011 48 48 Infl!ctious dl~e111se ln hO~I! 

521 ••• 01\-R 34 0308 4CJ 49 Pfl>t in home, stele 

5?2 ••• 0A-II ]S 

OlOA sn SO Wnr~ outsfdP home 

523 ••• oR-8 36 

03011 st "\2 Interco~rse frenuencv 

5'24 ••••••• 

030A 51 62 Rlanle 

5?5 ••• os-fl 37 

OJOA bl 64 SmokinCJ: claarettes, nu111ber per :lay 

526 ••• 08-11 111 

030R b5 65 ~,.:lfc~t1on taken 

s?7 ••• oR-fl 3CJ 03011 66 66 Phvslcl~n vtsfte:l 

528 ••••••• 0308 67 AO Blank 

49115 •••• VAII 17 52 53 s~olelno hlstorv: cl::tarettes Pl!r :lay now, nu•ber


O~ta Ite~s RPterenclnq form nR-ij, Re~e~t Prenatal History 

()ATA 

TT~I4 

Il'Eiol )., CARO 

TO ~JAM Nllfol fROM T11 OA fA T f~M tlAME 

49R6 •••• VAP 54

I. ftATIIMT IDfNTIPICATIOM 

REPEAT PRENATAL HISTORY 

(/merviewer) 

{Since La&t Visit) 

I 

15. 

- - ·- - 

.... ·- 

2. HISTORY TAKEN IY 3. 

4. DATE NEXT SCHEDULED VISIT 

I 

CHECK 

A,IOPIIATE 

COLUMN 

NO YES 

0 I 

6. FELT SICK IN ANY WAY >< >< 

7. HEADACHE 

I. VISUAL DISTURBANCE 

- 

9. WEAKNESS. NUMBNESS. DIZZINESS 

10. VOMITING 

- 

11. PAIN, ABDOMEN. PELVIS. lACK 

41. UST aT MUall AND O!SCIIa! ANY CONDITIC* NOT!D NIUNT 

AT U'T WITH A~OIIMATE OAT! 01 ONSIT, DUIIATIOM AND 

wn•n. 

12. URINARY URGENCY OYSUIIA . 

13. DIARRHEA 

... COLO. SORE THROAT, COUGH 

15. FEVER 

16. EYE INfLAMMATION 

17. RASH OR SKIN TIOUILE 

II. JAUNDICE 

19. SWOLLEN GLANDS 

20. COLO SORES 

- 

21. SOILS 01 ABSCESSED TEETH 

22. EARACHE 

23. SWELLING Of FEET OR LEGS 

24. SWELLING OF HANDS 01 FACE 

25. VAGINAL BLEEDING 

26. FAINTING 


21. ACCIDENT. POISON. INJUIY 

29. OPERATION 

30. RADIATION, X-lAY 

31. All TIAVEL 

32. INJECTION. VACCINATION 

33. INFECTIOUS DISEASE IN HOME 

34. SICK PET IN HOM! 

35. WOKS OUTSIDE HOME 

,............... .... - 

36. INTEICOUISE FREQUENCY ~ 

:11. NO. OP CIGAtmES SMOKED PEl DAY 

31. MEDICATION TAKEN, AND FlfQUENCY (............. ,....., 

39. PHYSICIAN VISITED 0 NO 0 YES 

0 1 

.00. NAME OF PHYSICIAN 

41. ADDRESS 

c..aw............... (.... 1..101 (01-8) 

,_.._.. .__....... "'"oa. NIH 

.............. 


II.A.l35 

OB-8


F'orrn Ite'TI '-'u'lloers ttnk:Pd to nata Items on 

OI:I•H, Pene"'t Pren'ltal Hlstnrv 

ITE"' 

OATA 

ON TTF'Ii! CARO 

rnttll! JO NIJ~ FPOII! Tl'l DATA TrF:114 NUF' 

4986 •••• VAR 54 54 S'llokln~ n1storv: ctqarettl."s uPr jay flOW, co:Jer1: S'IIOICer, non-smoker 

4 491 ••• 08•8 030R 11 18 F'or'll OB•R dAte (:Jayl 

4 490 ••• 08•8 0308 1" 16 Form n~-8 dAti." (110) 

4 49? ••• oa-8 o3oA 19 10 F'nrm 116•8 dAtP ( yr) 

4 4994 •••• VlR 7'5 80 Perfn=tt"l follow uo vtsft, OB•8, rtate of first C111n/,av/vr> 

4 

4987 •••• VlR 

55 "ib Pre-natal vt!lllts, total nu'lloPr 

, 

6 

493 ••• na-8 o3oA 21 11 S1clr fn any WAY 

7 494 •••08•8 030~ 2?. ?2 Heoadacht' 

8 495 ••• 08·8 o3o8 23 ?3 VIsual disturbance 

c, 49~ •••oa-a 030" 24 24 llf"atrn~ss: n11111hness; :lfz:~:ln_!!ss 

to 497 ••• 08•8 030~ 2"i ?5 Vtutft t na 

to 5t9CJ •••• VAR 307 307 Vn~lttna hy trimester of report 

tl HA ••• oa-8 o3oA 21> ?b Pl91n, ab::I.,IIIPO, nelvfs, bar< 

12 499 ••• 08•8 0308 27 ?7 Urtnarv urqPnry: 1ysurl'l 

H t] o;oo ••• os-a 01011 2fl 28 DfarrheA 

H 

14 

so1 ••• ns-a o3oA 29 29 

• 

• > 15 

'50? ••• 08•8 03011 30 30 

..... 

15 

519R •••• VAR 

301> 306 

w 

16 

!i01••• ns-8 0108 31 31 

0'1 

@ 

I 

(X) 

Colrt: snre throatr 

Ff'Yf'r 

Fevf'r by trimester 

Eve inflan~•atton 

cougt-t 

of rf'oort 

17 '504 ••• na-8 0308 32 n Rash; skin contfftfon 

18 50'5 ••• 08•8 03011 33 H Jlllun:ltcf' 

18 5?00 •••• VAR 3011 308 Jaundtcf' hy trimester of reoort 

19 '506 ••• 08•8 OlOA 34 34 swollPn atand~ 

?.0 '50'7 ••• ns-8 030A J" 15 Cnld ~ores 

?1 o;oR ••• ns-8 03011 Jf; 3b Bolls: ab!IICPssed teeth 

22 

o;oq ••• os-8 O'OII 37 17 F.arache 

23 

5tn ••• ns-8 030A 311 18 sweJltna nt tPet or lPQS 

24 5201 •••• VAR 309 ]09 E~ema nan~s or face by trtrnPster of rPport 

24 511 ••• 08•8 OlOA 39 19 swelltna of nan1s or f


For~ Ite~ ~u~b~rs link~d to nata Items on ns-8, Re~e~t Pren~t~l Hlst~rv 

ITE" 

nATA 

ON TTF.14 CARl" 

FORIIII II) NIIM f"RQIII TO OIITA TJF:I4 NAME 

3& ";2l ••• IJR•8 OlOA 51 '52 Int~rcourse tre~u~ncv 

37 41Jti'5 •••• VlR 5? '53 smolclnQ history: Cl!larettP.s PPr ::lilY now, null'ber 

17 '52'5 ••• 08•11 03011 61 f\4 Smolcincn cil'larettl"s, numoer PPr ::IllY 

39 ";26 ••• 08•8 030R f.l'5 65 MP.dtc~tton taken 

H 527 ••• ns-ll o~o" 6'> f\6 Physlcilln vfsft~~ 

1-t 

1-t 

.> 

..... 

w 

....... 

~ 

00

DEF'INITION OF CODES 


FOBM OB-8 CARD · 0308 

FIELD 


Code: 0 

CARD 

COLUMN 

1 


Code: 308 

3 

4. 

Revision Number * 

Code: 0 - Form dated: 

1 - Form dated: 

NINDB Number 

Item 1 

· 2-4 

l/59 

Rev. T/59 


Code: As· ·given 

5· Date 

Item 4 

Six-digit code for month (cola. 15-16), 

day (cola. 17-18) and year (cols. 19-20) 

Code: 

As given 

99 - Month, day and/or y-ear unknown 

5 

6-14 

15-20 

6. Felt Sick In AN Way (Rev. "O" only-) 

Item 6 

Code: 

r. Headache 

Item 1 

Code: 

0 - lfo 

1 - Yes 

T - 11ot on Revision "l" 


9 -Unknown 

0 - lfo 

l - Yes 

8 - ~estionable 

9 -Unknown 

21 

22 

8. Visual Dist~bance 

23 

Item 8 

Gede: Same as 1n Field 1 

* Unless specified , Fields ,Codes an~ Card Columns refer to 

Revisions· "o" and "1.". Item numbers refer to Form Dated: Rev. 7/59 

II.A.l38 

OB-8 



Card 03:8 

FIELD 

9· Weakness, Numbness, Dizziness 

Item 9 

.Code: Same as in Field 7 

10. Vomiting 

Item 10 

Code: Sane as in Field 7 

CARD 

COLUMN 

24 

25 

ll. 

Pain: Abdomen, Pelvis, Back 

Item 11 

Code: Same as !..n Field 7 

26 

12. Urinary Urgency, Dysuria 

Item 12 

Code: Sam~ as in Field 7 

13. Diarrhea 

Item 13 

Co9,e: S,?me as in Field 7 

14. Cold, Sore Throat, Cough 

Item 14 

Code: 2~~e as in Field 7 

15. Fever 

Item 15 


16. Eye Inflammation 

Item 16 


17. Rash or Skin Trouble 

Item 17 


18. .Jaundice 

Item 18 


27 

28 

29 

30 

31 

32 

33 

19. SWollen Glands 

Item 19 



II.A.l39 

OB-8


Card 0308 

FIELD 

CARD 

COLUMN 

20. Cold Sores 35 

Item 20 


21. Boils or Abscessed Teeth 36 

Item 21 


22. Earache 37 

Item 22 


23. SWellln§ of Feet or Legs 38 

Item 23 


24. Swelling ~f Hands or Face 39 

Item 24 


25. Vaginal Bleeding 4o 

Item 25 

Code: Same aa in Field 7 

26. Faintigs 41 

Item 2 


27. Convul.sions 42 

Item 27 

Code: Same aa in Field 7 

28. Accidentz Poison~ InJury 43 

Item 28 


29. Operation 44 

Item 29 


30. Radiation z X-Ray 45 

Item 30 

Same as in Fiel.d 7 


II.A.l40 

OB-8


FIELD 

F0Rf,1 OB-8 

Card 0308 

CARD 

COLU~1N 

31. Air Travel 46 

Item 31 


32. Injection, Vaccination 47 

Item 32 


33. Infectious Disease in Home 48 

Item 33 


34. Sick Pet in Home 49 

Item 34 


35. Works Outside Home 50 

Item 35 


36. Intercourse Frequency During Last Month 51-52 

Item 36 

Code for Rev. "0": 

00 - None 

01-79 - Number of times per week as given 

80 - Less than once a week 

81-87 As given 

88 - Frequently, innumerable 

89-98 As given 

99 - Unknown 

Code for Rev. "1": 

00 - None 

01-78 - Number of times per month as given 

79 - 79 or more 

80 - Less than once a month 

88 - Frequently, innumerable 

99 - Unknown 

Note: 

Rev. 1 - Use codes 89-98 as 79 or more in tabulations. 

Frequencies for "0" and "1" revisions cannot be combined. 

37. Blank 53-62 


II.A.l41 

OB-8

DEFINITION OF CODES (Contimed.) 

FORM OB-8 

Card 0308 

FIELD 

38. 

39· 

40. 

Number of Cigarettes Smoked Per Day 

Item 37 

Code: 

00 - None, never smoked 

01-60 - NUmber of cigarettes smoked per 

day as given 

61 - 61 or more daily 

70 - Regular smoker but less than one 

cigarette per day 

8o - Irregular smoker, less than 4 

cigarettes per month 

99 - Unknow. 

Medication Taken 

Item 38 

Code: 0 - No 

l - Yes 

9 -Unknown 

PhySician Visited 

Item 39 

Code: Same as in Pield 39 

CARD 

COilJMN 

63-64 

66 

Note: 

A card is punched -ror each visit with colllmns 1-66 same as above. 


II.A.l42 

OB-8

~ 

:: : 

j: 

~ 

: 

I~ =r ; 

Ia ~ ~ 

!~ ; 

1: ; 

~ 

'~ 

:;; 

~ 

,; lftlfr lllfi- .. .,....._,..,.,.(;#~ii :;•-;..__ ; 

~~ 

. ; 

":It 

2 : 

I~ 

~ 

~ 

: 

I; 

I~ 

I~ 

:; 

,:;; 

,. .......--... nli""••...l!".r :;; 

I 

~ ;. 

fJ 

'""' 

I 

I 

w 

"hi;If 

~ ~ 

~ 

li I.IK ; 

j; i 

I'.J/fi#W ; 

I~ 

Gill ; 

~ 

I~ 

~,._ 

I• 

s 

I• :z: . 

.. 

,. 

1.. 

r.! 

1 

r-J 

..... 

t: i 

. 

I• 

~ 

1- 

. .. .. : 

•I i • I 

I ! : : ... ! ! I ; 

OB-8 - 6 

* 

. 

II.A.143 

OB-8 




INSTRUCTIONS FOR INTERVIEWER 

This form must be filled out at each repeat prenatal visit and 

at the time the patient is admitted to the hospital - preferably 

before delivery. 

Item #2 

"History Taken Bv" 

Record your first and last name. 

Item #4 

"Date" 

Record the date of this interview in the order designated: month, 

day, and year (9/30/59). Record the date of the next scheduled 

visit in similar manner. 

This "Repeat Prenatal Histocy", OB-8 1 is quite similar to the 

"Histocy Since Last Menstrual Period", OB-3, and all instructions 

given for OB-3 apply to OB-8 a~so. In this form there is one new 

item, #38 "~ication Taken and Frequency". In this category, the 

patient should be asked the medication she is taking and how often 

she is actually taking it. In this connection, it is not necessary 

to know the dosage prescribed, but in the patient's own words how 

she is actually taking it. If the patient does not know the name 

of the medication, record her description of it and determine whether 

it was prescribed by her present obstetrician. If not prescribed by 

him attempt to identify the medication. 

INSTR.UC TIONS FOR LABOR QJ!!§IRYP 

A regular "Repeat Prenatal Histocy", OB-8, must be completed by 

the labor room observer at the time of admission of the patient 

to the labor room. Consult detailed instructions given in manual 

for Form OB-3, and OB-8. If the patient is admitted in advanced 

labor so that this histocy cannot be obtained prior to delivery, it 

should be taken at anytime before the patient leaves the hospital. 

Write "Taken after delivery" in large letters at the top of the space 

reserved for comments. 

February 1959 



II.A.144 

OB-8

,;.-~ 1•1. 

1J;,.... - ~ .. u;W'o' 

REPEAT PRENATAL HISTORY ,. 

(/nurvHvler) 

(Si11ce Laa Vuia) 

15. 

- - ·- - - · 

2. HISTOIT TAKEN IT 3. 

.. DATE NfXT SCHEDULED VISIT 

CHKX 

AI'PIOriiATE 

COLUMN 

NO YES 

0 I 

6. 'ELT SICK IN ANT WAY >< >< 

7. HEADACHE 

I. VISUAL DISTUHANCE 

9. WEAKNESS, NUMINESS. DIZZINESS 

10. VOMITING 

11. rAIN, AIOOMIN. rELVIS. lACK 

12. UIINAIY UIGINCY. DYSUIIA 

13. I)IAIIHIA 

14. COLD. SOli THIOAT, COUGH 

15. 'lVII 

16. EYE INFLAMMATION 

17. lASH 01 SKIN TIOUIIU 

II. JAUNDICE 

19. SWOlLEN GlANDS 

20. COlD SOlES 

21. lOlLS 01 AIISCESSED TEETH 

22. !AIACHE 

23. SWElLING OP FEET 01 LEGS 

24. SWILLING OP HANDS 01 PACI 

25. VAGINAL IIUIDING 

26. FAINTING 


21. ACCIDENT. POISON, INJUIY 

29. OP!IATION 

30. IADIATION, X-lAY 

31. All nAVEl 

32. INJKTION. V.I.CCINATION 

33. INPKTIOUS DISEASI IN HOMI 

34. SICX riT IN HOMI 

35. WOIIItS OUTSIDI HOMI 

rr..._....,_........._., 

36. INTUCOUISE PIIOUINCY 

~ 

(YJJ.-t ... ~ 

G. UST IY NUMIR AltO OISC.III ANl' CDNOITIOM NOTID "!SINT 

AT U'T WITH APPROJIMATI OAT! 0# OMSIT, DURATION AND 

IIYt:Rin. 

37. NO. OP CIGAIITTIS SMOXID Pfl DAY 

31. MEDICATION TAXIIN, AND PIIOUINCY (... ~.. ,..,.... 

39. PHYSICIAN VISITED ONO 0 YIS 

0 I 

o60. NAME OP PHYSICIAN 

.,. 

- 

ADDIISS 

(08-8) 

...........................O.,NIM 

.................. 


II.A.l45 00-8

~::-.. • REPEAT PRENATAL HISTORY J;P 

(For l""mn-). 

HISTORY TAKEN BY ~~..-.:

OB-9 

Prenatal Record 

Form OB-9, Prenatal Record, provided details on the present pregnancy, 

reproductive history, past medical history, family history and present 

examinations. It was designed for use as a regular hospital record and was to 

be used in conjunction with detailed histories obtained by the interviewer. The 

form was first used in January 1959 and was replaced in April of 1962 by 

OB-40, OB-42 and OB-43. Page 1 of OB-9 was replaced by OB-40, an optional form 

retained by the in.stitutions as a hospital record. Page 2 of OB-9 was replaced 

by OB-42, Past Medical History. Pages 3 and 4 of OB-9 were replaced by pages 1 

and 2 of form OB-43, Initial Prenatal Examination. Four cards were used to 

record information from OB-9 (Table OB-9.1). 

TABLE OB-9.1 




OB-9: Onset, Duration of Menses, 

Pregnancy Record 

OB-9: Basic Data, Pelvic Examination 

OB-9: Evaluation of Pelvis, Past Medical 

History, Family History 

OB-9: Mouth, Eyes, Heart, Breasts, 

Abdomen, Skin 

1309 

2309 

3309 

4309 

------ 

0 25,619 

25,619 

------ 

0 25,595 

25,595 

------ 

0 25,602 

25,602 

0 25,573 

25,573 


II.A.l47 

OB-9 


II.A.148 

OB-9 



H 

Ḥ 

• > ..... 

ol:lo 

\0 

@ 

I 

\0 

Oata lte~s R~ferenc1n1 F~r~ ns-9, PrPnatal RPcor1 

DIITA 

TfF:M 

ITE"' )If CARD 

TO FJRH NIIH FROIII TO DIITA TfFM NA14F. 

529 ••••••• 

1109 1 5 CAri nu~bPr (sequence, forn type, fortn nulllber, revision number> 

SJO ••••••• 

1109 f; 14 NTNOB CASf' number 

511 ••• 0R•9 1109 1'; 16 Fortn OB-9 datf' (110) 

532 ••• 0R•9 

1309 17 18 For111 ns-9 

53J ••• OR•9 

1309 19 10 Form no-9 date 

date (yr) 

( Hyl 

514 ••• 0R•Q 1 1309 2t 22 IIIPnarc-he; aoe at l"nset of llf'nstruatton 

51S ••• OR•9 t 1309 21 24 Menstrual perto1, usual tnterv111, mtnfm11111 

516 ••• oR-9 1 1109 2'5 ?6 Menstru~l perfoi, USUAl lntPrV!'Il, mAximum 

5'l7 ••• 0R-9 1 1109 27 78 Menstrual pertoi ~uratlon 

518 ••• 0R·9 2 1109 29 29 DysmenorrheA 

5'l9 ••• oR-9 3 1309 30 10 MPnstrual irre:JulArfttes 

54o ••• oR-9 4 1109 31 31 Ster111tv wor~uo 

541 ••• oR-9 5 1]09 32 13 MPn5trul'll h1storv: f,IIJP, f frst day (mol 

S42 ••• oR-CJ 5 1309 34 15 MPnstrual history: LMP, ftrst day (1ay) 

543 ••• oR-9 5 

1109 ](, 37 Menstrual htstorv: LIIIP, ff rst ::lay cvr> 

S44 ••• oR-9 6 

1309 3ft 19 MPnstrul'll hlstorv: PiliP, first dAy (mol 

545 ••• oR-9 6 

tJ09 40 41 MenstruAl htstorv: Pl4P, first ::lAy (1ay) 

546 ••• oR-9 6 

1)09 4? 43 MPnstruAl htstorv: PiliP, ftrst ::1"1'1 

547 ••• oR-9 7 

ll09 44 45 Qntckenfno Cmo) 

s4e ••• oA-9 7 

1109 46 47 ontckf'nlno (day) 

549 ••• 01~-Q 7 

1309 4q 49 autclcPnlno Cyr) 

S!'io ••• oA-9 8 

l'\09 50 '51 F.:OC: rstirnated iate of conflnenent Cmo) 

5o;1 ••• 0R-9 8 

1309 51 o:;3 tnc: rstllllatei date of conftnenent (day) 

5'52 ••• oR-9 8 1109 54 '55 F.nc: F:stt111ater' date of conflnf''liPnt (yr) 

5'53 ••• 0R•Q 9 

1309 sr. "51 PreCJnAncles, tot111 numbt'r orior to 

ss4 ••• oR-9 10 

1JOQ SA SA Fetal death; i!lbortlon, At 20 •eelcs 

so;s ••• oR-Q 11 

1109 59 '59 1111mature, 21 to 2A weeks oest~tfon 

study 

oestatton or tess 

556 ••• 0A•9 12 1309 60 f;O Premature, 29 to 16 weelc:s :~est3tlon 

so;7 ••• oR-CJ 13 009 61 61 Liveborn, full ter11 

5'58 ••• 0R•9 14 

130CI &2 62 Ff'Ul death: st tllbt rth, 1.9 weelc:s qestatton or qreater 

so;9 ••• oA-CI 15 

1109 61 63 Preonl!lnctes: multtole 

560 ••• 0R•CI lf\ 1309 64 64 Children, U.vtno, total nu11ber 

sr.1 ••• 0FI•Q 1109 61\ 65 E1lt code 

562 ••••••• 

1309 66 qo Blanlc 

563 ••••••• 

2309 t 5 Cttrrt number Cseouence, torn tvol!', for'll nu'llber, reviSion number> 

Sfi4 ••••••• 

2'lOQ 6 14 NT~na case number 

51\S ••• oR-9 

2309 15 16 Form n~-9 date ('110) 

566 ••• oR-9 

2109 17 18 Form na-9 date (day) 

567 ••• 01'1•9 

2309 19 10 Form 08•9 date (yr) 

568 ••• 0A•9 1 

2]0Q 21 73 Tf'!IIDerature 

5fli9 ••• 0R•9 2 2309 24 26 PUl!le 

570 ••• 0R•9 3 HO


H 

H 

• 

>. 

..... 

U1 

0 

@ 

I 

~ 

nata Items RPfl'!rl'ncing fnrm 

O!i•9, Prf'nl'ltal Rf'cnrr1 

DATA 

TTF:Iil 

ITEM J'-' CIIRO 

TO F'JQ" Nil Ill FROIIII TO Oil[ II TTF.II4 NIIIIIF. 

57l ••• OR•Q j 

2lOQ 30 12 Blood or!'SSUre, j1astoltc 

572 ••• oR-CJ 4 

230Q 31 35 Wf'i!lht, ore or!'Qn!'lncv (lbS) 

S73 ••• ofi-CJ 5 2JOQ 36 18 W!!icrht, oresent ( 1 bS) 

S74 ••• of\-9 6 230CJ 3Q 40 Hta1qht finches) 

s7s ••• of1-Q 7 

230Q 41 41 PPlViC; qenPtal1a; vulvar v~trtcostties 

576 ••• of\-CJ 7 

2lOCJ 4'2 42 Pf'lVic; OPOf'talta, other 

577 ••• oR-CJ 8 HOQ 43 43 Pelvic; 1ntro1t11s: urethro::ele, cvstocele 

s7e ••• oR-9 8 230CJ 44 44 PelViCI introitus; rectoceleo 

579 ••• oA-CJ 8 230CJ 4"\ 45 PelViCI lntrol tus: oerineal l~~tceoratlon, old 

5PO ••• Olll•9 8 210ca 46 46 Pelvic; 1ntrolt11s, other 

511l ••• OR•9 9 

2]0CJ 47 47 Pelvic; vaqtna, ebnor•a1itv 

512 ••• D"•' tn 

2109 4R 48 Pl!l¥1CJ uqtnlttsr trtcho•onas 

51Jl ••• DA•CJ 10 2309 4CJ 49 PPlVlC'J VIIQI nt tlsJ •ontlta 

5114 ••• oA-Q 10 

2109 50 ~0 Pelvic; v11qfnttts: non•soeclffc 

5R5 ••• 08•9 10 

2309 51 li1 Pelvic; v;~~qtnt.tfs, other 

5A6 ••• 0JI•CJ 11 

2109 52 ~2 Pf'lVte; bll!f'clinq; uterine 

5A7 ••• 0R•CJ 11 

230CJ 53 ''H PelvleJ bleeoHnctJ cervix or v~tqtna 

511B ••• DR•CJ tt 

2JOQ 54 '54 Pf'lVtc; blePdtna, other 

5A9 ••• llR•CJ 12 

2JOQ 5r; '55 PPlVit"; cf'rvtx, chronic cvstle cervicitis 

SCJ0 ••• 0'~•9 12 

2]0Q 56 "i6 PPlvtc; cervtx, erosion 

5cat ••• oR•CJ 12 

2]09 57 57 Pelvter eP.rvtx, eversion 

5CJ2 ••• 0R•9 12 2309 SP '58 Pf!lvtc; ctorvtw, DOlVD 

5CJJ ••• o!'-Q 1? 

2JOCJ SCJ ~9 PPlvte; ctorvtx, l!'lceratlon. ol:t 

594 ••• 0f\-9 11 

2]0Q 60 60 PPlVlc; Cl"rViY, otru'!r 

5Q5 ••• 0A•9 13 2)0Q 61 61 Pelvic; uterus; 'IIVoma 

SCJ& ••• o"-CJ t3 2JOCJ &2 62 Pelvic; uterus; con::,enital ano'llalv 

597 ••• 0f\•CJ 13 2JOCJ 6] 63 Pelvic; uterus, othP.r 

SCJB ••• OR•Q 14 2309 64 64 PPlvlc; artnex


nata Ite~s Referencinq ForM 08•9, Prenatal Recorrt 

o•u 

trE14 

I'I'EM JN CARD 

TO F'JPI4 NIIM FRO !Ill TO 

6t4 ••• o!'-ca 20 3109 3t 13 

&ts••• oR-ca 21 )309 34 16 

&t& ••• oA-ca 22 HOCJ )7 'J7 

6'7 ••• oR-ca 22 3309 38 18 

&t8 ••• oA-ca 2l 3309 H 19 

&t9••• oR-ca 24 3]09 40 40 

6:?0 ••• 0R•Q 2'i 3309 41 41 

621 ••• oR-9 29 HOCJ 42 42 

6?2 ••• 0R•9 29 3309 41 43 

&?3 ••• oR-9 26 )309 44 44 

&24 ••• oR-ca 1 H09 45 45 

6'25 ••• oR-ca 2 3lOCJ 46 46 

&2& ••• oR-ca 3 HOQ 47 47 

6?7 ••• 08-9 4 )lOQ 4A 48 

618 ••• oR-9 5 3309 4CJ 49 

629 ••• oR-9 6 HOCI 50 50 

H 630 ••• oR-9 7 3309 51 "it 

H 

. 

• 6lt ••• oR-ca 8 H09 52 52 

)It 632 ••• 0R•CJ 9 3309 51 ~3 

...... &ll••• oR-ca 10 3309 54 '54 

U1 

...... 

634 ••• 0R•CI 1t HOCI 55 "i5 

&35 ••• oR-9 12 3309 56 5& 

&3& •••oR-9 13 3109 57 57 

637 ••• oR-9 14 HOCI 58 "i8 

638 ••• oR-9 15 3309 59 '59 

619 ••• 0R•CJ 16 )109 60 60 

&40 ••• 0R•CJ 1 HOCI 61 61 

64t ••• OR•Q 2 HOCI 62 62 

&42 ••• oA-ca ) 3309 63 63 

643 ••• 0~-CJ 4 3309 64 64 

644 ••• oA-9 5 3309 65 65 

&45 ••• 0R•Q 6 H09 66 66 

646 ••• 08•9 7 3309 67 67 

647 ••• 08•9 8 3309 68 68 

648 ••• oR-9 9 3309 69 69 

649 ••• 0R•9 )JOQ 70 70 

@ 6!1'0 ••••••• 3309 71 AO 

I 

\0 

6"1 ••••••• 4)0Q t 5 

6"i2 ••••••• 4309 6 14 

653 ••• 0~-9 4309 1'5 16 

6"i4 ••• 0R•9 4309 17 18 

6'55 ••• QR•Q 410Q 19 20 

6o;& ••• OR-Q 1 430Q 2t ?.1 

OAU trF.M NA"'F: 

Pelvis: posterior s~qtttal 

Pl!'lvis; intercristal 

Pe 1 vis: sidewalls 

Pelvis: sacrosciatic notch 

Pelvis: asv111metrv 

Pelvis, other oelvlc abnornalttv 

PUvis: lnlPt 

Pelvis: mtd pelvis 

Pelvis; outlet 

R-.dlo'lriJPhVJ X•rav oetvtmetrv 

Childhood dtsea~es 

Tllbl!rCulosis 

Pllllllonarv dtsease, ctaronlc. other 

Allerctv 

Urlnarv trar.t disease 

svohilis 

Hvoertenslon 

C~r1iOVIJSCUlar 

rtlsease: rheulll,.tfc: fever 

vartc~se vefns 

Ane111h 

Cancer 

Thvrotd disease 

Otabetes 

Neuromuscular dtsease 

Concten 1t a 1 ano11a1v 

otsease, other slctnlftcant 

otahetes 

Tuberculosis 

Heart disease 

Cancer 

Neuroloqlcal condition 

Psvchfatrte dfsor1er 

Conqenital ano,alv 

MultiPle Preqnaney 

Famflv historv, other slqnlficant 

Edit code 

BlaniC 

Carrt number (sequence, forn tvoe, form number, revision nu•ber) 

NTNDB case number 

For• 08•9 dat~ C•o) 

For• 08•9 date c~av> 

Form 08•9 date (yr) 

Eves, inflammation


1-1 

1-1 

>• ..... 

U1 

1\.) 

@ 

I 

1.0 

Data Ite~s Referenr.lnQ form ~B-9, Pren~tAl Recor~ 

OATil 

TTF.M 

l't'E~~' JN CARO 

10 F'JIUt NUM FROM TO OATil TTF:M NAME 

&57 ••• oR-" 1 4309 22 '2 Eves, othPr abnor~alttv 

r,o;e ••• oR-9 2 4)0Q 21 23 Mouth: ~ent~l cArtes 

6'59 ••• 01~-9 2 4309 24 24 Mouth: tePtM ~irty 

660 ••• 013•9 2 4309 25 25 Mnuth: tepth mlsstn~, ~anv 

6fil ••• oR-9 2 430CJ 2fi 26 Mouth: e1entulous 

6fi2 ••• 0R•9 2 430Q 27 27 Mouth, nther Abnor~alttv 

6~3 ••• 0R•9 3 430Q 2A 28 RPsPlratory tract, uoner; oharynx inflammation 

6fi4 ••• 0R•Q 3 430Q 29 29 RPsoiratory tract, uooer: oreath soun~s ahnorMal 

665 ••• oR-9 3 430CJ )I) 30 RPsPiratorv tract, uooer; rates 

666 ••• 0R•9 3 4]0Q 3t 11 RPsotratorv traet, uooer: ~roans; wheezes 

6&7 •••0R•9 3 UO" 32 12 RPSDiratorv traet, upoer, 3t.ner abnormality 

61\I ••• OA•Il 4 noca )1 33 ~V~Ph nodPs en1ar1ed locallY 

6f\9 ••• DR•Il 4 4)0Q 34 14 ~v•oh nodes enlar3e~ ~enerallv 

&7o ••• oR-Q 4 410CJ 3!'i 35 Ly~oh nodPs, other abnor~alftv 

67l ••• DR•9 5 4lOQ 3fi 36 Thyroid enlarQe~ent, ~eneralize1 

672 ••• 0A•9 5 

noca 37 37 Thyroid enlarqe~. one lobe 

67J ••• OA•9 5 

4]0Q ]A lA Thvrofd, solitary no1u1e 

674 ••• DR•9 5 

4309 )Q ~9 T~vrofd, other abnor•alltv 

675 ••• 0R•9 6 

430Q 41'1 40 H~art •urMur 

676 ••• 0A•Il 6 

430Q 41 41 Heart rhythM, lrre~ular 

677 ••• oR-ca b 

430Q ., 42 H~art, nther abnor•allty 

67B ••• OR·9 7 430Q 43 43 Breasts: oaloable •ass 

679 ••• oR-Q 1 4309 44 44 BreAsts, ~t~er abnor~alftv 

6AO ••• OA•Il 8 4100 411\ 45 RreAsts~ ntooJes, tnverte1 

61H ••• OR•Q 8 430Q 46 4& Areasts~ ninole~, fissured 

6A2 ••• 0R•9 R 4109 47 47 Breasts: ntooles, other a~~or~alitv 

6Al ••• OR•9 9 4309 4A 48 Ah1omPn, oaloable or~an or ~ass 

6A4 ••• 0R•9 9 4309 4Q 49 Ah~omen, oo~ratfve scar 

&As ••• oR-Q 9 4)09 50 o;o 1\hjomen, hernia 

6A6 ••• 0R•9 9 

430Q !)1 51 AbjomPn, other abnormalftv 

6A7 • • .Of~-9 10 

HOCJ 5' ~2 F.xtremitv: e~ema 

6A8 ••• 0R•Q 10 

4109 53 '53 ~xtremttv: vartcosftles 

699 ••• 0R•Q 10 410CJ 54 ~4 ~xtre~ity, other abnor~alfty 

690 ••• 013-CJ 11 

4309 55 55 orthonedlc defect 

69l ••• oR-'l t' 430Q 56 '56 Skin: 1aun~tce 

57 Skin; 

692 ••• 0R•9 

693 ••• 0R•9 

694 ••• oR-" 

12 

12 

12 

4309 

4309 

4309 

57 

SP 

SQ 

~8 

S~in: 

rash 

lPsfon 

other ahnor~alltv 

59 S~ln, 

695 ••• 0R•9 11 4109 60 ~0 Ahnorma11t1Ps, other svste•s 

6CJ6 ••• 0R•9 4309 61 61 E~it co~e 

697 ••••••• 4309 62 RO Blank 

49A7 •••• VAR 5'5 56 Prenatal visits, total nuMb~r 

49«J5 •••• VAR b Rt R2 Hetoht fin)


nata Items RPterenclnQ Form 

oar11 

TrF.Iil 

1TE14 JN CARfl 

TO F'JPiil NIIM 

4996 •••• VAR 4 

49«H •••• VAR 4 

521D •••• VAR 25 

5217 •••• VAR 3 

5219 •••• YAR 

5248 •••• YAR 

3 

9-17 

nR-9, Prenet~l 

FRO~ 

TO 

81 fl5 

86 88 

]JQ 319 

32Q Ht 

]34 316 

l8A lAB 

Recnr~ 

!)l'fA T fEM NAM F. 

WeiC!ht, ore oreQnencv (lbs) 

Wf'laht aafn ( 1 bS) 

Pelvic su~matlon, Inlet 

Blood pressurP, ·svsto lie, ftrst recorie~ 

Blond oressure, :Uastolfc, first recorded 

Premature: htrt~s, total nu~bf'r orlor to current preQnancv 

'\ 

H 

H 

> • 

~ 

l11 

UJ 

~ 

~

THII )14fiTO,_.Y TAKIIN • ., 

PRENATAL RECORD 

(For Plly•ici•i 

4, STIRILITY 

WORICUP't 

I"R!SINT 

I"R!GNANCY 

SUIIIIMARY 

=NONI! 

CY!SIDumki 

5. lot o • ., LMP (M.,.D•Yr) ul•ll•"'"' (M...o..Yr) I, 

F. DC: 

9. TOT A'- NUW8CIIII 0_. 

•lllll&eNANCIII8 10. .~:·.::t~·:: II. ~~:::.T~~~ICII 12. i.':.~'; 

...., 

...ii'::.. 

13.,:~a........;::.. 1"'.~'.......~=~... IS,=~;;:."',.';.~, •• jl6. ::;..~:.'f.!YtNe 

011111 MO .. Ill) 

.. _..., 

RICORD I"RIGNAMC11S IM CMIONOLOGICAL OIDII (U•• C-i11•1i011 S"-•• iLR•••Nfi) 

P.REGNANCY ORDER: I 2 3 4 5 

17. OAT! 01' TERMINATION 

OP PREGNANCY 

18. GESTATION (VI../u) 

19. LIVEBORN? IY•• or Noi 

20. SEX IM or Fi 

21. NAM! 01' CHILO 

:Z:Z. OELIVERY: v..;,..l w 

c...,.... 

y...... 

a.-h 

o_.,,.,. .. 

sill_,.,._, 

23. OURATION 01' LABOR 

24. 81RTH WEIGHT ILb•..O•.J 

25. ABNORMALITIES 

AT 81RTH 

COMPLICATIONS Oft I'IIGMAMCY AND LABOI- DI!SCIIII IILOW WITH I'OOTNOTIS 

I 

26. PRESENT CONOITION 

OF CHILO 

II( ri••ri '""' dar• 11rwi """"• 

27. PLACE OF BIRTH 

ICuy «rwiH.,.pu«/1 

COLL.4eOllltATIVC ,._CSCA.. CH 

(08.9) F'AGE 1 OF • 

~K. ..INATAf.. lltCaCAllltCH ...ANCH, NINDe. NIM 

~CTHa•aa. 14, ,..0. 

II.A.l54 

OB-9 


C:OL.II.·- 

I•It 

NU\E IHOSPITAL MO. INIMDB MO. lfRis RISfbRV tlkEA 1Y 

SUMMARY OF ACUTE ILLNESS CURING PAST 12 MONTHS 

SUMMARY OF BLOOD TRANSFUSIONS AND REACTIONS, II" ANY 

SUioiMARY OF PREVIOUS HOSPITALIZATIONS OTHER THAN PREGNANCY 

SUMMARY OF PREVIOUS X-RAY EXAMINATIONS OR TREATMENT 

PELVIC DISEASE 

PELVIC SURGERY 

OTHER SURGERY 

1. CHILDHOOD DISEASES 

2. TUBERCULOSIS 

3. OTHER CHRONIC PULMONARY DISEASE 

4. ALLERGY 

5. URINARY TRACT DISEASE 

6. SYPHILIS 

7. HYPERTENSION 

RHEUMATIC FEVER OR RHO 

•• 

9. VARICOSE VEINS 

10. ANEMIA 

11. CANCER 

12. THYROID DISEASE 

13. DIABETES 

14. NEUROMUSCULAR DISEASE 

15. CONGENITAL ANOMALY 

16. OTHER SIGNIFICANT DISEASE 

1. DIABETES 

2. TUBERCULOSIS 

3. HEART DISEASE 

4. CANCER 

5. NEUROLOGICAL CONDITION 

6. PSYCHIATRIC DISORDER 

7. CONGENITAL ANOMALY 

MULTIPLE PREGNANCY 

•• 

9, OTHER SIGNIFICANT PAMIUAL HISTORY 

P' AST M8DICAL HISTORY 

NO YES COMMENT ON POSITIVE HISTORY 

I"AMILY HISTORY 

NO YES COMMENT ON POSITIVI! HISTORY 

COI.LA.OIIt4T1VC NC.CAIIICH (08-9) I'ACE 2 01' 4 

••MNATAL "UCAIIICM .IIIANCH, MINDa. NIH 

•CTHCSDA 1.&, MO. 

II.A.lSS 

OB-9 


C.JL.. •1.•10'JJ.. 9 

1•59 

EXAMINED I!Y 

!DATE (Mo.O•·Y•J 

1. TEMP. :2. PULSE 13. I!LOOO PRESSURE 

"F I /MIN i I 

~. NON-PREGNANT wEIGHT :s. PRES. weIGHT I'· HEIGHT 

I"ILVIC EXAMINATION 

7. EXTERNAL GENITALIA II. BLEEDING 

_: .....__, Nor-1 

:.None 

-Present 

=Vulvar Var~c••t•e• 

C From Utetua 

= Othe. =p,..,. Cervix w Vagi no. 

-Not Eva luoted 

=Other (Rectal, etc.) 

8. INTROITUS -Nat Evaluatecl 

~Normal 

12. CERVIX 

Abnormal 

=N--1 

= Urethrocele, Cystocele 

Abnormal 

,..._Rectocele 

=Chronic Cyatic C.rvicitia 

=Old Perineal Lae~ration 

I:Eraaion 

=other 

._ - Not Evajuated 

CE..nion 

=Polyp 

9. V"GIN" :J Old Loc:erati on 

- Normal =Ott... 

"bnornool 

-:Nat Evol.,.tecl 

=Abnormality present other than voginitia 

13 • UTERUS 

..._,Not Evaluated 

:.Nar....l 

10. VAGINITIS -Abnormal 

=None =,.., 

Preaent 

:-" Contenitol Anomaly 

..- Trtchomonaa ::Other 

.....,Nat Evoluatod 

=Monilia 

1 •• ADNEXA 

=Non.Spectfic 

....... N....-1 

=Other 

-Abn•-• 

=Not e ........... 

IVAI.UATION OP PI!LVIS 

.......,,__.. 

~Excessive Tenderneaa 

-Other 

-.-Not e ........... 

15. DIAGONAL CONJUGATE 16. SACRUM 17. SPINES 18. ARCH 

=Not R..ched ~Nar-•c- =Not Pr anti rwnt 

1""1Normal 

=:Reached at--- CMS. :Flat C P"omineftt A Wide 

i=A........... 

?1 Norrow 

19. Si·lachiol 120. Posterior So9ittol 21. ..._criatol 22. SIDEWALLS SACROSCIATIC NOTCH 

23. "SYMMETRY r~· OTHER PELVIC ABNORMAUTY =c-..90"' 

=None 

.....,N_ 

- PreHnt ;:::::; Pre..nt 

SUMMATION 

-- ....~- 

~Di..rgent 

=Average 

C:Wide 

::Narrow 

26. X·RAY PELVIMETRY !If Dort•) 

25. INLET !28. MIDPELVIS 29. OUTLI!T Marpheloty fTyp•) 

=:Adequate =Adequate OB c.,ju90,.: CMS. 

! 

::c--.."· 

lm.tapinoua: CMS. 

=Contractod =Controctecl Tr--roe Inlet: CMS. 

27. LIST BY BOX NUMBER AND DESCRIBE ANY ABNORMAL FINDINGS NOTED PRESENT ABOVE. 

COL..L.A80AAT1VIt AIISEA .. CH (08-9) P"GE 3 OF ~ 

_.II: lit IN A TAL. AlES IE AflltCH ... ANCH, NINO •• NIM 

SIE THilSDA 14, ~Oa 

II.A.l56 

OB-9 


•• 

'HISTORY NO. 

diRIRXL IXXMI ltioA 

1. I!Y!S 7. BRI!ASTS 

..._, 

ON·-· 

8'"'·-·- 

Other 

•• 

...,.._, 

8,.,.. 

C!N•-1 

QNetl!...._ ... 

Other 

'CJNetl... lueteol 

2. MOUTH NIJfPL.IS 

L..J"'·-· ........... 

··--· 

rl C:..lee In T-+t 

§T_.D~ 

Me.., T•th Mini,. 

l!delltul 

Other 

C!Netl!...luetM 

C!N•-1 

§'"........ ~_. 

CJNetl¥e11MtM 

'· ABCOMI!N 

Cl Her..I 

3. U,t!R RI!SPIIIIATOIIIY ..__, 

Altll·-· 

C!N•-1 

§'"'·--· 

llleiH 

··--· --· ....... t:!=· 

0...••'"-•n 

Otlw 

CJNetl!veiiMtM 

LYMPH NODI!S 

CJN.-1 

C! .......ltl• o...,.. ,.,•• 

:;:; o,.,.,,... s••• 

(Otkr ,._ a,.,;,J UI-J 

CJNeti!...IIMteol 

10. I!XTIIII!MITII!S 

CJN•-1 

•~a--• 

........... 

V•te••"•• 

§.,........ &..-11, =·..· 

~.... Ge_ll, 

...... Other 

:::JNetl!veiiMtM 

C!Netl!...l_.,. 

11. OIIITHOJfi!CIC DI!Jfi!CTS 

C!N 

C!N•-1 

........... 

oc..... ,..._ 

,....,Netl!wlueteol 

, Ge-.11.....,.••..-. 

12. SKIN 

§e......-"' an. 1.e11e 

CJNer...l 

~,Neolule 

s. THYROID 

......"' 

....._, 

...., Jcoulld Ice 

C!NetE... IIMteol 

~R..h 

6. HI! ART 

8 L.eei• 

CJN•-1 

A......_ I 

8:;;:;1er """" Rh,.._ 

::::NetE... Iueteol 

Or'- 

ON•E-1...... 

13. OTHER SYSTEM NOT EVALUATED ABOVI! 

Q ABNORMAL (D••m•• s,.,.,. ....4"-lillf &.law) 

1.&. LIST BY BOX NUMBER ANO DESCRIBI! ANY ABNORMALITY NOTI!D ABOVE 

15. RECORD ANY CLINICAL DIAGNOSIS MAO! DA Tl! 01' ONSI!T DO NOT USE 

COI.r..A•o•ATIV......AIIICM 

~C..tNATAL. JIUaAIICM MANCMt MINOa. NIM 

•aTHUDA ,._ MO. 

II.A.l57 

OB-9 



H 

H 

>• ..... 1 

U1 

(X) 

@ 

I 

'-0 

' 1 

t 

ror~ Ite~ ~U~bers Jinked to nata Ite~s on ns-9, PrPn~t~l RPcnr~ 

ITE~ 

OA'I'A 

ON JlF:~ CARO 

FOH~ 10 NUM FRO~ TO OAfA TTF:M NAMF. 

f;49 ••• 08•9 H09 70 70 E~lt co~e 

561 ••• 08•9 1309 65 65 E~tt co~e 

696 ••• 08•9 4309 61 61 E~it co~e 

60t ••• OB•9 2309 67 67 Edit code 

606 ••• 08•9 3309 17 18 form 08•9 date (1~vl 

5&6 •••n8-9 230CI 17 18 for~ OH•9 d~te (j~y) 

'i3?. ••• na-9 1109 17 18 for~ 08•9 datP (j~yl 

654 •••08•9 4J09 17 18 For~ IJB•9 date (d~v> 

651 ••• n8•9 4309 15 16 Fnrm 08•9 date c~o) 

230CJ 15 16 For• 08•9 date Cwo) 

)]09 tt; 16 Form ~A-9 d8te C•o) 

1109 15 16 For• 08•9 date C~o) 

'i67•••0B•9 2309 19 ?0 Form 08•9 d8te Cvr> 

533 ••• 08•9 1309 19 20 Form ns-9 date Cvr> 

t;6'5 •••n&•9 

60~ ••• 08•9 

5lt •••OB•9 

607 ••• 08•9 

6S"i ••• 08•9 

4987 •••• VAR 

624 ••• ns-9 

)309 

4309 

19 

19 

55 

4'i 

20 For• n~-9 date cvr> 

?0 Form ~8-9 date (yr) 

~6 Prenatal vlslts, total 

45 Childhood diseases 

number 

1309 

t 

640 ••• 08•9 ))09 61 61 

t 

6Sfi ••• n8'!'9 4309 21 21 Dtahetes 

Eves, lnftam•atto~ 

1 657 ••• 08•9 4309 22 22 Eves, other ahnormalltv 

1 534 ••• 08•9 1309 21 22 Menarche: aQe at onset of ~enstruatton 

t 5 )7 ••• 08•9 1309 27 ?8 Menstrual period duration 

"il6••• 08•9 1109 2"i 26 MPnstru~l pertod, 

53'5 ••• ne-9 1309 21 24 ~Pnstrual period, usual 

usu&l 

1 56fl ••• oa-9 2309 21 21 T~mperature 

2 'i39 ••• 0B•9 1309 2Q 29 Dvsmenorrhe& 

2 66?. ••• 08•9 4109 27 27 Mouth, other abnorm&lttv 

' 

659 •••08•9 4309 21 ?3 M~uth: ~ent~l cartes 

1 661 ...IJ8•9 4309 26 ?6 Mouth: edentulous 

2 659 ••• 08-9 4309 24 24 Mouth: teeth dlrtv 

?. 660 ••• 08•9 4309 2~ 25 Mouth: tePth m1ss1nQ, manv 

2 'i&9 ••• na-9 2309 24 26 Pulse 

2 625 ••• ns-9 3309 46 16 TubPrculosl~ 

2 

3 

1 

641 ••• 08•9 

571 ••• 08•9 

5219 •••• VAR 

3309 

230CI 

62 

30 

334 

f>2 

12 

336 

T"b~rculos15 

lntervaJ, 

intPrval, maxlmu~ 

minimum 

Blood press"re, diastolic 

Blood ore~surP, diastolic, first recorded 

3 570 ••• 08•9 2309 27 29 Blood pressurP, svsto11c 

1 5217 •••• VAR 32Q 331 Blood pressure, svstolic, first recor~ed 

3 64? ••• 08•9 H09 b3 63 Heart disease 

3 539 ••• na-9 tl09 30 30 MPnstru~l lrregularltles 

J f>26 ••• ns-9 )109 47 47 Pulmonarv disease, chronic, otner


H 

H 

>• ..... 

U1 

\0 

~ 

\0 

Form lte~ ~u~bers lin~ed to Oata Ite~s on 08•9, Prenat~l Recorrt 

ITEM 

OUA 

ON TrF:I4 CARO 

FORM Jl) NUI4 FR014 TO OArll JfF.:14 UI4F. 

1 fi67 ••• n8-9 430CJ n 12 Resoiratory tract, upoer, ~th~r abnormality 

] 664 ••• 08•9 4309 2CJ 19 Resoiratory tract, upoer: oreath soun~s abnormal 

J 666 ••• 08•9 430CJ 31 31 R~soiratory tract, uooer: ~roans: wheezes 

3 

3 

4 

6&3 ••• n8-9 

66'5 ••• 08•9 

627 ••• 08•9 

430CJ 

4309 

3309 

2R 

31"1 

4R 

18 

Jo 

48 

ResPiratory 

RP.soiratory 

Aller~y 

tract, 

tract, UPPer: 

upoer: oharynx 

ralPS 

4 643 ••• 08•9 3309 64 fi4 c~n~er 

4 

6&CJ ••• n8•9 430CJ 34 14 Lymoh nodP.s en1ar1ed qenerallY 

4 

669 ••• 08•9 4JOQ B 13 LV~Ph nodes enlar~ed locally 

4 

670 ••• 08•9 4109 H 3'5 LY~Ph nodPs, other abnormality 

4 

54n ••• 08•9 130CJ 31 31 Sterility wor~uP 

4 

4997 •••• VAR 

86 R8 wetoht aatn (lbs) 

4 499fi •••• VAR 81 RS WPiaht, pre preonancy (lbs) 

4 572 ••• 08•9 2309 31 15 weioht, pre preonancy (lbs) 

s '542 ••• n8•9 1309 34 35 Menstrual history: L14P, ffrst 1ay (~av> 

5 

t; 

5 

o; 

t; 

5 

5 

5 

5 

54t ••• 08•9 

'i43 ••• os-9 

644 ••• 08•9 

671. • .l"l8•9 

fi71 ••• n8-9 

674 ••• ns-9 

671 ••• os-9 

62R ••• 08•9 

c;n ••• n8-9 

1309 

llOCJ 

3309 

4109 

4309 

4109 

HOQ 

HOCJ 

21oQ 

32 

36 

6'5 

37 

36 

39 

3!t 

49 

36 

33 

37 

fi5 

17 

16 

19 

18 

49 

18 

MP.nstrual history: L14P, ftrst 

14enstrual hfstoryr L14P, first 

Neurolo~icat condition 

Thyroid enlaraed, one lobP 

Thyrotd enlaroemeot, oeneral17.ert 

Thyroid, other abnormalitY 

Thyroid, solitary nodulP. 

Urinary tract dtsease 

W~iant, present (lbs) 

6 &7"i ••• n8-9 430Q 40 ~0 Heart mur~ur 

·~; 

676 ••• 1"18•9 4309 41 41 He~rt rhvth~, irre~ul~r 

6 671. • • r!K•9 4309 42 42 Heart, other abnormalttv 

6 

4995 •••• Vl\R 

81 R2 Hei~ht Cin) 

6 

574 ••• o8-9 2309 39 40 H~ioht Ci"ches) 

6 

'i4"i •.•• 'l8•9 1309 40 ~1 Menstru~l hfstoryr PNP, first 

6 

544 ••• 08•9 1109 38 19 M~nstrual htstoryr P~P, ftrst 

'546 ••• 08•9 1309 4? 

6,. 

43 14enstru~l hfstory: P~P, ftrst 

645 ••• n8-9 3309 66 66 Psvch1atrfc d1sor1er 

6 62Q ••• 08•9 HOCJ 50 '50 svohilis 

7 67CJ ••• o8-9 430CJ 44 ~4 Breasts, other abnor•alitY 

7 

679 ••• na-9 4309 43 43 Breasts: Paloable mass 

7 

646 ••• 08•9 HOQ 67 fi7 ConQenttal anomaly 

7 

630 ••• 08•9 3309 51 '51 HVoPrtenslon 

7 

7 

7 

7 

7 

'576 ••• na-9 

'57'5 ••• n8-9 

54R ••• ns-9 

'547 ••• n8-9 

'54CJ ••• ns-9 

2309 

230CJ 

1309 

1309 

noCJ 

4' 

41 

46 

44 

4R 

42 

41 

47 

45 

49 

day 

day (yrl 

(mol 

jay 

1~v 

day 

inflammation 

(day) 

(mo) 

(Yrl 

P@lVic: QP.netalta, other 

Pelvi~: QP.n~talla: vulvar varicos1ttes 

QuickentnQ (day) 

auickPninQ Cmo) 

OuickPn1n~ (yr)


1-1 

1-1 

Form Item Nu~b~rs linked to Data Items on 08•9, PrPn~t~l Recorrt 

ITEIW 

DATA 

nN UP:II CARl'\ 

F"OHIW 10 NIIM FROiil TO Dlfll TfF:M NAMF. 

R 681 ••• n8-9 HOCJ 46 46 Breasts: nioples, ffssurert 

A 680 ••• 08-9 430Q 4"i 45 Bre~sts: ninple~, lnverterl 

R 681 ••• 08•9 430CJ 47 47 Br~asts: niooles, otner a~~ormallty 

R 631 ••• 08•9 33011 52 '52 c~rdl"vascular rtlsease: rheumatic fev~r 

9 ss1 ••• n5-9 1309 52 '53 EOC: F:stlmated date of conflne~ent (day) 

II 5so ••• n8-9 t3oCJ so '\1 EDC: ~stimatert rlate of confinement (mo) 

9 'iS?••• 08•9 1JOI) 54 '55 EOC: P.stimaterl rlate of conftnement Cyr) 

9 647 ••• 08•9 ]309 &A 68 MUltiole PrPQnanCV 

8 seo ••• 08•9 2loCJ 46 4& Pelvic; introftul, other 

8 5711 •••01~-9 2)09 4'5 45 Pelvic; 1ntroltu1: oer1ne~l laceration, old 

8 57& ••• na-9 21011 44 44 Pelvic; lntrottUIJ rectocele 

q 577 •••08•9 23011 41 43 Pelvic; 1ntrottus; urethro=ele, cystocele 

CJ 685 ••• 08•9 41011 sn 50 AbdOMen, hernia 

q 6tt4 ••• n8-9 410CJ 411 49 AhdomPn, operative scar 

9 686 ••• 08•CJ 4109 5t 51 Ahdomen, nther abnor~alttv 

q 681 ••• 08•9 430CJ 4R 48 Ahdomen, PaloablP. or~an or mass 

CJ 6411 • •. 08•9 310CJ 69 69 Fa•tlv history, oth~r stqnlflcant 

>0 9 sat ••• os-9 2109 47 47 Pelvic; vagina, abnor~alttv 

...... q 551 ••• 08•9 1}0Q 56 57 PrP.an~ncies, total nu•ber orlnr to study 

0\ 

0 9 612 ••• os-9 HoCJ 51 '53 varicose veins 

11·12 52411 •••• VAR 18~ lAB Premature; hlrths, total numbP.r orlor to eurrent oreQnancv 

10 6H ••• ns-9 no11 54 ~4 Anemi~ 

to 6BCJ ••• na-9 41011 54 ~4 Extremity, othP.r abnorm8lftv 

10 687 ••• n8-9 4'JOII 5? ~2 E~tre~Jty; e~e~a 

10 68A ••• na-9 4109 51 ~3 Extre~ity; varicosities 

10 '554 ••• n&-9 11011 SA ~8 rPt8l dPath: ~oortton, at lO wePKS aest8tfon or less 

to "i9"···ns-9 HOCJ 51 ~~ PP.lvic: VAQlnttfs, other 

10 583 ••• n8-9 HoCJ 411 4q PPlvir.; v~gtntt1s: monili8 

10 594 ••• ns-9 HOCJ so ~0 Pelvic; vagtnftls: non-soPctfic 

10 '511? ••• 08•9 2JOCJ 4~ 49 Pelvic; vagfnftts: trlcho~on~s 

t1 634 ••• ns-9 11011 55 '55 Cancer 

11 55'5 ••• 08•9 1109 SCJ ~9 Im~at"re, 21 to 211 weeKs Qestat1on 

11 690 ••• 08•9 4309 5'5 '55 orthooerlic 1efect 

11 5811. • .08•9 2JOCJ 54 54 PPlvlc: bleedina, other 

t1 587 ••• os-9 2JOCJ 51 '53 Pelvic: bJeedfna; cervix or vaqina 

@ 11 '586 ••• 08•9 23011 52 ~2 Pelvic; bleedina: uterine 

I 

1.0 

1 2 "iBCJ ••• ns-9 230CJ 55 '\5 Pelvic: cervix, chronic cystic cervicitis 

1 2 'i90 ••• 08•9 BoCJ 5~ "i6 PPlvic: cPrvix, erosion 

12 591 ••• 08•9 23011 57 57 Pelvic; cPrvix, eversion 

12 593 ••• ns-9 23oCJ 5q 59 PPlvic; cervix, laceration, ol1 

t 2 594 ••• ne-9 HOCJ 60 60 Pelvic: cervix, other 

12 "i92 ••• ~B-9 2JOCJ SR '\9 Pelvic; cervix, oolYP 

12 'i56 ••• nB•9 t'lOCJ bO ~0 Premature, 79 tn 36 weeKs ~Pstation


H 

H 

. 

Form Item Numb@rs llnK@d to nata Items on nR-9, PrPn~t~l Record 

ITEIIl 

nATA 

0111 TTF"M CARO 

FOR Ill In NUM FROM TO OATA lff:M NUl£ 

1 2 f;94 ••• oa-9 4309 59 59 S~ln, oth@r ahnor~alitv 

12 691 ••• n8-9 4109 Sf; "i6 S~in: 1~undtcP 

12 693 ••• 08•9 4109 511 "iB S~ln: lesion 

12 697 ••• 08•9 4309 57 57 Skin: rash 

12 63"i ••• na-9 H09 56 "i& Thvrotrt dfsea~e 

13 695 ••• 08•9 4]09 60 f\0 Ahnnrmalltles, nther svste~s 

13 631\ ••• 08•9 3309 57 57 otahetes 

tl 557 ••• n8-9 1109 b1 ~1 Liveborn, full terw 

t3 "i97 ••• o8-9 230ct 61 63 PP.lVlc: uterus, other 

t3 "i96••• ns-9 noct &2 62 PP.lvtc: uterus: conqenltal anomalv 

13 59"i ••• n8-9 230ct 6t 61 Pelvic: uterus: ~voma 

'4 o;sq ••• o8-9 noct &2 62 fPtal death: stillbirth, ?9 wP.eks qPstation or areater 

14 f\37 ••• 08•9 3109 511 "iS Neuromuscular disease 

t4 59ct ••• n8-9 2109 &5 65 Pelvic: artnP.xa, excessive tenrternPss 

14 598 ••• 08•9 2109 64 64 Pelvic: artnex~, mass 

14 

15 

t5 

15 

15 

600 ••• 08•9 

6311 ••• oa-9 

609 ••• 08-9 

60II ••• os-9 

55ct ••• na-9 

2309 

noct 

3309 

3309 

1109 

b6 

59 

2? 

21 

61 

6& 

59 

?.4 

21 

63 

PP.lvic: a~nexa, otner 

connenital anomaly 

Pelvis: dtanonal conjuq~te measur@mPnt 

Pelvis: dtaaonal conjuqate reach@~ 

Preanancies: multlole 

),. 

...... 

0'1 

...... 1& S6n ••• ns-9 1309 64 64 Children, llvfnq, total n"wher 

1& 619 ••• 08-9 3309 60 60 Disease, other sianlflcant 

1& 610 ••• oa-9 3309 2'\ ?.5 P@lVis: sacrum 

17 611 ••• ns-9 3309 26 ?.6 Pelvis: snines 

18 612 ••• 08•9 3)09 27 ?7 Pelvis: arch 

19 613 ••• na-9 3l09 2A 30 PPlvls: bt-lscntal 

20 614 ••• na-9 33oa 31 33 PPlvls: onsterlor s~~tttal 

21 61s ••• na-9 3'0il 34 '6 Pelvis: lntercrtstal 

?.2 617 ••• na-9 3309 lA 38 Pelvis: sacrosciatic notch 

22 6H ••• ns-9 3309 37 17 Pelvis: sidewalls 

23 6111 ••• os-9 3309 39 39 Pelvis: asymmP.trv 

74 61a ••• na-9 Hoa 40 40 Pelvis, other pPlvlc ~bnor~alttv 

25 5210 •••• VAR 11Q 319 PPlvic summation, inlet 

25 620 ••• ns-9 H09 4t 41 Pelvis: inlet 

@ 

I 

\0 

2& f\23 •••08-9 3309 44 44 Radloqraphy: X•ray Pelvimetry 

78 

62t ••• ns-9 H09 42 42 PP.lvls: ~td pelvis 

79 

62?. ••• na-9 33oa 41 43 Pelvis: o~tlet 

Ccms)

DEE'lNniON OF CODES 

~EECORD 

FOEM OB-9 CAlm 1309 

FIELD 

1. 

2. 

3· 

4. 

5. 

6. 

7 

Card Number 

Code: 1 

Form Number 

Code: 309 

Revision Number 

Code: 0 - Form Dated: 1/59 

NlliDB Number 

Nine-digit number for Patient Identification 


Date 

"Sii'=dig1t code for month ( cols. 15-1.6), 

day (cols. 17-18) 1 and year (col.s. 19-20) 


99 - Month 1 day and/or year unknown 

Age at Onset 

Page 1 - Item l 

Code: 

oo - Never menstruated 

o8-25 - As given 

99 - Unknown 

Interval 

Page 1 - Item l 

Four-digit code for lowest (eels. 23-24) 

and highest ( cols. 25-26) 

Code for each: 

00 - Never menS'truated 

Ol-86 - Number o't days as given 

87 ~ 87 days or more 

88 - "Irregular" 

99 -Unknown 

CABD 

COilJMN 

1 

2-4 

5 

6-14 

15-20 

2l-22 

23-26 


II.A.l62 

OB-9

~~J2ITTIGN OF CODES (Co~~i~ued) FCa-1 C3-9 

Card :.3G9 

FI3LD 

8. Du~tion of Menses 

Page 1 - Item 1 

~Jo-digit code for: 

Lowest (col. 27) 

~~~~est c~ol. 28) 

Code for each cob;~n: 

0 - Never menst:-Uated 

l-7 - :t..:mber of days as giv-en 

8 - 8 or more days, ; ,..:-egul.a.r 

9 - Ur.:...lmo.-..m 

CAFJ) 

COH.il·1N 

27-28 

9- 

Note: 00 - :l';ever ::nerrstrua ted.; 88 - 8 or more d.ays, 

L ... egul.a.r; 99 - U!lkno.-..m 

Page :;_ - I':.en 2 


1 - Sl::.ght 

2 - Moderate 

3 - Severe 

9 - Unknow-n 

29 

10. T-:-e~.1lari -t~es 

Page l - Item 3 


1 - !--regularity not w~thin past year 

2 - I.-regularity within past year or 

time not specified 

9 - Unknown 

u. Sterility Wcr~~ 

Page l - I':.em 4 

Code: 0 - Nc 

l - Yes 

9 -Unknown 

12. 1st Day - I1-1P 

Page-l - Item 5 



Code: As giYen 

( ( ( { ( ( - None since last dell-;ery 

99 - Honth, day and/or year un.k::lO-.rn. 

Sunu 1 e~ental codes for day: 

04 - 3eginning of mon~h, fi:-st Neek, early 

ll - Second •Jeek 

16 - Middle 

20 - Third ;,-eek 

27 Last week, end of ~on~h, late 

30 

31 

32-37 

Reproduced at the National Archives II.A.l63 OB-9

DEFINITION OF CODES (Conti.D.ted) 

FIELD 

13. First Day - PMP 

Page 1 - Item 6 

Code: Same as in Field J2 

14. Quickening 


Code: Same as in Field 12, except 

(( (( {( - None 

15. EDC 


Six-digit code for Month (cola. 50-51), 

Day (cols. 52-53) and Year (cola. 54-55) 

Code: 

As given 

99 - Month, day and/or year unkno'Wil. 

16. Total Number of Pregnancies 


Code: 

00 - No previous pregnancies 


99 -Unknown 

FORM OB-9 

Card 1309 

CARD 

COUIMN 

38-43 

44-49 

50-55 

56-57 

17. Abortions 



1-7 -As liven 

8 - Eight or more 

9 -Unknown 

18. Immature 



19. Premature 


Code: Same as in. Field 17 

59 

6o 

II.A.l64 

OB-9 



FOFM OB-9 

Card J309 

FIELD 

20. Full Term 



CARD 

COLUMN 

61 

21. Stillbirths 

Page 1. - Item 14 


22. Multiple Pregnancies 



23. Number of Living Children 



64 

24. Edit Code 

Code: 

Blank - Not applicable 

1 - No final resolution of ffiedical questions 

2 - Illegible data coded UP~own 

3 - Unable to determine source of data 

4 - Postpartum examination 

II.A.l65 

OB-9 



FOBM OB-9 

Card 2309 

FIELD 

CARD 

- 

COIIJMN 

1. Card Number 1 

Code: 2 

2. Basic Data 2-20 

Code: Same as in columns 2-20 of Card 1 

3. Temperature 21-23 


Three-digit code tor Fahrenheit temperature 

including tenths 

Code: 000 - 99.9, 100 degrees 

920 to 998 - 92 .0 to 99.8 as given 

001 to 079 - 100.1 to 107.9 as given 

999 - Unknown 

4. Pulse 24-26 



999 - Unknown 

5. Blood Pressure 27-32 


Six-digit code tor systolic (cols. 27-29) 

and diastolic ( cols. 30-32) 

Code for each: 

As given 

999 - Systolic and/or diastolie unknown 

Note~ Code limits in cols. 27-29 are 04o-28o and 

010-200 tor cols. 30-32 

6. Non-Pregnant W'E!'raht 33-35 

Page 3 - Item i 

Code: 050-350" - As given· in pounds 

999 - Unldlown 

7. · Present Weight 36-38 



8. Height 39-40 


Code~ 4o-8o - As given in inches 

99 -Unknown 

II.A.l66 

OB-9 


DEF~~ION OF CODES (Continued) 

PELVIC .El..Al~I!IP...TION 

9. ~ernal Genitalia 


~~o-digit code for: 

Vuh·ar Varicosities (col. 41) 

Code: 

0 - No:::-ma.l 

l - AbI!::>rr:Ja.l 

2 - Questionable abnormality 

9 - Unknmm 


Code: 

o - rror-~1 

1 - Abnorr:Ja.l 

9 - U:-1'lrr~o-.m 

10. Introitus 


Four-digit code for: 

Urethrocele, Cvstocele (col. 43) 

Code: 

0 - Normal 

1 - Abnormal - unspecified 

3 - Urethrocele only 

4 - Cystocele only 

5 - Cysto-urethrocele 

9 - Ur>...known 

Rectocele (col. 44) 

Code: 0 - No~~l 

l - Abnon:na.l 

9 -Unknown 

Old Perineal Laceration (col. 45) 

Code: Same as in Field 9, col. 41 

Other (col. 46) 

Code: 0 - Nomal 

1 - Abnormality other than relaxation 

unspecified 

2 - Relaxation unspecified 

3 - Combination of codes 1 and 2 

9 -Unknown 

FORM OB-9 

Card 2309 

CARD 

COWHN 

41-42 

43-46 

II.A.l67 

OB-9 



FORM OB-9 

Card 2309 

FIELD 

CABD 

- COllJMN 

ll. Vagina 47 


Code: 

0 - Nornal 

1 - Abnormal - qualified 

2 - Abnornal - unqualified 

9 -Unknown 

12. Vaginitis 48-51 



Trichomonas (col. 48) 

Montlia (col. 49) 

Non-apecific(col. 50) 

Code for each colwmn: 

Same as in Field 9 1 col. 41 

Other (col. 51).·: 

Code: 

0 - Nornal 

l - Abnormality present - other 

2 - V'ulvitis 1 vulvo-vagi.nitis 

3 - Combi.Dation of codes l and 2 

4 - Vaginal discharge without vaginitis 

5 - Combiaation of codes l and 4 

6 - CombiD&tion of codes 2 and 4 

7 - CombiD&tion of codes 1, 2 and 4 

9 -Unknown 

13. Bleeding: Source 52-54 


Three-digit code for: 

Uterus (col. 52) 


Cervix or Vagina (col. 53) 

Code: 

0 - Noral 

1 - Abnor..l but source unknown 

3 - From cerVix only' 

4 - From vagina onJ..y 

5 -From both 

9 -Unknown 


II.A.l68 

OB-9

DEFTIHTION OF CODES (Continued) 

FQRM OB-9 

Card 2309 

FIEW 

CARD 

COLUMN 

13. 3leedin Source (cont.) 

~~==~~~~~ 52-54 

Other col. 5 

Code: 0 - Nornal 

1 - AbnorEa1ity other than rectal 

bleeding 

2 - Rectal bleeding 


9 -Unknown 

14. Cervix 55-60 

Page 3 - Item l2 

Six-digit code for: 

9hronic Cystic Cervicitis (col. 55) 

Erosion 

(col. 56) 

.E-.rersion (col. 57) 

Polyp (col. 58) 

o::..d I.a.ceration (col. 59) 

Code-for each coluwn: 

~e as in Field 9, col. 41 


c;a:e: 0 - Normal 

l - Abnormality present other than 

specified in codes 2 and 4 

2 - Prolapse of cervix or uterus 


4 - Dilated and/or effaced 



7 - Combination of codes 1, 2 and 4 

9 -Unknown 

II.A.l69 

OB-9 


DEFD'UTION OF CODES (Continued) 

FIELD 

15. Uterus 


Three-digit code tor: 

Myoma. 

(col. 61) 

Congenital Anomal,y (col. 62) 

Code for each column: 

0 - Normal 

l - Abnormal 

2 - Questionable abnormality 

8 - Not palpated 

9 -Unknown 


C'O'de: 

o - Normal 

1 - Abnormality present, other than 

specified in codes 2 or 4 

2 - Tumor 

3 - Combination oi" codes 1 and 2 

4 - Abnormal size including multiple 

pregnancy 


6 - CombiDation of codes 2 and 4 

7 - CombiJtation of codes 1, 2 and 4 

8 - Not ~lpated 

9 -Unknown 

16. Adnexa 


Three-digit code tor: 

Mass (col. 64) 

EXCessive Tendeaess (col. 65) 

Code for each CG~ 

Same as in Field 9, c_ol. 41 

17. Edit Code 

Code: 


aoa:e: o - Normal 

1 - Abtlc>~l 

9 -Unknown 

Blank - Not applicable 

1 - No final resolution of medical questions 

2 - Illegible data coded unknown 

3 - Unable to determine source of data 

4 - Post~ examination 

FOBM OB-9 

Card 2309 

CABD 

COilJMN 

64-66 

II.A.170 

OB-9 



FIELD 

1. 

Card !Iumber 1 

Code: 3 

?03·1 C3-:. 

Card 3309 

CARD 

COIA.:Xr-: 

2. 

3 

4. 

Easic Data 2-20 

Coce: s~e as in cols. 2-20 of Card 2 

EVPJUJA~ION OF FELVJS 

DiagonaL Conjugate 21-24 


Four-digit code fo~ Reached (col. 21) and 

Hea.surement (cols. 22-24) 

Code for col. 21: 

0 - Not :-eached 

l - :S.eached 

2 - Heasurement recorded only 

9 - Unknown 

Code for cols. 22-24: 

010-699 - As given in cent~eters including ten~hs 

999 - UI1..k..11.own 

s~nnlemental codes for annrox~te mecsurements renorted 

as 11 less than 11 or "great~r than" within -:he i!1dicated 

limitS: 

770 Less than 10.0 to 10.9 

771 - Less than 11.0 to 11.9 

772 - Less than l2 .0 to l2 .9 

773 - Less than 13.0 to 13.9 

777- Less than 7.0 to 7-9 

778 - Less than 8.0 to 8.9 

779 - Less than 9.0 to 9.9 

880 - Greater than 10.0 to 10.9 


882 - Greater than l2 .0 to l2 .9 

883 - Greater t~~n 13.0 to 13.9 




887 -Greater than 7.0 to 7-9 

888 Greater than 8.0 to 8.9 

889 Greater than 9.0 to 9·9 

Sacrum 25 


Code: 0 - No~l curve 

1 - Flat 

2 - Angulated 

3 - Congenitally absent 

9 - Unknown 

II.A.l71 00-9 



FIELD 

Spines 

Page 3 

Code: 

6. Arch 

Page 3 

Code: 

- Item l7 

0 - Not prominent 

l - Prominent 

2 - Bord.erliDe 

9 - Unlalown 

- Item 1.8 

0 - Normal 

l - Wide 

2 -Narrow 

3 · 7D-90 d.esrees 

4- Reman 

5 -Gothic 

9 - Unlalown 

7· Bi-Ischial. 

Page 3 - Item l9 

Tbree-digit code tor centimeters, iDclnd.ing 

tenths 

Code: Same as in Field 3, coJ.s. 22•24 

8. Posterior Sagittal 


Tbree-d.igit code tor centimeters, 1Dcll1d1ng 

tenths 

Code: Same as in Field 3, cola. 22-24 

9 •. Intercristal. 

Page 3 - Item 2l 

Tbree-d.igit code tor centimeters, 1Dclnd1ng 

tenths 

Code: Same as in :riel4 3, cola. 22-24 

FOEM OB-9 

Card 3309 

CABD 

CODJMN 

26 

27 

28-30 

3l-33 

34-36 

lO. 

ll. 

Sidewalls 


Code: 0 - Divergent 

l - Ccmvergeat 

2 -Parallel 

9- UDkncwn 

Sacrosciatic Notch 


Code: 0 - Average 

l - Wide 

2 -Narrow 

3- Congeni~ absent 

9 -Unknown. 

37 

38 

II.A.l72 

OB-9 


ZEFT1ITTIO:i OF CODES (Con"'c:..!!Ued) 

FIELD 

F07i1·1 OE-9 

Card 3309 

CARD 

COIDMN 

12. AsYT??etry 39 



l - Present 

9 -Unknown 

13. Other Pelvic AbnoL'..3.lity 40 



14. Inlet 41 


Code: 

0 - Adequate 

1 - Contracted 

2 - Borderline 

9 - Un...knmro 

15. ?.fidnelvis 



16. Outlet 



17. X-F.ay Pelvi.!net~ 44 



1- Reported 

2· - Proposed or ordered 


18. Childhood Diseases 45 


Code: 0 - No 

l - Yes 

9 - Unkno'Wil 

19. Tuberculosis 46 



20. Other Chronic Pulmonary Disease 47 



21. Allers;r 48 




II.A.l73 

OB-9

DEF'INITION OF CODES (Continued) 

FIELD 

FORM OB-9 

Card 3309 

CARD 

COLUMN 

22. Urinary Tract Disease 49 



23. Syphilis 50 



24. Hn!ertension 51 



25. Rh.eumatic Fever or RBD 52 



26. Varicose Veins 53 

Page 2 - Item. 9 

Code: Same as 1n Field 18 

2j. Anemia 54 

Page 2 - Item lO 


28. Cancer 55 


Cod~: Same as 1n Field 18 

29. Thyroid Disease 56 

Page 2 - Item. 12 


30. Diabetes 57 



31. Neuromuscular Disease 58 

Page 2 - Ita. 14 


32. COE§enital .Anal!a~ 59 

Page 2 - Item i5 

Code: Same as in Fie1d ~8 

II.A.l74 

OB-9 



Card 3309 

FIELD 

33. 

Other Signi~icant Disease 



CARD 

COWMN 

6o 

34. 

35. 

36. 

37. 

38. 

39· 

40. 

41. 

42. 

FP.MILY HIS'l'ORY 

Diabetes 


Code: S~e as in Field 18 

Tuberculosis 


Code: S~e as in Field 18 

Heart Disease 



Cancer 



Neurological Condition 



Psychiatric Disorder 

Pege 2 - Item 6 


Congenital Anomaly 



Multiple Pregnancy 

Pe.ge 2 - Item 8 


other Significant Familial n~stoiy 



61 

64 

66 

68 

II.A.l75 

OB-9 



(Continued) 

FORM OB-9 

Card 3309 

FIELD 

CARD 

COLUMN 

Edit Code 

Code: Blank - l'at applicab~e 

l - Ho t1nal reso~ution of medical 

questions 

2 - ~elible data coded unknown 

3 - Unab~e to determine source of 

data 

4 - Postpartum examinations 

70 

II.A.l76 

OB-9 



FIELD 

FORM OB-9 

Card 4309 

CARD 

corm.rn 


Code: 4 


Code: Same as in columns 2-20 of Card 1 

3- Eyes 21-22 



Inflaomation (col. 21) 

Code: 

-- 

0 - None 

1 - Present 

2 - Questionably present 

9 - U :clmcwn 


Code: 0 -No other abnormality ~eported 

1 - Abnormalities other than severe 

visual impairment 

2 - Severe visual iiTpairnent 


9 - U:-.known. 

4. Mouth 23-27 


Five-digit code for: 

Cavities 

(col. 23) 

Teeth Dirty (col. 24) 

Many Teeth Missing (col. 25) 

Edentulous (col. 26) 


Same as in Field 3, col. 2l 

other (col. 27) 

Code: 0 - No other abnormality reported 

1 - Abnormalities other tr~n abno~l 

gums 

2 - Abnormal gums 


9 -Unknown 

II.A.177 

OB-9 



FORv1 OB-9 

Card 4309 

CARD 

COilJMN 

5· Upper Respiratory 


Five-digit code f'or: 

Inflammation of' Pharynx (col. 28) 

Abnoi'I!Bl Breath Sounds (col. 29) 

Bales (col. 30) 

Groans or Wheezes (col. 31) 

Code for each co~: 

Same as in Field 3 1 col~ 21 

28-32 

Other 

C'Ode": 

(col. 32) 

0 - No other abnoi'IIBlity reported 

l - Abnormalities other than nasopharyngeal 

and sinus conditiona 

2 - Other nasopharyngeal and sinus conditions 

3 - Combination of' codes l and 2 

9 -Unknown 

6. Lymph Nodes 


Tbree-digit code for: 

Enlarged Locally (col. 33) 

Enlarged General.l,y (col. 34) 

Code for each co~ 

Same as in Field 3, col. 21 

33-35 

other (col. 35) 

Code: 0 - No other abnoi'IIBlity reported 

l - Abnormality present 

9 -Unknown 

7. ThyrOid 



Generalized Enl..arl!!!pt 

Enlargement of'

DEFINITION OF CODES ( Con~inued) 

FCBl-1 OB-9 

Card 4309 

Cf...RD 

COLUMN 

8. Heart 



Murmur 

(col. 40) 

Irremlar Rhythm (col. 41) 



40-42 


Code: 0 - No o~her abnornality reported 

l - Abnonra.lities other than abnormal rate 

2 - Abnormal rate 

3 - Combination of codes land 2 

9 - Unknm.-n 

9- Breasts 


code for: 

Mass (col. 43) 



Code: 0 - No other abnornality repcrted 

l - Abnormalities other than inflanmation 

2 - In.fl.a.Ill!!lation 


9 - Unknown 

~~o-digit 

10. Nipples 



Inverted (col. 45) 

Fissured (col. 46) 



Other (col. 

·-- 

47) 

Code: 0 - No other abnornality reported 

l - Abnormali ~y present 

9 -Unknown 

43-44 

45-47 

ll. 

Abdomen 



Palpable Organ or Mass (col. 48) 

Ooerative Scar (col. 49)_ 

Hernia (col. 50) 



II.A.l79 

48-51 

OB-9 


DEFINITION OF CODm (Continued) 

FORM OB-9 

Card 4309 

FIELD 

11. Abdomen 

Other 

Code: 

( cont . ) 

(col. 51) 

0 - No other abnormality reported 

1 - Abnor:ualities other than codes 2 or 4 

2 - C.V.A. tenderness or pain 


4 - Other abdominal tenderness or pain 




9 -Unknown 

CARD 

COI1JMN 

48-51 

12. Extremities 



Edema (col. 52) 

variCosities (col. 53) 

Code for each co~: · 



Code: 0 - No other abnormality reported 

1 - Abnormalities other than current ulcers 

2 - Ulcers - current 


9 -Unknown 

52-54 

13. Orth~edic Defects 55 

Page 

Code: 

- Item ll 

Same as in :rield 3, col. 21 

14. Skin 



Jaundice (col. 56 j 

Rash 


(col. 5T 

LeSion (col. 58 

Code for each co:tu.l: 


~ (col. 59) 

Code: 

0 - No other abnormality reported 

1 - Abnormalities other than codes 2 or 4 

2 - Scars, operative, not elsewhere classified 

3 - Combination o:f codes 1 and 2 

4 - Scars, traumatic · 

5 - Combination o:f codes ~ and 4 

6 - Combination o:f codes 2 and 4 


-Unknown 

II.A.l80 

56-59 

OB-9


FORM OB-9 

Card 4309 

FIELD 

15. Other System Not E-v-aluated Above 60 


Code: 0 - No other at~o~lity reported 

1 - Abno~~lities other ttan obese 

2 - Obese 

3 - Combi~tion of codes 1 and 2 

9 - Un.knovn 

16. Zdit Code 61 

Co.ie: Blank - Not applicable 

l - No final resolution of medical 

questions 

2 - Illegible data coded unkno~~ 

3 - Unable to determine source 

4 Pcst~artum examinations 

CARD 

COIIJMN 


II.A.l81 

OB-9

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uJ 1-4-..0:::J 

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cC ~;....;:1 

a..~~ 

OB-9 - 23 

II.A.l84 

OB-9 


!:: llil\41.0 

~ ~~ ~'~"'~ 

-N 

OB-9 - 24 

II.A.l85 

OB-9 


PRENATAL RECORD 

{For Form OB-9, Dated l-59) 

INSTRUCTIONS FOR PHYSICIAN 

Par. l 

Par. 2 

Par. J 

Par. 4 

OB-9, the prenatal record, is a four-page form which is designed for 

use as a regular hospital record. It is also designed to be used in 

conjunction with the detailed histories obtained by the interviewer. 

At the tpp of the form in the box labeled "This History Taken By," 

record your name. 

In the box labeled '.'Title or Position," give your official position, 

such as "medical student," "intern," "resident," "project obstetrician 

"senior obstetrician," etc. 

Under "Date," record the date this record was taken in the designated 

order: month, day, and year. 

Item #1. "Menstrual History" 

This history may, for study patients, be obtained from the Interviewers' 

Gynecological History, OB-4. For non-study patients, or in 

institutions where an interviewer is not as yet obtaining the 

Gynecological History, OB-4, Items #1 through #6 must be obtained by 

the obstetrician completing this form. Under Item #1, Menstrual 

History, "Age at Onset" refers to the patient's age (at last birthday) 

at the time of onset of her menstrual periods. The next box, 

"Interval," refers to the average number of days from the first day of 

one menstrual period to the first day of the next menstrual period. 

"Duration" applies to the number of days the average period lasts. 

Item #2, "Dysmenorrhea" 

Check "None" if no discomfort is noted by the patient. Check "Slight" 

if the patient notes some discomfort but requires no medication. Check 

"Moderate" if the patient notes discomfort which requires medication, 

but continues with 'her usual activities. Check "Se'vere" if the discomfort 

is such that the patient is required to remain in bed or away 

from gainful employment for at least one day. 

Item #3. "Irregularities" 

Record any gross irregularities in menses. 

Item #4. "Sterility Workup" 

PRESENT PREGNANCY 


Check "None" if patient has had no sterility workup; otherwise check 

"Yes" and describe any sterility workup done. 

Item #5. "First Day LMP" 

List the first day of the last normal menstrual period: 

II.A.l86 

month, day, 

February 19 

(For Forms in Use April 196 

OB-9

PRENATAL RECORD (Con 1 t) 

PRESENT PREGNANCY (Can't) 

Item #5, "First Day LMP" (Con 1 t) 

and year. 

Item #6, "First Day PMP" 

List the first day of the menstrual period prior to the last normal 

period: ·month, day, and year. 

Item #7. "Quickening" 

If quickening has occurred at the time of this interview, list the 

appr~ximate date: month, day, and year; otherwise, it may be 

recorded l'ater when this event does occur. 

Item #8, "EOC" 

REPRODUCTIVE HISTQRY 

List the expected date of confinement: month, day, and year. (If at 

any time prior to delivery, you have reason to change the EDC, do not 

change the original date in this space, but give new EOC with the 

reason for change at the bottom of this page.) 

Par. 1 

Par. 2 

Par • .3 

If the interviewers' history, OB-2, is available, the physician may 

use it as an aid to filling in this portion of the prenatal record. 

If you are obtaining your information for this portion of OB-9 from 

the interviewers' record by discussion with the patient, attempt to 

enlarge on any areas which do not seem to be clear or fully developed 

in the interviewers' history, particularly in the areas of previous 

complications of pregnancy and labor, abnormalities at birth, etc. 

If former hospital records are availabl~ to you, information from this 

source should be included in your write-up of the previous pregnancy 

. 

experi.enc e. 

Under "Summary" the obstetrician is required to summarize the 

reproductive history in the various categories listed. 

Item #9. "Total Number of Pregnancies" 

List the total number of pregnancies the patient has had, not 

including the present pregnancy. 

Item #10. "Abortions" 

List the number of pregnancies terminating in a delivery of one or more 

infants (alive or dead) at 20 weeks gestation or less. 

Item #11. "Immature" 


List the number of pregnancies terminating in the delivery of on£ or 

February 1959 


II.A.l87 

OB-9

PRENATAL RECORD (Con't) 

REPRODUCTIVE HISTORY (Con't) 

PAGE 2 

Item #11. "Immature" (Con 't) 

more infants (alive or dead) at 21 to 28 weeks gestation. 

Item #12, "Premature" 

List the number of pregnancies terminating in the delivery of one 

or more infants (alive or dead) at 29 to .36 weeks gestation. 

Item #13. "Full Term" 

List the number of pregnancies terminating in the delivery of one or 

more infants (alive or dead) at .37 weeks gestation or more. 

Item #14. "Stillbirths" 

List the total number of babies which were born dead at 29 weeks 

gestation or more. 

Item #15, "Multiple Pregnancies" 

Each multiple pregnancy shall be counted as one, regardless of the 

number of infants produced. (6ne set of twins would be considered a 

single multiple pregnancy.) 

Item #16. "Number of Living Children" 

List the number of living children at the time this information is 

obtained. 

The previous pregnancies should be recorded in chronological order 

beginning with the first pregnancy. A second page 1 of this ·form OB-9 

must be used if there are more than five previous pregnancies. For 

instructions regarding Items #17 through #27, refer to instructions to 

interviewers, Reproductive History, OB-2, in the manual. 

Par. 1 

Par. 2 

In the space labeled ''Name," record the pati,ent 's full name. 

Record both the hospital and NINDE numbers in the spaces provided. 

Par • .3 

Par. 4 


In the space labeled "This History Taken By," record your own name. 

This must always be done, even though an addressograph has been used 

and pages 1 and 3 are fully identified. 

The first four items entitled "Summary of Acute Illness During the Past 

Twelve Months," usummary of Blood Transfusion and Reactions, if Any," 

"Summary of Previous Hospitalization Other than Pregnancy," and "Summary 

of Previous X-Ray Examinations or Treatment," may all be summarized from 

the interviewers' records of "Recent Medical History," OB-5, and "Past 

Medical History," OB-6, in those institutions which have an interviewer 

completing this portion of th~ protocol. In summarizing this information 

ou should rna e ce tain b di cussion with the atient that it is 

February 195 


II.A.l88 

OB-9

PRENATAL RECORD (Con 't) 

complete and accurate before transcribing it to OB-9. Do not add to or 

change in any way the forms which have previously been completed by the 

interviewer. 

Par. 5 

If·OB-5 and OB-6 have not been completed for this patient, this information 

must be determined by the obstetrician. In any case, whether the 

interviewers' history is available or not, ask the patient specifically 

about pe~vic disease, pelvic and other surgery, and record your interpretation 

of her answers in the appropriate spaces on this form. 


FAMILY HISTORY 

PAGE 3 

The interviewer and physicians' form "Infectious Disease and System 

Review," OB-7, must "be reviewed and any diagnosis found there transferred 

to this form. If this form has not been completed, tqis past medical 

history must be obtained by the obstetrician. Indicate with a check 

either "no" or "yes" for each condition listed and comment on any 

positive history. If there is a questionable history (if it cannot be 

presumed that a patient has actually had a specific disease), check 

"yes" and qualify this using the symbols DF (definite), PR (probable), 

or PS (possible). If there is any significant disease which is not 

listed specifically, check "yes" for Item #16 and describe the disease. 

Obtain this information on all patients directly from the patient without 

referral to any of the interviewers' forms. Comment on any 

positive answers. Inquire about any significant familial history which 

is not listed, and if a positive response is obtained, check Item #9, 

"yes," and describe the condition. 

Par. 1 

Par. 2 

In the space labeled "Examined By" record your name. 

In the space labele.d "Date" record the date of the examination in the 

order designated: month, day, and year (11/22/58). 

Item #1. "Temperature" 

Record the patient's oral temperature at the time of examination either 

in centigrade.or fahrenheit, whichever is the usual standard for your 

clinic. 

Item #2. "Pulse" 

The pulse should be taken in the us·ual way and recorded. 

Item #3. "Blood Pressure" 

Record the blood pressure at the time of the examination. 

Item #4. "Non-Pregnant Weight" 

Record the patient's usual weight before this pregnancy started. If she 


II.A.l89 

February 1959 


OB-9


Item #4. "Non-Pregnant Weight 11 

(Con't) 

has no idea or her usual weight, place 11 Unk 11 

in the box. 

Item #5. "Present Weight 11 

Weigh patient at time or this examination and record in pounds. 

Item #6. 11 Height 11 

Measure patient without shoes and record height in inches. 

PELVIC EXAMINATION 

Par. 1 

The pelvic examination is so designed that if for any item, there are 

no findings considered abnormal, a single check in the box marked 

11 

normal 11 will suffice. Any findings checked present under "abnormal 11 

must be listed by item number and described at the bottom of the page. 

If an abnormal finding is noted other than those described, check the 

box marked "Other" and describe in the space at the bottom of the page 

Par. 2 There is also a box in each space with the designation "Not Evaluated 11 

which should be checked if for any reason this particular item could 

not be evaluated. It is assumed that there will be very few situation 

in which an evaluation will not be possible. 

EVALUATION OF PELYIS 

Item #15. "Diagonal Con.iugate 11 

Determine this measurement in the usual manner during the pelvic 

examination. If the sacral promontory is reached, check the box marked 

11 

Reached" and record the distance in centimeters as measured on your 

hand with the calipers or the wall scale. If the sacral promontory 

cannot be reached, check "Not reached 11 and measure with the calipers or 

wall scale the distance on your hand and record after "Not.reached." 

This will mean that the d~agonal conjugate is greater than this 

particular distance. 

Item #16. "Sacrum 11 

Determine whether the sacrum has a normal curve or is abnormally flat 

or angulated and check the appropriate box. 

Item #17. 11 Spines 11 

Determine whether the spines are not prominent or are prominent enough 

to constitute an invasion or the birth canal, and check the appropriate 

box. 

Item #18, 11 Arch 11 

Determine whether the pubic arch is approximately normal or is unusually 

February 1959 


II.A.l90 

OB-9 


PRENATAL RECORD (Can't) 

EVALUATION OF PELVIS (Can't) 

SUMMATION 

Item #18, "Arch" (Can't) 

wide or narrow and check the appropriate box. 

Item #19. "Bi-Ischial" (bi-tuberous diameter) 

This is the distance between the inner surfaces of the tuberosities 

of the i~chium and should be measured as accurately as possible and 

recorded in centimeters. 

Item #29. "Posterior Sagittal" 

This item refers to the posterior sagittal diameter of the pelvic 

outlet. This measurement is made with a Thoms Pelvimeter and measures 

the distance from the mid-portion of the line joining the tuberosities 

of the ischium to the sacrococcygeal junction. This measurement should 

be determined as accurately as possible and reco~ded in centimeters. 

Item #21. "The Intercristal Diameter" 

This distance is determined with calipers and is the distance between 

the crests of the ilium. MOderate pressure should be used in order 

to determine this measurement as accurately as possible, regardless 

of the amount of subcutaneous fat. The measurement has questionable 

significance obstetrically, but is of use in the evaluation of nutrition. 

Item #22. "Sidewalls" 

Determine whether the sidewalls are divergent or convergent and check 

the appropriate box. 

Sacrosciatic Notch 

Determine whether the sacrosciatic notch is of average width or seems 

unusually wide or n~rrow and check the appropriate box. 

Item #23. "Asymmetry" 

If there is no apparent pelvic asymmetry, check "None." If any 

asymmetry is noted, check "Present" and describe under Item #27. 

Item #24. "Other Pelvic Abnormality" 

If any obvious abnormality is present which has not been covered, check 

"Presen~" and describe; otherwise, check "None." 

Item #25, "Inlet," Item #28, "Midpelvis," and Item #29, "Outlet" must be 

February 1959 


II.A.l91 

OB-9 


PRENATAL RECORD (Can't) 

SUMMATION (Can't) 

PAGE 4 

evaluated and described as either "Adequate" or "Contracted." If you 

feel that any of these planes may not be adequate, but are not sure, 

check the box marked "Contracted" and explain in the space at the 

bottom of the page (Item #27) that this item, although checked 

"Contr:.acted" is suspect only. Any item checked "Contracted" must 

be explained. 

Item #26. "X-Ray Pelvimetry" 

Item #27 

GENERAL EXAMINATION 

This item must be filled in whenever this type of pelvimetry is 

obtained. Morphology refers to the Caldwell-Malloy classification. 

The OB conjugate refers to the anterior-posterior diameter of the 

inlet. ·The transverse of the inlet is self-explanatory. The interspinous 

refers to the transverse diameter of the midpelvis. 

In this space list by item number and describe any fi~1ing which has 

been che-..:ked as abnormal, either in the pelvic examination or in the 

evaluation of the pelvis. 

As on page two of this form, record the full name of the patient, the 

hospital history number, the NINDB number and record your name under 

"Examined By." 

Normal findings need not be described. A single check in the box 

marked "Normal" will suffice for each item if it has been evaluated 

and found normal. Any abnormality checked "Positive 11 must be listed 

by item number in Item #14, and adequately described. If an abnormal 

ity is present which is not specifically listed, check the box marked 

"Other" and descr:i:be the abnormality below. If, uhder unusual circumstances, 

an item cannot be evaluated, there is a box marked "Not 

Evaluated" which may be checked. 

Item #13. "Other System Not Evaluated Above" 

Item #14 

Any abnormality found on general physical examination not covered in 

one of the above categories should be noted by checking this box and 

describing the system and abnormality in Item #14. 

Any abnormal finding must be listed by item number and described here. 


II.A.l92 

February 


OB-9


GENERAL IDl~ATION {Con't) 

Item #15 

If any clinical diagnosis .is made as a result of the first obstetrical 

visit, record it in this space. Record the a~proximate date of onset 

as nearly a-s· can be determined in the space marked "Date of Onset." 

II.A.l93 

OB-9 



II.A.l94

OB-42 


Form OB-42, Past Medical History, was used to record details of the 

patient•s previous medical and surgical history up to the time of interview. 

Information on childhood diseases and diseases of cardiovascular, respiratory 

and digestive systems was included, as well as gynecological and venereal 

diseases, other surgery, diseases of the renal and urinary tract, and other 

disorders. First used as a pretest form in July 1961, the form was implemented 

into the study in April 1962, replacing page 2 of OB-9. No revisions were made 

on the form. Data were punched onto card 0342 in the master file (Table OB-42.1). 

Some aspects of the patient•s past medical history were also recorded on form 

OB-6, where radiological treatments and results of other treatments and exams 

were recorded. 

TABLE OB-42.1 




OB-42: Past Medrcal Hrstory 0342 

0 31,313 

31,313 



:U.A.l95 

OB-42


II.A.l96 

OB-42


Oata Ite~s RefPrPncin~ rorm OR-42, Past Medlc~l Hfstorv 

OAT~ 

TrF.M 

ITE114 J"' CARO 

TD FJAM NIIM FROM TO I>AU JfE14 NAME 

IOA3 ••••••• 

034?. 1 5 car~ number (se~uence, for1 tvpe, form number, revlslon number) 

10A4••••••• 

014?. 

14 NTNOB case number 

IOAS •• OB•42 2 OH? 1'i " 16 Form nB•4? ~ate (mo) 

10A& •• nB-47 2 034? 17 18 Fnrm ~B-4? ~ate (1~y) 

tOA7 •• nB-4? 2 0342 tQ ?.0 Form ~H-4? ~ate


oat a Items RPfPrt>nclnQ form QR-42, Past Me•11 c~l ~tstorv 

01\TA 

ITEac 

TO 

tt?s •• nB-47 

112& •• nB-47 

t117 •• nB-47 

ll?B •• nR-4? 

11?9 •• 08-4? 

t13o •• nu-42 

t111 •• nB-4? 

113:.! •• nB-42 

un•.no-47 

1134 ••no-47 

1135 ••••••• 

49R7 •••• YAR 

tS 

17 

17 

11 

1#; 

17 

17 

17 

17 

tl' 

2 

lfF.M 

JN 

F')IH4 

CARO 

NIIM FQ0'4 rn OHA Tf~14 NlMF. 

0342 

034? 

034? 

034? 

Ol4? 

0342 

034? 

0342 

034? 

0342 

0342 

5R 

5q 

61) 

&1 

62 

61 

&4 

6S 

66 

67 

6A 

5" 

~H H]ood and transfusions, SUllm!lry cod!! 

~9 Blond and transfusions; ::~nemla 

60 Blond and transfusions; ls:>f111munU:at1on 

61 Rlood an::t transfusions; tr'!nsfustnns 

62 Con11tions, oth!!r: SU'IIIIIArV Co1e 

63 Con11t tons, oth!!r: :!ru~ se'l!';ltivttv 

64 CnnrHtlnF'I!'l, ot tiP r: allerqy 

65 CnnrH t tons, otner: lllaJform!ltlons 

66 ConrHtions, othl"rl oarasitle ~tse8se 

67 Htstorv, other sl~nlflcant 

AO Blank 

11\6 Prenatal vtslts, tot•l nuwtDer 

1-f 

1-f 

;. 

• 

...... 

\0 

00 

@ 

I 

N""'

-· 

eoL"-aooa-..a 

08-42 PAST MEDICAL HISTORY 

:::;=.~c~:~:;e:~.d:~=~~~:~L~;i:.~z=~·~u:'~~qh~ ~~· 

approJ:Ciate. 

2. DATE 4. HISTORY TAKEN BY 

I. PATIENT IDENTIFICATION 

Ma. 

3o.&PA TIENT"S HISTORY WAS 5. I LE OR POSI 'ION 

0OeTAIM&D ua111• THII POtt ... 

•••TttACTEO P'ttOM OTHII.Jt MCCORD I 

--: 

6. CHILDHOOD DISEASES 

QNONit 

7. CARDIOVASCULAR 

0NONI: 

' 

I17.SUMMARY 

I 

IQIIu•&LLA 

0MUMPI 

QHIEAIIIIT OISCASC 

o~~:~=~CI£NSION 

0"HCUMATIC "'lEVIER 

QVASCULAR OISCASIE 

I. RESPIRATORY 

QNONI: 

0 TUBCIItCULOSIS 

QASTHMA 

0PNCUMONIA 

I. DIGESTIVE 

QNONI: 

QHIEPATITIS 

QCHOLIECYSTITIS. 

LITHIASIS 

OPIEP'!'IC ULCC.. 

10. GYNECOLOGICAL AND VENEREAL 

QNONI: 

o:~::i~;ooae 

QINJI'IE.. TILITY 

QSYPHILIS 

QGONOfii.. HCA 

II. OTHER SURGERY 

QNONI: 

QOTHIE" ABDOMINAL 

SUfiiGIE,.Y 

12. RENAL AND URINARY TRACT 

0NONI: 

I 

QPYIELITIS 

I 0CYSTITIS 

IOQLOMO:IIULONO:PHIIITIS 

U. ENDOCRINE AND METABOJ-IC 

0NONI! 

14. NEUROMUSCULAR AND PSYCHIATRIC 

0NONI: 

II. BLOOD AND TRANSFUSIONS 

0NONI: 

I QTHVI'IOIO DYSfi'UNCTION 

I oo•••cTU MELLITUS 

I 

I 0MIG.. AINC 

I 0MCNTAL II.LNCSS 

I QCONYULSIYIE OISORDIEJII 

I 00THI:II NI!UII'>LOQIC 

OISIEASE 

IOANO:MIA 

: CJISOIMMUNIZATION 

16. OTHER CONDITIONS (Sidn. All•r.,, r,._., NeoplaerrM, Pe,...Hee, etc.) 

0NONI: 

"·LAY 

EDIT 

BY 

I OTIIANIP'USION 

I0 DIII:UG S&N!ITIYITY 

I00THI:II .LLI:IIGV 

I OMALP'OIIMATION• 

I 0 PA.. A&ITIC DIS& AS& 

I II. O~l~~~:f~~",.NJ"T 

! LISTED ABOVE 

COLLAaOIII:ATIY& "IEIIEA.. C:H 

PE..INATAI,. R.EI&AR.CH .RANCH, NINDe, NIH 

aiiETHIIESDA I .a, MO. 

08-42 


II.A.l99 

OB-42


ror~ 

2 

2 

2 

2 

1 

6 

7 

8 

q 

10 

t1 

12 

13 

t4 

1-1 15 

1-1 

• 16 

> 

•t\.) 

17 

t7 

0 

0 

t7 

17 

17 

17 

17 

17 

17 

17 

17 

17 

17 

17 

17 

17 

17 

17 

1 7 

~ 

,c:. 

17 

tv 17 

17 

17 

17 

17 

17 

Item 

ITEM 

nN 

FOR14 

~umbers lin~P~ to nata Items on OR-42, Past ~ejfc~l HtstJrv 

nATA 

IrF.H CARD 

10 Nll114 FROIII Tr) DATA JfF:II4 NAME 

108fi •• OR•42 0142 17 18 Form ns-4? date (day) 

108!'i •• 01"•42 0142 15 16 Form 08•42 ~ate (mol 

tos7 •• oA-42 0342 1«1 ?.0 Form 08•42 ~ate (yr) 

4CI87 •••• VIR so; 56 Prenatal Visits, total numoer 

108B •• OA•42 034~ 21 ?.1 History ohtatne1 usfna thts form or other recor~s 

108«1 •• o~-42 o342 22 22 Chil~hood diseases, su~m~rv co~e 

1092 •• OR•42 0342 lo; ?5 cardinvascular, su~marv coje 

1~'97 •• oA-42 0142 31l 30 Resoiratory, Kum•arv code 

1101 •• o~-42 Ol41 34 14 DfgPstive, sum•arv code 

ttos•• oA•42 034? 311 38 GvneeoloQtcal' venereal, su~•arv code 

1111 •• 09•42 0342 44 44 suroery, nt~er, su•mary coje 

tt n .• cn~-42 034? 46 46 Renalr urinary tract, sn•Marv co~e 

1117 •• ()1\•42 034? so 50 EndocrineJ metaholie, su~m!ry cod~ 

1120 •• 08•42 0142 51 o;3 NeuromuscularJ osvchiatric, su~mary code 

1 t2!'i •• OR•42 034? SA 58 Blood and transfusions, su•marv code 

112«~ •• oA-42 o34? 62 62 Con~itinns, other: SUMmary code 

1126 •• oR-42 0342 SCI 59 Blood and transfusions; anemia 

lt27 •• LJR•4:l 0342 bO 1>0 Blood and transfusions; 1s~l~•uni7.ation 

t12P •• OA•42 0342 61 61 Blood and transfusions: tr!nsfusions 

1093 •• OR•42 034? 26 ?6 Car~lovascular; heart dtse~se 

1094 •• oR-42 034? 27 77 Car~invascular; hypertensf~n, chronic 

1095 •• oA-42 034? 2A 28 cardiovascular; rheumattc fever 

1096 •• oR-4.2 034? 2Q 29 Car1iovascularJ v~scular ~lsease 

1091 •• JR•42 034? 24 ?4 Childhon1 dfs~asesJ ~umps 

to9o •• oR-42 OH? 21 23 C~ildhoo~ dtsPases; rub~ll! 

1111 •• 0~-·2 034? 64 64 Cnndltions, other: aller~v 

1110 •• oA-42 0341. bl 63 Conditlnns, otherJ 1ruq sensitivity 

113? •• 0R•42 034? 65 65 Conditions, other: malformations 

11 H •• OR•42 014? bfi ~6 Conditions, other: oarasttic diseas~ 

ltOJ •• Oq•42 Ol42 36 16 D1~estive: chnlecvstttts/llthlasts 

tto?. •• oR-42 o34? 35 35 ot~estive: heoatltis 

ll04 •• 0R•42 034? 37 17 otqestive: ulcer, peptic 

111Q •• o~-42 034? 5? o;2 f.njocrine: metabolic; diabetes mellitus 

111A •• OR•42 0342 51 51 Endocrine: metabolic; thyrJJj dYsfunction 

l10'l •• OR•42 0342 4? 42 GynPcoloqtc~l: venereal: QJnorrhea 

llo7 •• oR-42 0342 40 40 GvnecologlcalJ venereal: f~ferttJfty 

ttto •• oR-42 o142 41 43 Gynecoloqtcal: venereal: oelvfc inflammatory 1isease; PID 

1 to6 •• oR•42 o342 3Q 19 Gynecoloqtcal: venereal: s~rqerv 

ttoa •• oR-42 0342 41 41 GVnPcnloqfcal: venereal: svohflfs 

1121 •• 09•42 0142 51> 56 N~uromuscular: osychtatric: convulsive 1isorder 

1t22 •• 0R•42 0342 55 ~5 NPuromuscular: nsvchtatrtc: ~ental Illness 

1121 •• 0R•42 0342 54 54 Neuromuscular: osvchtatric: mtqralnP


For~ Ite~ ~u~bers linked to Oata Items on 

ITEM 

I"'UA 

ON TrF.N CARO 

rnRM Ill NIIM FROM TO 

17 1124 •• 0R-42 0342 57 ~7 

11 111 ~ •• o~-42 o34? 411 48 

t1 1 t tfi •• oR-42 0341 4q .-49 

t7 1114 •• oA-42 0342 47 47 

17 109Q •• OR-42 0342 3? 12 

17 1100 •• 0A-42 0342 H 33 

1 7 1091J •• OR-42 034? 31 ]1 

17 1t12 •• 0R-42 034? 4~ 45 

ty 1134 •• 08-42 0342 67 67 

OR-42, Past MP~fcal 

Hfst~rv 

OAU trF.M NANE 

Neuro~uscular: osvchiatrlc: neur~Joalc ~isease, other 

RPnaU urtn,.rv tr111ct: cvstlti!> 

Renal: urtn111rv tract; qtomeruloneohritis 

Henal: urtnarv tract; pyelitis 

ll"'spiratory: asth'lla 

RPsotratorv: I"'Of"U'IIOnla 

Resntratorv: tuherculosis 

suraery, abdominal 

Htstory, nther stqnlficant 

H 

H 

;,. 

• 

~ 

0 

...... 

~ 

~ 

~

DEE'INll'ICII.'f .OF CODES 

PAST MEDICAL HISTORY 

FOEM OB-42 CABD 0342 

1. Card Number l 

Code: 0 

CAED 

COilJMN 


Code: 3~ 

·' 

3· Revision Number 5 

Code: 0 - Form Dated: 4/62 

4. NINDE Number 6-14 

Item 1 

Nine-digit numb£ tor Patient Identification 


Date For.11 Completed 15-20 

Item 2 

Six-digit cede tor Month (cols. 15-l.C), Day 

(cols. 17-lB), &Z2d. Year (cols. 19-20) 


99 - Month, day ami/or year Wlkn~ 

6. Patient 's Ristm Was 21. 

Item 3 

Code: 

l .. Obt&1ned. using this f'orm 

2 - A.batn.c:ted !'rom other records 

3 - Combil:2at~on o~ codes: Land 2 

9 .. Tl'nkDml 

r. Chil.ahood Dis-.es 22-24 

Items 6 ami l7 

Tbree-d181t code tor: 

ReS'Conse (col. 22) 

Code : 

0 - I'OM 

l - Caa!ition(s) reported in item 11 onJ..T 

2 .. Coaiition( s) oth8r than those reported 

in it& l7 

3 .. C~tion ~ codes 1 and 2 

9 - TJ'nimam 

Rubella (col. 23) 

Code: 0 .. l'l'o 

l .. Yu 

9 . - TJ'Dimcm1 

MumpS (col. 24) 

Code: Same u in col. 23 

II.A.202 

OB-42 



FIELD 

8. Cardiovascular 

Items 7 and 17 


Response (col. 25) 

Code: .Same as in Field 7, col. 22 

FORM OB-42 

Card 0342 

CARD 

COilJMN 

25-29 

Heart Disease (col. 26) 

Chronic Hypertension (col. 27) 

Rheuma.tic Fever (col. 28) 

Vascular Disease (col. 29) 

Code for each col~: 


9· Respiratory 



Response (col. 30) 

Code: Same as in Field 7, col. 22 

Tuberculosis (col. 31) 

Asthma (col. 32) 

Pneumonia (col. 33) 



10. Digestive 

J.tems 9 and 17 




Hepatitis (col. 35) 

Cholecystitis-Lithiasis (col. 36) 

Peptic Ulcer (col. 37) 

Code for each col~ 


30-33 

34-37 


II.A.203 

OB-42

DEE'INITION OF CODES (Continued) 

FIELD 

- 

FORM OB-42 

Card 0342 

CARD 

COIIJMN 

ll. 

Gynecological and Venereal 


Six-digit code for: 



12. 

13. 

14. 

Gynecologic SUrgery (col. 39) 

Infertility 

! 

col. 4o) 

snhilis 

col. 41) 

Gonorrhea. col. 42) 

Pelvic Inflammatory Disease (c~l. 43) 


Same as in Field 7, col. 2j 

Other Surgery 





Other Abdominal Surgery (col. 45) 

Code; Same as in Field 7, col. 23 

Rena.l and Urinary Tract 


Four-digit code tor: 


Code: Same as in Field T, col. 22 

Pyelitis 

Cystitis 

(col. 48) 

Glomerulonephritis (col. 49) 



(col. 47) 

Endocrine and Metabolic 


Tbree-digit code tor: 



±hyroid DysfUnction 

Diabetes Mellitus (col. 52) 


Same as in Fi.eld 7, col.. 23 

(col. 51) 

44-45 

46-49 

50-52 

II.A.204 

OB-42 



FORM OB-42 

Card 0342 

FIELD 

15. 

16. 

17. 

18. 

Neuromuscular and Psychiatric 




Code: Same as in Field 7, col. .22 

Migraine 

(col. 54) 

Mental Illness 

(col. 55) 

Convulsive Disorder (col. 56) 

Other Neurologic Disease (col. 5T) 

Code for each column :' 


Blood and TransfUsions 



Resnonse (col. 58) 


Anemia (col. 59) 

Isoimmunization (col. 60) 

Transfusion (col. 61) 

Code for each column : · 


Other Conditions 

(terns 16 and 19 


~esponse (col. 62) 


Dr?g Sensitivity (col. 63) 

Other Allergy (col. 64) 

~~lformations (col. 65) 

Parasitic Diseases (col. 66) 

Code for each column : 


Significant Histort Not Listed Above 

Item 18 


1 - History reported 

9 -Unknown 

CARD 

COIDMN 

53-57 

58-61 

62-66 


II.A.205 

OB-42

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II.A.206 

OB-42

Instruction Manual for Obstetric Forms 

OB-42 PAST MEDICAL HISTORY 

I. Purpose of form To record details of patient's 

previous medical and surgical 

history up to time of interview. 

II. General Instructions 

A. Record know.1 diseaees and surgical procedures 

only. Do not use this form for 

symptom review. 

B. Give particular emphasis to medical history 

just prior to, and since onset of this pregnancy. 

C. Record appropriate details, such as dates of 

onset, duration, severity, place of hospitalization, 

operations performed, non-routine 

treatment, etc. 

D. If history for the item is negative, mark the 

box labeled, "None." 

E. The summary (Item 17) provides a means 

for flagging certain important conditions. It 

is incomplete and should not be used as a 

sole guide to obtaining past medical history. 

Ill. Specific Instructions 

Item Number 

2. Date. Record the date history is obtained 

from the patient. 

3. Patient's history was. Mark the appropriate 

box. When the entire past medical 

history is abstracted from hospital records 

without patient interview mark "'Abstracted 

from other records." 

4, 5. History taken by. Record the first initial 

and last name, and the title or position 

of the physician obtaining the history. 

6. Childhood diseases. Record history of the 

usual infectious diseases. Pay particular 

attention to the occurrence of such diseases 

in the three months prior to or 

since the onset of this pregnancy. 

7. Cardiovascular. Record history of rheumatic 

fever, St. Vitus dance, chorea, or 

other syndromes p o s s i b 1 y associated 

with heart involvement. Record any details 

of diagnosed or suspectedheartdisease, 

chronic hypertension, or vascular 

disease. 

Item Number 

8. Respiratory. Record history of chronic 

respiratory disease, such as tuberculosis, 

asthma, bronchiectasis, etc. Acute infectious 

respiratory diseases are considered 

significant only if requiring medical 

care or hospitalization. 

9. Digestive. Record history of gastro-intestinal 

disease, such as peptic ulcer, 

cholecystitis, cholelithiasis, regional ileitis, 

and chronic ulcerative colitis. Diarrhea 

of unspecified origin is considered 

significant only if requiring medical care 

or hospitalization. 

10. Gynecological and venereal. Record medical 

or surgical history of gynecologic disorders. 

A history of infertility is considered 

significant only if work-up such 

as endometrial biopsy, Rubin' s test, 

hysterosalpingography, etc. is carried out. 

Record any history of veneral disease. 

11. Other surgery. Record the details of 

surgical procedures not listed more appropriately 

elsewhere on this form. 

12. Renal and urinary tract. Record history 

of renal and urinary tract disease or 

surgery, such as glomerulonephritis, acute 

or chronic p yelo nephritis, cystitis, 

lithiasis, and nephrectomy. 

13. Endocrine and metabolic. Record any suggestive 

or definite history of endocrine 

disorder. 

14. Neuromuscular and psychiatric. Record 

any definite or suggestive history of disease 

of this system, expecially migraine, 

epilepsy, mental illness or retardation, or 

neuromuscular disorder. 

15. Blood and transfusions. Record the history 

of anemia, iso-immunization, leukemia, 

or other disorders of the blood. 

History of whole blood transfusions is to 

be noted, along with dates of administration 

and reaction, if any. 

16. other conditions. Utilize this space to 

record a history of disease or disorder 

not covered in the above items. Of especial 

importance are chronic diseases of the 

skin, allergies, trauma, malformations, 

neoplasms, and parasitic diseases. 

October 1962 


II.A.207 

OB-42

Instruction 1\lanual for Obstetric Forms 

08-42 PAST MEDICAL HISTORY (Continued) 

Item Number 

Item Number 

17. Summary. The summary provides a means 18. Significant his to r y not listed above. 

for flagging certain important conditions. 

Mark this box to index the history of a 

Complete the summary after the entire past 

disease or surgical procedure th;t may 

medical history has been obtained and re 

affect the outcome of this pregn2-!lcy, 

corded in items 6-16. Do not use the sum 

but which is not listed in the Sumnary 

mary as a sole guide fo.r obtaining the (Item #17). 

past medical history. 

October 1962 


II.A.208 

OB-42

OB-43 

Initial Prenatal Examination 

Form OB-43 was used to record results of the initial physical examination 

following selection of the pati~nt into the project sample. First used as a 

pretest form in July 1961, the form was implemented into the study in April of 

1962; form OB-43 replaced pages 3 and 4 of form OB-9, where information on the 

initial pelvic examination and general examination had been recorded. Page 2 

only was revised in October 1962. Data records generated by form OB-43 were 

punched on cards 1343 and 2343 of the master file (Table OB-43.1). 

TABLE OB-43.1 


CA~ NAME 


NUMBER NO. RECO~S 

OB-43: General Examination 

OB-43: Obstetrical Examination 

1343 

2343 

0 31 ,251 

31,251 

0 31,226 

31,226 


II.A.209 

OB-43 


II.A.210 

OB-43 



H 

H 

;,. 

• N 

..... 

..... 

~ 

~ 

w 

nata Items R~f@rencin~ Form OR-43, Tntttal Pren~tsl r.xam 

01\TA 

rrrl4 

I 'I' EM :JN CARO 

TO F'JQI4 NIIN FROIIII TO OATA J fF:N NAME 

' 1 36 ••••••• 

11)7 ••••••• 

11 n ..na-43 

1139 •• 08-43 

1140 •• nB-43 

tt41 •• na-43 

1142 •• na-4J 

1143 •• 08-43 

1144 •• 08-43 

t 145 •• oa-43 

1146 •• na-43 

1147 •• 08-43 

1148 •• 08-43 

1149 •• ns-43 

uo:;o •• oa-43 

t151 •• os-43 

t1"i2 •• na-43 

11"3 •• 08-43 

t15t •• n8-43 

11'55 •• nB-43 

tt'i& •• ns-43 

1157 •• 08-4] 

1158 •• 08-41 

1159 •• ns-43 

t160 •• 0B-4J 

1161 •• os-43 

t11i2 •• os-43 

1163 •• 08-4] 

tl64 •• na-43 

f 165 •• ns-43 

t16& •• os-43 

1167 •• 08-4] 

1168 •• na-4J 

1169 •• ns-43 

t17o •• na-43 

t17l •• OB-4l 

tt72 •• na-4J 

un..os-43 

tt74 •• na-4J 

1175 •• 08-43 

1176 •• 08-4] 

tl77 •• na-43 

2 

2 

2 

10 

11 

12 

14 

14 

14 

14 

t4 

t 5 

15 

15 

15 

1" 

15 

16 

16 

16 

16 

t6 

16 

17 

17 

17 

17 

111 

18 

1A 

1A 

111 

111 

19 

19 

1CJ 

19 

19 

20 

20 

1343 

1343 

1343 

1343 

1343 

1343 

1]43 

1343 

1343 

B4l 

D43 

1341 

1343 

1343 

1343 

1343 

1343 

1343 

1343 

1343 

1343 

1343 

13B 

1 ]43 

1343 

1343 

1343 

1343 

1343 

1343 

1343 

1343 

1343 

1343 

1343 

1343 

1343 

1343 

1143 

1343 

1343 

1343 

t 5 car~ nu~ber Cseauence, fora tvoe, for~ nu~ber, revision nu~berl 

f; 14 NTNOB C3SP number 

1'i tb Form ns-41 ~ate (mol 

17 18 Form 08-43 date (~ay) 

1Q ?.0 Form nB-43 ~at.e (Vrl 

21 23 ~eiaht, ore ore~nancv (lbs) 

24 ?5 Heiaht (inches) 

21; ?8 Pulse 

2Q 79 Aopearanc@, acutely 111 

30 lO 

31 lt Anoearance, 

AnpearanceJ chronically ill 

ohese 

32 32 Aopearanc~: dehv~rate1 

Jl 13 Aooearanc~, other 

34 34 Skin lesion 

]


H 

H 

• > 

• N 

.... 

N 

@ 

I 

.c:: 

w 

ne~ta Items RPferE>ncir'lg fnr111 OR-43, Tnftfal Prenatal Ex;~m 

o•rA 

trfM 

ITEM 

J~l caR" 

TO F'JRM NIIM FROM TO DATA TfF.M N•IIIIF: 

t178 •• nR-43 20 1343 63 63 Thvrofd, nther Rbnor~alttv 

t179 •• nB-43 21 1343 64 64 Breasts: roalPAble mass 

11AO •• OB•43 21 1343 65 65 Breasts: tnfla'lllftl!tlon 

tlAt •• ns-43 21 1141 66 66 Breasts: niPPles, Inverted 

t1A2 •• 08•4'J 21 1143 67 67 Elreasts, nther abnormality 

11A3 •• 0B•41 22 1343 68 69 Luncrs, auscultation abnorlllal 

f1A4 •• 06•43 2'1 1343 69 69 Lunas, oercus~lon abnormal 

11AS •• 08•43 2'1 1343 70 70 Lunas: rtyspnei'l at rE>st 

t 186 •• oe-43 27. 1343 71 71 Lunas, other AbnorMality 

un••oe-43 2l 134~ 7?. 72 Heart mnr111ur 

71 

,. 

U98 ••n&•41 21 

1141 

73 H~art rhyth• trreQular 

t 1119 ••08•43 2] llU 

74 H~ert, oroenfe heart disease 

uoo•• ns-41 21 

1341 7~ 75 H~art, nther i'lbnor•Alfty 

1191 ••08•43 24 1343 76 76 Extre•tttes: vartcostttes, •oder!lte 

1192 •• nB-43 24 1H3 77 77 .Extre•H feu vartcos1t1es, severe 

tllll ••ns-41 24 1141 7R 78 Ewtre•ltles: ulcers 

ttll4 •• oe-41 

11115 ••••••• 

11CJ6 ••••••• 

1107 ••••••• 

t1CJ8 •• ns-41 

tto9 •• na-41 

24 

1343 

1343 

2343 

2341 

2341 

2343 

79 

80 

t 

6 

l!i 

17 

79 

AO 

5 

t4 

16 

18 

susoected 

Extremttt~s, nther abnormality ~not edeMa) 

Blank 

C11rrt nuMber (seauence, for'l type, tor• nullber, 

NtNna cas~ nu111b~r 

2 

For• DB-41 date (llo) 

2 

Form OB•43 date (day) 

1200 ••08•43 2 2343 111 20 For• 08•43 rtate (yrl 

t 201 •• ns-43 2'5 2343 21 21 Neuroloalcel; reflexes 8bnor'llal 

1202 •• na-H 2"; 2H1 22 12 NeuroJootcal, otnPr evidencP of :t1 sorder 

1203 •• 08-41 26 2343 2l 23 fnnrtuscootc: VeSSPl chanaes 

t 204 •• n8-43 26 2341 24 '14 Fnnrtuscnotc: retinal cn~naes 

12ns •• 08•41 26 2343 2"i 25 funduscootc: dis::· Ch!ln::JPS 

1206 •• 08•43 26 23H 26 16 funttuscoptc: het~~orrh;~oe 

1207 •• na-43 26 2343 27 '17 funduscopic: PXlldlltl" 

1208 •• 08-41 26 

2141 211 28 

t 209 •• os-43 27 

2H3 2Q 29 

12to •• nB-43 2 2343 30 30 Ah::lomE>n, llbnor'R~l m&ss 

1211 •• 1"18•41 2 2343 31 31 Ahctnmen: hernia 

1212 •• 0B-4'J 2 2343 3?. 12 Ahctomen: tencJerness 

1213 •• 08-41 2 2343 H 33 Ah::tomen: rVA ter'l::lerness 

1214 •• 118-41 

1215 •• 1')8-41 

t2t& •• na-43 

2 

3 

3 

2341 

2343 

2343 

34 

3"; 

36 

14 

35 

3b 

funduscopic, other abnormalttv 

Ahnormalltles, 'iOO'IIlllles, :>ther 

Ah::IOIIIPn, other abnor~alttv 

uterus, s1ze not comoatthle 

Uterus: tnmor 

t217 •• na-H 3 2341 )7 37 Uterus: multiple pre::,nancy 

12tB •• nB-4l 3 2343 3R 38 Uteru~, tPnriern~ss 

t219 •• '1B•41 3 214 3 3CJ 19 Uterus; oo1vnv::tra111ntos 

t2?0 •• f')B-41 3 23B 40 40 Uterus, other abnoronaJltv 

with dates 

revtston nuMber)


H 

Ḥ 

)II 

• N 

...... 

w 

@ 

! w 

nata Ite~s RPferencing For~ OR-43, TnitfaJ Prenatal Exa• 

DUA 

JfF.II 

ITEM Jlf CARO 

TO F'JRfi4 NUll FRO~ TO 01\ U TrF.:M NUll: 

t221 •• ns-41 4 2141 41 41 GP.nftalia, P.xternalJ vuJvar varfcos1ties 

12'12 •• 08•41 4 2341 42 42 GPntt~lia, other ~bnormaltty 

t2'23 •• nB-41 s 2343 43 43 Introitus, urethrocelP 

t 224 •• ns-41 s 2343 44 44 Introitus, cystocele 

12'15 •• 08-41 5 2343 4'5 45 Introttus1 rertocele 

12'-& •• ns-43 s 2343 46 46 Introftus, other abnormalitY 

t2?7 •• na-4l b H43 47 47 VAQin~; VRQiottfs 

t2?.8 •• ns-41 6 2141 4A 48 va~foa, blePjfn~ site 

t 2?9 •• nB-41 6 

2343 4q 49 Va~fna, other abnormality 

121 o•• os-43 ., 

2343 so 50 Cervix: laceratt~n, ol1 

t2ll •• IJB•41 7 2343 51 'il Cervix, bleectfna site 

1212 •• ns-41 7 2343 5? "i2 cervix, bleecttno throuqh os 

t 2H •• nt:t-H 7 2141 51 "i3 Cervix: cervtcitis 

1214 •• na-41 1 

2141 54 "i4 cervix, 1flatej or efface1 

1235 •• nB-41 7 

2141 55 '55 Cervix, other abnormality 

1236 •• 08-41 8 

2341 56 56 A1nexa, mass 

1237 •• r'IB•43 8 

2341 57 '57 A1nexa, ten~erness 

t23a •• ns-41 s 

2341 SA '58 A~nexa, other abnormality 

1219 •• oa-43 9 

2343 59 '59 RajfooraohyJ x-rav oelvtmetry 

1240 ••'lB•H 

10 

2141 60 ~0 Pelvic mensuratfon1 jfaoon!l con1uQate 

1241 •• 08•41 10 

2343 61 63 Pelvic ~ensnrationJ ~taaonal con1uQate reache~ 

1242 •• 08·41 11 2343 64 ~4 Pelvic mensuratton1 sPines 

1243 •• na-43 12 2143 6'5 65 Pelvic mensuration: sacrum 

1244 •• ns-43 tl 2341 &6 66 Pelvic mensuration, sacrosciatic notch 

1245 •• 08•41 14 2341 &7 67 PPlvic ~ensur8tfon~ st~~walls 

1 24& •• ns-41 1'5 2)41 &A 6~ Pelvl~ mensur~tfon1 sub ouofc ~rch 

1247 •• na-43 16 2341 61J 71 P~lvic mensur8tfon1 intertuherous measure~ent· 

1248 •• ns-41 11 

2141 72 74 P~lvic ~ens11r8tton1 posteriorsaqittal outlet 

1249 •• 08•41 lP 

2141 7~ 75 Pelvic mensur~ttonJ oelvtc abnor•alitv, other 

t2"iO •• OB•4l 19 2143 76 76 Pelvic mensuratfon1 su~mation inlet 

t2"H •• 08·43 20 2341 77 77 Pelvic mensur~tfon; sum~atton ~11 PPlViS 

12'52 •• 08•41 20 2341 78 78 Pelvic mens11r~tton~ summation outlet 

12'53 ••••••• 2343 71J RO lllanlc 

491'7 •••• VAP 2 5~ 'i6 Prenatal visits, total number 

49CJS •••• VAR 

499& •••• VAP 

4997 •••• VAP 

'i210 •••• VAP 

11 

10 

tn 

1Q 

Bt 

Al 

86 

llQ 

A2 HeiQht (in) 

RS w~iaht, pre preanancv (lbS) 

R8 ~eloht oatn (lbs) 

319 PPlvlc 5umm8tion, inlet 

measurement (em)

COLR-3003-4A 

.... 


08-43 INITIAL PRENATAL EXAMINATION PAGE 1 

Z. DATE 6. THIS EXAM 7. FilE•&>< AMI""'" -av 

WAS 

I 

I 

0 CONOUCTilD 

iio. 1 Dey 'Pear 

1 I USIN. TNia 

4. EX A MIN ED BY 

'0Rtrol 

I. TITLE 011 POSITION 

---. 

I 

0 OTN~II 

•. 9 :::.-:-.::'" 9 ~~.:,--::~. 

5. TITLE OR POSITION 2 (See 

--- M•ual) •&YIIWCO R~YI~W~D 

(lniUIOI All Ch-1..) 

10. NON· 

PREG. I"· 

WEIGHT 

•• 

•• 

HEIGHT 

IIZ. PULSE 


1•. GENERAL APPEARANCE 0 ...... 

0 NOJU..... L D ACUTELY ILL 

Ox 

___ 1__ _1 0 NOT EVAL. 0 CHftONICALLY ILL 

ox 

15. SKIM 0 LESION 

ONOitWAL 

ox 

0 NOT EYAL. 

ox 

16. EDEMA 

ONONE 

ox 

0 NOT EVAL. 

ox 

11. LYMPH MODES 

0 NORWAL 0 

rr. NOT 

ox 

EVAL. 

I e. EMT AND MOUTH 

0 NOT OON& (•aplllln) 

QoaM'I'O•ATU 

OoTMCII 

0 HANDS 0"'&T1eiAL 

0 A.BOOMINAL WALL o:::~ .....,.. 

ENLARGED LOCALLY 

::::J ENLARGED GENERALLY 

0 "'OAWAL 0 ~':.~';.~':;'AT ION 01' 

ox 

0 NOT IVA'-• 

0 OTHIII INPLAWWATION 

.. 

0 NIARIN. IW~A.IAMIUIT 00TMU 

II. EYES 

0NOttMAL 

o. 

0 NOT I VAL. 

ox 

OJAUNOICC 

zo. THYROID AND THYROID FUNCTION 

O"OitWAI.. AT 

Ox CI.UIICAI. EXAM o:~~~~~~~~O:T::.:·OIO 

0 NOT I VAL. AT EXAhll. 

ox 

Zl. BREASTS 

::J 

Ow••• 

NORWAL 

0. 

rl NOT I VAL. 

w 

u. LUNGS 

ONORfrroiiAL 

ox 

0 NOT IYAL • 

Z3. HEART 

QNORMAL 

ox 

0 NOT IYAL. 

ox 

z•. eXTREMiTieS 

O•••"MA&. euMa 

O tNYHTI.D 

Nl"k&8 

OoT•a 

D:='.':~T 

aueNCTU 

Do..,.• 

ONORWAL 

VAitiCOaiTIEa, 

0 

Ox 

WODEIItATI 

CJ NOT IYAL • 

• ox 

Z5. NEUROLOGICAL .,._ avtoc•cc 

~ NOitMAL 0 :::~::-:.&. 0 f!W' HUit.~HICA~ 

Dt-.aa 

:J NOT IYAI..o 

21. FUNDUSCOPIC m

COL ..-3008-41 

UIIYe 10.U) 

1. PATIENT IDENTII'ICATION 

08-43 INITIAL PRENATAL EXAMINATION 

OBSTETRIC EXAMINATION 

2. ABDOMEN (except uteftle) 

QNOitMAio. O••..oaMAL MAee 0 CYA TlttDI.ItMI.S8 

ox 

0 NOT EYALe 0 

h 

•• 

•• 

•• 

MEitMIA 

0 AaOOMIMAL TEM0EitME88 

QoTNER 

l. CORPUS UTERI 0 SIZE MOT CONI'ATI.LE 0 UTCitiME TEMOEitNES. 

WITH OATES 

QNOitMAL II"Oit 

OX WI.I:AS 

GI.STATIOM 

DMOT 'IYAL. • 

w MOitNAL 0 

0 NOT EYALe 0 

4. EXTERNAL GENITALIA 

YULYAit VAitiCOSITIIS 

OTMEit 

OoTNI.It 

5. INTROITUS 0 UOCTMOO«•• 0 ltiCTOCEl.C 

QMOitNAI.. 

0 MOT CYAL. D CTSTOCCLC 

6. VAGINA 0 vAeiMITis QoTNIIt 

gMOitMAL. 

0 MOT CYALe 0 

7. CERJrx UTERI 

•I..EIDIMe •tTl 

0 o•o ••«UTION D ClltVICITIS 

0 NOT IVAI,.. 0 •u:CDJNe SITI 

.. 

0 OILATID OR CP'rACED 

OoTMCit 

I. ADNEXA 0MA88 OoTMCIIt 

QNORMAI.. 

O•oT IY.t.L • 

CLINICAL PELVIC MENSURATION 

I 

0NOT OONO:(Expl•ln) 

--T--t 

PAGE 2 

I 

.\lark (X) All apprupft•ta bo••• .,.d' de•cribe .ny poeUlve llnd.ina• •t riljht. 

10. DIAliDNAL I;DNJUliATI: 11. SPINES IZ. SACRUM 13. SACROSCIATIC NOTCH 14. SIDEWALLS 

I Ci AVIItA.I CUitVI. QAYEitAGI C••~t•a..a..IL 

I 0 MOT ...OMINI NT 

ct::!CMCD AT .... 

I 0 

0 

0 

I OP'I..AT 

O••ltltOW 0 CONVUIGIMT 

Q lti:ACMCD AT 

i c;:J "'OMINCMT 

0 I I I 

CWO ANGUI..ATilD OIVCRGilNT 

I Ow•oE 0 

::J NOT CVAI... 

• • • 

tilt 

11. '" fi:HTUIII:IUJU~ II. OTHER PELVIC 

SUMMATION 

AIHORMALITY 

15. SUB PUBIC ARCH If. INLET 120. MID PELVIS 21. OUTLET 

0NONI 

9 AOIQUATC ~ AOIOUATil ~ ADI.QUATI 

O•vERAec ONAitltOW CWO 0 

0 I 

17. POST. SAG. OUTLET 0 ASYMMI:TitY O•oltDI.It• 

o oooo... -I 0 0000&0· 

.... 2 •• 2 

• 

at done) 1 I..INI 1 

\.INC 1 \.INC 

I 

Owtoc 

z QOTMCit 0 COMTRACT• 0 COIItTitACTED D COMT,.ACTI:D 

23. CON• 24. AltJIIIIOaiNATI: 

SUI..TATION DATE OP" 

22. DIAGNOSTIC IMPRESSIONS (Record.,, lndu.un, ol>ererrlciiiJ SOUGHT OMtiiT 

I 

I 

I 

25. LAY EDIT ,26. MED !lwtTM . 

:27. MEDICAL ; Zl. TITLE OA 

BY EDIT T ~:::~TAL 9i21!t,Y.l... : EDIT IIY 

. 

: POSITION 

COLL.A80fii:ATIVR RIEIIEAIItCH 

Pa.. INATAL .. IESIEAIIII:CH B .. ANC:H. NINO•• NIH {ltCV • 1 O.aa f 

:~:~ 08-43 

BETHESDA 14. MD. 

!IeA.215 

OB-43 



~orm Ite~ ~u~bers linked to nata Items on OR-43, Tnftfal Prenatal ~xam 

ITEiof 

OATA 

I'JN TrF:M CARO 

rnw1111 10 Nllll4 FROIII TO DAtA TfF:M NAIIH: 

2 1210 •• 0R•43 2141 30 )0 Ah::I01lPn, ~bnor11Al '11855 

2 1214 •• 0R•43 2343 34 34 Ahdomen, other ~bnor'llalttv 

'l 1213 •• 0R•43 2343 31 33 AbdOmPn: ('VII ten::lerness 

'1 1'11t •• OR•43 2343 31 31 Ahdomf'n, hernta 

'1 1211 •• oB-43 2341 31. 32 Ab::lomen: tendPrness 

'1 lt 3Q •• OR•4J 1343 17 18 For~ nK-41 rtate (1av> 

2 119q •• OR•43 234~ 17 18 forM 0~·43 rtate (~a~) 

2 1t3II •• OR•U 1)41 15 16 form 08•41 ~ate (•o> 

2 1t911 •• DI\•4l 2343 IS 16 for• 08•43 date (•o> 

1 uoo •• oA•4l 2343 tq 20 For• 08•41 ~ate Cvr> 

' 

tun •• oA-43 t343 1q 20 for• OR•4l ~ate Cvr> 

4987 •••• VAR 5'5 ~6 Prenatal visits, total nulllber 

'3 1220 •• oR-43 2343 40 40 Uterus, othPr ahnormalltv 

3 1'11~ •• 0A•43 2343 3'5 35 Uteru,;, stze not comoatlble wlth dates 

H 3 121A •• OA•43 2341 311 38 Uterus, tenderness 

H 3 1211 •• oR-43 2343 37 37 Uteru,;; multiple oregnancv 

• )II 3 12tq •• oA-43 23H H 39 uterus; polvhvdralllntos 

• 3 t ?16 •• oR-43 2343 36 l6 Uterus; tiJIIIOf 

Ṇ 

... .. l'12t •• oq-43 2343 4t 41 Genftalta, externalJ vuJvar vartcosttles 

0\ 

~ 

4 1222 •• uR-43 2343 41 42 GPntt~tlia, other abnormalftv 

5 1226 •• oR-•3 2343 4f> 46 Introttns, other abnormalftv 

'5 1224 •• DR•43 2H1 44 114 ]l'ltrottus; cystocele 

'5 l12!' •• 0R•43 2143 4'5 45 Introttns; rectocele 

'5 1221 •• oB-43 234' 41 4j Introitus: nrPthrncPlP 

6 12211 •• oR-43 2343 411 48 V"'t'J1na, bleec1fn'l site 

6 122q •• oR-43 2341 4q 49 VaQfna, other annormalitv 

6 1227 •• 0R•43 2341 47 47 Vaatna; vaqtnftts 

7 1131 • .OR•43 2341 51 51 c .. rvtx, blePdfnq slte 

7 1232 •• 0R•43 2341 5? !'2 Cervix, bleedfna tnrough os 

7 12H •• OR•4l 2343 54 c;4 Cervtx, ~tlatrd or efface~ 

1 123'5 •• OR•43 2341 5'5 "iS CPrvix, othf'r ahnormalitv 

7 1233 •• oR-43 2343 53 53 CPrvtx; cervicitis 

7 t23n •• oR-43 2341 51'1 50 CPrvix; lacer~ttfon, old 

8 1236 •• 0R•43 2H3 56 c;& Adnex::~, mass 

A t13R •• OR•43 2l4l sq '58 Artni!Xil, othf'r ahn:>r~alltv 

II t237 •• 0R•43 2341 57 '57 A-1nPxa, tPnl'!ernl!ss 

~ q 12H •• OR•43 2141 sq !'9 R~dfo'lraohv: 

w 

l(-rav oelvtmetrv 

to 1141 •• o~-43 2341 61 63 Pelvic rnensnrl'ltfonJ ::lfaqon~l con1uqate ~easurement (CIII) 

to 1240 •• 0R•43 2341 60 60 PPlVl~ mensnr~ttoll; 11a'lonal con1ug~tte rl!sched 

10 41197 •••• VAR R6 118 WeiQht qafn (lbS) 

to 41196 •••• VAR 91 AS WP1Qht, ore preanancv (lbS) 

10 tt4t •• oR-43 1341 21 23 WPlOht, ore oreanan~v (lbS)


H 

Ḥ 

!):II 

• "-> 

..... 

-.J 

Form lte~ MumbPrs linked to nata Ite~s on OR-43, Tnftfal PrPn~t~l Exa~ 

IT~~ 

OATA 

nN Jf~M CARll 

F'l'lRM In NIIM F'R014 TO DA fA TfPM NAMF.: 

t1 4Q9!'\ •••• VAR 81 A2 Heiqht £in) 

11 1142 ••.OR•43 1341 24 25 HPi~ht (inches) 

t1 124? •• oR-43 2143 64 64 PPlvic mensur&tton: soines 

12 1243 •• 0~-4.3 2343 6"i 65 Pelvic mensuration: sacrum 

12 1143 •• 0R•43 1H3 21; ?8 PUlSe 

13 1244 •• oR-43 2343 bfi 66 PPlvic mensurstton: sacrosciatic notch 

14 tt4• •• oR-43 1341 2Q 29 AopParancP, acutely ill 

14 tt4'5 •• uR-43 1341 )1'1 30 Aopearance, chronically tll 

14 

lt4A •• Of'•43 1343 H 33 Aopearance, 

14 un•• oR-43 1343 31 32 Aopearance: other 

dPhVdrated 

14 1146 •• 0R•43 1343 31 11 AooParance; ohese 

t4 1245 •• oR-43 2343 67 67 PPlvic mensur8tfon: slde~~lls 

15 1246 •• oR-43 2341 6A 6~ Pelvi~ mensuration: sub pubiC arch 

15 tt4Q •• o~·4J 1H3 34 14 Skin lesion 

15 t1st •• oR-43 1341 3f' 36 Skin oiomentation abnormal 

15 

IS 

15 

15 

1& 

16 

115o •• oR-43 

1154 •• 0R•43 

tl5?. •• 0R·43 

1153 •• 0R•43 

1157 •• UR•43 

11bO •• OR•43 

1H3 

1143 

1343 

1343 

1343 

1343 

3'5 

39 

37 

)A 

4? 

45 

35 

39 

37 

38 

42 

45 

Skin scars, ooerative 

Skin, othPr ahnormalitv 

Skin: hirsutism 

Skin: rash 

E~ema, abdominal wall 

Edema, ankle/foot 

16 lt5'5 •• 0R•43 1343 40 40 Ede•a, face 

16 115fi •• OR•43 1343 41 41 Edema, hands 

16 lt5A •• 0!\•43 1341 41 43 E~e~a, Pres~cral 

16 115Q •• OR•43 1343 44 44 E~e~a, nrPtibf~l 

t& 1 ?.47 •• OR-43 2H 3 69 71 PPlvtc mensuration; intertuberous mPasure~ent 

17 1162 •• 0R•43 tH'l 47 47 Lymoh no1Ps, Pnl3r~Pd qenerally 

17 1161 •• 09•43 1341 46 46 Lvmnh no~es, Pnlar~e1 loc~lly 

17 11&4 •• oR-43 1343 4CJ 49 LV~Dh nodes, other abnormality 

I 7 1161 •• 0R•43 B43 4A 48 Lymon nodP.s, tenjerness 

17 t24A •• OR•43 2343 71 74 PPlvic mensurattonJ oosteriorsaqittal outlet 

1 8 1170 •• 0R•43 1343 5'5 55 ENT and mnutn, other abnor~ailtv 

18 1tbA •• OR•43 1343 51 ~3 E~r and mnuth7 qu•s abnorm9l 

18 1t67 •• 0R•43 1343 52 52 E~T and mouth: heartno 1mP91rment 

18 lt66 •• 0R•43 1343 51 ~1 ENf and mnuth: tnfla~mation, other 

I 8 116"i •• OR•43 1143 50 ~o ENf and mnutn: Pharvnx tnfla~mation 

18 tt&9 •• oR-43 1343 

~ 

54 54 ENf and mouth: teeth carious or ~tssing 

~ 

w 

18 

l24CJ •• oR-43 2343 7'5 75 Pelvic 

18 

12sn •• oR-43 2343 76 76 Pelvic mensuratfon: 

mensuration: 

19 1l12 •• 0R•43 1343 57 '57 Eves, inflammation 

19 tt 75 •• oR-43· 1343 60 60 Eves, other ahnormalttv 

19 1t71 •• 0R•43 1343 56 ~6 Eves, PUPillary reflexes abnormal 

19 tt n ..oR-43 1343 58 58 Eves: 1&und1cP. 

pelvic abnor~altty, 

summation inlet 

other


H 

H 

•> 

"" .... 

(X) 

For~ Ite~ ~u~bers linked to nata Ite~s on o~-43, Tntttal Pr~natal Exa~ 

19 

19 

20 

20 

20 

20 

20 

21 

21 

21 

21 

22 

22 

22 

22 

2) 

2l 

2l 

23 

24 

24 

24 

24 

25 

25 

26 

26 

26 

2& 

?6 

2& 

27 

ITEM 

ON 

FOR!ol 

f)ATA 

Ttf;:M 

Ill 

1174 •• 0R-43 

S?.to •••• VAR 

1251 •• os-u 

1252 •• Q"t-4l 

t t7f; •• oR-43 

un..oq-u 

1t78 •• 0il-4l 

t18? •• 0A•43 

ueo •• oR-43 

ttBt •• DR-43 

tnct ••OR•U 

1 tal •• DA•4l 

1 taft •• DA•43 

I' 84 •• OR•U 

118!'i •• D8•U 

1187 •• 0A•43 

1188 •• 08•43 

1189 •• 08•43 

ll90 •• 0A•43 

lt94•• DR•43 

1191 •• oA-43 

1191 •• OA•U 

1192 •• OA•U 

1202 •• 0A•43 

1201 •• 08-43 

120A •• OA•43 

nos •• oR-43 

1207 •• DA•43 

1206 •• OR•43 

l?.04 •• 0A•43 

l203 •• 0R•4] 

120CJ •• OR•43 

CARD 

NUM 

1343 

2343 

2343 

1343 

1343 

1343 

1343 

ll43 

1343 

U4l 

1341 

lJ43 

1143 

1343 

1343 

1343 

1343 

1141 

1343 

1343 

1143 

134 3 

2343 

2343 

2343 

2341 

2343 

2343 

2141 

2343 

2343 

FROIIII 

SQ 

31CJ 

77 

7A 

61 

62 

b3 

67 

65 

66 

64 

69 

71 

69 

70 

72 

73 

74 

75 

79 

78 

76 

77 

2? 

21 

2A 

2S 

27 

26 

24 

23 

29 

TO 

OAfA IfEM NIIME 

59 Eves; visual l~oatr~ent, severe 

319 Pelvic su~m~t1on, inlet 

77 Pelvic mensurAtion; summation ~11 pelvis 

78 Pelvic mensuration; summation outlet 

61 Thyrotd and thyroid function, sf~ns of dysfunction at ewa~ 

62 Thyroid, abnor~al to oaloatton 

~3 Thyroid, other Abnor~allty 

67 Breasts, other abnor~alltv 

65 BreastsJ lnfla•~atton 

66 RreastsJ ni~Ples, Inverted 

64 ~reastsJ oalDable •ass 

68 Lunas, auscultation abnor•al 

71 Lunas, other abnor•alfty 

69 Lunas, oercussion abnormal 

70 Lunasr ~yspnea at rest 

72 Heart •ur•ur 

73 Heart rhythm trreaular 

74 Heart, or~antc heart disease suspected 

75 Heart, other abnor•altty 

79 Extremities, other abnormality (not ede•al 

78 ExtreMitl~sr ulcers 

76 ExtreMities: varicosities, moderate 

77 ExtreMitl~s: varlcostttes, severe 

22 Neuroloqlcal, other evi~en:e ot disorder 

?1 Neuroloatcal: reflexes abn~r•al 

?8 Fun~uscopic, other 8bnor~~lity 

25 Funduscopic: ~isc chanqes 

?7 Funduscnotc: exudate 

?6 run~uscootc: hemorrhaae 

?4 Fun~uscoptc: retinal chanqes 

?3 runduscootc: vessel chanQes 

29 Abnormalities, ano~altes, otner 

@ 

I 

~ 

w


miTIAL PRENATAL EXAMINATION 


FIELD 

-- 

1. 

2. 

3· 

4. 

5· 

6. 

7 

Card Number 

Code: 1 

Form Number 

Code: 343 

Revision Number 

Code: 0 - Form Dated 4/62 

NmDB Number 



Date of Examination 

Item 2 

Six-digit code for Month (eels. 15-1.6), Day 

(eels. 17-18) and Year (eels. 19-20) 



Non-Pregnant Weight 

Item 10 

Code: ~0B0-350 - As given ±n pounds 

999 - trnknown 

*Additional codes r~viewed and approved: 36o 

Height 

Item 11 

Code: 40.:80 · - As given in inches 

99 - Unknown 

CARD 

COillMN' 

1 

2-4 

5 

6-14 

15-20 

21-23 

24-25 

8. 

Pulse 

Item 12 


999 - Unknown 

26-28 


II.A.219 

OB-43

DEFTIHTION OF CODES (Continued} 

FIELD 

GENERAL EXAHINATION 

9· General Appearance 

Item 14 


Acutely Ill (col. 29) 

Code: 0 - Normal 

1 -Abnormal 

9 - Unknown 

Chronicall,y Ill (col. 39) 

Obese (col. 31) 

DehJdrated (col. 32) 


Same as in col. 29 

FOR-i OB-::,.3 

Card 131.3 

CARD 

COWMN 

29-33 

Other 

Code: 

(col. 33) 

0 - Normal 

1 - Underweight 

2 - Lethargic, depressed 


4 - Nervous, hysterical, tense 




9 -Unknown 

10. Skin 

Item 15 

Six-digit code :tor: 

Lesion 

Scars - Operative 

Abnormal Pigmentation 

Hirsutism 

Rash 


Same as in Field 9, 

(col. 34) 

~col. 35) 

col. 

36~ 

(col.. 37 

(col.. 38) 

' 

col. 29 --- 

34-39 

Other 

Code: 

(col. 39) 

0 - Normal 

1 Abnormal.ity other than code 4 

4 - Scars, traumatic 


9 - Unknovn 

· 

II.A.220 

OB-43 



FORM OB-43 

Card 1343 

CARD 

COIIJMN 

ll. 

Edema 

Item 16 


Face 

Hands 

Abdominal Wall 

Presacral 

Pretibial 

Ankle and/or Foot 


Same as in Field 9, 

col. 29 

40-45 

12. 

13· 

14. 

Iqmph N~ 

Item 17 


Enlarged Localiy 

Enlarged Generaliy 

Tenderness 

Other 

(col. 46) 

(col. 47) 

(col. 48) 

(col. 49) 

C0a:efor each column: 

Same as in Field 9, col. 29 

Ent. and Mouth 

Item 18 


Infla.mmation of Pharynx 

Other Inflammation 

Hearing Impairment 

Abnormal Gums 

Carious or Missing Teeth 

Other 

COa:etor each co~: 


~ 

Item 19 


Abnormal Pupillary Reflexes 

Infla.mmation 

Jaundice 

Severe Visual Impairment 

Other 



(col. 50) 

(col. 51) 

(col. 52) 

(col. 53) 

(col. 54) 

(col. 55) 

(col. 56) 

col. 57) 

col. 58) 

~ col. 59) 

(col. 60) 

46-49 

50-55 

56-60 

II.A.221 

CB-43 


DEFDITTION OF CODES (Continued) 

FORM OE-43 

Card 13!.;.3 

CARD 

COIDMN 

15. Thyroid and ThyrOid Function 

Item 20 


Signs of Thyroid Dysfunction at Exam (col. 61) 

Abnormal to Palpatio~ (col. 62) 

Code for each column:· - -- -· · 

same a~_~n Fi~~ 9, col. 29 


Code: 0 - Normal 

1 - Abnormality other than code 2 

2 - Thyroidectomy 


9 - Unknown 

16. Breasts 

Item 21 


Mass (col. 64) 

Inflammation (col. 65) 

Inverted Niuules (col. 66) 

Code for each c6lunin:- 

same -a.:s· E··l'ield_-9; col. 29 

-- --·-- -- 


Code: 

0 - Normal 

1 - Abnormality other than cede. 2 

4 - Ectopic breast tissue 


9 -Unknown 

17. Lungs 

Item 22 


Abnormal to Auscultation (col. 68) 

Abnormal to Percussion (col. 69) 

Dysunea at Rest (col. 70) 




64-67 

68-71 


II.A.222 

OB-43


FIEID 

18. ~ 

Item 23 

Fbur-digit code for: 

Murmur 

Irregular Rb.ytbm 

Organic Heart Disease ~ 

Suspected 

Code !or each column: 


Other · 

- o - Norma.J. 

1 - Abwrmallties other than 

abnormal rate 

2 - AbiJOrma.J. rate 

9 - Unla:lowu 

19· Extremities 

Item 24 


Varicosities, MOderate 

Varicosities, Severe 

Ulcers 

other (Bot Edema) 


Seme as in Field 9 1 col. 29 

(col. 72) 

(col. 73) 

(col. 74) 

(col. 75) 

(col. 76) 

(col. 77) 

(col. 78) 

(col. 79) 

FORM OB-43 

Card 1343 

C.ARD 

COLUMN 

72-75 

76-79 


II.A.223 

OB-43

DEFTIITTION OF CODES (Continued) 

FIELD 

FORM OB-43 

Card 2343 

CARD 

COIIJMN 

l. Card Number 1 

Code: 2 


Code: Same as in eels. 2-20 of Card 1 

G:E:NERAL EX:AMJll'ATION (cent.) 

3- Neurological 21-22 

Item 25 


Abnormal Reflexes (col. 21) 

Code: 0 - Normal 

1 -Abnormal 

9 - Unknow 

Other Ev;dence of Neurological Disorder (col. 22) 

Code: Same as in col. 21 

4. funduscopic 23-28 

Item 26 


Vessel Changes (col. 23) 

_!\etinal Changes (col. 24) 

_Disc Changel! (col. 25) 

Hemorrhage (col. 26) 

LXUdate (col. 27) 

Other 

(col. 28} 



5. Other Abnormalities and Anomalies 29 

Item 27 


OBSTETRIC EXAMJ:l'iA!riON 

6. Abdomen 30-34 

Item 2 (page 2) 

Five-digit code for: 

Abnorml !!...ass (col. 30) 

Hernia 

(col. 31} 

Abdominal Tenderness (col. 32} 

CVA Tenderness (col. 33} 

Other 

(col. 34) 


Same as in Field 3, col. 2~ 

II.A.224 

OB-43 



FOBM OB-43 

Card 2343 

CARD 

COIIJMN 

8. 

9· 

10. 

Corpus Uteri 

Item 3 (:page . 2 ) 


Size not Compatible with Dates 

Tumor 

MUltiple Pregnancy 

Uterine Tenderness 

Pol.yhydra.mnios 

Other 

eodefor each colwnn: 

Same as in Field 3, col. 21. 

Elcternal Genital.ia 


Two'-digi t code for: 

Vulvar Varicosities {col. 41) 




Introitus 

Item 5 (page 2) 

Four-digit code for: 

Urethrocele {col. 43) 

Cystocele (col. 44) 

Rectocele (col. 45) 




~ 

IteiilO (page 2 ) 


Vaginitis (col. 47) 

Bleeding Site (col. 48) 




(col. 

(col. 

(col. 

(col. 

(col. 

(col. 

35) 

36) 

37) 

38) 

39) 

40) 

35-40 

41-42 

43-46 

II.A.225 

OB-43 



FIELD 

FOIM OE-:.3 

Card 2343 

CARD 

COliJMN 

ll. 

12. 

13. 

14. 

Cervix Uteri 50-55 



Old Laceration (col. 50) 

Bleeding Site (col. 51) 

Bleeding through Os (col. 52) 

Cervicitis (col. 53) 

Dilated or Effaced (col. 54) 



~e as in Field 3, col. 21 

Adnexa 56-58 



:t-!as s (col. 56) 

Tenderness (col. 57) 




X-Ray Pe1vimet¥ 59 

Item 9 (page 2 

Code: 0 - Not available 

l - Available 

2 - Ordered 

CLINICAL PELVIC MENSURATION 

Diagonal Conju~te 60-63 

Item 10 (page 2 


Reached (col. 60) 

Code: 

0 - Not reached 

1 - Reached 

9 -Unknown 

Measurement in Cms. (cols .- 61-63) 

Code: 010-699 -As given in ems. including tenths 

999 - Unknown 

Suppl~ntal codes for approximate measurements 

reported as .. less than" or "greater than'' within 

the indicated limits 

770 - Less than 10.0 to 10.9 

771 - Less than 11.0 to 11.9 

772 - Less than 12.0 to 12.9 

773 - Less than 13.0 to 13.9 

777- Less than 7.0 to 7.9 

778 - Less than 8.0 to 8.9 

779 - Less than 9·.0 to 9.9 

II.A.226 

OB-43 


DEF'INITION OF CODES (Continued) 

FOEM OB-43 

Card 2343 

- FmJ) CABD 

COWMN 

14. Diagonal Conjuga.te 60-63 

Measurement in Cms. (cont.) (cols. 61-63) 

Code: 880 - Greater than 10.0 to 10.9 

881 -Greater than ll.o.to 11.9 

882 - Greater than 12.0 to :!2 .9 

883 - Greater than 13.0 to 13.9 

884 - Greater than 4.o. to 4.9 

885 - Greater than 5. 0 to 5.9 

886 - Greater than 6.0 to 6.9 

887- Greater than 7.0 to 7.9 

888 - Greater than 8.o. to 8.9 

889 - Greater than 9.0 to 9·9 

15. Spines 64 


Code: 0 - Not prominent 

l - Prominent 


9 -Unknown 

16. Sacrum 


Code: 0 - Average curve 

l - Flat 

2 - Anguls.ted 

3 - CongenitallY absent 

9 -Unknown 

17. Sacrosciatic Notch 66 


Code: 0 - Average 

l - Wide 

2 -Narrow 

3 - CongenitallY absent 

9 -Unknown 

18. Sidewalls 


Code: 0 - Divergent 

l - Comrergent 

2 -Parallel 

9 -Unknown 


II.A.227 

OB-43


FOFM O:E-43 

Card 23.!.:-3 

FIELD 

19. Sub-Pubic Arch 68 


Code: 

0 -Average 

1 -Wide 

2 - narrow 

3 - 70°-90° 

4 - Roman 

5 - Gothic 

9 -Unknown 

CARD 

COIDMN 

20. Intertuberous 69-71 


Code: Same as in Field 14, eels. 61-63 

21. Post Sa!!j Outlet 72-74 

Item 17 {page 2) 

Code: Same as in Field 14, cols. 61-63 

22. Other Pelvic Abnorma.litl 


75 

Code: 

0 - None 

1 - Asymmetry 

2 - Other 

9 -Unknown 

23. Inlet 76 


Code: 

0 -Adequate 

1 - Contracted 


9 -Unknown 

24. Mid Pelvis 77 



25. Outlet 78 




II.A.228 

OB-43

 

I ,rnrn:r s 

YIN.Ct:l 

S6¥:;~rn 

Ill 

~ ~~.L~ ..,_.,.. :: 

.. 

;! 

.. 

.. 

-~ ::! 

; .J,...N ~-~ 

~7"'_-"'' 

'If 

::! 

- 

;::: .,,, .. 

Of 

.,;r li! 

at 

dw"7' 

. 

'J.TW-- 

~= 

"'"' 

Revised April. 1965 

II.A.230 

OB-43 



OB-43 page 1 INITIAL PRENATAL EXAMINATION 

I. Purpose of form To record the results of the 

initial physical examination 

following selection of the 

patient into the P r o j e c t 

sample. 


Item Number 

10. Non-pregnant weight. Record 

known non-pregnant weight. 

the last 

11. Height. Record measured height in inches, 

without shoes. 

12. Pulse. Record. 

A. This form should be completed at the patient's 

initial or second prenatal visit. If examination 

of a particular patient cannot be done 


prior to admission for pregnancy termination, 

OB-43 may be completed during 

A. If a general examination is not done, 

hospitalization. 

mark "not done" and explain the 

reason. 

B. For each item, mark all boxes that describe 

positive findings. Describe positive findings 

14. General appearance. Mark all boxes which 

in the space provided. If there are none, 

describe the general state of the patient. 

mark "normal" box. 

15. Skin. Mark boxes applicable to skin of 

C. Indicate any items not evaluated by marking any area of the body. Operative scars, 

the appropriate box. 

wherever present on the patient, are 

reported on I y here. Scars other than 

operative are not considered important 


unless indicative of major trauma, in 

which case record under "other." 

Item Number 

16. Edema. If edema is present, designate 

2. Date. Record the date of examination. 

the location by marking the appropriate 

box(es). In the space to the right, describe 

the degree of edema in each 

4, 5. Examined by. Print the first initial and 

location, designating it as +1 to +4; 

last name, and title or position of the 

pitting or non-pitting. 

examining physician. 

6. This exam was. 

a. Mark the box "completed using this 

form" when the examination findings 

are recorded directly on pages 1 and 

2 of this form. 

b. Mark the box "other" when this examination 

is initially recorded on non 

Study forms. In this case, abstract 

the findings and stamp the form (pages 

1 & 2) "Not according to protocol." 

7-9. Re-examination. 

19. Eyes. Severe visual impairment is described 

as any impairment which prohibits 

the patient, correctly fitted with 

glasses, from reading unmagnified news 

print. Description should include the 

degree of impairment of vision. Include 

under "other" such difficulties as tunnel 

vision, color-blindness, etc. 

a. Mark the appropriate box(es) if find 

ings are re-evaluated by a more senior 

physician. 

b. The senior examiner is to initial any 

changes made in the original report. 

17. Lymph nodes. If any lymph nodes are enlarged, 

specify whether they are a single 

local group or all the superficial nodes 

by marking the appropriate box. If any 

lymph nodes are tender, mark the appro 

priate box. Describe the abnormal nodes 

and their location in the space provided. 

18. ENT and mouth. Mark the appropriate 

boxes. Inflammation of the pharynx includes 

pharyngitis and tonsillitis. "Other 

inflammation" includes rhinitis, otitis, 

and abscessed teeth. 

October 1962 


II.A.231 

OB-43

Instruction :\Ianual for Obstetric Forms 

OB-43 ,age 1 INITIAL PRENATAL 

EXAMINATION (Continued) 

Item Number 

20. Thyroid and thyroid function. Report here 

physical signs of thyroid dysfunction, e.g. 

hypo- or hyperthyroidism, by marking the 

appropriate box and describing in the avail 

able space. This includes findings in other 

systems (e.g., eyes, skin, neurological). 

Do n o t mark "Signs ofthyroid dysfunction'' 

when the thyroid gland is abnormal only 

to palpation. 

21. Breasts. If an inflammatory mass is 

present, mark both boxes, "mass" and 

"inflammation." 

22. Lungs. Report findings of physical exami 

nation. Record markedly reduced vital 

capacity under "other," and describe. 

23. Heart. If any findings lead to consideration 

of organic heart disease, always mark the box 

sa labeled, in addition to marking any ather 

apprapri ate boxes. If a murmur is con 

sidered physiological for pregnancy, or 

Item Number 

functional, mark "murmur"and describe 

as "normal for pregnancy," etc. 

24. Extremities. Record all findings pertaining 

to extremities here, ather than edema 

or scars, which are reported in items #16 

and 15 respectively. 

25. Neurological. Mark all appropriate boxes. 

N e u r o I o g i c a I disorders should include 

muscular abnormalities secondarv to 

neurological involvement. 

26. Funduscopic. A funduscopic examir::otion 

is optional. 

27. Other


OB-43 page 2 INITIAL PRENATAL EXAMINATION 


a. If obst.etric examination is not done, 

mark "not done" and explain the reason. 


Item Number 

2. Abdomen. Mark all appropriate boxes 

which describe the findings of abdominal 

examination, other than of the uterus. 

3. Corpus uteri. The uterus is evaluated 

abdominally and/or vaginally. 

a. Mark "normal for weeks gestation" 

if uterine size is compatible with 

dates, and no other abnormality is 

present. 

b. Mark "not evaluated" only if no attempt 

is made to evaluate, either 

abdominally or vaginally. 

c. Denote the findings of any other abnormality 

of the corpus uteri by 

marking the appropriate box(es). If 

the size of the uterus is larger or 

smaller than would be expected for 

the calculated period of gestation, 

mark the box so labeled and explain 

at the right. 

4. External genitalia. Abnormalities of the 

external genitalia include vulvar varicosities, 

old perineal lacerations, cysts, 

and . developmental abnormalities. Mark 

all appropriate boxes. 

5. Introitus. If any significant degree of 

relaxation of the anterior or posterior 

vaginal walls is noted, mark the appropriate 

box. Describe the degree of relaxation 

at the right as +1 to +4. If there 

is associated stress incontinence, note it 

at the right. 

6. Vagina 

a. If vaginal examination is not done, 

mark "not evaluated" and record the 

reason at the right. 

b. If bleeding is noted to o r i g i n a t • 

from the v a g 1 n a and the site is 

Item Number 

recognized, mark ''bleeding site." If 

the bleeding site in the vagina cannot 

be located, mark "other" and note 

"Vaginal bleeding from unknown site." 

7. Cervix uteri 

a. If for any reason the cervix is not 

visualized, mark "not evaluated" and 

describe the reason. 

b. "Old laceration" refers to thatdegree 

of cervical laceration that lends to 

the cervix. a "fish-mouth" appearance. 

c. If the bleeding noted upon examination 

is thruugh the os, mark "bleeding 

through os." 

d. Cervicitis refers to any degree of 

cervical e r o s ion or ectropion and 

should be described as mild, moderate, 

or severe. If cervicitis has resulted 

in bleeding, mark both "cervicitis" 

and ''bleeding site." 

e. If the cervix is dilated or effaced, 

mark this box and describe at the 

right. Of special importance is dilatation 

of the internal os. This does 

not include the normal patulousness 

of the multiparous cervix. 

f. If any other abnormality is noted, 

such as tumor, ulceration, leukoplakia, 

etc., mark "other" and describe. 

8. Adnexa. Mark all boxes as indicated and 

supply appropriate description. Mark 

"not evaluated" only when pelvic examination 

is not done. 

CLINICAL PELVIC MENSURATION. If 

not done, mark the box so labeled and 

explain the reason elsewhere on the page. 

If clinical mensuration is completed subsequently, 

record the date of examination. 

X-ray pelvimetry is not a substitute for 

clinical evaluation. 

9. X-ray pelvimetry. If x-ray pelvimetry 

was done during a previous pregnancy 

and results are available, mark "available"; 

if ordered at the time of the initial 

examination, mark "ordered." In either 

case, record the results on form OB-:-45, 

Laboratory Record. 

October 1962 


II.A.233 

OB-43

Instruction l\lanual for Obstetric Forms 

OB-43 page 2 INITIAL PRENATAL 

EXAMINATION (Continued) 

Item :\umber 

10-17. Pelvic examination. Record the information 

required for eachitem. Measurement 

of the posterior sagittal diameter 

of the outlet is optional for study purposes. 

18. Other pelvic abnormality. Indicate gross 

asymmetry of the pelvis by marking the 

appropriate box. If any other pelvic abnormality 

is noted, mark "other" and 

describe. 

19-21. Summation. For each plane of the pelvic 

bore, indicate estimation of the adequacy 

by marking the appropriate box. 

22. DIAGNOSTIC IMPRESSIONS. Following 

completion of the initial prenatal history 

and physical examination, record all 

diagnostic impressions (including obstetric) 

made or considered at this time. 

23. Consultation sought. Record by marking 

"X" in the column opposite the appropriate 

diagnostic impression, to indicate 

consultation is being sought. 

Item Number 

24. Approximate date of onset. \\'hen appropriate, 

record the date of onset opposite 

each diagnostic impression, with particular 

emphasis on acute infectious processes 

and toxemia. The date ofonset\•·ill 

represent the physician's best estimate of 

the date on which the disease process 

began. 

25-28. Editing. Report completion of the editing 

procedures for the past medical history 

and inital prenatal examination (forms 

OB-42.and OB-43) through completio:1 of 

these items. 

25. Lay edit by. Initial upon completion. 

26. Medical edit. Record whether editing was 

accomplished with or without the aid of 

the hospital chart. "Hospital chart" as 

used here includes all records of medical 

care during or prior to the current pregnancy 

which are in the Study institution. 

27, 28. Medical edit by. Provides for the sig:J.ature 

and position of the medical editor. 

October 1962 


II.A.234 

OB-43

I, I'ATIENT IDENTI,.ICATIDN 

OB-43 

INITIAL PRENATAL EXAMINATION 


0 NOT DONO: (lbplabt) 

--.,..--, 

PAGE 2 

I 

~--r-, 

1 I I 

'--·--· 

0 ................... O evA T&•cawcaa 

O~tc•••• 

QoTM&a 

O•T ....... 

.. 

J. CORPUS UT!RI 0 •nc NOT cON•ATiaL.c 

WITM OATI8 

D ......... ,.•• 

OX W&IIKI 

•• 

9&1TATIO• 

QMOT &VALe 

0TVMOR 

4. EXTI!RMAL GI!MITALIA 

~ MOaMAL 'lUI.'I ... YAAICOIITICI 

0 

g MOT C'f'A&.e 

0 OTMIA 

s. IMTROITIJ$ 0 R&CTOCC\.1 

gMOAMAL 

O•oT &VA&.. 

•• 

1. VAGINA 

~ ......... 

QMOTCVAto.. 

Oc'nTOCI:t.& 

7. !iRVIX UTili QoLo I.ACUATIOM 0 CIRVICITII 

:J •OT CYAI.• 

•• 0 IL&IIDIH TMttoua• oa 

w........"' 

QIIOTC'IAt..• 

•• 

qoTMCJI 

a. ADMIXA 0 ...... 0 ....... 

CLINICAL PELVIC MENSuRAnOH 

oNoT ooNa(a_,_, 

0 •&ACMIIO AT _____CMI I 

I 

c... 

o-· 

' (It-o) I 

OwtDC 

•z. s~....u. IJ, ;oA"RVa..,ATII; MOn.H 14,~Do:wA"u 

c;J A'I&RAI& CUa¥& QA¥UMI o~........u . 

• 

QrL.AT 

0•,..••• c;J • C01t¥11tiiMT 

I 

9 AMULAHO 

r:;J••oa 

9DIYIIHCMT 

II. OTHI!R I"I!LVIC 

AIMORMALITY 

O••ooe 

• 

17, I"OST. SAG. OUTLI! 0 ..,......,..,. 

• 

c... 

c;J•,..... 

zz. DIAGNOSTIC IMPRI!SSIONS (It••"' "''· 1n.,_• ...,...,..,) 

11. IMLI!T 

9 AO&OUATI 

O•o..c.. 

1 1.11111& 

SUMMATION 

ZO. MID I"I!LVIS 

c;J AOCOUATI 

QHaO&W• 

1 I.IMC: 

9 COMTaACTKD 

Zl. OUTLI!T 

c;J AOKQUATK 

O•••o•a 

1 ...... 

Oc••ntACTI:D 

U. LAY I!DIT I•· MED QwiTM 

;27, MEDICAL 

BY I EDIT 1 ~=::~TA&, ' EDIT BY 

COt...t...AeO.. ATIV ......A..CH 

~...INA TAt.. .....A ..CH ...ANCH, MINOa. NIH 

e•TH.SOA 14, MO. 

·- 

;28. TITLE Oflt 

I ~ITION 

:~;~ 08-43 


II.A.235 

OB-43


II.A.236 

OB-43

OB-10 

Return Visit and Laboratory Record 

Form OB-10, Return Visit and Laboratory Record, was used to record return 

visits, clinical findings and laboratory findings. It was first used in 

January 1959 and revised once in July 1959. Revisions resulted in an 

itemization of the form and added space for recording results of new tests. 

OB-10 was replaced by two new forms, OB-44 and OB-45, in April 1962. 

OB-44 replaced that portion of OB-10 where clinical findings (return 

visits) were recorded. OB-10 clinical findings (return visits) data are 

punched with the OB-44 prenatal observations data on Card 0344 (see field 3, 

revision number). 

OB-45 replaced that portion of OB-10 where laboratory findings were 

recorded. OB-10 laboratory findings from approximately 20,000 records were 

punched onto two cards of the master file (Table OB-10.1). The remainder of 

the OB-10 laboratory findings, approximately 4,000 cards, were punched with the 

OB-45 laboratory data on the 1345-7345 card series (see field 3, revision 

number). When using the data file, the 345 file should be used with the 310 

file. For data on blood drawn from virology study see Volume IV, Work Files 

11-15. 

TABLE OB-10.1 



CAFU NAME NUMBER NO. RECOFUS 

08-10: Blood Type. Titer. Hemaglobtn. 

Coaros Test 1310 

0 20.190 

20,190 

08-10: Serology, Urinalysis, Pap Smear, 

Fathers Blood Type 3310 

0 20,202 

20,202 


II.A.237 

OB-10 



II.A.238 

OB-10


. 

H 

H 

)II 

• N 

w 

\0 

@ 

I 

...... 

0 

nata Items RPferen~ln~ Form OR•tO, Return vtsft and LAboratorv Pec~r~ 

OATil 

ITEM 

TO 

6~8 ••••••• 

6CJ9 ••••••• 

70o •• ns-tn 

7nt •• ns-to 

702 •• 08-10 

703 •• nt~·tO 

704 •• os-tn 

7ns •• na-to 

7n& •• ns-to 

707 •• 08-10 

70e •• os-tn 

7n9 •• nA-to 

7to •• ns-to 

7t 1 •• na-to 

7t2 •• na-to 

7tJ •• na-to 

714 •• niJ-10 

7ts •• os-to 

716 •• 08-lll 

717 •• 08-10 

7tB •• n8-lO 

719 •• 08•10 

72o •• ns-tn 

7?t •• na-to 

7?.2 •• os-to 

723 •• n8-to 

724 •• 08•10 

ns ..ns-to 

716 •• na-to 

7?7 •• ns-tn 

na •• na-to 

729 •• 08•10 

HO •• OB•tO 

H1 •• 1'lR•10 

7l2 •• rtB•t0 

7H •• ns-to 

734 •• ns-10 

ns..na-to 

716 ••••••• 

737 ••••••• 

71:8 ••••••• 

739 •• OB-10 

20 

21 

2? 

22 

22 

2? 

22 

22 

23 

23 

23 

23 

23 

23 

23 

23 

23 

23 

23 

23 

24 

24 

24 

24 

24 

24 

24 

24 

24 

24 

24 

24 

25 

25 

25 

ugM 

JN 

FJ~M 

CIIRO 

NIIM 

1310 

1310 

1110 

tHO 

lJtO 

1310 

1310 

1310 

1310 

13t0 

tHO 

tHO 

tHO 

tHO 

tHO 

1310 

1 'HO 

1310 

tHO 

tHO 

1310 

1310 

131" 

1Jt0 

1110 

1310 

tHO 

1310 

tHO 

1310 

1310 

1310 

1HO 

tHO 

tHO 

nto 

tHO 

1310 

t310 

3310 

3310 

3310 

FRO~ 

t 

.. 

1!5 

t6 

17 

JQ 

20 

2? 

24 

25 

27 

2P 

30 

3?. 

33 

36 

38 

40 

41 

44 

46 

49 

40 

5? 

54 

56 

57 

&O 

62 

b4 

65 

6ll 

70 

71 

71 

76 

71f 

79 

80 

1 

6 

1'5 

TO 

5 

14 

15 

16 

18 

19 

?.t 

23 

?4 

?6 

11 

29 

11 

12 

15 

37 

39 

40 

43 

45 

47 

48 

'H 

'53 

"i5 

56 

"i9 

61 

63 

64 

67 

69 

71 

72 

75 

77 

78 

79 

AO 

5 

14 

15 

OAf~ 

Trf:M NIIMF. 

Car1 nu'llbPr (seque-nce, for11 tvpe, tor111 numoer, revision number) 

NTNOB CASP nu'llber 

Blood tvoe 

Rh tvpe 

Rh titer, ftrst (IIIO) 

Rh titer, ffrst 

Rh titer, l~tst 

Hemo:Jlobln, 

He'IIOQlObln, 

HP.mnqlohln, 

Hemoglobin, 

He;aoqlobln, 

Hromoqlohln, 

HemoqJohll'l, 

Hemoqlohin, 

HP.IIIOQlObin, 

Hemoqlohin, 

HPIIIOQlohln, 

HP.'IIOCJlohln, 

He'lloqlohin, 

HP.'IIAtncrlt, 

Hematocrit, 

Hematocrit, 

Hematocrit, 

Hematocrit, 

HP.'IIatocrit:, 

Hematocrit, 

HPrnl!ltocrit, 

Hematocrit, 

Ht"rnatocr1t, 

Hematocrit, 

Heml!ltncrtt, 

Cno'llbs" test 

result 

totAl nu:aber: 

tst ('ftO) 

tst C1av> 

tst cvr> 

t st vl!!llue (qms) 

2n:1 ('llol 

2n:t (1sv) 

2n:l cvr> 

2n::l value Cams) 

Jr::l (lllo) 

3r::l C::tavl 

Jr::l cvr) 

3r::l value (qms) 

tst ('110) 

tst (1aV) 

tst Cvr> 

tst Vlllue (~) 

2n:t ('110) 

2n:l C:hv> 

2nd cvrl 

2n::l ViHUe (I) 

lr::l ('ltoJ 

3r:l (1aV) 

3r::l cvr> 

3rct V'lllue (II!) 

Cmo) 

(yr) 

ne'ftl!ltocrlt, tot"l nu11ber 

COOIIIbS" test 

Coombs' tP.st, result 

Blanlc 

Card number (seQuence, for11 type, for111 nUIIIber, reViSion nu111her) 

NTNOB case number 

Sl!roloCJV for svohtlts, tst


H 

H 

• > 

• to.) 

.. 

0 

nata Ite~s Reterencina For~ UFI•10, Return Visit ~nd LAbnr~torv RecJrj 

OA ra 

Trl'.:" 

ITEM i) .. CARO 

Tl> fJQ" NIIM FRO .. TO OAfA TfF.M NAME 

74o •• ns-1n 

741 •• ns-1n 

742 •• na-1o 

743 •• 08•10 

744 •• na-to 

745 •• na-to 

746 •• os-10 

747 •• 08•10 

748 •• 08•10 

749 •• na-1n 

750 •• 08•10 

7!H •• 08•10 

7"\2 •• 08•10 

7 .. 1 •• ns-1o 

754 •• 08•10 

7"\5 •• 08•10 

7t;6 •• os-1o 

7';7 •• 08•10 

7r;s •• no-10 

7';9 •• 01\•10 

760 •• 08•10 

7fit •• na-1o 

7fi2 •• 0B•10 

7fi3 •• ns-to 

7fi4 •• no-1f\ 

71;5 •• 08•10 

26 

26 

26 

2fi 

2fi 

26 

26 

26 

2f> 

2f> 

26 

26 

2fi 

26 

26 

27-32 

27-32 

27-32 

27·32 

27-32 

27·12 

27•32 

27•32 

3310 

3310 

3110 

3~10 

3310 

H10 

3HO 

J110 

HlO 

3310 

HlO 

ntn 

3310 

H10 

3310 

3310 

3110 

H1n 

3310 

H1n 

3110 

3310 

JHO 

3310 

3311'1 

3310 

16 

tA 

1Q 

20 

21 

n 

24 

25 

2fi 

27 

2A 

)1'1 

31 

n 

33 

]4 

3f> 

37 

lfl 

40 

42 

43 

4'1 

17 

18 

19 

20 

11 

73 

Seroloqy 

seroloay 

Serolnav 

seroloqy 

Seroloay 

Serolnav 

for 

for 

for 

for 

for 

for 

24 seroloqy for 

?5 seroloay for 

16 seroloav for 

?7 Seroloav for 

19 

30 SernlOQV 

seroloav for 

31 

12 

33 

15 

~6 

37 

19 

41 

42 

44 

45 

4& 

48 

"iO 

sypntlfs, 1st 

svontlts, 1st 

svpnllts, 1st 

svonllis, 1st 

svontlts, 1st 

~vonllfs, ?nrt 

~yontlts, 2'lrt 

svonllts, 2nd 

svonl1ls, 1nd 

svont1ls, 2n1 

(110) 

Cvr> 

result 

result 

result 

('IIO) 

cvr> 

result 

result 

result 

for Syo~llls, 1r:.t 

svonllfs, 3rrt Cyr) 

C11o) 

seroloav for syohtlls, Jr1 

seroloqv for svohllts, lrrt 

Seroln~y for syonllls, lrrt 

urtnatvsts, lst ('110) 

IJrlnalysis, 

Urinalvsts, 

Urinalysis, 

Urinalysis, 

Ur1nalys1s, 

Urtnatvsts, 

Urtnatysi~, 

urtn~tysts, 

Uri'lalv!115, 2n::l, 

2n::l, 

Urin~ly~ts, 

Urinalvs15, 2n1, 

1st (yr) 

lst, type 

lst, RBr. count 

1st, IIBC count. 

lst, casts 

2nd ('IIO) 

2nd (yr) 

27-32 

46 

tvoe 

27-32 

4., 

R~C count 

27•12 

4Q 

766 •• ns-to 27-32 3310 51 '51 

2nd, ~BC count 

casts 

767 •• 08•10 27-32 HlO 52 '13 ur tnal ysiS, 3r:l (IIIOl 

7fiB •• ns-tn 27-12 H10 54 '14 Urinalysis, 3r1 (Vrl 

769 •• 08•10 27-32 3310 55 o;s urtnatvsis, 3rd, type 

71o •• ns-1n 27-32 HlO 56 '17 Urlnatvsu, 3rd, RBC count 

771 •• ns-10 27-32 331" 51! '19 Urinaly!lls, 3r::l, WBC count 

112 •• ns-1n 27-32 3310 60 60 Urinalysis, 3r1, casts 

773 •• ns-1n ]4 

3310 &t 62 Urine culture (mol 

774 •• ns-10 34 3310 63 63 Urine culture (yrl 

775 •• ns-tn 34 3310 64 64 Urine culture result 

@ 

17b •• nK-10 34 

3310 fi"'i 66 

I 

777 •• nu-tn )4 

3110 67 67 P"D 

Pao s"'e11r (1110) 

smear (yr) 

....... 

0 

ns ..ne-10 )4 

3310 6A 68 Pap s111ear result 

779 •• nB-10 )4 

3110 61) 69 Thvrofd tests 

7flo •• nu-to 34 3HO 70 70 Rtood suqar: alueose toter!nee 

7A1 •• 1'JB•10 35 3310 71 71 Blood type (father> 

71!2 •• ns-ln 36 H10 1' 72 Rh tvoe (father) 

result 

result 

result 

test 

test 

test 

test 

test 

test 

test 

test 

test 

1 

2 

3 

1 

2 

3 

1 

2 

3


nata Items Referencln~ Form O~·tO, Return vts1t and J,aboratorv Pec~r:l 

D~U 

ITEIII 

TO 

793 •• r'IB•10 

7A4••••••• 

49QB •••• VAR 

sono •••• vA~t 

522t •••• vAq 

'52?5 •••• VAR 

o;2?& •••• vAq 

"2'-7 •••• vAq 

"i22B •••• VAR 

41 

24 

H 

20 

25 

21 

24 

23 

TrF.114 

Jtf 

F' JIU4 

CARO 

""" 

3310 

331('1 

FRO Ill 

H 

H 

89 

93 

344 

]4-; 

Hf'i 

147 

35' 

TO 

73 

flO 

!Jt 

q5 

344 

345 

346 

3"i2 

3-;9 

!)~fA TTF:II4 N~ME 

H~t:Holollv: 'IC•T!IV, :ll!lc,nost ic 

RlaniC 

lfem11tocr1t lowest level, roercentl 

H~IIIOCJlOI"Iln, lOWPSt val uP (:trams) 

Blond tvpe 

COO!IIbS' tPst 

Rl'l factor 

H~m8tncr1t, date of lowf'st V!lllll" (mo/1av/vr> 

Htomoatobin, d~tl'! of lnw~st valu~ rmo/rtavtvr> 

1-t 

1-t 

> • N 

~ 

~ 

0

c 01..1'1.•3003-10 I, ~ATIIENT IDIENTI,CATION 

... ltV. ?-1" •· ftiS-3003-JO w-- ~ 

/1)-r' 7•5""1 

r 

/1..{...,.,~ 

RETURN VISIT AND LABORATORY RICORD 

-i~ 0.8- 'f'f ( '(.,J.j 

t1" 

~ 

::a·-t:f" ('f~-


H 

H 

;,. 

• N 

~ 

UJ 

~ 

0 

Form Item Numbers tinkPd to nata Items on OR-10, Peturn Vtstt and ~Aboratorv Record 

l'I'EM 

OUA 

ON trF" CARO 

FOR" Ill NU" FRO" TO OllfA TrF:M N~ME 

7oB •• oR-tO 1310 27 27 Hemoqlohin, total ~umberJ he~atocrit, tot8l nu~ber 

739 •• oR-10 33to 15 15 seroloqv for synhtlfs, 1st 

20 7oo •• oR-1 o 1310 1"; 15 Blood typP 

?0 5224 •••• VAR 344 344 stood type 

21 5226 •••• vr.R 346 346 Rh factor 

21 701 •• 01\•10 1310 16 16 Rh tvoe 

22 702 •• 01\•10 1310 17 18 Rh titer, ttrst (~ol 

22 703. 0 01\•10 1310 19 t9 Rh titer, ftrst



~orm Item Mu~b~rs linked tn nata Items on OR-tO. Peturn Vts1t and Labor~tnrv Recor1 

ITEM 

O"TA 

ON TrF.N eaRn 

FOR'- 11"1 NUN FROM TO OlfA J rF:N tUNE 

36 782 •• 0A-t0 3311'1 7?. 72 Rh tyee (fath~>rl 

41 783 •• OR•tO HlO 1' 73 R.~tdloloCJv: ~-rav. dlaqnostlc 

H 

H 

.> 

t\.) 

~ 

l1l 

~ 

..... 

0


LABORATORY DATA 


FIELD 

CARD 

COLUMN 

l. Card Number l 

Code: 1 


Code: 310 

3· Revision Number * 5 

Code: 0 - Forms Dated: l/59 and Rev. 7/59 

4. NlliDB Number 6-14 



5. Gravida's Blood Type 15 

Item 20 

Code: 0 = 0 

1 = A 1 

2 = A 2 

3 =A 

4 = B 

5 =A~ 

6 = ~2B 

7 = AB 

9 =Unknown 

6. Gravida's RH 16 

Item 21 

Code: 1 - Positive 

2 - Negative 

9 - Unknown 

7- RH TITER - FIRST 17-21 

Item 22 


Month (eels. 17-18) 

Year (col. 19) 


OU.'O - Not applicable 

999 - Unknown 

* Item numbers refer fo Form Dated: Rev.-7/59 

II.A.246 

OB-10 



FIELD 

FOBM OB-10 

Card 1310 

CARD 

COIDMN 

7. RH TITER - FIRST (continued) 17-21 

Code for cols. 20-21: 

00 - No reaction 

01-10 - Dilutions as reported 

91 - 1:1 

92 - Positive - unqualified 

99 - Unlmown 

8. RH TITER - LAST 22-26 


9· Total Number of Hemoglobin and/or 27 

Hematocrit 


l-7 - Number of different dates as 

reported 

8 - 8 or more different dates · 

9 -Unknown 

10. Hemoglobin - First 28-35 

I-cem 23 

Eight-digit code for month (cols. 28-29), 

day (cols. 30-31), last digit of year 

(col. 32), and value (cols. 33-35) 

Code for cols. 28-32: 

As given 

00000 - Not applicable 

99 - Month and/or day unlmown 


000 - Not done 

040-200 - Grams as reported in tenths 

999 - Unknown 

11. Hemoglobin - Second, excluding First and Last 

Cod.e: Same as in Field 10 except 

36-43 

O's in entire field= no second hemoglobin 

12. Hemoglobin - Third 44-51 

Code: Same as in Field 10 except 

O's in entire field = no third hemoglobin 


II.A.247 

CB-10


FIELD 

FORM OB-10 

Card 1310 

CARD 

COLUMN 

13. Hematocrit 

Item 24 

- First 52-59 

Code: Same as in Field 10 except cols. 

120-599 - 12-59-· g{o as given 

6co - 601> or more 

999- U~wn 

57-59 

14. Hematocrit - Second 


O's in entire field = no second hematocrit 

60-67 

15. Hematocrit - Third 


O's in entire field= no third hematocrit 

68-75 

16. Coomb' s Test 

Item 25 

Four-digit code for Month (cols. 76-77), 

Last Digit of Ye~ (col. 78), and Results 


As given 

000 - Not applicable 

999 - Unknmm 

Code for col. 79: 

0 - Negative or not done 

l - Positive 

9 -Unknown 

(col. 79) 

76-79 

Note: 

"Test Not Done" = 0' s for entire field 

II.A.248 

OB-10 


DEFTIUTION OF CODES (Continued) 

FORM OB-10 

Card 3310 

CARD 

COWMN 


Code: 3 

1 


Code: Same as in cols. 2-14 of Card 1 

3· Number of Serology Reports 15 


1-7 - Number of different dates as 

reported 

8 - 8 or more dates 

4. Serolo~ - First 16-21 

Item 2 


Date· fc~~:h_JJJ.~· l6-l7}J~~t Digit of Year 

Code: 

As given 


999 -Unknown 

Result: Test r- (col. 19) 

Code: 0 - Negative, not done 

1 - Positive 


9 -Unknown 

Result: 

Code: 

Test II' (col. 20) 

Same as col. 19, except 

8 - Second test not done 

Result: Test m (col. 21) 

Code: Same as col. 19, except 

8 - Third test not done 

Note: "Test Not Done"= O's forcols. 1.6-19 and 8's for cols. 20-21 

5. Serology - Second 

Code: Same as in Field 4 except that "Test Not Don~" 

22-27 

= O's for entire field 


II.A.249 

OB-10

DEFINITION OF CODF.S (Continued) 

FORM OB-10 

Card 3310 

FIELD 

CARD 

COIIJMN 

6. Serology - Third 28-33 

Code: Same as in Field 4 except tbat "Test Not Done" 

= 0' s for entire field 

7. Urina1ysis - First 

Item 27, 30-32 

Nine-digit code for: 

Date /Month (cols. 34-35); Last digit of Year 

-- '[col. 36)] ·-- - -· - 




~ (col. 37) 

Code: 0 - No specilllen 

.1- Voided 

2 - Clean catch 

3 - Catheterized 

9 -Unknown 

RBC (eels. 38-39) 

W.OC (eels. 40-41) 

Code for each: 

00 - None, no urinalysis 

01-94 - As given 

95 - 95 cells or more 

96 -Few 

97 -Many 

98 - Too numeroa.s to count 

99 -Unknown 

Casts (col. 42) 

Code: 0 - Negative, no urinalysis 

l - Positive 

9 -Unknown 

Note: 

"Test Not Done" = O's for entire field 


II.A.250 

OB-10


FOBM OB-10 

Card 3310 

CARD 

COWMN 

8. URINALYSIS - SECOND 43-51 

Code: Same as in Field. 7 

9· URINALYSIS - THIRD 52-60 


10. URnlE CULTtrnE 61-64 

Item 34 

Four-digit code for month (eels. 61-62), last 

digit of year (col. 63), and Results (col. 64) 

Code for eels. 61-63: 

Same as in Field 7, eels. 34-36 

Code for coL 64: 

0 - Negative 

1 - Positive 

9 - Unknow. 

-----: 

ll. PAP Ero:AR 65-68 

Item 34 

Four-digit code for month (eels. 65-66),1.ast 

digit of year (col. 67), and Results (col. 68) 

Code for eels. 65-67: 

Same as in Field 7, eels. 34-36 

Code for col. 68: 

0 - Negative - unqualified 

1-5 - Grade of cytology as given 

6 - Positive - unqualified 

7 - Ca in situ 

8 - Doubtful 

9 -Unknown 

Note: O's in eels. 65-67 and 9 in col. 68 = test not done 

]2. Thyroid 69 

Item 34 

Code: 0 - Protein Bound Iodine 

1 - Butal Extractable Iodine 

2 - Basal Metabolic Rate 

3 - Iodine 131, Radioactive Iodine 

4 - Other Thyroid test 

5 - Combination of two or more above 

9 -Unknown 


II.A.251 

OB-10


Card 3310 

FIELD 

CARD 

COLUMN 

13. Blood Sugar and Glucose Tolerance 70 

:, Item 34 

· Code: 1 - Reported 

9 - Not reported 

14. Father's Blood TYPe n 

Item 35 

Code: 0 - C 

1- A 1 

2- A 2 

3- A 

4-B 

5 _.A~ 

6- ~21! 

7- AB 

9- Unknown 

0 

15. Father's RH 72 

Item 36 

Code: 1 - Positive 

2 ~ Negative 

9 -Unknown 

16. Diagnostic X-R!f. 73 

Item. li1 

Code: 

1 - Cheat 

2 - Other 

3 - Cheat and Other 

9 - Un:imown, none 

II.A.252 

OB-10 



H 

H 

• 

l:...... 

- Ot.)~* 

:- 

R 

1- • ' 

- 

LAllORATORY DATA ( OB-10) 

I u. 22. u .a~ as 

X --,234 ~ 1. '1111121J14 -~ "71111JI21 D2425"li ·, 1121 Jill uu un»l7ll2t•••aou •~•5hl hi 51 U 5I ~l 5I ~UI 61 6UUUU6 U 61" 1111 lHh4 l~ 16 11 II ,I.--- 

I HEMOQLOB\N HEMATOCRIT !" 

~ FIRST LIST 

I s:"' 

a: 

> 

R'- ft'- s~ 

~ llTEft tne• 

- lOt 

1- 

F\RST SEtaUD l1URD FlRST ~ECONb l\URI> 

I 

1 

0 l 

I - 

b 4 \t 

1-- CAll> IJIUD&• 

•I:Jj 

I 

s fl: ~ 

\() 

)II 1 

. ·~·0 

N 

l11 : 

w ' ~ 

7 

1- ~ 

I ~ ~ 

~ .... ... ~ t.J 

~ ~ i l i 

~ 

i ~ ~ ~ i ~ ~ i 

' • 

1- ~ ';lo, '> 

i 

~ 

' 

I IIi ~ i I ~ s ~ ~ ~ ~ ~ 

. ! ~I_~ ~i!.J-~.!..~!!_1!!!_14 S 61111 l02l~U 4 UI~JJill Jill l~~~ ~J ' ~~~1434 !!;~!_!41 1115111 ~U ~~ 15! lSISU96 626 11!11 161 II In a 

* Item numbers refer to form dated: Rev. 7/59 

~ 

I i i ~ ! i l ~ i ~ ~~ 

~~"" ~" n "'' 

ctJ 

~ 

...... 

0


LABORATORY DATA ( OB-10) 

ne .. =~~: 

- Olol foRMA 

'I '* I 24 . 29, 30-32. 3~ 

I- 

X ~--· 'f2T4- · I' 1 1 • ..-mi 13 u - 1Jllllt • 21 n n ,. H 26 21111 Jt 111 Jl n 1 J 1-.ut.lU!u u ss 56 u,. stii liifW6J' 

-- &JI 

• 

1- 

!f'-RoLoG~ uRitJAL~SIS ~~ 

d :..I 

I ~B 

1 

-; faRST .• ~I> FlRSt . SECo~ TlfiRO 

0 

tp 

i JfnE b'lE l>A1E ~ ~ ~ ~ 

b - 2\ ~ rE 

-~ c•~> .,,..».8 # 

~ I # 

H 

H ~ ~0 ~ ~ 

> • 

• 

!\) I~ .. IN ' r a ' $ ~ 

U'l 

~ !_ It -1, ~ ' ' l ~ ~ 

' i 

I~ I~ 11o. !ll .., • " !'t 

~~~ i ~~· • n • q • -? ~ 

·~ ............,.,,.,.....at! ~ :..:,.~ ~-~ .: .! :.: .~ .! ~-~-~ .~ 

* Item numbers refer to form dated: Rev. 7/59 

Nt~l!}ql 

34..., 

su "' p.i f ,. u 76 77ll7t 11 -; 

~ a: 

I 

:m ~ 

0. 5: !;c 

~ ~ 

t 

~ 

- 

I~ 

r; 

I 

:BL&~K 

P 

.: li 1: .......... 

@ 

I 

..... 

0

4/16/61 

OB-10 RETURN VISIT AND LABORAWRY RIDORD 

Instructions for Physician 

This record is intended to be used as a record of return visits 

and laboratory examinations. For each visit to the clinic, including 

the initial visit, record the following: 

Item No. 

2. Physician. Record the last name of the examining physician. 

3. ~. Record t~e month, day and year. 

4· Week. Record the week of pregnancy as closely as can be determined. 

5. Weight. Record the patient's weight in pounds. 

6. Blood Pressure. Record the patient's blood pressure. 

1~8. Urine Examination. Albumin and Glucose. If there is no albumin, 

write either "0" or "neg." If albumin is present, grade as "trace," 

"l,i," "21-," "3f" or "41-." Record glucose findings using same notation 

as for albumin. 

9-14. These items are concerned with the history of difficulty since the 

previous prenatal visit and are designed to be used in conjunction 

with the interviewer's "History Since Last Menstrual Period" and 

"History Since Last Prenatal Visit," OB Forms 3 and a. You should 

go over these interviewer's forms in detail in the presence of the 

patient. Kpositive history in any of these six categories should 

then be marked here as positive (,t) and described fully on Form 

OB-11 1 "Record of Current Pregnancy." If the history is negative 

in these areas, this should be indicatad with a "0." Fo~ non-study 

patients or Study patients in those institutions which do not have 

an interviewer obtaining OB-3 or OB-8 1 these six items must be 

evaluated by the o~stetrician when this form is completed. 

15-19. Obstetric Examination 

15. Ht. Fundus (ems). Record the height ot the uterine fundus in centimeters. 

16. Position or Presentation. Record the ~osition or presentation of 

the fetus. 

· 17. Engagement. Record the approximate ertgagement. 


II.A.255 00-10

Instructions, OB-10 (cont.) 

Ite!1\..l!Q.. 

18~1.9. FHR. Record the fetal heart rate in item 17 and indicate the quadrant 

of the mother's abdomen in which the fetal heart is located in item 

19. 

20-41. I.aborgtory Elcaminatigns. Record the date the specimen is taken and 

when the result has been returned, record the result in the appropriate 

space. When blood is drawn for virology study, record the 

date (month, day and yeEr) the specimen is obtained. If diagnostic 

X-rays are obtained while the patient is receiving prenatal care, 

record the date, indicate the reason, and describe the findings 

briefly. If the patient is seen more than eight times during the 

prenatal course,,a second Form OB-10 should be used. 

The following are the prenatal laboratory requirements: 

Procedure 

Schedule 

1. Urinalysis (Complete) At initial visit 

2. Urinalysis (Albwnin and Sugar) At each return visit 

3. Microhematocrit reconunended (At initial visit 

(Cyanmethemoglobin acceptable) (At about 32 weeks of gestation 

4· Serology Once during pregnancy 

5. ABO Type and RH Type Once during pregnancy 

6. Indirect Coombs Once during pregnancy 

(if D and Du nesative) 

It is recommended tbat abnormal or suspicious laboratory findings 

be followed up with additional laboratory work as indicated and 

the results ~e reported on OB-10. 

This form should be forwarded after the termination of pregnancy 

and after the form has been edited. 


II.A.256 

OB-10

~"........ ,... 

~,_~.a., 

RETURN VISIT AND LABORATORY RECORD oJ ;J 

7- 5" 'l "'1..£-r • 

PHYSICIAN 

DATE 

WEEK 

WEIGHT 

BLOOD PRESSURE 

URINE 

EDEMA 

ALBUMIN 

ACUTE ILLNESS 

BLEEDING 

SURGERY 

TRAUMA 

IRRADIATION 

HT. FUNDUS (CMS) 

POSITION OR 

PRESENTATION 

ENGAGEMENT 

P.H.R. 

GLUCOSE 

INDICATE POSITIVI HISTORY OP THI POLLOWIMG WITH A CHICK (v') ABSINCI WITH A ZIRO


II.A.258

OB-44 

Prenatal Observations 

Form OB-44 was used to record obstetric data at the initial prenatal 

examination and at each subsequent prenatal clinic visit. Introduced in April 

1962, form OB-44 replaced that portion of OB-10 where clinical findings were 

detailed. Information from OB-44 (and from OB-10 regarding return visit) was 

coded on card 0344 of the master file (Table OB-44.1). The form was not 

revised, though data from a pretest form (dated 7/61) are included on the file. 

TABLE OB-44.1 




OB-44: Prenatal Observations, Return 

VIsit 0344 

0 179,409 

1 238,788 

418,197 



II.A.259 

OB-44


II.A.260 

OB-44


. )II 

1-1 

1-1 

N 

0\ 

1-' 

&1 

I 

~ 

nata Ite~s RPterPncln~ F~rm 01'-44, Prenat~l Observation~ 

DATI' 

JrE:II 

l'I'E'4 JN CARO 

TO r:'JIU4 NIJM FROIIII TO DAfA JfF.M NAME 

12'54 ••••••• 0344 t 5 C~trd nulftber (~eauence, torn tVpl", tor~ nu'llt>~"r, revision number) 

12'55 ••••••• 0344 I; 14 NTNOB case number 

12'5& •• os-44 0344 1'i 16 Prenatal visits, tot '!11 nnrnoer 

t2'57 •• nB-44 0144 17 18 Vtstt number 

12'58 •• 08•44 4 OH4 1Q 10 Form 08•44 ~ate ('IIO) 

12"i9 •• 1"18•44 4 0344 21 22 Form ns-44 ~ate l ~hV) 

1260 •• ns-44 4 0344 23 14 fnrm 08•44 date (yr) 

t26t •• ns-44 6 0144 25 '17 Wl"iCJht Clhs) 

1262 •• 1'18•44 7 0144 21t 10 Blood pressure, systolic 

1263 •• 08-44 7 0344 31 13 Bloo~ Pre5surP, Hastolfc 

1264 •• 1"1R•44 8 0344 34 H ur lne: albumin; [orflt,.inurtal 

1265 •• os-44 9 0344 3'5 15 Urine: 11lncnsl!' 

1266 •• '18•44 10 0344 36 lb Urine: ~~tcl"tnnP 

1267 •• 08•44 1t 0344 37 17 Illne~s, l'tCUte 

t268 •• r.IB•44 12 0344 3{1 18 fever 

1269 •• 1"18-44 

1270 •• n8-44 

1271 •• 08•44 

1272 •• 08•44 

1273 •• 08•44 

t 274 •• 08•44 

1] 

14 

15 

16 

17 

lA 

0344 

0344 

0344 

0344 

0144 

0344 

H 

40 

41 

42 

41 

44 

39 

40 

•1 

42 

43 

44 

vorntttno 

Urlnarv svmotoms 

swelltna, face 

swellfn'l, hflnds 

swelltn!l, lf>tt~ or feet 

Headache 

1275 •• '1S•44 19 0344 45 45 VIsual tHsturbance 

1276 ••'18•44 20 OH4 46 46 Fl"tl'tl acttvftv 

1277 •• 08•44 21 0344 47 47 Vaqinal bleedtnq 

t278 •• ns-44 22 0344 4R 48 MP:H cal c111re, other 

1279 •• 1JB•44 H 0344 4Q "iO Fnnt1us hetqht 

12110 •• 08•44 24 0344 51 'i1 Presentfltton 

t2R1 •• 08•44 25 0344 52 'i2 En;Jflttement 

t2A2 •• 0B•44 26 0344 51 53 FPtfll hPart anj quadrant 

12R3 •• 08•44 29 0344 54 54 E~ema, face 

t 2114 •• os-44 30 0344 5'5 55 Edema, hann~ 

12115 •• 08•44 30 0344 56 '56 E1ema, "bdo'llinal wall 

t2A6 •• nB-44 3?. OH4 57 "i7 E~ema, Prl"sacral 

t 2fl7 •• os-44 H 0344 58 58 E1ema, PrPt fbfal 

t2RB •• OB•44 34 0344 5Q "i9 E~e111a, ankle/foot 

12A9 •• 'JB•44 

t2QO •• ns-44 

t 2Ql •• OB•44 

35 0344 

0'344 

0144 

6" 

&t 

62 

60 

61 

62 

Ahnorrnallty, other 

E~ema, quantity -fthout sttP. 

Irr~tdlatton: lr8~tooraphlc exoosurel 

~ 

12Q2 •• 0B•44 0344 6'3 63 Acetone prior to first Vislt 

12Q3 •• ns-44 27 0144 64 64 FP.tal wei!lht Pstlmated flhsl 

t2Q4 •• 0B•44 27 0144 6" 66 FP.tl'll wPlaht Pstl~ate~ (01.:) 

t2Q5 •• 08·44 21! 0344 67 68 Gestation"! aqe ov examfn~tlon f•lc:s)


1-t 

1-t 

• > 

• N 

nata Items Referencin~ Form OA-44, Pr~natRl Ohservatlnns 

OlTl 

JfF"\14 

ITE\14 Jll ClRO 

TO F'JPI4 NIIM FP0\14 TO OAflf Tff.l4 Nli4F' 

12Q& ••••••• 

0144 6CJ IJO Blan~ 

49A7 •••• VAR 4 

5'5 '56 Prenatal visits, total numoer 

49CJ7 •••• VAR & 8ft 88 Welnht natn (lbs) 

'\Oo9 •••• VAR B 104 11l4 Albu~tn~rta: orntP.lnurla 

'50tO •••• VAR R tO'\ 105 AJbum1nur1a: oroteinurla, orlor to 1.4 wee~s qestatlon 

'\011 •••• VAR 8 106 lOb AJb"mtn••rta: orotP.lnuri~, 24 wePKS qestAtlon to labor 

S212 •••• VAR 7 127. 3?2 Blond press"re systolic 140 or Qreater an1/or 11astolic 90 or 

1reater; lhyoertensln~J 

"12t3•••• vA" 8 121 324 Albn•tnur1a: ornteinuriA, 2+ or •ore, nu•ber of urine soect•ens 

5216 •••• VAA 9 327 328 Glu~osuria, 2+ or wore, nu•ber of urine soeci•ens 

5217 •••• Y,R 1 ]2CJ J11 Blond 

'\2t8•••• YAR 

H7 H3 Blood oressure, oressurP., svstoltc, 

svstoltc, first 

ftrst recorded recorde~ 

Ccodedl 

li2t9 •••• YAR 7 134 H6 Blood oressurP., ~tastollc, first recorded 

"'i2?0•••• VAR 3]7 h8 Blood oressnre, diastolic, first recorded (co1ed) 

'5222•••• VAR 10 140 340 Acetonuria 

5273 •••• VAR 

631.2 •••• w-9 

63?3 •••• 11-9 

6 

1 

8 

141 

tt 

14 

343 

11 

14 

welQht, prior to delivery, final flbsl 

Blood pressnre, ~fastollc, Maxlmu• 

Protetnnrta: urtne1 albu•tn, ~axl•um 

0'1 

N 

~ 

~ 

~

..... 

C:Ol..llt-IOOa-44 

1. PATIENT IDENTII"ICATION 

08-44 PRENATAL OBSERVATIONS 

a) Record lindlnqa of aU prenatal clinic visitls, whether or not 

the patient Ia seen by a phystdan. 

b) Each prenatal visit at which th..-l"ltient is seen by a physician 

is to be summarized on Fonn 08-46. 

c) Findings at the initial clinic visit are to be recorded on this 

form, which is to be uaed in conjunction with 08-43. 

--~--. 

Record Initial I I 

--T--t TiaU here __ l._...J 

I I 

. 01 02 03 04 05 06 07 

Z. PHYSICIAN 

3. TITLE 

4. DATE (Mo.-D-..Y..,) 

5. WEEKS GESTATION 

BASED ON LMP 

8. WEIGHT (Street Clotllea 

No Shoea) 

7. BLOOD / / / / / / / 

PRESSURE 

/ 7 / / / / 7 

u 8. ALBUMIN 

R 

I I. GLUCOSE 

N 

10. ACETONE 

E (lf d-•) 

HISTORY lndl..,• ,_w... fmrUnQa by (X) •d deacnbe on OB-4


H 

H 

•>•1\J 

0\ 

~ 

@ 

rorm Ite~ ~u~bers 11~kej tn nata Items on JR-44, Pren~t~l Ohservattons 

ITEM 

OUA 

nN IrF:M CAHO 

FnRM 10 NIIN F'R0114 Tn DAY~ ITF:H NANF: 

1?91. •• 0R-U 0344 63 63 Acetone orlnr to first ViS it 

5220 •••• VIIR 337 318 

521fi •••• VAR 1]1. 313 Rlond 

Blood oressure, ::ltastolfc, first recorded Cco1ed) 

oressure, svstollc, first recorder! (coded) 

1290 •• iJR-44 0344 61 61 E11ema, ~u~ntttv without site 

129t •• oR-44 o344 6? 62 Irradtatlnn: rr~dtoqr~ohlc exoosurel 

11.56 •• 0R-44 0144 15 16 Prenatal visits, total ~umber 

1257 •• 0R-44 OH4 17 t8 Vtslt numher 

4 USCJ •• 08•44 0344 21 22 For~ 08•44 rtate (1ay) 

4 125" •• 0'1•44 0344 1CJ 20 For• 08•44 date (Mol 

4 U60 ••0A•44 0144 21 7.4 For• 08•44 date 

4 4987 •••• VAR 51\ 56 Prenatal vUlts, tot!ll nu•oer 

6 1261 •• 08•44 0344 25 27 Welctht (lbs) 

6 

4997 •••• VAR 

86 ~~ Welaht aatn (los) 

6 

5223 •••• VAR 34t 343 Welcrht, pr1or to 1eltverv, final Clbs) 

7 5217 •••• VAR 32? 322 Blood pressure svstoltc 140 or areater and/or dlastolfc 90 or 

7 

7 

7 

7 

ll 

8 

1261 •• os-u 

51.19 •••• VAR 

6322 •••• W•9 

5217 •••• VAR 

sooca •••• vAR 

5211 ••• • VAR 

0344 31 

334 

11 

32CJ 

104 

123 

33 

316 

13 

311 

104 

324 

crreaterr lhv~>ertenslo.,J 

Blood pressure, cHastoltc 

Blood oressure, cllastoltc, first recorded 

Blond pressure, ::UastoUc, III!!IXiiiiUIII 

Blood pressure, svstollc, ffrst recorded 

Albu•fnurtar proteinuria 

Albu11fnnrtar nrotelnurla, 2+ or •ore, nu111ber of urine specl•ens 

A 501l •••• VAR 106 106 Albumtnurta: oroteinurla, 24 weeKs aestatlon to labor 

II soto •••• VAR tor; 105 Albumfnurta: orotelnurlt~, or lor to 24 w~e~s qestatlon 

9 6323 •••• W•9 H 14 Protetnurtu urine; albn111tn, maximum 

9 

1?&4 •• oq·44 0344 l4 14 Urine; albumin: lorotelnuriaJ 

9 

5216 •••• VAR 127 328 Glucosuria, 2+ or :~~ore, nuwher of urine specl•ens 

9 126S •• OR•44 0344 35 35 Urine: a1ucose 

to 5222 •••• VAR 340 340 Acetonuria 

'0 

1?66 •• uR•44 

t1 

1767 •• 0R•44 0344 36 16 Urine: 11cetnne 

0344 37 37 Illness, ACIItP 

12 1261l •• OR•44 0344 31! 18 Fever 

t3 12&Q •. OR•44 0344 3q 39 Vomfttno 

14 1270 •• OR-44 0344 40 40 Ur1narv svmPtoms 

'5 

1 6 

1 7 

1271 •• 01\•44 

1272 • .ilR-44 

1273 •• 013•44 

0344 

0344 

0344 

41 

4:? 

4"J 

41 

42 

43 

swelllntl, 

swelltno, 

Swell tna, 

f~ce 

hAn"'s 

ll"qs or teet 

I 

~ 

~ 

t8 l274 •• 0R•44 0344 44 44 Heao1ache 

t9 127~ •• 0R•44 0344 45 45 VIsual rttsturbance 

?0 1276 •• (}!~-44 0344 41\ 46 retal acttvttv 

21 

11.77 •• QR•44 

?2 

1?7A •• OR•44 OH4 47 47 Valfnal 

0144 411 48 MedtcAl care, bleedfnq 

oth!!r


Porm Item ~u~bers tln~ej to nata Items on OR-44, PrenatAl Jbservatlons 

ITI::M 

OUA 

ON JlF:M CARO 

FI")Hiol II) NIIM FRO"' rn DATil JfF.M NAMF. 

23 

127Q. • OA-44 0344 49 'iO F•JI"'dus height 

14 

12BO •• OR•44 0344 51 '51 Present,.tton 

?.5 l?.Bt •• OR-44 0344 52 '52 En:uu;~ement 

?b 

1?82 •• 0R•44 0344 51 '53 Fetal heart an1 quadrant 

27 

129J •• OR•44 0344 b4 64 Fetal wPiaht P.sti~atei £lbs) 

?.7 1294 •• 0R•44 0'44 65 6b Fetal •e1aht Pstimated (O'Z) 

28 129') •• 0R•44 OJ;44 &7 68 Gestatinn~l ane bV examination f•ks) 

?9 1?111 •• 0fl•44 0144 54 '54 t:f1ema, fat:e 

30 128'5 •• OR•44 0344 56 '56 El1e111a, "blio1111nal wall 

30 1284 •• 0R•44 0344 5'5 '55 Eliema, hands 

J2 l28fi •• OR•44 0344 57 '57 Eliema, oresAcral 

H l287 •• 0R•44 0344 5~ 58 E"'e~a. oretlblal 

H l?8A •• OR•44 0144 5Q '59 E1ellla, l'lnklP/foot 

35 l?.89 •• 0R•44 0344 61) 60 Abnormality, other 

H 

Ḥ 

>. 

IV 

0'1 

l11 

@ 

I 

~ 

~

FIELD 


Code: 0 

DEFINITION OF CODES 

PRENATAL OBSERVATIONS 

FORMS OB-10 (Return visit) CARD 0344 

OB-44 

CARD 

COLUMN 


Code: 344 

3. Revision Number * 5 

Code: 0- OB-10 Forms dated: 1/59 and 7/59 

1 - OB-44 Forms dated: 4/62 

4. NINDB Number 6-14 

N1ne-d1g1t number for Patient Identification 


5. Total Number of Visits 15-16 

Code: Ol-98 - As given 

6. . Visit Number 17-18 


7. Date 19-24 

Item 4 

Six-digit code for Month (co1s. 19-20), Day 




8. Weight 25-27 

Item 6 

Code: 050-350 - As given in pounds 

999 - Unknown 

Additional codes reviewed and approved: 352,357,359-365,366,368-370, 

374,375,376,377 

9. Blood Pressure 28-33 

Item 7 


Systolic (cols. 28-30) 


999 - Unknown 

Diastolic (cols. 31-33) 



* Item numbers refer to Form 08-44 dated 4/62 except where otherwise 

specified 

II.A.266 

OB-44 


:FDRMS 03-10 

DEFINITION OF CODES (Continued) and 03-44 

Card o34.4 

FIELD 

10. Albumin 

Item.d 

Code: 

0 - None 

1 - 1+, 30 mgs, slight 

2 - 2+, 40-100 mgs. 

3 - 3+, 150-350 mgs, moderate 

4 - 4+, 600-2000 mgs, severe 


7 - Trace, less than 30 mgs. 


9 - Unknown 

11. Glucose 

Item 9· 

Code: 0 -None 

1 - 1+, slight 

2 - 2+ 

3 - 3+, moderate 

4 - 4+, severe 


7 - Trace 


9 - Unknown 

12. Acetone 

Item 1.0, 

Code: 

0 - None 

1 - 1+, sligh-: 

2 - 2+ 

3 - 3+, noder.;te 

4 4+;· severe 

1) 5 - Positive - unqualified . 

7 - Trace 


9 - Unknown 

13. Acute Illness 

Item ll 

Code: 0 - No 

1 - Yes 


9 - Unknown 

CARD 

COLUMN 

34 

35 

36 

37 


II.A.267 

OB-44

DEFINITION aF CODES (Contilllled) 

FORMS OB-10 

and OB-44 

Card 0344 

CARD 

COTIJMN 

14. Fever (Rev. 1 only) 

Item 12 

Code: Same as in Field 13, except 

9 - Unknown, not on Rev. "O" 

38 

15. Vomiting (Rev. 

Item 13 

Code: Same as 

1 on:cy) 

in Field 14 

39 

16. Urii:f! Symptoms (Rev. 1 only) 

Item 1 


17. Swelling 

Item 15-17 


Face !col. 41) 

Hands col. 42) 

~or Feet col. 43) 


0 -None 

l - l+, sli&ht · 

2 - 2+, moderate 

3 - 3+ 


5 - Positive - unqwantified 

6 - Positive - quantified but 

specific: site 

7 - Trace 

8 - Questionable history 

9 -Unknown 

Note: 

- 

Positive ~tified but no 

= 6' s in atire field 

18. Headache (Rev. l on:cy) 

Item 18 


no 

specific: site 

40 

41-43 

44 

19. Visual Disturbance (Rev. l 

Item 19 


on:cy) 45 


II.A.268 

OB-44


~·FOB}lS OB-. 

\ 

and CB-44 

Card 0344 

FIELD 

20. Fetal Activity (Rev. 1 on~) 

Item 20 

46 

Code: 

0 - None for entire period 

1 - Yes for entire period 

2 - Yes for part of period 


9 -Unknown, not on Rev. "0" 

21. Vaginal Bleeding 47 

Item 21 


1 - Yes 


9 -Unknown 

22. Other Medical Care 48 

Item 22 

Code for Rev. "O": 

0 - None 

1 - Surgery on~ 

2 - Trauma on~ 

3 - Surgery and trauma 

9 - U:nknown 

Code for Rev .. "1": 

0 - None 

4 - Yes 


9 -Unknown 

CARD 

COilJHN 

23: Heig:ht of Fundus h9-50 

Item 23 

Code: 01-87 - As given in ems. 

88 - Measurement other than c~. 

99 -Unknown 

24. Presentation 51 

Item 24 

Code: 0 -Vertex 

1 - Breech 

2 - Transverse lie, oblique, shoulder 

3 - Compound 

4 - Multiple pregnancy 

9 - Unknown 


II.A.269 

OB-44


FIELD 

FORMS OB-10 

and OB-4.4 

Card 0344 

CARD 

COLUMN 

2 5 • 

Engagement 

Item 25 

11 

Code for Rev. 0 11 : 

0 -Not engaged (includes codes 2 and 4 of Rev. "1") 

1 - Engaged (includes codes 3 and 5 

11 

of Rev • 1 11 ) 

9 -UnknoWn 

52 

26. 

27. 

28. 

Code for Rev. "l": 

2 - Not engaged 

3 - Engaged 

4 - Probably not engaged 

5 - Probably eugaged 

9 -Unknown 

Fetal Heart and Qu.adrant 53 

Item 26 

Code: 0 - Not heard 

l - Heard 

2 - Feta~ activity only 

8 - ~estionable 

9 -Unknown 

Edema (Rev. "~" onl.y) 

Items 29-34 

54-59 


Face (col. 54) 

~ (col. 55) 

Abdominal Wall (col. 56~ 

Presacral 

Pretibial 

!col. 57 

col. 58 

Ankle and/or F 00 t 

col. 59) 


0 -None ·· 

1 - Slight, l+ 

2 - Moderate, 2+ 

3 - 3+ 

4 - Severe, 4+ 

5 - Positive - unquantified 

7 - Trace 

8 - Postura~ 

9 - Unknown, not on Rev. "O" 

Other Abnormality (Rev. "1") · 60 

Item 35 

Code: 0 - No 

1 - Yes 

9 - Unknown, not on Rev. 11 0" 

II.A.270 

OB-44 



FIELD 

FORMS OBand 

OB-44 

Card 0344 

CARD 

COilJMN 

29. Edema - Q;uantity without Site (Rev. "O" only) 61 

Item 9 * 


1 - 1+, slight 

2 - 2+, moderate 

3 - 3+ 


5 - Positive - unquantified 

7 - Trace 

8 - Questionable history 

9 - Unknown, not on Rev. "1" 

30. Irradiation (Rev. "O" only) 

Ite!Il 14 * 

Code: 0 - No 

1 -Yes 

9 - Unknown, not on Rev. "1" 

31. Acetone Prior to First Visit (Rev. "0" only) 

Item 33 * 

Code: 

Same as in Field 12 except 

9 - Unknown, not on Rev • "1" 

32. Estunated Fetal Weight (Rev. "1" only) 64-66 

Item 27 .. 

Code: Blank ~ Not on Rev. "0" 

001-915 - As given in pounds and ounces 

988 - 10 lbs. and over 


33- Weeks of Gestation by Exam (Rev. "1" only) 67-68 

Item 28 

Code: B~ .:: Not on Rev. n-on 

01-50 - As given 

88 - Term 

99 -Unknown 

Note: A card is punched for each visit with columns 1-68 

same as above 

* Item number refers to OB-10 dated 7/59 

II.A.271 

OB-44 



RETURN VISIT ( OB-10) 

'- J!:!!-* - 

I 

1 + ? ~~:l3hl~ R? J28 

- ' 

XI 112n 16 ) I t llll12ll~fJ lillf p Q R R 2ft :16 Vlli 2t lUI 31 ~JUU116t Jt u n n '' 75lnna Jt 11 

··-~--~ 

- 

~ ~~~ HISTOR~ OBSlEl~IC 

-• ~ EXfl11tf\liON 

(J 

- a: 

0 - 

1 

J_ 

:l G E.DEHR 

2 

.~ t! - 

,JI! ' 

li. ~ . 

Nllll#. ) 

~ 

~ /Jl/IN/( 

H 0 

• H 1 ~~I~.. 

> ~1..:1~111 .. 

• 1 

~ 

• 1 

rftN~ 

tiJ S~ I ~I ~ 

--.1 

~ 

w 

~~ 

I· 

1!'11:111 

h aJ • ltl• J. • • 1111 IJJ:I •d•t ...." .. '' ah• ~, 2~u :M vL. Jt llllu n ·~ ~~~!~ ,, nmHt'*nit-''·" 

* Item numbers refer to OB-" form dated: ~/62 

** A card is required for each visit 

~ 

,s::. 

,s::.

Instructional Manual for Obstetric Forms 

OB-44 PRENATAL OBSERVAllONS 

I. Purpose of form To record obstetric data at 

the initial prenatal examination 

and at each subsequent 

prenatal clinic visit. 


A. Use a separate column for each prenatal 

visit. 

B. When a patient is delinquent, record the date, 

and note this fact in the appropriate column. 

This is optional. 


Item Number 

2, 3. Physician. Record the last name and the 

title of the examiningphysician. Ifpatient 

is not seen by a physician use space provided 

by items #2 and 3 to note this fact. 

4. Date. Enter the date of each visit. 

5. Weeks gestation based on LMP. 

a. Record the completed weeks gestation 

as calculated from the onset of the 

last normal menstrual period. This 

number may or may not coincide with 

weeks of gestation by examination 

(item #28). 

b. If there has been no LMP for this 

pregnancy, leave item blank and 

explain on OB-46 at the initial examination. 

c. Whenever the date of LMP is modified, 

utilize the new date to calculate item 

it5 thereafter. Do not correct previously 

recorded weeks of gestation. 

Note the basis for the change of EDC 

on OB-46. This should be on the basis 

of history or re-interview of the 

patient. 

6. Weight. Record weight (in pounds) wearing 

street clothes but no shoes or coat. 

7. Blood pressure. Record the blood pressure 

in the top box provided in the 

column. If a repeat blood pressure reading 

is taken, record the second reading 

in the lower of the two boxes. 

Item Number 

8. Urine albumin. Record at each prenatal 

visit the results as "0", "trace", " +1", 

"+2", "+3", "+4." 

9. Urine glucose. Record at each prenatal 

visit the result as "0", "trace", " +1", 

"+2", "+ 3", "+4." 

10. Urine acetone. If this optional test is 

done, record result. 

HISTORY. Items #11-22 are concerned 

with the physician's history of symptoms 

since the last prenatal visit (since LMP 

for the first visit). Indicate positive history 

by marking "X" in the space provided, 

and negative history by marking 

"0". Elaborate upon positive findings on 

OB-46. 

11. Acute illness. Record as positive any 

history of acute illness (with or without 

hospitalization or other medical care), 

including upper respiratory infections. 

12. Fever. Record as positive any definite 

history of fever or of a temperature of 

100.0 degrees or over, regardless of 

duration. Note that item #11 (acute illness) 

will frequently be marked positive, 

but it will be unusual to have item #12 

positive without a corresponding positive 

history in item #11. 

13. Vomiting. Record as positive any vomiting 

which was more than one short episode 

dally. 

14. Urinary symptoms. Record as positive 

any history of symptoms suggestive or 

indicative of urinary tract infection; i.e., 

dysuria, pyuria, hematuria, pain, etc. 

15-17. Swelling. Record any positive history of 

edema in the areas listed. 

18. Headache. Record as positive any history 

of persistent or recurrent headaches. 

19. Visual disturbances. Record as positive 

any significant episodes of visual disturbances, 

such as persistent diploplia, 

blurring, spots, etc. 

October 1962 


II.A.273 

OB-44

L1struction l\lanual for Obstetric Forms 

OB-44 PRENATAL OBSERVATIONS (Continued) 

Item Number 

20. Fetal· activity. Record the presence of 

fetal movement by history with "X", and 

the absence of such activity with "0". 

Record the date of quickening as specifically 

as possible. The absence of fetal 

movement as felt by the patient requires 

commentary on OB-46 only when such 

absence might be indicative of fetal death 

in utero. 

21. Vaginal bleeding. Record as positive any 

history of vaginal bleeding or spotting. 

22. Other medical care. Record as positive 

any history of medical care other than 

at the obstetric clinic of the Study institution. 

This would include private physicians, 

in-patient and out-patient services 

of otherbospitals, emergency rooms, 

and hospitalization anywhere in the Study 

institution. 

OBSTETRIC EXAMINATION. Items #23 

35 are concerned with the findings of 

examination at each prenatal visit, including 

the first. Evaluate and comment on 

abnormal findings on OB-46. 

23. Height of fundus. The height of the fundus 

is measured abdominally as a straight 

line from the superior border of the 

symphysis pubis to the top of the ft

OB-45 

Laboratory Record 

Form OB-45 was used to record the results of laboratory studies, X rays, 

and EKG 1 s performed on the study patient. First used April 1962, the form was 

not revised. Form OB-45 replaced the section on OB-10 where laboratory data 

were recorded. 

Information from the form was recorded on seven cards (Table OB-45.1). 

Approximately 4000 OB-10 laboratory findings were coded with the OB-45 

laboratory findings on the 1345-7345 card series of the master file {see 

field 3, revision number). The 345 card series should be used in conjunction 

with the 310 card series.) For data on blood drawn for Virology Study see 

Volume IV, Work Files 11-15. 

TABLE OB-45.1 




OB-45: Rh, Coombs Test, Serology and 

Blood Sugar, Pap Smear 

1345 

0 4,187 

1 32,797 

2 1,252 

------ 

38,236 

OB-45: Hematocrit Data 2345 

OB-45: Hemoglobin 3345 

0 3,596 

1 31,040 

2 2,109 

------ 

36,745 

0 3,355 

1 20,615 

2 942 

------ 

24,912 


II.A.275 

OB-45

OB-45: Urinalysis 4345 

OB-45: Xray Pelvimetry 5345 

OB-45: Cultures, Glucose Tolerance 6345 

OB-45: Additional Cultures 7345 

0 

1 

2 

0 

1 

2 

0 

1 

2 

0 

1 

2 

3,340 

271938 

2,033 

----- 

33,311 

3,110 

27,934 

1,818 

------ 

32,862 

422 

12,112 

336 

------ 

12,870 

4 

322 

10 

----- 

336 


II.A.276 

OB-45 



H 

H 

• > . 

rv 

-....! 

-....! 

6l 

I 

~ 

U1 

nata Ite~s ReterP.nclng rnr~ OR-45, Laboratory RPcnr~ 

Dill II 

TrEM 

ITEM JN CARO 

'[[) F"JRM NIIM rqo~o~ TO OATil lfF"M NAME 

12CI7••••••• 

134"i 1 5 C11r11 number cseauence, for11 tvoe, form nurnber, revision number) 

1208 ••••••• 

1345 6 14 NINOB CI!ISP nu~ber 

1209 •• 08-45 l 1145 1"; 15 Rloocl type 

1300 •• nf'-4"i 3 lH"i l'i 16 Rh tyPe 

t301 •• 0B-4'5 3 

134"i 17 17 Rloocl type (father> 

t302 •• nB-4'5 3 

1145 lR 18 Rh tyoe (fatnerl· 

1.J03 •• nB-4'5 4 134'5 1CI 19 cnomb's tf"st, n•1•ber of tPst 1ates 

1304 •• 08-4'5 4 134'5 20 21 Coomb's test, :tate of most recent ('110) 

1305 •• n8-4'5 4 

1345 2? ?3 Cno~b's test, 

1306 •• 08-4'5 4 

134'5 24 24 cno111b's tPst, :tate of most recent 

tvoe of 'llost recent (yr> 

1301 •• nR-4'5 4 114'5 2"i 25 Cnornb's test result of rnost recent 

tlOB •• 'lU-45 4 134"i 2~ ?o Rh titer, n•1:nher of illtP.S 

1309 •• 08-4'5 4 134"i 27 ?B Rh titer, ftrst :ll!lte ('110) 

1310 •• oB-4"i 4 

134"i 2CI 10 R"t titer, ftut :tate Cyr> 

1311 •• 08-41\ 4 

114'5 31 11 lsUc 

result 

result 

(110) 

Cvr>


1-1 

1-1 

•)I 

0 

!j 

(X) 

!lata Ite~s Referencln~ for~ LIR-45, Laboratorv Recor~ 

OlH~ 

IrE"' 

ITEM J~ C~Rn 

TO F"JIU4 Nll"' FROM TO DAfA ITF.M NAM F. 

t 319 •• ns-45 D4'i 7ft 76 P~P s~e~trs, nu11her of il'ltes 

t140 •• nB-45 1345 77 77 Ll'lboratorv test serfes, nu11ber 

t341 •• nR-4'5 1H'i 7R 78 Cultures, numher of :tates 

1342 •• ns-4'i lH"i 7Q 79 Glucose tolPrance tests, nu~ber of dates 

1343 ••••••• 1345 81) ~0 Blank 

1344 ••••••• 

2345 

5 Card nu~oer (sequence, for11 tvoe, form nu!llber, revision number) 

1345 ••••••• 

2345 

1, 14 NTNOB cas~ nu~bPr 

134& •• ne-45 2345 1'5 15 CAr1 se~uenre nu•her 

t347 •• na-4'5 6 214'5 1" 17 HemAtocrit, nth date Cmo) 

t34B •• nB-4'5 6 2H"i 1R 19 HP•Atocrlt, nth dAte (dAy) 

049 •• oa-45 6 

2145 20 21 

n~-o••ntt-4'5 6 

214'5 2? 74 He•atocrit, 

HP-•,.tncrlt, nth nth date fyr) 

result 

t35t •• nB-4'5 6 2)45 25 26 He•atocrtt, nth date ('10) 

U1112 •• ns-45 6 2145 27 28 Hematocrit, nth date Cdavl 

1353 •• nB•4"i 6 2H5 2Q 30 Hf'•Rtocrlt, nth dllte Cvr> 

13'54 •• os-4'5 6 2345 31 :u HP'Iatocrlt, nth result 

U'55 •• nB-4'5 

1356 •• llR-4'5 

1357 •• 08•4'5 

6 

6 

6 

214'5 

234'5 

2345 

34 

36 

38 

35 

17 

39 

He!utocrlt, nth :late 

Hematocrit, nth :Sate 

Hematocrit, nth :late 

He•atocrlt, 

He•atocrlt, nth 

nth result 

Cmo) 

C::lavl 

Cvr> 

13"i8 ..1)8•4"i 6 

234'5 40 42 

U59 •• ne-n 6 

214'5 43 44 

:late Cmo> 

1360 ••08•4'5 6 214'5 45 46 HPmatncrlt, nth :ll!lte C111vl 

1361 •• 08•4'5 6 234"i 47 48 Hematocrit, nth :ll!lte Cvr> 

131;2 •• ns-4'5 6 234!'; 4Q 'H HPIIIatocrit, nth res•Jlt 

1363 •• 08•4'5 6 

2345 5? '51 Hf'~l'ltncrlt, nth :lAte (!110) 

l3t>4 •• ns-4"i b 

2345 54 55 Hematocrit, nth ::I:Jte (jay) 

1165 •• 08-4'5 b 

214'5 St> 57 HP!IIatocrtt, nth :ll!lte (yr) 

1366 •• ne-4'5 6 2145 SR r.o HPmatocrtt, nth rf'SUlt 

11t>7 •• ns-45 6 2]45 61 62 HPIIIAtocrlt, nth :l"te Cmo) 

13t>B •• OB•45 6 

214'1 61 t>4 HP'II,.tocrlt, 

t3'i9 •• nB-45 6 

2345 &5 66 HP118tocr1t, ntn 

nth ::l,.te :l~te (ct8Vl 

 

f J70 •• IJK-45 6 2345 b7 'i9 HPmatocrlt, nth ri"SUlt 

t 371 •• ne-45 6 

2345 70 71 HPmAtocrlt, nth :lAte Cmo) 

1372 o .ns-4'1 6 

2345 71 73 HP!IIatocrit, nth :l!itt' (day) 

137l •• I'JB-45 b 2145 71 75 HPmatocrlt, nth :tate 

nth result 

1374 •• ns-4'5 6 2345 7ft 78 HPonatocrlt, 

@ 

t.J,7S ••••••• 

2145 7'l RO Bl!lnlc 

I 

~ 

1176 ••••••• 

)145 

5 Card numbt'r 

l11 1177 ••••••• 3345 6 ' 14 NTNOB case nuonber 

1378 •• 08-45 B4'5 1'1 15 Card sequence number 

1379 •• ns-45 6 3345 16 17 HPmoglobln, nth ::late Cono) 

13RO •• I1B-45 6 3345 lR 19 Hemoqlohln, nth :tate (dRY) 

t]Rl •• nH-45 b 3145 20 11 Heonoqlohin, nth ::late (yr) 

(sequPnce, tor11 tYPI", for!ll number, revision number)


. 

H 

H 

)II 

. 

N 

-..J 

1.0 

@ 

I 

~ 

l.n 

Oata Items Referencin~ For~ OR•45, Laboratory Recnr1 

DIITA 

ITEioll 

TO 

1JR2 •• llB•4"i 

13A1 •• n8-4"i 

1384 •• 08•45 

t3AS •• ne-4"i 

t1116 •• 08•45 

t 3A7 • .OH·4·o; 

t3A8 •• nB-4'i 

1 n9 •• os-4'5 

t]QO •• OB•4'i 

1JQ1 •• oB-4"i 

t3Q2 •• na-4"i 

1JCJ3 •• nB-4'5 

13Q4 •• 0B•4"i 

1JQS •• n8-4"i 

13Q6 •• nB-4'5 

t3CJ7 •• na-4"i 

13CJY •• IlH•4'5 

t3CJ9 •• n8•4"i 

141'10 •• 08-4'5 

14nt •• m~-4'5 

1402 •• os-45 

14~"~3 •• nH-4'5 

1404 •• n8-4'5 

uos •• ns-4'5 

1406 •• nB-4"i 

1407 ••••••• 

1408 ••••••• 

1409 ••••••• 

1410 •• 08•4'; 

141 1 •• nB-4'5 

1412 •• 08•45 

141J •• n8-4"i 

1414 •• oa-45 

14ts •• na-4'5 

141& •• ns-4"i 

1417 •• nB-4'i 

14tB •• nB•45 

t419 •• 0B•45 

t42o •• no-4'5 

1421 •• 08-4'5 

1422 •• 08•4'5 

1423 •• 08•4'; 

1414 •• 08-4'5 

b 

6 

6 

6 

6 

6 

b 

b 

6 

b 

b 

b 

6 

6 

6 

b 

6 

b 

6 

b 

b 

6 

6 

6 

& 

7 

7 

7 

7 

7 

7 

7 

7 

7 

7 

7 

7 

7 

7 

TrP.:M 

Jill 

F':JR" 

CIIRO 

NIIM 

H45 

H4"i 

H4"i 

114'5 

314'5 

H4"i 

334'5 

H4'5 

334"i 

H4"i 

314'5 

334'5 

314"i 

H4"i 

334'; 

114"i 

314"i 

314"i 

3H"i 

3]4"i 

334'5 

314'5 

334'5 

H4"i 

H4"i 

Jl4'5 

4145 

414'5 

414'5 

414'5 

4l4"i 

4345 

414'; 

4145 

4H"i 

4145 

4l4'5 

414"i 

4345 

4145 

434'5 

414"i 

434'5 

FROM 

22 

25 

27 

29 

]t 

34 

3,; 

311 

40 

41 

4'i 

47 

4Q 

5? 

54 

Sfi 

511 

61 

61 

6"i 

67 

70 

7? 

H 

7fi 

7Q 

1 

fi 

l"i 

11; 

til 

20 

21 

2?. 

21 

24 

2"i 

2fi 

27 

2A 

30 

32 

3J 

TO DATil tfF.M NAIIIF. 

?4 Hemoqlobin, nth result 

76 llemn~lobln, nth :tate (110) 

18 He!ftnqlohln, nth :i~tte Cdayl 

10 HI!IIIOQlohln, nth :tate (yr) 

]] HP'IIOQlohln, nth result 

15 Hemo.:,lot>ln, nth :tate (1110) 

37 HP'IIn(Jlnhtn, nth :illltP (d~ty) 

19 Hf'110glo..,tn, nth :tittP (yr) 

12 Hellnctlohln, nth rPSUlt 

14 HP110Q1oh1n, nt:h :tate (mn) 

46 HP!IIOQlObin, nth :tate (day) 

18 HP'IIOqlohln, nth :IllitE' cvrl 

'51 HP'llnqlohln, nth result 

"i3 He11oqlobln, nth :tate ('110) 

'55 HP110Q1ohln, nth :Illite (day) 

"i7 Helloctlohtn, nth :tate (yr) 

60 HP'IIOQlohin, nth result 

fi2 He11nqlohln, nth :tltte (1110) 

,;4 HP'IIO~lot>ln, nth :tate (d3V) 

fi6 Hf'111'1Qlohin, nth :tate Cvr> 

69 HP'IOQlOhtn, nth result 

71 HE'111'1Qlohln, nth :tate Cmo) 

73 Hf 01 IIO:J}Ohin, nth :tate (diJiyl 

75 HP:~~nqlohtn, nth :tate Cyr) 

78 Hf''IO:Jlol"ttn, ntn result 

AO Blanl( 

5 C~tr1 nu111ber (se~uence, for11 tvpe, form nu111oer, 

14 NlHOB C8Sf' numbf'r 

1'5 C~tr1 se~uence nu11ber 

17 UrlnaJy~;ts, ntn :tate Cmo) 

19 Urinalysis, 11th :t~tte 

?o urtnalvst~, nth tVPP. of specimen 

11 Urinatvsts, nth centrttuqe:l 

12 Urinalysis, nth :tlucose 

73 urtnatvsts, nth albu'lltn 

?4 Urtnatysl~, ntl'l !lcetone 

15 IJr tnal vst!l, nth bloo:t cells 

?& Urtoalysls, nth casts 

'11 Urlnalvsts, nth blllcteria 

?9 Urinalysis, nth :t~tte (1110) 

]l Urlnalvsts, nth :t"te (yr) 

'32 Urtnatvsis, nth typp of specimen 

33 Urinalysis, nth centrtfuqe:l 

re.,lslon number)


1-1 

1-1 

• 

• > 

~ 

Q) 

0 

@ 

I 

.a:. 

U'1 

Oata Ite111s Referenclrq For111 

l)R-45, l.ahoratorv Hecorri 

OiHA 

Tr~!4 

ITE~ J'f CARO 

TO F'JPM NIIM FRO"' rn I) ATl TrF:Jo4 "4111111F: 

1425 •• nB-4"i 7 434"i 34 H urtnalvsls, nth :,tucose 

14?6 •• OI~-4"i 7 414"i .l"i 15 Urtnalvsts, ntn al btntn 

1427 •• ne-4"i 7 434'i H 16 Urlnalysi!l;, ntn acetone 

14?s •• ns-4"i 7 4'14" 37 11 Urinalysis, nth bloo.J ct>lls 

t429 •• nB-4"i 7 434"i ]q 19 urtnalvsts, nth c111sts 

t410 •• nB-4"i 7 41411\ 3Q 1q Ur1na1V51s, nth b'lcterlll 

14H •• OK•45 7 

414S 40 41 urtnalyst!l, nth ('110) 

1412 •• na-4'i 

141J •• oa-4"i 

1434 ••fl8•4"i 

t ns•• os-4'i 

7 

7 

7 

7 

414'i 

434"i 

414"i 

4341i 

4? 

44 

4'5 

4~ 

43 

44 

45 

4& 

Urlnaly~is, 

Urinalysis, 

Urlnalysls, 

Urtnatvsts, 

ntn 1'llte 

:t!!lte 

nth 

nt n 

nth 

(yr) 

tvoe of soecl~en 

cent r I ftiQI! :1 

;JlUCOSe 

1416•• nB-4"i 7 41411i 47 47 Urinalysis, nth ~loo•1n 

1417 •• 08•45 7 4145 4R 48 urtnalvsts, nth acetone 

1438 ••06•4'5 7 414"i 4Q 49 Urtnaly!lls, ntn o\oo:'l cttlls 

1419 •• nB-4'5 7 41411\ so "iO Urinalysis, ntn c!!lsts 

1440 •• £l8•45 

1441 •• oo-45 

1442 •• OB•4"i 

t44l ••'l8•4'i 

t444 ••0K-4"i 

1445••08•4'§ 

144& •• na-4'5 

7 

7 

7 

7 

7 

7 

7 

414'5 

4145 

4145 

43411\ 

4H"i 

4H"i 

4341i 

51 

5? 

54 

56 

57 

"iA 

SQ 

'51 

51 

55 

'56 

'57 

"i8 

59 

Urtnalysts, 

urtnalysts, 

Urtnalysts, 

Urln!tlysts, 

Urinalysis, 

Urinalysis, 

Urtnalysts, 

nth 

nth 

nth 

nth 

nth 

nth 

nth 

b~tcterh 

:tate Cmo) 

:IIJitP (yr) 

tvoe of soe~i~en 

c=entrlfuqe1 

~lucose 

!llbU'Iln 

1447 •• 0B•4"i 7 414"i bO 60 Urtnalysl~, nth :~cetone 

1448 •• 08•45 7 4145 61 f\1 Urtna\ysl!l, nth bloo:l CP11s 

1449 •• na-4S 7 

4H"i &7. F;2 Urlnalysts, 

14"\0 •• na-4"i 7 

4H"i &1 fi3 Urinalvsts, nth 

nth Cl'lsts 

b"'lcterl~t 

14''H •• na- 4"i 7 

41411\ &4 65 Urinatvsts, 

l4"i2 •• na-4"'i 7 

434"'i 6ft r..7 Urlnaly51s, nth 

nth :tate 

:i!ltt' (mo) 

( yr) 

14"il •• ns-45 7 

414'5 &R 68 UrtnalV!Il!!, nth tvoe of soeci~en 

141\4 •• 08•4'5 7 

414"'i f)Q F;9 Urinalvsts, nth ::~ntrfflloej 

14'55 •• nK-4S 7


H 

Ḥ 

>. 

IV 

14R7••••••• 

(X) 

...... t4R8 •• r'IB-4'5 

t4R9 •• 0B-4'i 

t4CJO •• nB-4"i 

14Q1 •• 1'lB-4'i 

Oata Ite~s Reterencin~ Form oR-45, Lahoratorv Recorrt 

O"TA 

ITF.M 

ITE,_ J" C~RO 

TO F"JPII NnM FROM TO OATA.TfF.M NAMF. 

1468 •• oa-4'i a 5345 22 23 Radioar~ohv: x-rav oeJvtmetrv: Caldwell-Molov classlfic&tlon 

1469 •• f'l8-4'5 8 534'5 24 26 R~~~o~raohy: x-rav oeJvtmetrv, measurements, Inlet AP 

1470 •• 08-45 8 514"1 21 ?9 R~dfoaraphy: x-rav oelvfmetrv, measurements, Inlet transverse 

t471 •• nB-4'5 8 534"1 30 12 Radtooraphy: x-ray Pelvimetry, me&surements, Mi~ pelvis AP 

1472 •• 08•45 8 5345 ]] 15 Pa1foor~ohy: x-rav oelvt~etry, measurements, •1~ oelvls transverse 

1473 •• na-41i 8 

514'5 36 18 R~1toar~ohv: x-ray 

1474 •• f'lB•4'i R 

5l4"i 3Q 41 R~dtoaraphy: x-rav oelvtmetry, 

oelvtmPtrv, ~easurements, 

measnrements, outlet ml~ oelvts oost. saq. 

AP 

t 475 •• nR-4'i 8 5345 4? 44 Ra1foqraphy: x-ray oelvtmetry, measurements, outlet transverse 

1476 •• os-4'5 8 534'5 45 47 Radfoaraphy: x-ray Pelvimetry, measurements, outlet oost. saq. 

1477 •• na-45 11 514'5 411 49 Pap smear, ~ate (mo) 

1478 •• na-4S 11 5345 50 '51 P~o s•e&r, date (Vr) 

t 479 •• nB-4'5 11 534'5 52 "i2 P~o sme~r, result 

t4AO •• na-4'5 11 534'5 5'l 54 Laboratory test series, date C~o) 

t4A1 •• OB-4'5 13 534'5 5'5 '\& J,,.bor,.tory test serf es, c:t"tP ( c:tay) 

14R2 •• 1'1R-45 13 514'5 57 li8 Laboratorv test series, date (yr) 

t4Rl •• na-4'5 13 514"1 sq 59 Laboratory test series, tvoe 

l4R4 •• OB•45 13 534'5 60 60 Laboratory test series, nu~ber of days 

14R5 ••••••• 

5345 61 AO 81anlc 

14R6••••••• 

&34'5 t 5 Card number (sequence, for~ type, form number, revision number) 

9 

9 

9 

9 

9 

9 

9 

9 

9 

9 

9 

9 

&345 

&345 

&14'5 

&341i 

&]4'5 

6 

1'5 

17 

lQ 

21 

14 

16 

tR 

?0 

?1 

NTNOB case number 

Cnltures, nth 

Cnltures, nth 

Cultures, nth 

Cultures, nth 

1ate (mo) 

date (yr) 

tvoe 

result 

14"2 •• ns-4"i 

&l4'\ 2?. ?l 

14CJ3 •• na-4'i 

&34"1 24 25 Cnltures, nth 

Culture~, nth 1ate Cno) 

ct~te (yr) 

t4Q4 •• ns-4'5 

&34'5 26 11 

14QS •• OB-4"i 

&345 2A ?a Cnltures, 

Cultures, nth nth tvpe 

result 

UQ& •• ns-45 

&H"i 2Q 10 

14'l7 •• 08-4'i 

&H"i 31 12 Cultures, 

Cultures, nth 

nth 1ate 

date (yr) 

Cmo) 

14CJ8 •• ns-4'5 

634"i 33 14 Cultures, nth tyoe 

t4Q9 •• nB-45 

&l4"i 35 35 Cultures, nth result 

t5oo •• os-4'5 9 b34"i 36 17 Cnltures, nth d~te (~o) 

tsni •• na-4'i 9 bl4"i 3R 19 Cultures, nth date (yr) 

1502 •• 08•4'5 9 

b34"i 40 41 

1503 •• 08-45 9 

&l4!'i 42 42 Cultures, 

Cultures, nth 

nth tvpe 

result 

1504 •• 08-4'5 10 

&l4"i 41 44 Glucose tolerance, date (mo) 

~ 

tso5 •• os-4'i to 

634"i 45 46 Glucose toler~nce, d~te (~ay) 

~ 

l.11 1506 •• 08-4'5 10 

6345 47 48 Glucose tolerance, date (yr) 

1507 •• 08•4'5 10 

6345 49 49 Glucose tolerance, how administered 

tso8 •• na-45 10 634"i 50 52 Glucose tol~ranr.e, blood, tastin~ (~gms/100 ~1) 

t509 •• 1'l8-45 10 

634'5 53 '55 Glucose tolerance, blood, 1/2 hr. (mqms/100 ~1) 

t5tO •• f'l8-4"i 10 

614'5 56 "i8 Glur.o5e toler~nce, blood, 1 hr. (mqms/100 ~1)


H 

Ḥ 

>. 

N 

00 

nata Items Referencing Form OR-45, ~aboratory ~ecor~ 

ottn 

IrF.M 

I'I'EIIo! JN CIIRO 

TO F'JRM NIH! FPOM rn DIITtt HF.M NAME 

tSll •• nB-45 

15t2 •• 0B•4"i 

t5t3 •• 0B•4"i 

t5t4 •• nB-45 

10 

10 

10 

10 

6l'4'i 

&l4'i 

634'i 

&345 

51J 

6'? 

&"i 

6fi 

fil 

64 

65 

66 

Glucose 

Glucose 

Glucose 

Glucose 

tolerance, 

tolerance, 

tolPrance, 

tolerance, 

blood, 

bloo!1, 

urtnf", 

urine, 

t5t5 •• nB-4'5 10 614"i &1 67 Glucose tolerance, urtne, 1 hr 

t5t6 •• 0B•45 10 &345 &R 68 Gluco~e toleranc~, urtn.. 2 hrs 

tst7 •• ns-4'i tO 634'i 61l 69 Glucose tolerance, urine, 3 nrs 

1518 ••••••• 

&34'i 70 

1519 ••••••• 

7145 t 

1520 ••••••• 

7145 6 

li2l ••Oat•t5 9 

7H5 1'5 

t522 •• nB-4'i 9 7341i 17 t8 cultures, nth :jlllte Cvr> 

1523 •• oa-45 9 7l4"i til 10 Cultures, nth tVDI'! 

1524 •• 08•45 9 7l4'i 21 21 cultures, nth result 

1525 •• na-45 9 H4'i 22 ?3 Culture!!, nth ~ate ('110) 

1526 •• na-45 

t527 •• ns-45 

1528 •• 08•45 

1529 •• 08•45 

ts1o •• na-45 

9 

9 

9 

q 

7345 

7345 

7345 

714'i 

1345 

24 

2fi 

21! 

2q 

31 

2 hrs. (mqms/100 

1 hrs. (mqms/100 

fastin:J 

t/2 hr 

80 

5 Card Blank 

nulllbf'r (seQuence, for11 tvpe, form nu'lber, reviSion nu11ber) 

14 NTN~B case number 

16 Cultures, nth :jllte ('IO) 

25 

11 

18 

10 

32 

Cultures, 

cultures, 

cultures, 

cultures, 

Cultures, 

nth 

nth 

nth 

ntll 

nth 

~ate 

 

tyoe 

result 

:jate ("Ro) 

9 

~ate Cvr> 

N 

t 511 ••oa-45 9 734!1 31 14 cultures, nth tvoe 

15'J2 •• no-45 q 7345 35 15 cultures, nth result 

1533 •• 08•45 9 734'5 36 17 Cultures, nth date C111o) 

@ 

I 

~ 

l11 

t514 •• no-4r; 9 

734"i 31! 19 cultures, 

t515 •• ns-4'5 9 

H4'i 40 41 Ctlltures, ntll 

nth :Jate 

tvoe Cvr> 

t51& •• no-45 9 1345 42 42 cultures, nth result 

t 537 •• nR-45 9 7345 41 44 cultures, nth :late (110) 

1538 •• 08•45 9 7345 4'5 46 Cultures, nth :l~tte (yr) 

1539 •• nB-4') 9 

7345 47 48 

t540 •• f1B•4'5 q 

714"' 41l 49 cultures, nth 

Cultures, nth tvoe 

r~sult 

t541 •• rtB•45 9 7345 50 'il Cultures, nth :1-!tte (110) 

t542 •• nB-45 9 7345 52 '53 cultures, nth :J-"tP. (yr) 

t543 •• 0B•4'i 9 734'5 54 55 Cnlt ures, nth tVDI'! 

t544 •• nB-4'5 9 134'i 56 '56 Cultures, nth result 

ts4s •• nn-4'5 9 H4S 51 '58 cultures, nth :late f11o) 

1546 •• 08•45 9 

7145 Sll 60 Cultures, nth :tate (yr) 

t547 •• nB-45 9 

734"i 61 "2 cultures, nth tyoe 

t54B •• OB•4'5 9 

7345 &1 63 Cnltures, nth result 

t549 •• ns-4'i 9 

734'i 64 65 Cultures, ntll :late ('110) 

t5!'io •• n8-4'5 9 714'5 66 67 Cultures, nth dat~ (yr) 

t 5'51 •• ns-45 9 7345 61! 69 Cultures, nth type 

t5"i2 •• ns-4"i 9 

7145 70 10 

t5'53 •• ns-4!'i 9 

734'5 71 12 Cultures, 

Cultures, nth 

nth result 

:J~tt~ (no) 

'Ill) 

'Ill)


nata Ite111s Rl!fl"rtonein;J For"' 

OATil 

ITE14 

TO 

1554 •• 013•45 

tso;s •• nB-4"' 

t5"ib •• OB•4'i 

15'57 ••••••• 

49Q9 •••• VAI! 

4999 •••• VAI! 

sooo •••• VAA 

soot •••• vAR 

'5222 •••• VAR 

52?4 •••• VAR 

52?5 •••• VAR 

'i22& •••• VAA 

52?7 •••• VAR 

52?8 •••• "AR 

9 

9 

9 

b 

b 

7 

3 

4 

3 

b 

b 

nr.N 

::1'1 

F'JP14 

CARD 

NIIM 

134"' 

734"' 

7J4"\ 

1'l411\ 

OR-45, f,ahoratorv Rl"enrr! 

FRUiol 

n 

7"\ 

11 

71! 

89 

9? 

9') 

96 

340 

344 

345 

]41; 

347 

151 

TO 

74 

1& 

77 

AO 

IH 

92 

95 

9b 

340 

344 

345 

34& 

3"\2 

3511 

OATA Hfl:l4 NA"'E 

cultures, nth :tate cvn 

cu 1t ures, nth tvoe 

C11ltures, nth result 

Blank 

HP•natocrlt lowest l!'!vel, (oPreentl 

He111atncr1t lowest lPvel, l"'rouoer! 

HPmoc:n on in, }Oiii'!St val uP C;Jra'lls) 

HP'IIOQlohin, l!HII"'St Y!llUP. (;Jrouoei) 

Aroetonuria 

Rloo:t tvpe 

COO'IIbS' tPst 

Rh factor 

Hf''llatocrit., dAte of lowl!st value Cmo/davtvr> 

Hemoqlobln, dAtf' Of lOWf'St value Cmo/r!av/vr) 

. 

1-1 

1-1 

>. 

N 

co 

w 

~ 

l11

C:OLA-3001-411 11. ~ATUENT IDENTIFICATION 

..... a 

OB-45 

Z. VIROLOGY 

_!oc_c.__oo 

LABORATORY RECORD 

~___A_! 

; ._, 

... .. .... .. 

OATI;a 

I 

BLOOD 

OAAWN I I 

i I 

QNAVtOA 

1 

I 

I 

_l 

I 

I 

I 

: 

'Yo!; 

-r-l 

3. BLOOD TYPE AND RH 7. u 

·~ _!·~IJR~ 

_OAT< ~!. ~ O~


>. 

H 

Ḥ 

"-> 

co 

l.n 

9 

I 

~ 

l.n 

Form Ite111 Nut~~ol'rs liniCP:f to nata !tell's on OR-45, r.ahoratorv Q@'corct 

lTEIIIl 

f>ATA 

ON UF.IIIl ClRil 

FOR Ill 10 'filM FROIIIl ·ro OATil TTF.I4 NlllllF. 

1146 •• uA-45 2345 15 15 c~r~ seauPnce nunber 

1 HIJ •• OR•45 334'i 15 15 C~rd se~uPnce nunber 

1410 •• 0A•45 434'i l'i 15 c~rd ~e~uPnce nunher 

134t •• oR-45 134'i 7!1 78 Cultures, numher of iates 

1342 •• OA•45 D4'i 70 79 Glucose tnLPr~n~e tl'sts, numbPr of dates 

4Q9Q •••• VlR 9? Q2 Hf"lllltocrtt lowest Ievtol, orouoe-t 

1334 •• 0R•45 134"1 6R 69 HP~1"'tocri t, nn11ber of tPsts 

soot •••• VlR 96 Q6 Hemoqlohln, ln.rl'st valuf' ( ~ronof':U 

1H"i •• OA•45 134'5 70 71 Hl'llloglo'-in, numher of tests 

1340 •• OA•45 134'5 77 77 Lllboratorv test Sl'rtes, nunber 

1 HQ •• OA•45 114'i 76 76 P~to smear~, nu'llher llf dates 

1337 •• 0R•45 134'i 74 74 Rartfolnaohic: x-r"V oi'Jvlllletrv 

1336 •• 0A•45 134'i 7') 73 Urinalysis, number of tl'sts 

1 1?.99 •• 08•45 134'i 1'5 IS Bloo:f tVOI' 

3 5224 •••• VlR 144 344 Rlood tVPI" 

3 

1301 •• 0A•45 114'i 11 17 Blood tVDI' {father) 

3 

J 

3 

4 

4 

4 

4 

5226 •••• VlR 

noo •• oA-45 

lJO?. •• OA•45 

1307 •• 0A•45 

1304 •. OR•45 

1305. • 0A•45 

1J03 •• 0R•45 

134'i 

1345 

1 H'i 

134'5 

134'i 

114"i 

146 

16 

1R 

2'5 

20 

21 

1Q 

346 

16 

18 

25 

21 

?3 

19 

Rh factor 

Rh tyoe 

Rh tyop 

Coomb's 

Coomb's 

Cnomo's 

Coomb's 

(fathPr) 

tPst result of most ri'CI'nt 

tPst, :fat!' of most recent (mol 

tl'st, 1~tte of most recent (yrl 

tf'st, nu11her of tPst ~ates 

4 1306 •• OR•45 134"\ 24 24 coomb's tPst, tVD'-" of most recent 

4 5225 •••• VIIR H'i 345 Coombs' ti'St 

4 lJOQ • • OR•45 134'5 27 28 Rh titer, ffrst :Jate {mn) 

4 1310 •• oA-45 B4'i 29 30 Ph titer, first :tate (yr) 

4 1H2 •• :JA•45 U4'5 31 33 Rh titer, first rl'sult 

4 13lt •• oA-4S 134'i 31 H Ph titer, ftrst tVol' 

4 1313 •• oA-45 134'i 34 15 Rh tltl'r, l~st date (1110) 

4 

1314 •• oR-45 134'i 36 37 Rh titer, ll'lst iate (vr> 

4 

13lf> •• 08•45 134'5 ]Q 40 Rh titer, last result 

.. 

1ll~ •• o.--4s 1345 ]A 38 Rh titer, last type 

4 130R •• OR•45 1345 2ft 26 Rh titer, number of :l~ti'S 

131A •• Oq•45 1345 42 43 Sl'rologv, ffrst :iat~ f111ol 

ll1Q •• OA•45 134'5 44 45 serology, first :l~te (yr> 

tl2n •• oq•45 lH'i 4ft 46 Sf'roloqy, ff rst result 

1324 •• OR•45 134"i 52 53 SPrl:llt:~gy, last ~hte (mol 

5 132"i •• OA•45 1345 54 '55 seroloqy, last rtate (yr) 

5 

5 

r; 

5 

lj 132f> •• OR•45 tH"i 56 '5b Serology, l~st result 

5 

1117 •• o.--4s 134'5 4t 41 Serntoqy, 

r; 

1121 •• 01'1•45 t34S 47 411 SPrnlnqy, number 

sPconrt 

of ::tatl's 

1ate (1110)


F'orm Item ~lu'lloers lloK@d to nata Items on LJP-45, Lahorat~rv Hecorrt 

5 

'5 

f; 

6 

ITEU 

ON 

rnRM 

nATA 

TrF.M 

xn 

nn•• oR-45 

nn •• oq-45 

tJ31 •• OA-45 

tno •• oR-45 

1 HO. • OR-45 

132A •• Jq•45 

4QQA •••• VIIR 

5227 •••• VAR 

CIIHO 

MIIM FROM TO 01\fA.JfF.M NAMF. 

tH"i 

t34'5 

134"i 

114'5 

40 

51 

b'l 

so 

50 

'it 

65 

60 

62 

59 

ot 

l"i2 

Seroloqy, secon1 r:tate (yr) 

Sf'rnloay, st'cnnrt result 

Blond suaar, fastlnQ hlqhest result 

IHond SUQ;!Ir, fastlna, date ot ht~hest 

result Cmo) 

6 

134"i bt Blood suqar, f'asttoCI, datt' of hl~hest rf'SUlt (yr) 

f; 

1145 SA Bloo:t sua~tr, fasttno, nu'llher of ::tates 

f; 

(IQ HemAtocrit lowest level, roerce11tl 

6 

147 H@matocrlt, date of lowest value 

> •to.J 6 

115'5 •• D£'•45 2345 l4 15 He•atocrit, nth :late ('IIO) 

6 

1347 •• DA•45 2145 16 17 Hfl!matncr it., nth :l'lte Cmo) 

~ 6 tl71 •• DR•45 2145 70 71 Hematocrit, nth :late C•o> 

6 1350 •• oA-45 2J4"i 41 44 HP'IIatncrit, nth date Cillo) 

6 1340 •• OR•45 2145 20 21 Heml'ltocrlt, nth :i11te (yr) 

6 1373 •• oR-45 234"i 74 75 Hematocrit, nth jate fvr> 

@ 

I 

~ 

'i 

tl57 •• oo-45 2H'i )A 39 Hf!''ll!ltocr1t, nth :lat~ fyr) 

6 

1165 •• OR•45 2J4


. 

1-1 

1-1 

. > 

"' co 

..... 

@ 

I 

~ 

l11 

For~ lte~ Nu~bers linked tn nata Items on OR•45, Lahoratorv R~cord 

ITEIC 

n~TA 

ON lll':N C~Rn 

f'ORIC 10 Nil lit FROIC TO OArA TIFM •UNF 

fi 

1400 •• 0R•45 

6 

1404 •• 0R•45 314'5 

H4'5 61 fi4 Hl"moqlohin, nth 

72 7) HI"IIIOQlOhin, nth :il!ltP. (d~V) 

d~ttP. (d~y) 

6 

1Hfi •• OR•45 H45 54 55 Hl"moglohln, nth :i~tte (dlty) 

6 

1HQ •• OR•45 3141\ 61 62 Hemo::,lohln, nth i~tte Cmo) 

6 

119'5 •• 0R•45 334"i 5? '51 Hemoqlohin, nth :tate Cmo) 

fi 

1387 •• OR•45 H4'5 1-' 15 Hemoqlobln, nth 

6 

1403 •• 01'\•45 334'5 70 71 Hl"mo,;,lohln, ntn :tate (mo) 

:tate ('110) 

6 119t •• OR•45 334'5 41 44 Hemoglobin, nth ::li!ltP. (rno) 

6 1 HQ •• OA•45 334'5 16 17 Hemn~lobln, nth tiflltf~ (~o) 

6 1383 •• OA•45 H4'5 2'5 1.6 HP.IIIO:;J]ob1n, nth :IIJte c~o) 

6 1405 •• 0R•45 334'5 14 75 Hemoqlobln, nth date Cyr) 

6 

6 

6 

6 

6 

6 

6 

fi 

6 

6 

6 

1H1 •• 0A•45 

t395 •• o


H 

H 

• )II 

0 

tiJ 

rorm Item Numbers tinkPd to nata Items on 

OR-45, tahoratorv Recnr~ 

ITE14 

DATA 

nN ~rr-. CARn 

FrJR14 II) Nllfl4 FROio! TO OAf II TfEfl4 NAfi4F. 

7 

143A •• 

7 142'2 •• 0R•45 4J4'.i 30 11 Urinalysi5, nth date Cyr) 

1 144?. •• OR•45 414"i 54 55 Urinalysl5, nth date Cyr) 

7 141? •• 01\•45 434"; lA 19 Urinalysis, l'lth :llttP Cvr> 

7 t45"i •• OR•45 414t; 70 70 Urlnalyo;is, ntll :Jlucose 

@ 

I 

~ 

U1 

7 

141"i •• OR•45 434"i 2'2 '1.2 Urtnatvs15, 

7 

143'.i •• OR•45 434"; 46 46 Urtnatvsts, ""' nth :Jlueo5e :;Jlucose 

7 144'5 •• 0R•45 434'.i 511 58 urtnatysis, nth :;Jlucose 

7 t421i •• OR•45 4345 34 34 Urinalysis, nt:h Qlucose 

7 t423 •• 0A•45 434"i 3? 32 Urlnatystll, ntll tVoP of soecl~en 

7 1451 •• 0R•45 434'5 6A 68 Urinalysis, nth type of soeclmen 

7 1443 •• oR-45 4145 5f'i '\6 Urinalysis, ntll tvoe ot soeci~en 

7 1433 •• OR•45 4345 44 44 Urinalysis, ntll type of soeci~en 

7 1413 •• 01'1•45 4345 20 20 Uril'lalysts, nth tvoe of soeci~en 

A 

A 

A 

A 

1465 •• 01'1-45 

1464 •• 0R·45 

1466 •• oR-•s 

14bQ •• QI\•45 

1470 •• JI\•45 

5345 

SHt; 

534'5 

5H'\ 

534"; 

17 

15 

1'l 

24 

27 

t 8 

16 

1.0 

?b 

29 

Rll ::i1 o'lr aphy ~ x-rav 

H"::llo11raohy: x-rav 

HA::Jfo'lraohy: x-rav 

Rl'ldfoqraohy: x-rav 

R"dfo'lraohy~ Y•rav 

oelvlmetrv, 

oelvtmetry, 

oelvtmetrv, 

oelvlmetrv, 

oelvlmetry, 

d~te (dav> 

'late (~O) 

1ate 

melunrernl!!nts, 

measurements, inlet 

A 

inlet transverse 

~P 

A 1471 •• 01\•45 SH"i 30 12 R'tdiol'lrllohy~ x-rav oelvtm~try, me~tsuremf!nt.s, mid pelvis AP 

A 1471 •• 01'1•45 534'\ 36 19 R"dlollr~tphy~ x-rav oelvlmetrv, me11surements, mid oelvis post. sa,. 

A 1472 •• oR-45 5H"i ]l 15 H't:Hor'lrl'lphy~ x-rav oelvtrnetrv, mellsurl"mPnts, mid oelvts transverse 

A 14H •• OR-45 534t; ]Q 41 Rad1ollrAot-ty: x-rav oelvlrnetrv, rne11surements, outlet AP


H 

Ḥ 

>. 

IV 

co 

\0 

~ 

.c:o. 

l11 

Form lte~ ~u~bers Jinked to nata Ite~s on QR•45, Lahoratorv Record 

l"'E" 

nATA 

ON ITI':fll CARD 

FOR114 In NIIM FROIC TO OAU ITF.M NAJIIE 

A 

1476 •• OR•45 

A 

1475 •• OR•45 5145 4"i 47 RA :it oaraot'tv: X•rav 

514S 41. 44 RA:it O'lrAPtlVJ X•rav oelvtmetrv, oelvlm~trv, measurements, 

me11surements, outlet oost. sao. 

outlet transverse 

A 1467 •• 08•45 5345 21 1.1 R11cH 011r~tot\y: x-rav oelvf~~trv, 111ethod 

A 14b£I •• OR•45 534"i 22 ?3 RA:Hoarllot'tv: X•rav nelvfm~trv: Cald•ell•Molov claastftcetton 

q 1537. • OR•45 1345 43 44 Cultures, nth ;tate C111o) 

q 1Soo •• oR-45 634"'i 36 17 Cultures, nth :late C'IIO) 

q 154t •• ()R•45 7145 50 51 Culture!l;, nth :JI\te ('110) 

9 154S •• OR•45 7341) 57 SA Culturel'l, nth :iAtfl ( 111)) 

q 1551 •• 0R•45 134"i 71 72 Cultures, nth date (lfto) 

9 1549 •• OR•45 7145 64 65 cultures, nth date ( '110) 

q 1492 •• OR•45 &HS 22 23 C•Jltures, nth :tate (1110) 

q 

t496 •• JR•45 6H"i 29 30 C•11tures, nth date (110) 

q 148A •• OR•45 634"i l"i 16 Cultures, nth date ( '110) 

q l"i25 •• 0R•45 714"i 22 ?3 CulturP.s, nth dAte (1110) 

q 

1"i29oo0R•45 7345 29 30 Cultures, nth date (1110) 

q 

q 

q 

q 

q 

q 

15H •• OA•45 

1"21 •• 0R•45 

15JA •• OR•45 

t"i34 •• 0R•45 

1489 •• 0R•45 

7345 

7l4S 

714S 

7341\ 

36 

t"i 

41j 

3A 

17 

37 

16 

46 

39 

Cultures, nth date 

Cultures, nth dl!lte 

Cultures, nth dl\te 

CUltures, nth :J~tte 

Cultures, 

Cult ure5, nth 

nth date 

dt!lte 

Cmo) 

(110) 

cvr> 

cvr> 

&HS 

18 

Cvr> 

1491 •• 01\•45 6H5 24 25 

Cvr> 

9 1"i54 •• 0R•45 7145 71 74 Cnltures, nth df.lte Cvr> 

9 1'5JO •• QR•45 1345 31 32 Cultures, nth date Cvr> 

q 1'522 •• 0R•45 734"i 17 18 cultures, nth :tate fyr) 

q 1ssn •• oR-45 714o; bfi 67 Cultures, nth dAte Cvr> 

q 1497 •• 0R•45 6H5 31 12 Cultures, nth :late Cvr> 

q 154? •• 0R•45 7345 52 SJ Cultures, nth date cvr> 

9 1"iOt •• OR•45 6345 311 19 cultures, nth d~tte cvr> 

9 1"i26 •• QR•45 7145 24 ?.5 Cultures, nth :tate Cvr> 

q 1S4'i •• OR•45 734"' 5Q fiO Cnltures, nth dste rvr> 

q t544 •• oR-45 714o; 56 56 cultures, nth rt'SUlt 

q J"i2A •• OR•4S 734'\ 2A '28 Cultures, nth result 

9 1'556 •• 0R•45 734'5 77 77 Cultures, nth result 

q t'524 •• oa•45 714'5 21 21 Cultures, nth result 

9 1491J •• OR•45 6345 H 15 Cultures, nth result 

q 1'532 •• 0R•45 7145 3o; 15 cultures, nth result 

9 1495 •• Ol\•45 634"i 21! ?8 cu 1t ures, nth result 

q 

1o; 36 •• OR•45 734S 41 42 Cultures, 

Q 

1491 •• oA-45 6345 21 21 Cnltures, nth 

nth ff"SUlt 

result 

9 l"i52 •• 0R•45 734'5 70 10 Cultures, nth rPsult 

9 154R •• OR•45 7H5 61 63 Cultures, nth result 

q 1540 •• 0R•45 734o; 4Q 49 cu 1t ures, nth rt'SUlt 

q t


1-1 

1-1 

• > 

• t-J 

\0 

0 

@ 

I 

oi:Oo 

U1 

Form Ite~ Nu~bers linKed to nata Items on 0~·45, Laboratory Record 

ITE~ 

f\ATA 

fl~ TrF:M CARO 

FflR114 10 Nll!ol FRUfll TO OATA ITP.M NA!oiF. 

q t '\02•• 0~·45 &34'\ 40 41 Cultures, nth tvoe 

q 1 '\.)'i • • :JR•45 7145 40 41 Cultures, ntn tvoe 

q 1494 •• 0R•45 &34!; 26 27 cultures, nth tvoe 

9 1527. • 01\•45 734'\ 26 '11 cu 1t ures, nth tvof! 

9 1490 •• oA-45 &34'i 1CJ '10 Cultures, nth tvoe 

q 1543 •• 01\-45 714"i 54 55 cultures, ntn tvoe 

q 1'551 •• 01\-45 7345 &II .69 Cultures, nth tVPI" 

9 1"'11 •• 01\•45 714'5 31 14 Cultures, ntn tvpe 

q 1517 •• DI\•45 7H'i 6t 62 Cultures, nth type 

7"i 76 

.., 

q 

1"iS!' •• OA•45 H4'i 

CUltures, nth tvoe 

9 

1539••OIIl•45 7;145 

48 cultures, nth tvoe 

C) 1'52l •• OA•45 734'i 19 20 Culture~, nth tvpe 

C) 14911. ~OA•45 U4'i H 34 Cultures, nth tvoe 

to t'HO •• OA•45 634'5 56 "'8 Glucose tolerance, hlood, I nr. (IIIQIIIS/100 'Ill) 

to I '50CJ • • OR•45 & 34"i 51 55 Glucose t~lerance, bloort, 112 hr. (!IIQIIS/100 1111) 

to 1!;11 •• 01\-45 b34o; 5CJ 61 Glucose tolerance, blood, 2 nrs. (IIQIIS/tOO till) 

to 

to 

10 

10 

to 

to 

1'51?. •• 09•45 

150A •• OR•45 

150'5 •• 01\•45 

1'504 •• QA•45 

150fi •• OR•45 

lo;o7 •• UR•45 

&34"' 

634'5 

6145 

634"i 

614"' 

614'5 

b?. 

5fl 

45 

41 

47 

4Q 

64 

52 

4& 

44 

48 

49 

Glucose 

Glucose 

Glucose 

Glucose 

Glucose 

Glucose 

toler~nce, blood, ) hrs. (IIQIIS/1 00 1111) 

tolerance, blood, f8Stin~ (IIIQIIIS/100 Ill) 

tolerance, date (d!IV) 

tolerance, :tate (III:Jl 

tolerance, date cvrl 

tolerance, how ad•1n1stered 

10 t 'H6•• 01\•45 &14o; &R 68 Glucose toler~nee, urine 2 nrs 

10 1'51 .... 01\•45 &J4o; &1 67 Glucose tolPrance, urfne, 1 nr 

10 1514 •• UA•45 &14"i &F. 66 Glucose tolPr~nce, urine-, 112 nr 

10 1'i17 •• 0"'•45 &145 6Q ~9 Glucose tnl•r~n~e, urtnP, l hrs 

to 1'513 .. 0"'•45 614'5 6'i 65 Glucose toler~nce, urtn~. fastin~ 

t1 1471 •• 0A•45 514"' 4R 49 Pap S'lle,.r, rfate (1110) 

11 t47R •• Oq•45 5345 5(l "it PiliP sme~tr, riate 

t1 147CJ •• OA-45 534~ 52 '52 P~P S'"el'lr, result 

12 1HR •• OR-45 1145 75 75 P"dJoqri'IPhic; x-rav, rHaQnosttc 

11 1481 •• L)R•45 5145 so; 56 Laboratorv test sertes, d!ltP (::18V) 

13 

11 

1.3 

11 

1480 •• JR•45 

1482 •• 01\•45 5145 

5145 

t"I:I4 •• 0R•45 

148l •• OR-45 5345 

5J4"i 

51 

57 

60 

5Q 

54 L~boratnrv test series, 

58 Laboratorv test series, 

~0 Ll'lboratorv 

59 Laborl'ltorv test 

test series, 

se-rtes, 

date 

date 

nu11ber 

tvoe 

(mo) 

(yr) 

of days

DEFllUTION OF CODES 

LABJRATORY RECORD 

FOR~~ OB-lO(Lab Data) CARD 1345 


NOTE: USE THIS FILE WITH 310 FILE. CARD 

FIELD 

COLUMN 

Card Number 

Code: 1 


Code: 345 

3· Revisions Number 5 

Code: 0 - OB-10 Forms dated: ll59 and rev. 7/59 

1 - OB-45 Form dated: 4/62 



Item 1 

5· 



Blood T:rpe: Gravida 15 

Item 3 

Code: 1 - 0 

2 - A 

3 - B 

4- AB 

9 - Unknown 

6. Rh: Gravida 16 

Item 3 

Code: 

1 - Positive -unqualified 

2 - Negative -unqualified 

3 - Positive-qualified 

4 - N~tive-qualified 

9 - U O'WD. 

7· Blood TYpe: Father 17 

Item 3 


8. Rh: Father 18 

Item 3 

Code: Same as.. in Field 6 

Coomb's Test: Number of Different Test Dates 

Code: 1 - One 

2 - Two or nore 

9 - None reported 

1 

19 


II.A.291 

OB-45

DEFINITION OF CODES (continuted) 

FIELD 

10. Coomb's Test: Most Recent 

Ite:n 4 


Montli (cols. 20-21) 

Yee.r (cols. 22-23) 

Code for each two columns: As given 

99 - UnkDown 

~ (col. 24) 

Code: 

1 - Indirect 

2 - Direct 


9 - Unknown 

Result (col. 25) 


2 - Negative 

9 - Unknown 

Note: 

Net reported = 9' s for entire field. 

11. Rh Titers: Number of Different Dates 

Code: 1 - Two or less 

2 - More than t;ro 

9 - None reported 

12. Rh Titer: First 

Item 4 

Seven-digit code for: 

Month (cola. 27-28) 

Year (cols. 29-30) 

Code for each twa columns: 

As given 

99 - Unknown 

~ (col. 31) 

Code: 1 - Saline 

2 - Albumin 


9 - Unknown 

Result (cols. 32-33) 

Code: 00 - No reaction 

Note: 

01-10 - Dilutions as given 

91 - 1:1 dilution 


99 - Unknown 

Not reported= 9's for entire field 

FOR..i\18 OB-10 

(Iab Data) 


Card 1345 

CARD 

COLUMN 

20-25 

26 

27-33 

II.A.292 

OB-45 


DEFJNITION OF CODES (continued) 

FIELD 

13- Rh Titer: last 

Item 4 


14. SerologY: 

Code: 1-7 

8 

9 

15. Serolo~: 

Number of Dates 

- As given 

- 8 or more 

- None reported 

First 

Item 5 


Month (cols. 42-43) 


Code for each two columns: As given 

99 - Unknown 


Code: 

Note: 

1 - Negative 

2 - Positive 

3 - Combination of 



6 - Combination bf 


9 - Unknown 

codes 1 and 2 



codes 1, 2 and 4 

Not reported = 9's for entire field. 

16. Serolo&: Second 

Item 5 


17. Serolos;;:£:: last 

Item 5 


18. PBI 

Item 6 

Code: 

1 - Done 

9 - Not done 

FORMS OB-10 

(Lab Data) 


Card 1345 

CARD 

COLUMN 

34-4o 

41 

42-46 

47-51 

52-56 

57 

19. Fasting Blood Sugars: Number of Different Dates 



II.A.293 

OB-45

DEFINITION OF CODES (continued) 

FIELD 

FORMS OB-10 

(lab Data) 


Card 1345 

CARD 

COLUMN 

20. Fas~ing Blood Sugar: 

Item 6 

Highest Result 59-65 

Seven-digit code for: 

Month 

-- 

(cols. 59-60) 


Code for each two columns : As given 

99 - Unknown 

Result (cols. 63-65) 

Code: 040-299 -As given in mgms. 

300 - 300 mgms. or over 

999 - Unknown 

Additional code reviewed and approved: 

039 (39 mgms. or less) 

Note: Not reported ~ 9's for entire field. 

2l. Sickling 66 

Item 6 


2 - Negative 

9 -Unknown 

22. Hemo~lobin Electrophoresis 

Item 6 


23. Number of Hematocrits 68-69 


01-97 - As given 

98 - 98 or more 

24. Number of Hemoglobins 70-71 


25. Number of Urinalyses 72-73 


26. X-Ray Pelvimetry 74 


27. Type of Diagnostic X-Ray 75 

Item l2 

Code: 1 - Chest 

2 - Other 

3 - Combination of codes 1 and 2 

9 - Unknown 


II.A.294 

OB-45


FORMS OB-10 

(Lab Data) 


Card 1345 

28. Pap Smear: Number of Different Dates 76 


1-7 - As given 


29. Test Series: Number of Different Dates TI 


30. Cultures: Number of Different Dates 78 


31. Glucose Tolerance Test: liumber of Different Dates 79 


1 -One 

2 - Two or mre 

CARD 

COLUMN 


II.A.295 

OB-45


FLSLD 

Card Number 

Code: 2 

2. Basic nata 


3- Card Seguence Number 

Code: 0 - First card 

1-9 • As giYen 

FORMS OB-10 

(Lab Data) 


Card 2345 

CARD 

COLUMN 

1 

2-14 

15 

4. Hematocrit: First 

Item 6 

5· 

6. 


1-'f..onth 

Da.y 

Year 

Code for each two 

Result 

Code: 200-500 

996 

99v 

(cols. 16-17) 

(cols. 18-19) 

(cols. 20-21) 

columns: 

As 

99 

(cols. 22-24) 

20.0 to 50.0~ 

0.1 tc 19.9% 

50.1 tc 99·7~ 

Hematocrit: Secona 


Blank = not reported 

Hematocrit~ 

Code: 

Third 

Same as in Field 5 

given 

- UnkDown 

16-24 

25-33 

34-42 

7 

8. 

9· 

10. 

Note: 

Hematocrit: 

Code: Same 

Fourth 

as in Field 5 

Hematocrit: Fif'th 


Hematocrit: Sixth 

Co de: Same as in Field 5 

Hematocrit: Seventh 


As many hematocrits are completed as reported. 

Additional cards, as indicated in Field 3 1 will be 

required >-lith all columns the same as in above. 

43-51 

52-60 

70-78" 


II.A.296 

OB-45

DEFINITIDN OF CODES (continued) 

FORMS OB-10 

(Lab Data) 

a!ld OB-45 

Card 3345 

CAPJ) 

COLUMN 

1. C12.rd Number 

Code: 3 

1 

2. Basic Data 


2-14 

3· Card Seauence Number 15 

Code: 0 - First card 


4. Hembglobin: First 16-24 

Item 6 


~ (cols. 16-17) 

Day 

(cols. 18-19) 

Year 

(cols. 20-21) 

Code for each two columns: As given 

99 - Unknown 

Re-sult (cols. 22-24) 

Code: 050-170 5.0 tol7-0 gms. 

997 - 0.1 to 4.9 gms. 

9~ - 17.1 to 99·7 gms. 

5· Hemoglobin: Second 25-33 

Item 6 

Code: 

Same as in Field 4 except 

Blank =not reported 

6. Hemoglobin: Third 34-42 

Item 6 


7· Hemoglobin: Fourth 43-51 

Item 6 


8. Hemoglobin: Fi:rth 52-60 

Item 6 


Hemoglobin: Sixth 61-69 

Item 6 



II.A.297 

OB-45


FELD 

FORlviS OB-lJ 

(Lab Data) 


Card 3345 

CARD 

CCWMN 

10. Hemoglobin: Seventh 70-78 

Item 6 

Code: .Same as in Field 5 

Note: 

As many hemoglobins are completed as reported. 

Additional cards, as indicated in Field 3, will 

be required with all columns the same as in above. 

II.A.298 

OB-45 


DEFTIUTION OF CODES (continued) 

FORMS OB-10 

(Lab Data) 

and OB-L~5 

Card 4345 

FIELD 

-- 

Card Number 1 

Code: 4 

CARD 

COLUMN 



3· Card Seguence Number 15 

Code: 0 - First card 

1-9 - As given 

4. Urinalysis: First 16-27 

Item 7 

Twelve-digit code for: 

MOnth 

(cols. 16-17) 

Year 

(cols. 18-19) 

Code for each two columns: 

~ 

Code: 

1 - Voided 

2 - Clean catch 

3 - Catheterized 

9 - Unknown 

Centrifuged (col. 21) 

Code: 

1 - No 

2 - Yes 

9 - Unknown 

Glucose (col. 22) 

Albumin (col. 23) 

Acetone (col. 24) 


Blood Cells (col. 25) 

Code: 

As given 

99 - Unknown 

(col. 20) 

0 - None 

1 - 1+, slight 

2 - 2+ 

3 - 3+ 1 moderate 

4 - ~~ severe 

5 - Positive- unqualified 

7 - Trace 


9 - lJ'J:l.kDown 

0 - None 

1 - vmc only 

2 - RBC only 

3 - Combination of codes 1 and 2 

9 - Unknown 


II.A.299 

OB-45

DEFDHTION OF CODES (contiiilled) 

FISLD 

FORMS OB-10 

(Lab Data) 


Card 4345 

CARD 

COLUMN 

4. Uri~abrsis: F~~st (cont.) 16-27 

5· 

Casts 

(col. 26) 

Bacteria (col. 27) 

Code for each column: 0 - No 

1 - Yes 

9 - Unknown 

Urinalysis: Second 28-39 

Item 7 

Code: S2~e as in Field 4 except 

Blank - not reported 

6. Urinalysis : Third 40-51 

Item 7 


T· Urinalysis: Fourth 52-63 

Item T 


8. Urinalysis - Fifth 64-75 

Item T 


Note: 

As many urinalyses are completed as reported. 

Additional cards, as indicated in Field 3, will 

be required with all columns the same as in above. 


II.A.300 

OB-45


FIELD 


Code: 5 

2. Basic Data 


FORlviS OB-10 

(Lab Data) 


Card 5345 

CARD 

COLU!viN 

1 

2-14 

X-RAY PELVlMETRY 

3· Date 

Item 8 


MOnth (cols. 15-16) 

Day (cols. 17-18) 



4. Method 

Item 8 

Code: 

As 

99 

given 

- Unknown 

1 - Thoms 

2 - Colcher-sussman 

3 - Caldwell-Mbloy, Stereoscopic 

4 - McLane, Isometric 

5 - Snow 

6 - Parala.x 

9 -Unknown 

Caldwell-Mbloy Classification 

Item 8 

Code: ll - AJ:rthropoid 

12 - AJ:rthropoid - Gynecoid 

13 - Anthropoid - Platypelloid 

21 - Gynecoid - Anthropoid 

22 - Gynecoid 

23 - Gynecoid - Platypelloid 

24 - Gynecoid - Android 

31 - Platypelloid - Anthropoid 

32 - Platypelloid - Gynecoid 

33 - Platypelloid 

42 - Android - Gynecoid 

43 - Android - Platypelloid 

44 - Android 

99 - Unknown 

15-20 

21 

22-23 


II.A.301 

00-45

DEFTIHTIDN OF CODES (contiillled) 

FOR.\18 OB-10 

(Lab Data) 


Ca:cd 5345 


AP 

(cola. 24-26) 

CARD 

COLU1·ITT 

6. Me2.surements: Inlet 24-29 

Item 8 

(cola. 27-29) 

Code for each three columns: 010-997 - As giYen to 

tenths of em. 

998 - 99.8 ems. or more 

999 - Unknown 

1· Me2.surements: ~d PelYis 30-38 

Iteni 8 

Nine-digit code for: 

AP 

(cols. 30-32) 

Trans (cola. 33-35) 

Post Sag (cols. 36-38) 

Code for each three columns: Same as in Field 6 

8. Measurements: Outlet 39-47 

Item 8 

Nine-digit code for: 

AP 

(cols. 39-41) 

Trans (cols. 42-44) 

Post Sag (cols. 45-47) 

Code for each three columns: Same as in Field 6 

9· Pan Smear 48-52 

Item 11 

Five-digit code for: 

Month (eels. 48-49) 

Year (eels. 50-51) 

Co de for each two col'WIIlS : 

Result 

Code: 

As given 

99 - Unkllown 

(col•.52) 

0 - NegatiYe 

1 - Class, Group or Grade I 

2 - Class, Group or Grade II 

3 - Class, Group or Grade III 

4 - Class, Group or Grade IV 

5 - Class, Group or Grade V 

6 - PositiYe - unqualified 

7 - Ca in situ 

8 - Doubtful 

9 - Unknown 

II.A.302 

OB-45 


DEFINITION OF CODES (continuted) 

FIELD 

FORMS OB-10 

(Iab Data) 

and OB-4-5 

Card 5345 

CARD 

COLUMN 

10. Test Series 53-60 

Item 13 

Eight-digit code for: 

r.bnth 

Day 

Year 

(cols. 53-54) 

(cols. 55-56) 

(cols. 57-58) 

Code for each two columns : 

As given 

99 - UnkDDwn 

~ (col. 59) 

Code: 1 - Urine albumin 

2 - Urine glucose 

3 - Blood sugar 

4 - Acetone 


6 - Protein bound iodine 

7 - Sugar and albumin 

8 - Other · 

9 - Unkno-w·n 

Number of D~ys (col. 60) 

Code: 1 - 7 - As given 

8 - 8 or more 

9 - Unknown 


II.A.303 

OB-45

DEF:r:NITION OF CODES (continued) 

FT?LD 

FORMS OB-10 

(Lab Data) 


Card 6~45 

CARD 

COLUMN 

C3.rd Uumber 1 

Code: 6 

2. Basic Pata 2-14 


CULTURES 

3· 15-21 

Item 9 


Month 

( cols. 15-16) 

Year 

(cols. 17-18) 

Code for each t""' columns: As given 

99 - Unknow'D. 

~ (cols. 19-20) 

Code: 01 - Bartholin gland 

02 - Cervix 

03 - Ear 

04 - Endometrium 

05 -.Eye 

06 - Mamilla 

07 - !rose 

08 - Placenta 

09 - Rectum 

10 - Throat 

ll - Urethra 

12 - Vagina 

- Sputum 

~d Aiimiotic fluid 

21 - Blood 

22 - Spil:la.l fluid 

23 - Urine 

30 - Stool 

4o - 

Gonorrhea 

80 - Other 

99 - Unkmwn 

Result (col. 21) 

Code: 0 - Negative 

1 - Positive 

.9 - Unknown 

Note: 

Not reported = 9' s for entire field. 


II.A.304 

OB-45

DEFTIHTION OF CODES (continued) 

FIELD 

FORMS OB-10 

(Lab Data) 


Card 6345 

CARD 

COLUMN 

4. Second 22-28 

Item 9 


5· Third 29-35 

Item 9 


6. Fourth 36-42 

Iten 9 


GLUCOSE 'IDIERANCE 

T· Date 43-48 

Item 10 


Menth (eels. 43-44) 

Day. 

(eels. 45-4.6) 

Year 

(eels. 47-48) 


8. Method of Administering Glucose 

Item 10 

Code: 1 - Oral 

2 - IV 

9 - Unki!Own 

As given 

99 - UnkllOwn 

9· Blood: Fasting 50-52 

Item 10 

Code: 001-997 - As given in mgms. per 100 ml. 

998 - 998 mgms. or more 


10. Blood: 1/2 Hour 53-55 

Item 10 


11. Blood: 1 Hour 

Item 10 



II.A.305 

OB-45

DEFINITIOU OF CODES (continu:ed) 

FELD 

J2. Bleed: 2 Hours 

Item 10 

Co de: Same as in Field 9 

13. Blood: 3 F.ours 

Item 10 


14. Urine: Fasting 

Item 10 

Code: 0 ·- Negative 

1 - 1+ 

2 - 2+ 

3 - 3+ 

4 - 4+ 

7 - Trace 

9 - Unknown 

15. Ul~ine: l/2 Hour 

Item 10 


16. Urine: 1 Hour 

Item 10 

Code: Same aa in Field 14 

17. Urine: 2 Hours 

Item 10 


18. Urine: 3 Hours 

Item 10 


FOID-f.S OB-10 

(Lab Data) 

and OB-45 

Card 6345 

C.A.RD 

COL"L'£.ITT 

59-61 

62-64 

65 

66 

67 

68 

69 


II.A.306 

OB-45

DEFTIUTION OF CODES (continued) 

FIELD 

FORMS OB-10 

(Iab Data) 


Card 7345 

CARD 

COLUMN 

Card Number 1 

Code: 7 


Code: Same as in cols. 2-14 of card 1 

Additional Cultures 

3· !illh 15-21 

Item 9 


M::>nth (cols. 15-16) 

Year (cols. 17-18) 


~ (cols. 19-20) 

· Code: 01 - Ba.rtholine gland 

02 - Cervix 

03 - Ear 

04 - Endometrium 

05 - Eye 

06 - Mamilla 

07 - Nose 

08 - Placenta 

09 -Rectum 

10 - Throat 

11 - Urethra 

12 - Vagina 

13 - Sputum 

20 - Amniotic fluid 

21 - Blood 

22 - Spinal fluid 

23 - Urine 

30 - Stool 

4o - GoDOrrhea 

8o -other 

99 - Unknown 


Code: 0 - Negative 

1 - Positive 

9 - Unknown 

As given 

99-UI!kl:lown 

4. Sixth 22-28 

Code: Same .as in Field 3 except Blank = None reported 


II.A.307 

OB-45


FIELD 

FORHS Ob-::..0 

(Lab Data) 

. and. OB-45 

Card 7345 

C.ARD 

COLTJMN 

5· Seventh 29-35 


6. EiAAth. 

Code: ·same as in Field 4 

36-42 

7· Ninth 43-49 


8. Tenth 50-56 

Code: same as in Field 4 

9· Eleventh 57-63 


10. Twel f'th 64-70 


11. Thirteenth 71-77 


IDTE: 

As many additional cultures are completed as reported. Additional 

cards, with all columns the same as above, will be required for 

mere than 13 cultures. 


II.A.308 

OB-45


LABORATORY RECORD 

FORMS OB-10 and OB-!~5 

rt& 

6 " l..a -s., ~~~ 'fll lu-~11 J!.a ~~~,;~.a u.~O..I~~g 

w 1- I~ ~ & 1 • 'a c II c .• • I I • ._ ,.. 0 ~I~ 

0 

\0 1 ~ I J. 1~ 1: a ' ~ I l ~ ' j J :J a I! l ~ I~ ! 5 I~~ Ill~ 1~ • 

I- 1 ~c~ 1.ol! ~~~~ .. ~ ._ "' I~ I! ,;; 111 

"' ~ ~ ' ,' ~ ~P.I~ , 1 

,..::; ''! 

_ .. " If ,. ar z z z I'" 

' 

1 2 1 • 1 ' 1 • 9 10 11 u n 1 1 1 lu 1 :111 21 n1 1 • iu 1 11 ~ ~ l lll 1415 » 1 Jt" • 41 H •• • • "41 9 11 1 115l '' s Jj 1 l~o St 6G 1' ~~ u • • u • J!J_ ~ ~ 1 6 111111 10 

*Item numbers refer to OB-45 dated: 4/62. 

Q 

~ 

l11


_ 

I 

-- 

:rl&IM :.li ~ 

Ot.l-'OitiM 

LABORATORY RIDORD 

FORMS OB-10 and OB-45 

1- 

R 

1- 

X I 2 J 4 6 7 I t 10 II 12 1214 116 ' 11 It :111 21 n n 24 n x 27 21 :19 »1.-n-Jili n 36 n lilt • •1 •2 n •• •~ u .,.... Y ~~ n 162U 64 6116 .6) 6169 

1- 

I 

HEMRTOCRlT 

1- 

I 

fiRST SECOND THIRD FOURTH fiFTH SllTH 

1 

0 

':' 

ẕ r DATI DAT& • .,.a: .DATE OATI em 

J; J ~,. Jolea.)tl 

- 

4 # 

234S 

1\) - 

0 s #f. 

1-1 

1-1 1 

• 

~ ~ ,_ ~ ':C t '¥ ~ ':C 

• > .. 

~ 

~ 

1- 

• 

:I 

::t :I fiJI 

\a ~ ~ ~ ~ cr 

.. • b 

w ' c a .. 

.... ,_ 1 .. 

0 li 

~ 

• •• • • • 

~ 

fll a a ,. fl Ji •,. 2 J : • •,"' li 7' 

lo 

• • • 2 

': I 

• :a a ~ .. • 

I 

~~- 

7910 

SEVENTH 

Dllrli 

~ 

~ .. ~ :I 

Ji ,. 

I a 

)/. 

• 

' 

I 2 J 4 ~ 6 7 I t 10 II 12 Ill I 161 1119:1112 222l2 IJo 21 21 2tll lllU· ~Jl JUilll 40414 CU4 4544 47 41 "so~ USl U IU ~1"1616 ~J'


LABORATORY ~ORD 

FORMS OB-10 und OB-45 

- ~· 

o~..q~i 

- 

R 

Co 

- 

X I 2 3 4 - . J • ' 1111 12 ll .. 

- 

I 

1 

- 1il. 1J lilt» 21 22 n 24 2S :N 21 2129 31111 223l U U :16 J lilt ~"jfij.lo"" •• .. Y A'TE J)RTE. J)ATE J)AT& J)AT& DATE 

¥ 

VI 

1- ~,0 

H I "'..'8 'Jt 

H 1\) 

. • ._. 1- ~5·· -:11 

2 

« 

)II 

I 

.J 

• Cl 

w 1- .,_ 

... ~ .. ':; .. , tl :1 

~ ... • .. 

:r. ... s s ~ ~ ~ ~ ~ 

i • II J A 41 .. • • : • 

tit 

-:E ... -:E 

..... 

- .. 

:1 01 :t ~ 0 ~ 

' 

~ :1 

7 

.,. c .. 

2 ... 2 .. e • .. 2 .,. • c .. ~ .. • « WI 'i 7' .. 

& ... • I Ill • • e .. 

- iA ~ ~ a 7' 

• • A = .q ~ A ,. • l A 7' ... • • 

" 

1:11 

" • 

-I 

' = 

' 

I 2 1 6 ! 6 I I t 10 II 12 11 16 

161 Ill 102 nn 2 2526 121 If]( II U 1 un 1M 11 lll 40 61 4 1146 54 61 6 69505 su 50 !65 515f6C 

* Item ntmibers refer to form OB-11-5 dated: 4162. 

** A.ddi tionul card ( ld) required if oore thun 7 lleooglobins. 

" ·~' 

6H6 6161' 107 121 IU 767711 ltiCI 

~ 

l11


-- 

LAEORATORY RECORD 

FORMS OB-10 und OB-45 

~~~ 

o.:»-CO•J 

1 

7 

1- 

t----..-21-.- ~ ~"11""-,To-.-.-., 11 ••fs 

1- 

I~ 

URINAL VSIS 

flRSI SECOtij) THIRD 

I 

i.MT&! IMTi 

~~~e 

ICM.P 

• 

1-1 

1-1 

>• 

w 1- 

..... 

8 

YINJ)8. 

I 43tS" i li 

N ,_ =~ ~ 

1- 

I 

lir-1 

~3di ~ = ~ Cl ~ 

~iii u l1ili - ~ ~ c al,\J iii 

It__!___!____!)~~~- • ' 10 11 12 11 !iM" •lla• ~tl~nMnl7~2~~~ •••In 

* Item numbers rere:r to OB-45 dated: 4(62. 

** Additional card u} requirea if mre h!Ul 5 Urinulyses. 

lij 

S6 sisa-stii~4 n 

FOURTH 

)ATEi 

l~lli 

~ 

i ~ l.ul-f"'~!OJ 

I J! 1(.1~~·~ 

1slls• 

FIFTH 

1111111 I ~ .8LANt( 

IUju, 

''' n 11 7t 111 

@ 

I 

~ 

Ul


LABORATORY RECORD 

FORMS OB-10 and OB-1~5 

~·-4' 

- o..:l -'o'~ B -:~. 

'I II 1.;;1 

I- 

X~ m--.- 'J I' 1011121JI411HUl llt:ID21222l242Sl6 Jli19Jiii"l2nlils1ilfli3H0414HH4 S4HI~19!0SIS2 lii1n& ,~... 16UUUHU16U9l01fi2nJ41SI6J1JI1t10 

1- 

I 

X-RAY PELVIMETRY 

~p 

SMIAR ~iSISilll&:S 

H 

H 

0 

tJj 

~--~- DATE I~ PElVIC MEASUREMEI\ltS 

I 

Z !! :INl.&T MID PElVIS OUTLI:T 

~ 1-- ~~~r--;r--T--~--~~~~,__, 

~ CARD NIND.B*- J 

II) 

w 

4 ~ ~ 

; ~4!i ~ 

>• ' .. ~ . 

Cl 

.., 

w -- ~ c c 

..... i I "' ~ Ill Ill 

w 7 e - :1 ~ '2 ... 2 .... 

-- 

! 

I- • I; II '~ ~ L ~ .. ~ I! 0. ~ ~ 

1 E J\ ,. !li :) c ,.. < t- c c: t- o. 

' 

i 

u 

I 2 3 4 \ 6 1 I 9 10 II 12 131411~ ~ II I It :10 2 n 242S 2< 11 21 :II 30 31 3 1330 36 ll J 3940 4 U 0 4 4S4HI I fl SO Sl S S354SH6SI S1 S '" U U ~~ 6UJ6U16Ut lO JIJ2 JJ JHSJUJJIJt. 

* Item numbers refer to OB-45 dated: 4/62.. 

DATE 

J)AT£ 

~ 

I!; I~ 

,_ 13 ~ • 1121~ 

~ ~I~ 3 ~ : ~~~~ 

c " ~e~ e A .,. 110 1 ::~ 

~ .BlANK 

~ 

l11


_r=:.l "... 

R 

LABORATORY R.lOOORD 

FORMS OB-10 and OB-45 

IO 

0 

If' 

XI pn 4 ",......--;lilil21-ffi~~ M Jl II If» 21 U U l1 ts l4 JJ lJ n ll! ll Jl n l1 U 3t U :J1 n tO 41 gpl4f fS H 41 t1 I 50 U U SJ 54 U 56 i7 51 S! fO tltl tJ tf U H 676! ttjli II if7l 74 7S 76 n lilt 10ft- 

I CULTURES G-LUCOSE TOLERANCE 

- 

I FIRST I SfCONj) I THIRJ) FOURTH I ])ATE .BLOOj) URINE 

- 

J .... 

~ J 

- 

4 

1-1 ~ - 

1-1 s 

• )II 

• w 

.... ' 

~ 

7 

- 

I 

- 

' 

:tm )ATI! )AT& 

!I 2 1 •Is h 1 1 t 10 11 u lll41~t._l6)!!._11f1Ui1121(2!_t~lt 2!f26 24JIIf7t~!4f!_~ ~~tl~ ~·l!~~!•hs ~4414!Mso sJS;fn u s!isun•ls• ~!l~t!l~~~tll!l!t~ll! 7pp~ 14. 1J 7! n lilt_!! 

* Item numbers refer to OB-45 dated: 4/62. 

**Additional cultures appear on 7345 card(s). 

@ 

I 

~ 

lTI


I 

-- 

~1"~~-* 

...:_1 Oi'l FoRM 

1 R 

X.,.______ 

,~ 

LAB>RA!IDRY REOORD 

FORlofl OB-10 and OB-45 

2-:14-rs J611-tiii Iilfili4,1S 16 U II It J11 J11'liiNU :lllfll Jt lll ll JfjjJ4:15l6 Jill lttl 41 43•0 U 4S 46 41 61 4t S1 Sl SJ Sl W SS S6 Sl !ii"UI 6:fn 64 6S 46 61 61 6t lllllltll U IS 16 nfn It lOll-- 

CULTURES 

I~ (ArE 

I~ 

.. 

0 :t 

b:l - (MbH N1Hb8'#' 

I I 

H fo' 

• 

• H VI ·- 

)II I 

5 

• 1\) -- 

X 

5th 

1rtC~ 

-' ,.. ou? o.,.. o 111 ,. o 111 > ~"'~~~~~,..~\II~ ow~ -J 

w VI 

...... t cJ. 

01 c 

7 

1-- 

' 

CJ 

0 \!~~ ~ ~~~ =·~~~: ~~~ ~~~~ t ~~~ ~ \f~~ t 4~ ~ ~~ ~ 

E ~ .._ s>- E>f- €,..\- s"" > >r ?" e?" jlQ 

I J l 4 U 16 I I t 10 II U llUIIS 16l111lt JOIJI~ Jl.US~U,fll~tlll~l llln ~~h~!~~...~_!l~!.b.!•l~! ~·vk!~!!~~ !!~~! !!l! ~U2Jn~tsfiUIJ6Htllllt17liiJ741WII'UI7tl 

* Item nwnberl:l refer to OB-1~5 dated: 4/62. 

*lf AdditJonal card(s) required if more than 13 cultures. 

~ 

~ 

01


08~5 LABORATORY RECORD 

I. Purpose of form To record the results of laboratory 

studies, x-rays and 

ill. Specific Instructions: 

EKG' s performed on the Study 

patient. 

Item Number 

2. Virology. Record, without referral tothe 


virology technician's records, the dates 

on which maternal serum samples for 

virology were drawn. This includes speci 

A. See Procedure Manual for required and mens taken in the prenatal clinic, at the 

recommended laboratory studies. 

delivery admission, and at 6 weeks postpartum. 

B. Report dates and results legibly in the space 

or area of the form provided. 

1. Do not cross out pr!nting to report other 

3. Blood type and RH. 

information in a space reserved for a 

particular test; utilize item #11, "other 

laboratory studies." 

a. Record type as 0, A, B, AB. 

b. In all cases, record the RH as 

"positive" or "negative" in item #3. 

2. The date·' of the examination is the date If further typing or sub-typing is 

on which the procedure was performed, 

or the specimen obtained from the patient, #11. 

rather than the date on which the de 

termination was completed or reported 

carried out, report the results in item 

by the laboratory. 

4. Tests for maternal antibodies. For each 

test done, report results in appropriate 

3. If several determinations of the same 

terminology. Report indirect Coombs 

type were performed on the same date 

tests as "positive,• "negative,• or "doubt 

(e.g., pre- and post-transfusion hemo 

ful." 

globin), report as specifloally as pos 

sible the time done, or the relationship 

5. Serology. Record the name and date of 

of one result to the other. 

each serologic test, and report the re 

sult of each test as "positive," "nega 

4. If certain information is more appro tive," or "doubtful." Record titers if 

priately recorded on a continuation sheet 

done. 

(CP-5), refer on OB-45 to this additional 

record of laboratory findi..-. 

C. For all urine or blood chemical determi 

nations, record the appropriate UDits, i.e., 

mgm. %. mEq., etc. 

D. If a Study requirement is not met (test not 

done or report not obtainable), mark "not 

done" in the space reserved for the reporting 

of that test. 

E. If a laboratory determination is of doubtful 

validity this should be so noted. 

6. Blood chemistry and hematology. Indicate 

each hematocrit or hemoglobin determination 

recorded by marking the box in 

the appropriate column. Utilize the re 

maining spaces for any chemic a I or 

hematological blood test done. 

7. Urinalyses. 

a. For each analysis, record the date 

specimen was obtained, the method of 

obtaining, and whether or not the 

specimen was centrifuged prior to 

microscopic examination. 

b. Record the results of each test in the 

appropriate space. For glucose, al 

F. Use separate forms to record the laboratory bumin and acetone determinations, redata 

for the OPD and for each hospital ad 

cord the qualitative interpretation, 

mission. 

rather than color. 

October 1962 


II.A.316 

OB-45


OB-45 LABORATORY RECORD (Continued) 

Item Number 

Item Number 

8. X-ray pelvimetry. 11. Other laboratory studies. Record the 

results of cytology and other miscellana. 

Record the date and method of x-ray eous laboratory tests. 

technique utilized. 

b. Using the Caldwell-Moloy terminology, 

record the pelvic classification. 

12. Diagnostic x-ray, EKG, etc. Record here 

the results of diagnostic studies, such 

c. Record the measurements of the var as x-ray, EKG, EEG, and those using 

ious pelvic planes in centimeters. 

radioactive isotopes. 

9. Cultures. Record the results of cultures, 

noting the source of the specimen, the 

13. Test series. This space may be used to 

date obtained, and the result. 

record results of a test which is repeated 

frequently (such as daily blood 

10. Glucose tolerance test. sugar, etc.). Clearly specify the test 

and, if necessary, the method used. 

a. Record whether the test was oral or 

intravenous by marking the appro 

priate box. 

If a series of determinations (such as 

daily urine albumin or blood sugar) is 

b. Record the blood and urine determi within normal limits, the results may 

nations for each time period in the 

appropriate space. 

be summarized in the following fashion: 

c. If the glucose tolerance test was re "Daily blood sugar (Folin-Wu), 3/10 to 

peated, report under item #11. 3/15, 100-110 mgm %. " 

October 1962 


II.A.317 

OB-45


II.A.318 

OB-45

OB-11 

Record of Current Pregnancy 

Form OB-11 was used to record the obstetrician•s evaluation of positive 

items recorded on OB-3 (History Since Last Menstrual Period) and OB-8 (Return 

Prenatal History). It was used as a physician•s worksheet only; no cards are 

included in the master file. This form was first used at the beginning of the 

study, revised once in July 1959, and replaced by form OB-46 in April 1962 

(Physician•s Clinic Record). Records are available on microfilm only. 

II.A.319 

OB-11 


I 

II.A.320 

OB-11 


CO~A·3C03·11 

lltEV. '7·58 

I. PATIENT IDENTIFICATION 

RECORD OF CURRENT PREGNANCY 

INSTIUCTIONS• for each visit record and com~~tent on1 

1. Unusual e..nts, signs, symptoms. 

2. Findings of physical uomination. 

3. Significant laboratory results and tests ordered. 

-4. Summary of Consultations. 

5. Diagno~e~ and impreuions. 

6. Medications preKribed and instructions givett. 

DATI! AND SIGN EACH ENTIY. 

AT fiiST VISITo 

SUMMARIZII ANTEPARTUM COU.-SE TO OATE 

-a 

Collaborati,. ·-ell 0 B-11 (lo•. 7·591 

Pori- .._ell, NINDI, NIH l'a9• of 

I~. MG. 


II.A.321 

OB-11


(For Form OB-11) 

THE COLLA!llRkTIVE STUDY ON CEREBRAL PALSY, 

MENTAL RET.Aqll)Anc>N, AND OTIQR NEUROLOGICAL AND 

SENSORY DlBOliDERS OF INFANCY AND CHILDHOOD 

Febr~ry 1959 

(~r Forms in Use April 1961) 

II.A.322 

OB-11 



(For Form OB-11) 

INSTRUCTIONS FOR PHYSICIAN 

Par. 1 

Par. 2 

Par. 3 

Par. 4 

This is the record of the obstetrician's evaluation of positive items 

obtained by the interviewer on OB-3, "History Since Last Menstrual 

Period", and OB-8, "Return Prenatal History". Each positive item must 

be di~cussed with the patient and described here. If any physical 

examination is done other than the routine obstetrical examination 

called for on the "Return Visit and Laboratory Record", the examination 

done and results should be recorded here. Start with first visit, 

summarizing antepartum course to date. Record any diagnosis made and 

indicate whether it is definite (DF), based on physical examination 

and/ or laboratory findings at the time of this visit, or is probable 

(PR) or possible (PS), made purely in retrospect based on the patient's 

history. 

If the interviewer indicates that a physician has been seen, you must 

contact him and summarize his findings and diagnosis. List any nonroutine 

laboratory examinations made and the results. Indicate any 

medication prescribed and any special instructions given. ~lways be 

sure to include Items 1, 2, 3, 4, 5 and 6 as indicated at the top of 

this sheet. It is important to date and sign each entry. 

If the patient is sent for a consultation, summarize the consultation 

report on this sheet or append a copy of the consultation, laboratory 

report, or other pertinent record. 

When you run out of space, start a new sheet, making sure that the 

patient is identified on the next sheet by name, hospital number, and 

NINDB number, but remember to number each page in the lower right 

corner. 

February 1959 



II.A.323 00-11

PHS-3003·11 

REV. 7-ea 

~ 


1. PATICNT &OCNTI ... IeATION 

INSTRUCTIONS: Fer each visit record und c-t•• 

1. Unusual events, signs, symptoms. 

2. Fir.din~s of physical examination. 

3. Significant laboratory results and tests arderecl. 

d. Su:nmary of Consultations.. 

5. Oiagnostts and impressions. 

6. Medications pr.scribed and instructians giftlft. 

DATE AND SIGN EACH ENTRY. 

, 

cc ' r 

AT FIRST VISIT: 

SUhiiMARIZ& ANTII:PA"TUM COURSE TO DAT. 

0.-t of H-lth, EclucaH-, .... Wei' 1 

t•n. ·••• (OB-11) PAGE 

Publlc H-lth S...lco 

OF 


II.A.324 

OB-11

,... 


INSTRUCTIONS. B• s,.,. to: (I) D.scrib• conJitions witb 

fJMUifl• his1ory «rut otb.P umutull w.,.t.r, (2) lrotiictll• -.sult.r 

of....,. plrysic«l .,... .,;,...;oro fflllli•, (3) R•corti ...., tiit1po11is, 

(4) L.ist tUrJI UU.cmuory ..,..,.,;,..,,;ou fflllli•, t1rui ") lruiic«t• 

,.JicatiOJU pHscrib•d arui sp•cilli ii'ISt.1'11CliOftS rivers. 

BE SURI! TO DATI! AND SIGN EACH ENTRY. s-11rin 

or iru:lwh copiu of c011•ullt11ioros obtlli,..tl. lilboNiory .-ports, 

tlrui otb.P p.n;,.,., .-cords. 

0.-., He.lth, 1!4....tl........ w...... (08.11) PAGE OF 

...... He.hh s...... 


II.A.325 

OB-11


II.A.326 

OB-11

OB-46 

Physician•s Clinic Record, Record of Current Pregnancy 

Form OB-46, Physician•s Clinic Record, was used to record the physician•s 

notes pertaining to the prenatal examination and each subsequent prenatal 

clinic visit. It was first used in April of 1962 as a replacement for OB-11 

and did not undergo revision. No cards containing this information were 

included in the master file; records are available on microfilm only. 

II.A.327 

OB-46 


II.A.328 

OB-46 


COLR-1001-4e 

4-a 


08-46 PHYSICIAN'S CLINIC RECORD 

INSTRUCTIONS: F"or each visit record and comment on: 

1. Medicationa aclminiatered, preacribed, or discontinued 

2. DIAGNCSES AND IMPRESSIONS made ot confirmed 

3. Abnormal or Wluaual events, aiqna, aymptoma 

4. Treatments and procedure•. 

5, DATE AND SIGN EACH ENTRY. 

AT INITIAL VIS ITo 

SUMMARIZE ANTEPARTUM COURSE TO DATE 

PAGE 01" 

COLLABOfltATIYC .. CIIIIA ..CH 

PCfltiNATAL "IIIICAIIIIC:H B ..ANCH, MINOa, NIH 

BCTHIIIIOA 14. MD. 

08-46 


II.A.329 

OB-46


OB-~ 


I. Purpose of form For physicians' information 

pertaining to the p rena t a 1 

examination aDd at each subsequent 

prenatal clinic visit. 


A. Date each entry. 

B. Enter name and title of the physician whose 

findings are being reported, following each 

note. 

C. If more than one physician sees the patient 

at a particular visit, record the comments, 

diagnoses, impressions, etc. of all physicians. 

D. Report clearly the source of all data recorded 

which is not obtained at a prenatal 

visit; i.e., telephone conversation, perusal 

of records, etc. 

E. Summarize findings in sufficient detail to 

demonstrate the logic of aay conclusions 

reached. 

F. Avoid repetition of facts adeqqately reported 

elsewhere, if they do not coatribute to the 

commentary and evaluation that these notes 

should contain. 

Ill. Initial note. In addition to data recorded as on 

other visits (listed below), report the following 

in the initial note: 

A. Events noted in the past medioalorobstetric 

histories which may influence the course of, 

or treatment during, the current pregnancy. 

B. The general health of the pa.Uent at the beginning 

of pregnancy. 

C. Description of the course of pregnancy to 

the time of the initial note. 

IV. All prenatal notes 

A. Elaboration of history. Elaborate upon any 

suggestive or positive history of disorder 

obtained by the interviewer (OB-3, OB-8), 

or the physician (OB-42, OB-44). This 

should include onset, duration, and severity. 

B. Elaboration of positive physical findings. Describe 

in detail any abnormal physical findings 

noted on OB-43 or OB-44. 

C. Interpretation of laboratory findings. Interpret 

findings indicative or suggestive of 

pathological states, when laboratory reports 

are first available. 

D. Diagnoses. Record all diagnostic impressions 

arrived at as a result of interpretation 

of the history and physical findings. 

E. Procedures or treatments. Record any diagnostic, 

therapeutic, or prophylactic procedures 

or treatments initiated or ordered, 

including medication. Specify: 

1. All medications administered at prenatal 

visits (specify dosage, route). 

2. All medication given to or prescribed 

for the patient (specify daily dosage, 

manner of use, total amount provided or 

prescribed). 

3. All medication discontinued (specify date). 

4. Medication the ph y s i c i an knows the 

patient is taking, obtained from other 

sources. This will include medication 

routinely taken for chronic diseases such 

as epilepsy, diabetes, etc. (specify dosage, 

change in dosage). 

5. Medication given for research or prophylactic 

purposes only. 

F. Duration of pregnancy 

1. Record original EDC. 

2. Record any change in EDC as a result 

of: 

a. Re-evaluation of menstrual history. 

b. Interpretation of obstetrical examination 

findings. 

G. Non-Study prenatal care (out-patient). This 

will usually describe a positive mark in 

item #22, OB-44 Prenatal Observations. 

1. Consultations: Record the date of and 

diagnoses made by consultation. Procedures, 

treatments or changes in 

October 1962 

II.A.330 

OB-46 


Instruction :\l:J.nual for Obstetric Forms 

OB-46 RECORD OF CURRENT PREGNANCY (Continued) 

obstetrical management are handled as 

in IV, E. 

3. Outside Study hospital: Record the date, 

diagnoses, and treatment given as learned 

by patient history or direct communication 

with the facility which rendered care. 

2. Study hospital, non-Study facilities: Re Submit supporting data such as abstracts 

cord as for consultations. 

or photostats when obtained. 

October 1962 


II.A.331 

OB-46

II.A.332 

00-46 


OB-12 

Summary of Hospitalization for Any Antepartum Condition 

Form OB-12, first used at the beginning of the study, was intended for use 

when a study patient was admitted to the hospital for a reason other than 

delivery. It was replaced in April 1962 by form OB-47, Summary of Antepartum 

Hospitalization. Records for both forms are available on microfilm only. 


II.A.333 

OB-12


II.A.334 

OB-12

SUMMARY OF HOSPITALIZATION 

FOR ANY ANTEPARTUM CONDITION 

(\ 

1. PATten IDENTIFICATION 

Q_e,vJ 

INSTRUCTION: Uae thia form whfJft, at the time of admiaalon, 

delivery ia not anticip.eted. 

2. SUMMARY I!Y ! 3. TIT L.C Oflt POliTI ON 

I 

' 

4. OATil. AOMITTI:O I s. OATil. OIICHARCI&O 

\fo. : Day Year ·lfo. ! Dey 1 

Year 

I i : 

I 

I 

I 

6. REASON FOR ADMISSION (Give condition ""'lch nec..elteted Petl.,t'a edml..lon to thl• fltnPit•l. 11 •

~ o'13-P.. (I'ft.r,l,;cr) ~,...._ ..~ 

'-"'e- 'fl (Y-~:J.J 

; 6 

.. •.. L1.t:.. ,'77\~ ~~.,l.d ~ 

~tz.... 0. ...~ @~-A.tt-~ h' 

~ ~./ JD-t..~ ~ f.

SUMMARY OF HOSPITALIZATION FOR ANY ANTEPARTUM CONDITION 


INSTRUCTIONS FOR OBSTETRICIAN 

This form is to be used for summar~z~ng any antepartum admission, to 

any service of any hospital, terminating in the discharge of a patient 

who is either undelivered or delivered of a fetus of 400 gms. weight 

or less, or less than 20 weeks gestational age (based on LMP). 

Item #2 , "SUI!)miry .!By" 

•• 

j 

Insert your first and last name. 

Item #3. "Title or Position" 

Give your o:t:'ficial title, such as "medical student", "intern", 

"resident", 'J.project obstetrician", etc. 

It~m 

#4. "Date Admitted" 

Record the date the patient was admitted to the hospital: month, day, 

and year. 

'.,_, 

It.eya #5. "Dat.e Dism.lM.pged" 

' Recortfr :W~ dMe tl~e patient was di~~Etd'- from· the htri.spi tal: month, 

day, mid tea:/. 1 "· ~' 'i.;:,.,~ '"'"' 

1\· . ··-: ·: ' : 'l 

iW #6. "Reaso;n for •·•·•J...iG>.n 11 

Give as complet@ a description as li>®Ss-d.ble 0f the condition for which 

the platiel'lt was hom~italized. This is ill'(!lortant in the event that 

a speeific dill•f'li'l(iH!!is eamnot be mede. I'f a•dmitted to another hospital, 

specify »a·me ®f liJ.iH.pi tal. 

•· 

If • .,.,.,;itemt neeivea anesthttsia ~il!il ~s hm-s;pi talization for any 

rea~t0'lll·, fe'1!' ei~laei.ll' X". it tM p.etient did receive 

anes~l!l,eeia, the ail!.l\e-stl

SUMMARY OF HOSPITALIZATION FOR ANY ANTEPARTUM CONDITION (Can't) 

Items #9-#10, "Diagnosis" (Con' t) 

of onset in the appropriate box. 

Items #11-#13. "Therapy" 

If therapy consists of observation or bed rest only, so indicate. 

Record in the appropriate space any medical therapy the patient 

received. List specific drugs, dosage, dates given, response to 

medication, untoward reactions etc. If a surgical therapeutic procedure 

is performed, describe it carefully and be sure to have the 

anesthesia record completed. 

Item #14. "Status of Pregnancy on Discharge"· 

This is intended to distinguish between the status of the pregnancy on 

discharge and the status of the condition for which the patient was 

admitted. If the status of the pregnancy was unaltered by the conditi 

for which the patient was admitted, or by therapy, check appropriate b 

If for reason other than unchanged or terminated, specify the change i 

such terms as "aborted", "suspected fetal death", etc. 

Item #15. "Condition on Discharge" 

This refers to the patient's status on discharge as far as the conditi 

for which she was admitted is concerned. Check the appropriate box to 

indicate whether in your opinion she is cured, improved, unchanged, 

worse, or deceased. 

February 

(For Forms in Use April l 


II.A.338 OB-12

':.::-•••suMMARY OF HOSPITALIZATION 

FOR ANY ANTEPARTUM CONDITION 

INSTRUCTION: u.. 11M foritt .......


II.A.340 

OB-12

OB-47 

Summary of Antepartum Hospitalization 

Form OB-47 was used to summarize any antepartum hospitalization or portion 

of hospitalization and to record all maternal deaths prepartum or postpartum. 

It was first used in April 1962 and revised once in February 1963. OB-47 

replaced form OB-12, Summary of Antepartum Hospitalization. Records are 

available on microfilm only. 


II.A.341 

OB-47

II.A.342 

OB-47 


· 

COLIII-IOOa..7 

(CHANGIED 2-8a) 

08-47 SUMMARY OF ANTEPARTUM 

HOSPITALIZATION 

I. PATIENT IDI!NTIP'ICATION 

J. DATI! 

DIS- 1---~--- 

Mo. · DaJI · r..,. I CHARGED -:cM::-o-.+,-De:-,.-+,-:y::-.-.,- ; i 

... "LACE HOS~IT ALIZED Ql fn otlller ua.n etudr ltoepllal •peclty ~• •d ac:fcfN•• ot the lnetlfllt'on. .-ad, II a priYete c..e. ,.., of !the ett_.dln.. 

pllyolciM.) 

~THIS HOSPITAL. 

Qt:I.St:WHt:Rt: 

a 

S. ADMISSION IIIPRUSION 

1. CONDITION OP' P'I!TUS AT DISCHARGe: 

0 ALlY& 0 UNC&OYAIN (Specll)') 

I 

I 

9 D&AO 9 •OT &VAL.. 

7. CONDITION OP' IIOTHIER AT DISCHARGE 1. IP' EXPIRED: AUTOPSY DONI! t. HOSPITAL. WHI!RI! AUTOPSY DONIE 

OcuRco Ou•lwPWov&o I Q•o 0••• Qu..•ow• D••ccartco 

: 1 a • 

1 I• ITIW 

I c;:J IWPit..:&D ~ IX~IRIID .... 

' 

10. SURGICAL. PROCI!DURIES II.DATI! OP' SURGERY 

0•-• 

r---,---,---· • 

: ~ : ~ 

~~~~~~~~------~~~DI_SCH__A_R_G_E__ D_IA_G_~E~S-----------------r.~~~~~ 

__ 

R....... ...... 

[IJ 

12. DaiTI!TRic DIAGNOSES ~~A.~':~~~~::.~I!! 

-----------------------------------------------------------+---------' 

14. NO..-ITIETRIC DIAGNOSI!Il;;J•••• 

~--r--T 

I '-- I ' __ J ' 

II. COIIMIENTI: 

... IIIEDICAL. n ••Y• nwiTMOU1" I i 17. MEDICAL. t:DIT ay iII. TITI.I! OR 

EDIT 'T' ~~fr~YAL T .....,,..... : I 1 POSITION 

CIIQT . 

TO BE COMPL-ETED BY L-AY EDITOR 

II. ANIESTHI!SIA GIVIEN 1 zo. RADIATION IZI. DRUG THiRAPY , 22. CAioMAfoMv WORK 

0•• On• : 9•• r;Jno : 0•• Qno : 0•• 0••• 

0 I (A,_clt 0841) 

(Attolclt Re-o) I 0 I (AIIoch Dotollo) : 0 I (Attolch Roou/lo) 

· 

COLLA.ORATIV .. fllaSt.t.RCH 

P ..fUNATAL IJIIIaa .. ARCH ...ANCHe NIND •• NIH 

•aTHaaDA 1419 MO. 

08-47 

(CHANG .. O z..ell 


II.A.343 

OB-47

08-47 SUMMARY OF ANTEPARTUM HOSPITALIZATION 

I. Purpose of form 

A. To summarize any antepartum hospitalization 

or portion of a hospitalization. 

B. To record all maternal deatha prepartum or 

postpartum. 


A. This form may be completed by any member 

of the Project staff. In all oases, lay and 

medical editing are required procedures. 

B. When hospitalization has occvred in a non 

Study hospital, supporting data in the form 

of abstracts, photostats, etc, are required. 

C. This form is required in all cases of maternal 

death whether delivered or undelivered. 


Item Number 

2. Date admitted. Record. 

3. Date discharged. Record date discharged 

or transferred. If to another institution, 

state this fact. 

4. Place hospitalized. 

a. If in the Study institution, mark "this 

hospital"; if in anolaer institution, 

mark ''elsewhere" and record the name 

and address of the heepital, as well 

as the name of the private physician, 

if any. 

b. If on a non-Study faciUty of the Study 

institution, note area; e.g., "medical 

ward." 

5. Admission impression. Record. If unknown, 

record reason for admission. 

6. Condition of fetus at diaeharge. Record 

the estimated condition of tbe fetus at 

discharge or transfer by marking the appropriate 

box. Ifthe statueoftbefetus was 

in doubt at that time, mark "uncertain" 

and specify details. If there is no knowledge 

of the condition, mark "not evaluated!' 

Item Number 

7-9. Condition of mother at discharge. 

a. Mark as appropriate. In the event the 

patient expired, complete items #8 

and 9, specifying details regarding 

autopsy. If autopsy was not done in 

place hospitalized, specify the name 

and address of the institution at which 

the autopsy was performed. Submit 

autopsy findings. 

b. If reporting a maternal death which 

did not occur during a period of 

hospitalization, complete items #7, 8 

and 9, reporting any other details 

known in item #15, and complete 

items #12 and 14 if appropriate. 

10, 11. Surgical procedures. Record all, with 

dates. If none, mark "none." 

DISCHARGE DIAGNOSES 

a. Record all discharge diagnoses, using 

standard nomenclature whenever 

possible. If information at discharge 

is insufficient to establish a firm 

diagnosis, probable and/or possible 

diagnoses are to be included and be 

so titled. 

b. Complete OB-47 based only on information 

known at the time of discharge. 

(Subsequent editors' comments 

may be based on later information, 

but editor must not delete any 

findings or conclusions originally 

noted.) 

12. Obstetric diagnoses. Record all, such as 

"Pregnancy, u te rin e, undelivered"; 

"Threatened abortion"; "Pre-eclampsia, 

mild"; "Possible placenta previa." For 

false labor (with or without other diagnoses), 

mark the box provided. 

13. Approximate date of onset. Opposite any 

diagnosis for which it is appropriate 

record the approximate date of onset, 

especially of acute infectious processes 

and toxemia. This should be the date on 

which the condition is thought to have 

first occurred, rather than the date of 

diagnosis. 

October 1 Qll? 

II.A.344 

OB-47 



OB-47 SUMMARY OF ANTEPARTUM 

HOSPITALIZATION (Continued) 

Item Number 

14. Non'-obstetric diagnoses. Record all, such 

as "Rheumatic heart disease, Class II," 

etc. 

15. Comments. Use space provided here as 

appropriate. 

EDITING. Report completion of the edit 

ing procedure by completing items #16 

18. 

16. Medical edit. Record whether editing is 

accomplished with or without the original 

hospitalization record. 

17,18. Medical edit by. Provides for the signature 

and position of the medical editor. 

19. Anesthesia given. Indicate whether or not 

any anesthetic agent was administered 

during the hospitalization. If ''yes," complete 

and attach form OB-57. 

20. Radiation. Mark to indicate if there were 

any diagnostic x-rays or radiation therapy 

during the hospitalization. If "yes," report 

results or summarize therapy administered 

on form OB-45 and attach. 

Alternatively, attach photocopy of hospital 

record. 

Item Number 

21. Drug therapy. Indicate whether or not 

drug therapy was administered during the 

hospitalization. If "yes," record details 

(including dosage, route of administration 

and dates of· commencement and discontinuance) 

on form CP-5, unless previously 

recorded on OB-32 during observation 

for labor. Alternatively, attach 

photocopy of hospital record. 

"Drug therapy" includes all medications 

prescribed for the treatment of the 

patient, other than aspirin, routine vitamins, 

and laxatives. Of especial importance 

are those drugs which mayhave 

an effect upon the fetus. Specifically to 

be reported would be: all antibiotics, 

chemotherapeutic agents, hormones, narcotics, 

sedatives, trltnquilizers, oxytocics, 

or other medic_ations given to inhibit 

or initiate labor. 

22. Laboratory work. Indicate whether or 

not laboratory studies were done during 

the hospitalization. If "yes," record results 

on OB-45 and attach. 


II.A.345 

OB-47

.... 

C:OI..III-~QOJ•47 

OB-47 

SUMMARY OF AHTEPARTI.N 

HOSPITALl ZATIOM 

1. IOATI&NT IDENTII'ICATIDN 

u- th1a form to report only th- hoaplt..u.aufrom 

which tho qravlcia la diac:hczrqed ....a.uverwd. 

z. DATE 

ADMITT&D 

.wo. 

4. PI.ACE HOSPITAI.IZED 

0 TMia M08~1TAI. 

, 

:J Cl.aCWM&•& 

• 

S. ADMISSION IMIO!IIESSION 

(11 In oeller rll• aiUdp ,....,., ._..,IF n-• •d ....... ol &lie lnatttur•otl• ..d. it a pnv.te caae,----ulat o 1ne au..arnQ 

pltyajcfan.) 

e. coNOrTION oP' friTUS AT OISCHXMGI 

0 APo.IYC ::J UMCP'fAUI (SpecUy) 

I 

I 

10. SURGICAl. PAOCI!DU!IID 

0••.. 

---~-~--~ 

' ' I I 

' 

ctNOT l'f'.._o 

.. 

a. i' iXJI"ao: AUToiiiY boNI S. HOSPIT.~I. WHEIOE AUTOPSY DONE 

~ 0 •~cct,.u:a 

CJ.. On• 0•"""""" 

, 1 IN ITI:N 

J • • 

DISCHARG! DIAGNOS!S 

' ...... 

II.DATE 01' SUAGEIOY 

12. 081TETJitiC OIAGNOSIII ~,....... L.Aee• J.AII~.. OXI~ATE 

! OA TC: 01111' ONai:T 

14. NONo081TI!T!IIIC DIAGNOI&S Iii! .... ~-···-· 

' : 

II. CDIIII&NTS: 

;1f. G618.t.C i6rT eY 

;11. T1TCI Q,. 

, IOOSITION 

0 

I f 

TO eE cbMPl.ETEb Sv LAY !bltdA 

11. ANI!STH&SIA GIV&N 1:&0.111ADIAT16N 

;n: &..AidMlfdMY WONk 

0•• 0••• I W"' I 0.. ::JY&a 

0 1 (AI- o.-11) : 0 I 0 I 

l 

(Aa'-M .RaeuJta) 

C:OLL.A80111AT1YI: 1111:8&ARCH 

III&RINATAL .. I:I&ARCH aRANCH. NIND8. NIH 

••••o• r•, wa. 08-47 


II.A.346 

OB-47

OB-15 


Form OB-15, introduced in May 1963, served as an in-house worksheet for 

recording drugs taken during pregnancy. Data were recorded on card 0315 in the master 

file (Table OB-15.1). 

Data on drugs were abstracted by nurses and medical students at the 

Perinatal Research Branch (NINCDS) from study forms submitted by the 

collaborating institutions. From the raw data on drugs, Dr. Dennis Slone 

(co-director of the Drug Epidemiology Unit, Boston University Medical Center) 

created two drug files (see Volume IV of this user's guide). Researchers 

wishing to use drug data are directed to the drug work files. 

TABLE OB-15.1 




08-15: Drugs 0315 

0 222,398 

222,398 


II.A.347 

OB-15 


II.A.348 

OB-15 



nata Ite~s Refere~einQ For~ OR-15, Oruas tn Preqn~nev 

DIITII 

I ft::M 

ITE'4 Jli CAR!"' 

TO FJRIIII NIIM FROIIII TO Oil fA TrF.M NAME 

' 

7AS ••••••• 0315 5 CArd nu~ber (sequence, forn typP, form nu~ber, revision nu~ber) 

7A6••••••• 031'5 6 14 NTN08 case number 

787 •• 08-15 0315 1'5 16 MPnstru8l history: L~P fron OR·4 Cmo) 

7fle •• nB-1'5 031'5 t7 18 Menstrual history: L~P fron ~R-4 (dfty) 

7"9 •• 08-1'> 031'5 1Q ?.0 IIIIPnstruftl hfstory: ~~P fron JR·4 Cvr) 

7CJO •• OR•15 031'i 21 21 Hnsoital 8d~isstons, ~u~ber ante oartum 

7CJ1 •• OIJ•1"i 031'5 2?. ?2 Forms, OB•12, nu~ber 

7CJ2 •• 08•1'5 0315 21 13 Forms, 118•47, nuwber 

7CJ3 •• 08•1'5 0315 24 24 oruas: ~e~lratlons, none taken 

7CJ4 ••1'l8•1'5 031'5 2'5 ?.5 Radioaraphy: ~-ray oelvtmetry 

795 •• 08-15 0115 26 19 Orua nth, nAme 

7CJ6 •• 08•1" 031'5 30 10 orua nth, 4 wks. orfor to tmo 

7Q7 •• n8-1'5 031'5 31 31 Orun nth, lun~r wonth of orP~nancy t 

7Q8 •• 1'l8-1'5 0315 3?. 32 orua nth, lunar wonth of pre~nancv 2 

799 •• 08-15 031'5 33 H orua nth, lunar nonth of ore~nancv 3 

H 

H 8no •• n8-15 031'5 34 34 Oruo nth, lunar •onth of ore~nancv 4 

•)II 

80t •• n8-1'5 0115 3"i 35 Drua nth, lunar wo~th of ore~nancv r; 

• 802 •• 08-1'5 031'5 36 36 Drun nth, lunar wo~th of oreQn~ncv 6 

w 

~ 

803 •• 0B•t'5 031r; 37 17 orua nth, lunar month of oreQnancv 7 

\0 804 •• 08-1'5 o31r; )A 38 orua nth, lunar ~onth of preQnancy R 

805 •• nB-1'> 0315 )Q 19 Drua nth, lunar wonth of nre~nancv 9 

806 •• 08-1'5 031'5 40 40 orua nth, lunar wonth of oreQnancv to 

807 •• 118•15 031'5 41 41 orua nth, lunftr no~th of or~~nancv 11 or more 

808 •• 08•1'> 031'5 42 42 orua nth, lunftr nnnth of oreqnancv u~known 

809 ••••••• 031'> 41 RO Rlank 

6164 •••• VAP 1463 1463 Hosoltaltzations antepartun 

6214 •••• w-3 10 1 3 orua, tra~e nft~e, cnje 

6215 •••• w-1 14 14 Druo, tra~e nftne, use freauency, four weeks prior to L~P 

621& •••• w-3 1"i 15 oruo, tra~e nawe, use freauenr.v, lunar month of pr eCJnancv, t 

62t7 •••• w-3 16 16 Drua, tra~e n8~e, use treouencv, lunar month of precanancv-, 2 

62t8 •••• w-3 17 17 Oruo, tra~e nane, use freauencv, lunar month of pregnancy, 3 

62PJ •••• 11-1 1R 18 Druo, tra~e nane, use freaue~cy, lunar ~onth of preCJ'\IIIncv, 4 

6220 ••••11-1 11J 19 Druo, trade nane, use treauency, lunar month of preCJnancy, !I 

6211 •••• 11-3 20 20 Orua, tra~e nane, use treouencv, lunar month of preonancv, 6 

6222 •••• 11-1 21 21 oru~. tra~e nane, use freauencv, lunar month of preQnancv, 7 

6223 •••• 11·3 2?. 22 orua, tra~e nane, use treaeuncy, lunar month of pre!Jnancv, 8 

~ 6214 •••• w-3 23 13 oruo, tra~e n8~e, use treouenry, lunar month of preqnancy, 9 

U1 

6225 •••• 11·1 24 ?.4 orua, trade name, use freouency, lunar Month o~ preCJnancv, tO 

6226 •••• w-3 2'5 :?5 Orua, tra~e na•e, use freauencv, lunar month of preCinanr.y, t1 plus 

6227 •••• w-3 26 26 Druo, trade n~mP, use freouency, lunar mo~th of preq~ancv, unkno•n 

fi23o •••• w-4 tO 13 orua, active co~poun1, code 

6211 •••• w-4 14 14 orua, activ~ compound, use fre~uencv, tour weeks Prior to LMP


oat !I Items R~fPre~cin~ form OR-15, Oruqs 1n PreQrHincv 

OAIA 

ITEM 

TO 

fi212 •••• w-4 

62J.J •••• w-4 

fi2Jt •••• w-4 

62J5 •••• w-4 

621& •••• 111-4 

6237 •••• 11-4 

62J8 •••• w-• 

6239 •••• 111-4 

624o •••• w-4 

624t •••• w-4 

6242 ••••111-4 

6243 ......... 

TTF'IC 

)!I 

F' JRM 

CARD 

Nil foil F'R014 TO OATA TTEJoll NAJIIIE 

t'i 

lfi 

17 

1P 

1q 

21) 

21 

2?. 

23 

24 

2!'; 

26 

15 

16 

17 

t8 

19 

?0 

71 

72 

23 

74 

75 

76 

orur.r, 

Drua, 

Drua, 

Orua, 

orua, 

Orurr, 

Orua, 

oruq, 

IJrua, 

Orua, 

Drug, 

actfve co"'ooun:J, 

active c:omo(')uni, 

ac:ttve comoounj, 

active CO'IIDOUnj, 

active co111ooun1, 

active co111oOun:J, 

ac:ttve c:o111ooun:t, 

active co111ooun:t, 

active co•ooun:i, 

active co111poun:i, 

actlVf' co•ooun:i, 

ntus 

active co•poun:i, 

Druq, 

unknown 

IJSI! 

use 

use 

use 

use 

USP 

use 

nse 

use 

use 

lise 

use 

. 

f re :tlli!OCV, 1unsr 

frequency, lunsr 


fre'luency, lunar 


tre1uency, lunar 

frll':tnency, lunar 

frequency, lunar 




fre~uency, 

lunar 

~onth of 

~onth of 

~onth of 

'llonth of 

•onth of 

111onth of 

month of 

~onth of 

•onth of 

•onth of 

aonth of 

•onth of 

oreQnancy, 

oreanancv, 

oreanancy, 

oreQnancy, 

oreqnancy, 

oreanancv, 

pregnancy, 

oreonancv, 

oreanancv, 

pre~nancv, 

oreonancy, 

oreonancy, 

1 

2 

3 

• 5 

6 

7 

8 

9 

to 

11 

H 

H 

:.,. 

• w 

U1 

0 

\ 

@ 

I 

I-' 

l11

PH S.300S.18 

..... 

PATIENT IDENTIFICATION 

OB-15 DRUGS IN PREGNANCY 

WORKSHEET 

LMP(OB-4) 

NUMBER OF 

ANTEPARTUM ADMISSIONS 

NUMBER OF 

OB-12 FORMS* 

NUMBER OF 

OB-47 FORMS* 

NO DRUGS TAKEN 

X·RAY PELVIMETRY 

ABSTRACTED 

IMO.IOAY IY~.l 

D 

D 

D 

D 

D 

DRUGIHDEX 

Pogo I I 

Pogo 2 

Pogo 3 

u 

m 

Pago4 IV 

Pago5 v 

Pogo 6 

VI 

Pogo 7 vu 

Pogo 8 Vill 

Pogo9 IX 

ANTI-INFECTIVE$ 

ANALGESICS, RELAXANTS, ANTIARTHRITIC$, 

SEDATIVES, ANTICDNVULSANTS 

ATARACTICS, TRANQUILLIZERS, ANTINAUSEANTS, 

ANTIHISTAMINICS, ANTIPRURITIC$ 

STIMULANTS, AUTONOMIC$, HORMONES 

ANTIHYPERTENSIVES, DIURETICS, 

MISCELLANEOUS 

IMMUNIZATIONS, VAGINAL MEDICATIONS, 

CONTRACEPTIVES 

COMMON COMBINATIONS- PRESCRIPTION 

COMMON PATENT MEDICINES 

Ml SCEL LAN EOUS DRUGS (cardiac, utaro,_ic, ca... 

medicine, vitomln K., poclophyllln-contoinlng) 

I!XCLUDI! ALL OP THE POLLOWIHG 

Topical medications 

Loxativoo, oxcopt tho .. containing podophyllin 

Vitamin•, except for vitamin K 

Minetola (oxcopt parenteral iron) 

Antacich 

Saito (oxcopt all iodidoo) 

Drugs not roportod loy specific n-o, oxcopt for "sulfa" ond 

•ontihiatomine•, not otherwise specified 

1088 - "Sulfa", NOS 

9345 - • Antihistamine", NOS 

DIE~AIIITMIENT Ofl HEALTH. EDUCATION ANO WIEL,AIItiE 

~U.LIC HIEALTH IIENVICIE 

.... 

II.A.351 

OB-15 


PATIENT IOt:NTI I"ICATION 

OB-15 DRUGS IN PREGNANCY -I 

COD!: A- TAKEN 1 DAY ONLY 

8- TAKEN 1-7 DAYS 

C - T AK!N MOR! THAN 7 DAYS 

D- TAKEN UNKNOWN TIME 

AHTI-IHFECTIVES 

ANTIBIOTICS, BACTERIAL 

1001 chloramphenicol. • • • • • • • • • • • • • • • • • • • D 

1002 erythromycin • • •. • • • • • • • • • • • • • • • • • • I 003 furadantin ••••• • • • • • • • • • • • • • • • • • • • D 

1004 penicillin (all derivatives) • • • • • • • • • • • • • 1005 streptomycin ••• , ••••••••••••••••• • D 

1006 tetracycline •••••• • • • • • • • • • • • • • • • • • D 

~~:: ~~~;~!.. ..... ..... ..... .... ~~-~ ~~~;~!..................... D 

SULI'ONAMIDES 

1007 sulphlsoxazole (Gantrisin) ••••• • • • • • • • • D 

1008 sulfadiazine • • • • • • • • • • • • • • • • • • • • • • D 

1009 sulphamethoxypyridi~zine (Kynex) ••• , •• •. 0 

~~:: ~~j:y~..................... 0 

~~:: ~~~i~y!. • • • • • • • • • • • • • • • • • • • • D 

MISCELLANEOUS 

1010 Flagyl (~etronidazole)................ 0 

DDDDDDDDDDDD .DDDDDDDDDDDD 

~DDDDDDDDDDDD 

~DDDDDDDDDDDD 

EDDDDDDDDDDDD 

!DDDDDDDDDDDD 

3DDDDDDDDDDDD DDDDDDDDDDDD 

DDDDDDDDDDDD 

DDDDDDDDDDDD 

DDDDDDDDDDDD 

DODDDDDDDDDD 

DDDDDDDDDDDD 

. 0 0 o·oD D D D D D D D 

1011 grls-fulvin ••••••••••••••••••••••• ~ DDDDDDDDDDDD 

1012 INH(Isaniazid) •• ••••• ••• •••••••••• D E DDDDDDDDDDDD 

1013 Mondelamine •••••••••••••• "'"'"'' i DDDDDDDDDDDD 

1014 mycostatln ••••••••••••••••••••••• ! DDDDDDDDDDDD 

1015 PAS(p-aminosalicylicacid) ••• ,,,,,,.,, D $ DDDDDDDDDDDD 

1016 quinine .......................... D 1DDDDDDDDDDDD 

~:~~~~~;~!..................... ~ ODDDDDDDDDDD 

~~e:~~~;~!••••••••••••••••••••• 0 l DDDDDDDDDDDD 

OIEPA~TMKNT 011" HW:Al..TH, IIOUCATION AND W.L ..&RK 

~U.LIC HCAL.TH S&ftVICK 

II.A.352 

OB-15 


.... 

PMS•3003•18 


OB-15 DRUGS IN PREGNANCY- II 

CODI: A- TAICIN I DAY ONLY 

I- TAlC IN 1-7 DAYS 

C- TAKEN MORI THAN 7 DAYS 

D- TAKIN UNKNOWN TIMI 

ANALGESICS 

RELAXANTS, ANTIARTHRITIC$ 

SEDATIVES, ANTICONVULSANT$ 

ANALGESICS 

2017 Aopirin..... • • • • • • • • • • • • • • • • • • • • • D DDDDDDDDDDDD 

2018 codeine•••••••••• • • • • • • • • • • • • • • • • DDDDDDDDDDDD 

2019 Oarvon (dextropropoxyphene)•••••••• • • • • D 

a 

DDDDDDDDDDDD 

2020 Zactirin (ethoheptozine)••••• • • • • • • • • • • D. ~ 

DDDDDDDDDDDD 

~h~: ~s~~~:!..................... 0 i DDDDDDDDDDDD 

ac 

RELAXANTS, ANTIARTHRITIC$ ... 

z 

2021 phenylbutazone•••• • •• • • • • • • • • • • • • • • D ~ DDDDDDDDDDDD 

2022 Robaxin (methocarbamol) • • • • • • • • • • • • • • ; 

... DDDDDDDDDDDD 

2023 Soma (corioprodol) • • • • • • • • • • • • • • • • • • D : DDDDDDDDDDDD 

2024 Zoxozolamine (Fiexin)•• • • • • • • • • • • • • • • D DDDDDDDDDDDD 

~h~ ~~~~~y! __.______________ ._. _D . DDDDDDDDDDDD 

SEDATIVES, AHTICOHVUUANTS 

2025 chloral hydrate, •••••• • • • • • • • • • • • • • • D DDDDDDDDDDDD 

2026 dilantin••••••• • • • • • • • • • • • • • • • • • • • D DDDDDDDDDDDD 

2027 Dorlden (glutethimide) •• • • • • • • • • • • • • • • D DDDDDDDDDDDD 

2028 Noludor (methyprylon) •• • • • • • • • • • • • • • • D DDDDDDDDDDDD 

2029 pentobarbital (Nembutal) • • • • • • • • • • • • • • D DDDDDDDDDDDD 

2030 phenobarbital ••• , • • , • • • • • • • • • • • • • • • D 8 EDDDDDDDDDDDD 

2031 Plocidyl (ethchlorovynol) • • • • • • • • • • • • • • D ~DDDDDDDDDDDD 

2032 Seconal (Secobarbital).~.,,,.·. • • • • • • • • D !DDDDDDDDDDDD 

2033 Volmid (ethinomote) , , , ••••• • • • • • • • • • D sDDDDDDDDDDDD 

~h-~ ~S~I~y!. .................... D ~DDDDDDDDDDDD 

~h.-: ~s~~Y!... _.......... ....... 0 DDDDDDDDDDDD 

~h.-: ~s~:~~Y!....... _. ............. 0 

DDDDDDDDDDDD 

Oll~A.. TMilNT Ofl' HllAL.TH. EDUCATION AND WIEL~A.. E a.ea PAGE ----- 

PUaL.IC HEALTH l&ftVIC& 

ZOFt 08-15 

II.A.353 

OB-15 


PATIENT IOIENTIP'ICATION 

OB-15 DRUGS IN PREGNANCY - Ill 

CODE 

A- TAKEN I DAY ONLY 

8- TAKEN 1-7 DAYS 

C- TAKEN MORE THAH 7 DAYS 

D- TAKEN UNKNOWN TIMI 

ATARACTICS, TRANQUILLIZERS, 

ANTI NAUSEANTS 

ANTIHIST AMIHICS, ANTIPRURITIC$ 

ATARACTICS. TRAHQUILLIZERS 

3034 Compazine (prochlarpemine) • • • • • • • • • • • .D 

3035 Equanil(meprobamate) •••••••••••••••• D 

3036 Librium (chlordiazepoxide) • • • • • • • • • • • • • D 

3037 Sparine (promazine)••••••• • • • • • • • • • • • D 

3038 Thorazine (chlaropromazine) ••••••••• • • • D 

3039 Trilafon (perphenazin;) •••• • • • •. • •. • • • D 

~~--: ~~~~i~y!..................... 0 

AHTIHAUSEAHTS 

AHTIHIST AMIHICS, ANTIPRURITIC:$ 

3045 brompheniramine (Dimetane) • • • • • • • • • • • • D 

3046 chlorpheniramine••• • • •• • • • • • • • • • • • • • 0 

3047 diphenhydramine (Benadryl) ••• • • •• • • • • • D 

3048 promethazine (Phenergan) ••••••••••• • • • D 

3049 trimeprazine (Temaril) ••••••• •. • ••• • • • 0 

3050 tripelennamine (Pyribenzamine) ••••••• • • • 0 

~~:: ~~~;:!................. -... D 

~~--: ~~~:~::................---.- 0 

CKPARTMKNT Ofl' HEALTH. EDUCATION AND W.LP'ARK 

PUIIL.IC M lEAL. TH Sll.. VICC 

D D D DODDD D D D D 

DDDDDDDDDDDD 

g D D D DD DD D D 0 D D 

!DDDDDDDDDDDD 

~DDDDDDDDDDDD 

~DDDDDDDDDDDD 

3DDDDDDDDDDDD 

.. 

3040 Dramamine ••• • • • • • • • • • • • • • • • • • • • • D . 

DDDDDDDDDDDD 

3041 mecllzine (Bonadaxin, Bonine) • • • • • • • • • • D 

DDDDDDDDDDDD 

3042 Mornidlne (pipamazine) •••••••••••• • • • D .. 

3043 Tigan (trimethoben"zomide) •••• • ••••• • • • D 

. DDDDDDDDDDDD 

DDDDDDDDDDDD 3044 Torecan (triethylperazine) •••••••••• • • • 0 DDDODDDDDDDD ~~--: ~~~i~y!..................... 0 DDDDDDDDDDDD 

~~.-:~~~~~y!..................... D DDDDDDDDDDDD 

DDDDDDDDDDDD 


iDDDDDDDDDDDD 

iDDDDDDDDDDDD $DDDDDDDDDDDD 

~DDDDDDDDDDDD 

. ~DDDDDDDDDDDD 

:ODDDDDDDDDOD 

:~;; 08-15 

II.A.354 

OB-15 


PHI·IOOI .. 1B 

P"TIENT IOENTIFIC"TION 

08-15 DRUGS IN PREGNANCY- IV 

CODI!: A- TAKI!H I DAY OHLY 

I- TAKI!H 1.7 DAYS 

C- TAKI!H MORI! THAN 7 DAYS 

D- TAKI!H UHKHOWH TIMI! 

STIMUL.AN TS 

AUTONOMICS 

HORMONES 

CHS STIMULAMTS, ANTIDEPRESSANTS 

4051 amphetamine (Dexedrine) •• • • • • • • • • • • • • • D 

4052 ephedrine , , •••• • • • • • • • • • • • • • • • • • • • D 

4053 epinephrine , ••••• • • • • • • • • • • • • • • • • • • D 

4054 phenylephrine (Neaoynephrine) •••••• •. • • • D 

4055 Preludin (phenmetrazine) •••••• • • • • • • • • • D 

~~-e: ~s~ ;~y!. . . . . . . . . . . . . . . . . . . . . . 0 

ANTICHOLINERGIC 

4056 atropine ••• • • • • • • • • • • • • • • • • • • • • • • • D 

4057 banthine •••••••••••••••••••••••••• D 

4058 belladonna • , •• , • • • • • • • • • • • • • • • • • • • D 

4059 probonthine ••••• • • • • • • • • • • • • • • • • • • • D 

~:h_e: ~s~:~Y!. _. __ .____ .___________ 0 

HORMONES AND ENDOCRINE RELATED 

4060 Chlorpropamide••• • • • • • • • • • • • • • • • • • • • D. 

4061 Cortioone ••••••••••••••••••••••••• D 

4062 Delalutin••••• , ••••••••••• , •••• , , •• D 

4063 Eno¥id,., ••••••••• , ••••••••••••• , .D 

4064 prog..terone •• , •••••••••••• , •• , , • • • D 

4065 propylthiouracil •••• • • • • • • • • • • • • • • • • • D 

4066 Stilbeoterol, ••••• • • • • • • • • • • • • • • • • • • D 

4067 tolbutamide ••••• • • • • • • • • • • • • • • • • • • • D 

4087 "inoulin" ••••••••••••••••••• • •• • • • D 

4088 "thyroid" • • • • • • • • • • • • • • • • • • • • • ' • • ' D 

~:h_e: ~~~~!.. -- . --........ --... --D 

DDDDDDDDDDDD 

DDDDDDDDDDDD 

aODDDDDDDDDDD 

~DDDDDDDDDDDD 

~DDDDDDDDDDDD 

~DDDDDDDDDDDD 

~ 

1 

"' 

~DDDDDDDDDDDD 

~DDDDDDDDDDDD 

lDDDDDDDDDDDD 

lDDDDDDDDDDDD 

~DDDDDDDDDDDD 

.·DDDDDDDDDDDD 

:DDDDDDDDDDDD 

-DDDDDDDDDDDD 

8DDDDDDDDDDDD 

~DDDDDDDDDDDD 

!DDDDDDDDDDDD 


sDDDDDDDDDDDD 


lDDDDDDDDDDDD 

lDDDDDDDDDDDD 

DIE~A .. TMIENT OP' HIEAL.TH. I:DUCATIQN AND WIEL"A"IE 

!5·11 

II.A.355 

OB-15 



OB-15 DRUGS IN PREGNANCY- V 

CODI!: A- TAKEN I DAY ONLY 

8- TAKI!N 1.7 DAYS 

C - TAKI!N MORI! THAN 7 DAYS 

D- TAKI!N UNKNOWN TIMI! 

ANTIHYPERTENSIVES 

DIURETICS 

MISCELLANEOUS 

ANTIHYPERTENSIVES 

5068 hydralazine (Apreooline), •••••• • • • • • • • • D 

5069 reserpine••••••••• • • • • • • • • • • • • • • • • 0 

~~h~: ~:.~i~y~................. _.. _D 

~:h~: ~:.~i~y~ ..............-...-.. 0 

DIURETICS 

5070 acetazolamide (Diamox) •••••••••••••• • -o 

5071 ammonium chloride ••••••••• • • • • • • • • • D 

son b•n•droflum·•hiazid•. • • • • • • • • • • • • • • • • D 

5073 chlarthalidone (Hygrotan) • • • • • • • • • • • • • • D 

5074 chlorothiazide (Oiuril) •• • • • • • • • • • • • • • • D 

5075 hydrochla~hiazide (Eodtix) • • • • • • • • • • • • • D 

5076 Mercuhydrin •••••• • • • • • • • • • • • • • • • • • D 

5077 trichloromethiazide (Naqua) •• , •• , • , , • • • D 

~h~ ~~~i~y! __ .__________________D 

~:h~ ~~~i:y~ _D 

MISCELLANEOUS 

~~l~y~ •••• - •• - - •••• - ••• - - - - -.. • 

~s~~~~Y! .................._...... 0 

~~~~:~...............--.... -... 0 

~:.~i~y! ..................-...... D 

~~~y!................--....... 0 

~S~i~y!................... -..... D 

~s~-:_;~y! ....................... _. 0 

~s::,~y! ....... ~ ................. D 

OEPA,.TMKNT 0~ HllAL.TH, II.OUCATION ANOWIE&..P'ARIE 

PUBL.IC HCALT..., SI[.. VICI[ 

DDDDDDDDDDDD DDDDDDDDDDDD 0 DDDDDDDDDDDD 

2 

• IU 

L DDDDDDDDDDDD 

.... 

c 

• = 

... 

z 

IU 

DDDDDDDDDDDD 

:1 

... 

c DDDDDDDDDDDD 

.... 


DDDDDDDDDDDD DDDDDDDDDDDD . DDDDDDDDDDDD . DDDDDDDDDDDD 

DDDDDDDDDDDD 

DDDDDDDDDDDD DDDDDDDDDDDD 

DDDDDDDDDDDD 

2 0 

• IU DDDDDDDDDDDD 

L 

~ 

= DDDDDDDDDDDD 

•... 

DDDDDDDDDDDD 

:1 

... 

li 

DDDDDDDDDDDD 

c 

.... 



DDDDDDDDDDDD 

e ..ea 

..-~~E9 08-15 

II.A.356 

OB-15 


PATI~NT IDENTIFICATION 

OB-15 DRUGS IN PREGNANCY - VI 

CODE: A- TAKEN 1 DAY ONLY 

8-TAKEN1-7DAYS 

C- TAKEN MORE THAN 7 DAYS 

D- TAKEN UNKNOWN TIME 

IMMUNillTIONS 

VAGINAL MEDICATIONS 


IMMUNIZATIONS 

6078 influ..,zo (polyvalent) , , •• , •• , , ••••• , , 

6079 measles (ki lied) , ••• , , , , , , • , , , •• , , •• 

6080 measles (live - oral) • , ••• , , , •••••••• 

6081 polio (killed), , •• , ••• , , • , •••••••••• 

6082 polio (live - oral) ••••••••••••••••••• 

60P3 smallpox vaccine , , , , • , •• , , ••••• , , •• 

608A tetanus • ••••••••••••••••••• • • • • • • 

Other (Specify) 


VAGINAL MEDICATIONS 

6085 F loraquin , , , , , , • , , , •••• , ••• • • • • • • 

6086 Furocin , , , , , ••• , , , • , • , , , , , , •• , , • 

6087 Mycostatin, , , , , , • , •••••••• , •• • ••• • 

6088 Sporostacin , , , , , , • , , , •• , , , , , •• , ••• 

6089 Triple Sulfa, , • , , , , , , , , , • , , , ••••••• 

Oth• (Specify) 



6090 Oelfen , , • , ••••••••••••• • • • • • • • • • 

6091 Emko,,,,,,,, •• ,, •• • • •• • • • • • • • • • 

6092 Orthogynol , , • , , • , , , • , , , • , ••••••• • 

6093 Preceptin , • , , , , , , , , , ••••• • • • • • • • • 


................................... 


O&PAIItTMENT 0~ HKA~TH. •DUCATION AND WaL.II'AIItll 

PUBL.IC HaAL.TH ll:lltVICK 

DDDDDDDDDDDD D DDDDDDDDDDDD 0 DDDDDDDDDDDD 

D~DDDDDDDDDDDD 

D i.DDDDDDDDDDDD 


o;ODDDDDDDDDDD 


D DDDDDDDDDDDD 

DODD 

DODD 

D DODD 

0 DODD 

D DODD 

D DODD 

D DODD 

... 

oC 

D ~.. DODD 

!;; 

z DODD 

Ill 

:a 

D 

... DODD 

... 

D DODD 

oC 

D DODD 

D DODD 

.... 

PAG~ 

I OF 9 

-ll8-1s 


II.A.357 

OB-15

OB-15 DRUGS IN PREGNANCY- VII 

CODE: A- TAKEN 1 DAY ONLY 

I -TAKEN 1·7 DAYS 

C- TAKEN MORE THAN 7 DAYS 

D- TAKEN UNKNOWN TIMI 

COMMON COMBINATIONS 

PRESCRIPTION 

7106 Achrocidin•••••••••••••••••••••••• D j DDDDDDDDDDDD 

7452 Ambor,,,,,,,,,,,,,,,,,,,,,,,,,,, D l DDDDDDDDDDDD 

7455 Amphedau ....................... 0 l DDDDDDDDDDDD 

n11 APC(anacin) ...................... 0 ! DDODDDDDDDDD 

7340 Bendectin,. ..................... , D i DDDDDDDDDDDD 

7401 Cafergot, •••••••••••••••••••••••• D ~ DDDDDDDDDDDD 

7434 Combid •••••••••••••••••••••••••• D ~ DDDDDDDDDDDD 

7351 Co-pyranil .............. " ........ D ~ DDDDDDDDDDDD 

n19 DarvonCampound ................... D ~ DDDDDDDDDDDD 

7 451 Dexarnyl ......................... D ~ DDDDDDDDDDDD 

7458 Dannatal ......................... D ~ DDDDDDDDDDDD 

n16 Edriaal .......................... D l DDDDDDDDDDDD 

7448 Eakatrol ......................... 0 l DDDDDDDDDDDD 

7346 Novahiotine,,,,,,,,,,,,,,,,,,,,,,, 0 DDODDDDDDDDD 

7214 Pabalate ......................... D l DDDDDDDDDDDD 

n18 Percodan ........................ 0 l DDDDODDDDDDD 

n15 Phenaphen ....................... D ~ DDDDDDDDDDDD 

7341 Prenauaen ........................ D e DDDDDDDDDDDD 

7334 Prozine •••••••••••••• ••••••••••• 0 ~ DDDDDDDDDDDD 

7449 Quadrinal ........................ D ! DDDDDDDDDDDD 

,. 

7453 Tedral .......................... D S DDDDDDDDDDDD 

~~~·::s~~~~y:..................... D 7 DDDDDDDDDDDD 

~:h_·:~~~~~y: ••••••••••••••••••••• 0 l DDDDDDDDDDDD 

~:h.~~~~y: ••••••••••••••••••••• D l DDDDDDDDDDDD 

S-03 PAGE 

70F9 

OB-15 

II.A.358 

OB-15 


..... 

PHS .. 3003 ... 11 

PATII!NT IDI!NTII'ICATION 

08-15 DRUGS IN PREGNANCY- VIII 

CODI!• A- TAKI!H I DAY OHLY 

I- TAKI!H 1·7 DAYS 

C- TAKI!H MOttl! THAH 7 DAYS 

D- TAKI!H UHKHOWH TIMI! 

COMMON PATENT MEDICINES 

8212 AlkaS.ltzer •••••••••••••••••••••• D 

~ DDDDDDDDDDDD 

8215 B.C.Pawdera ••••••••••••••••••••• D 

~ DDDDDDDDDDDD 

8214 Bromoquinina •••••••••••••••••••••• D l DDDDDDDDDDDD 

8213 BromoMltzer •••••••••••••••••••••• D ·~ DDDDDDDDDDDD 

8346 Coricidin •••••••••••••••••••••••• D i DDDDDDDDDDDD 

8345 Driston •••••••••••••••••••••••••• D ~ DDDDDDDDDDDD 

Ill 

8217 Four•woyColdToblets ••••••••••••••• D ~ DDDDDDDDDDDD 

8348 lnhist ••••••••••••••••••••••••••• D j DDDDDDDDDD·DD 

8349 Somin•• ••••••••••••••••••••••••• D DDDDDDDDDDDD 

8216 Stanback ••••••• ••••••• ••••••••••• D DDDDDDDD.DDDD 

DDDDDDDDDDDD 

~~::·.(-~~~~---················· D DDDDDDDDDDDD 

............................... D ~ DDDDDDDDDDDD 

.........·...................... D ~ DDDDDDDDDDDD 


............................... D i DDDDDDDDDDDD 


............................... D e DDDDDDDDDDDD 


............................... D ! DDDDDDDDDDDD 

............................... D s DDDDDDDDDDDD 

............................... D Y DDDDDDDDDDDD 


i347 Suparonohist •••••••••••••••••••••• D 


O&PAIIIITNIENT Oil' H&ALTH. &DUCATION AND waJ..pi'A ..K .... PAGI! 

~U.LIC HII.ALTH aaJitVIC& IOI'I 08-15 

II.A.359 

OB-15 


PHS.300!o.1S 

!S .5! 

PATII!NT IDIENTII"ICATION 

08-15 DRUGS IN PREGNANCY- IX 

CODE 

A· TAKEN 1 DAY ONLY 

I· TAKEN 1-7 DAYS 

C- TAKEN MORE THAN 7 DA\'S 

D- TAKEN UNKNOWN TIME 

MISCELLANEOUS DRUGS (cardiac, ":'""::' 

uterotonic, cough medicine, vitamin K, ~llf-'---r-""'I'T"'"--rr-~-r--T'!r---TT--rr--rr---rr--rr-"TT"""""'"l 

odo yllin-c:ontaining 

·1 

9500 Alevaire ••••••••••••••••• , , , , , , • • 0 

9102 Bony lin •••••• • • • • • • • • • • • • • • • • • • • • 0 

9905 Carter's Little Liver Pills , ••• , •• , • , • • • 0 

9905 Cascara sagrada •••• • • •• • • • • • • • • • • • • 9103 Choracol ••••••••••••••• , • , • , • , , • • 0 

9105 Colban cough medicine ••• • • • • • • • • • • • • D 

9905 Compouncl caacara tabs .......... • • • • • • • 0 

9001 digitalis ••• , •••• • •• • • • • • • • • • • • • • • D 

9002 digitoxin ••••• • • • • • • • • • • • • • • • • • • • • 0 

9109 Endatusain ••••••• • • • • • • • • • • • • • • • • D 

9050 heparin •••••••••••••• • • • • • • • • • • • • D 

9905 Hinkle's pill a , •• , , ••••••• • •••• , • • • 0 

9106 Pertuaain , • , , ••••••••• • • • ••••• • • • 0 

9402 Pitacin ••••••••••••• • • • • • • • • • • • • • 0 

9107 Pyraldin ••••••••••• • • • • • • • • • • • • • • D 

9104 Robituaaln••••••••• • •• • • • • • • • • • • • • D 

9403 Sparteine sulfate (Spartocin) ••••••••• • • • D 

9401 Syntocinon •••••••••• • • • • • • • • • • • • • 9101 Terpin Hydrate (elixir), ••• • •• • • • • • • • • • 0 

9403 Tocoaamine ••••••••••• • • • • • • • • • • • • 0 

9108 Tuaoaminic ••••• • • ••• • • • • • • • • • • • • • 0 

9901 Vitamin K (Menadione) •••• • •••••••• • • • 0 

~~.-~ ~~~~:!...................-- D 

~:':e: ~~~~:!..................... D 

DIIJIIAftTM&NT orr HIIAL.TH. t!:OUCATION ANIO W.LfiAa. 

PU •L.IC HEAL. TH SCIItV1C& 

DDDDDDDDDDDD 

1BBBBBBBBBBBB 

!DDODDDDDDDDD 

iDDDDDDDDDDDD 


~DDODDDDDDDDD 

~DDODDDDDDDDD 


DODDDDDDDDDD 

DDODDDDDDDDD 

DDODDDDDDDDD 

DDODDDDDDDDD 

DDDDDDDDDDDD 

DDDDDDDDDDDD 

.DDDDDDDDDDDD 


~DDDDDDDDDDDD 

iDDODDDDDDDDD 

iDDODDDDDDDDD $DDDDDDDDDDDD 

1DDDDDDDDDDDD 

lDDDDDDDDDDDD 


.... 

II.A.360 

OB-15 



H 

Ḥ 

)I 

. 

Form Item Nulllbers 11nlced to n11ta ltPIIIS on o~-15, nru1!l t n Pre!lni!lncv 

I TEN 

OATA 

ON JrF.N CARO 

FOR14 10 NUM FRO Ill TO DAtA IrF.N NANF. 

796 •• 0A•t5 

797 •• ()A•15 

1106 •• 01'•15 

0315 

031~ 

30 

31 

40 

30 

Jt 

40 

oruq 

Orun 

Orua 

nth, 

nth, 

nth, 

4 wlcs. or tor to .lmo 

lUnflr 11ontn of oreqnancy 

lUnflr ,.,ntn of oreqnancy 1 

031'5 

to 

807 •• 0~·15 031'5 41 41 Drua nth, lun~tr •onth of Drf'Qruncy H or more 

79R •• OA•t5 0315 3?. 'l2 orua f'lth, lunar 'llnntn of oreqnaf'lcy 2 

79CJ •• OR•t5 o:us H JJ orua f'lth, lllnflr 'llontt'i of oreqnancv ] 

IIOO •• OA•15 031'5 34 14 OTUIJ ntt'l, lnn~tr IIIOnth of' orP.:Jnancv 4 

1101 •• 01'•15 031"i 3'5 :l5 Oruo ntl't, lunar •onth of oreq.,ancy '5 

II02 •• 0A•15 

AOJ •• os-t5 Ol1"i 36 J6 oruq 

031'5 37 J7 oruq nth, 

nth, lunar 

lunar •onth of 

111ontn of oreql"'ancv 

orPqnancy 6 

7 

A04 •• 0A•15 031'5 n l8 orua nth, lllnflr 111ontn of oreCJnancv 8 

ROS •• OA•15 0~1"i H 'l9 orua nth, lunar 'IIOnth of oreqnal"'cV q 

AOfi •• OA•t5 

79"i •• OA•15 031'5 47 42 

OJl"i 26 79 orua oruq "th, lun~tr 'llonth ot orP.qnancv unknown 

ntl't, nltllll" 

623n •••• w-4 10 13 oruct, actfVf' COIIIPOUnd, code 

6231 •••• w-4 

14 14 Orua, arttve eompound, use frequency, 

6732 •••• w-4 

15 15 Druq, active co111oounc1, use frequency, 

&241 •••• w-4 

24 74 orun, IIC"ttve COIIIOOUf'ld, liSP. freqnel"'cy, 

&24?. •••• 111-4 

2"i 75 orua, aC'tiVI" COIIIoOUnd, use frP.quency, 

four weeki prior to LMP 

lunar month of oreqnancy, 

lun'lr 111ontn of oreanaf'lcy, 

lun~tr montl\ of ori"Qnancv, 

w 

olus 

0'1 

.... 6233 •••• w-4 

16 16 oruo, active compound, use frequency, 

6234 •••• 11-4 

17 17 oruCJ, act1Vf' COIIIDOUnd, liSP. frequency, lunar lunar 111ontn 

month of of 

oreqnancy, preqnancy, 2 

3 

6235 •••• 111•4 

111 '8 

b236 •••• w-4 

1CJ 19 orua, 

Orua, acttve 

acttve co'llpound, use frequency, lunar month of 

COIIIDOUnt:l, use fre~uency, l1Jnl'.lr 111ontn of oreqnancy, 

oreqnancy, 4 

5 

6237 •••• 1111-4 20 ?.0 oruct, active co'llooun:t, use frequ~ncv, lunar •onth of oreqnancy, b 

6238 •••• w-4 21 ?1 Orua, acttvl" COlli POUnd, liS@ frP.quencv, lunar IIOnth of oreqnancy, 7 

6239 •••• 111-4 

21. ?2 orua, a~tlve compound, use fr@quencv, lunar 11onth of preqf'lancy, 8 

6240 •••• 111-4 2) 23 orua, ltC'tiV@ C'OIIIOOUnd, use frequency, lunar 11101\th of preqf'lancy, 9 

6?41 •••• 111-4 

26 ?6 orua, acttvP comoound, l1S@ fre~llency, lunl'.lr 11onth of oreqnancy, 

unlenow" 

6214 •••• 1i•3 10 13 orua, trarte na111e, co::le 

&22J •••• w•3 

22 22 

621S •••• w-3 

14 14 orua, 

Drua, trade 

trade name, use freqeuncy, lunar 111onth of pregnancy, 9 

name, use frequency, fonr weeles prtor to L.. P 

6216 •••• 111•3 1"i 15 Orua, tratte name, use freauenev, lunar 111ontn of pregnancy, 1 

622S •••• w-3 24 ?.4 oruo, trade n~tme, use frenuency, lunar month of oreqnancy, tO 

b126 •••• il-3 

2"i 75 orua, tra1e n~tmf!, use freauency, lunar lllol"'th of oreanancy, t1 plus 

Q 

6217 •••• N-3 

16 1b Orua, trat1e nRIRe, use fre!luP.ncv, lul\ar month nf oreqnancy, ?. 

I 

.... 

6219 •••• N•l 

l11 621CJ •••• w-3 

622o •••• w-3 

6221 •••• w-3 

&227 •••• 111•3 

17 

1~ 

1Q 

20 

21 

17 

18 

19 

20 

71 

oru11, 

orua, 

Drua, 

oruo, 

orua, 

trat1e 

trade 

tral1e 

trar'le 

trar'le 

na111e, 

na111e, 

name, 

na11e, 

nl'.l'lle, 

use 

use 

use 

use 

use 

frequency, 

freauency, 

frequency, 

frequf'ncy, 

tren


F"orm Item ~umbers lln~ed to nata Items on OR-15, Or II CIS fn Pre:lnitn~v 

lTI::"'' 

ON 

FO~Ioll 

!lATA 

rrr::M 

10 

&224 •••• 111-l 

6227 •••• w-l 

793 •• 08•15 

791 •• OR•t5 

H?. •• oR-15 

790 •• 01\•15 

&l64 •••• VAR 

7BA •• Ol'•t5 

787. • OR • t 5 

78CJ •• OA•l5 

794 •• DR•15 

CARO 

NIIM FRO loll TO DArA TrF.114 NAMF. 

OHS 

OH"i 

o:uo; 

0315 

0315 

0 31 c; 

Oll"i 

Oll"i 

21 

26 

24 

22 

21 

21 

14&1 

17 

15 

t«J 

2"i 

23 

?& 

14 

22 

13 

?1 

1463 

18 

tb 

20 

25 

use freauen~v, 

lunar month 

lunar month 

uruq, trarte n~t111e, 

orun, tr~t1e nt~nP, use frenuPncy, 

oruasJ merticatlons, none t31cen 

F'or111s, 08•12, nu11ber 

Forms, OB•47, nu11ber 

Hospital lldmtsstons, numbPr antP partum 

Hnsoltallzatlnns !lnteoartll'R 

Menstru111 history: f,ICP fro11 01\•4 Cdayl 

Menstrual hlstorv: LMP frO'I 01'\•4 (1110) 

Menstrual hlstorv; L'IP frO'I OR•4 cvrJ 

NacHot'frephVI X•rav oelvJ•etrv 

of 

of preanancv, 

preqnancy, 

9 

unknown 

. -~· ... 

H 

H 

> •w 

.., 0'1 

@ 

I 

....... 

l11

DEFINITION OF CODES 

DRUGS lN PREGNANCY 

FORM OB-15 CARD 0315 

FIEW 

CARD 

CODJMN 


Code: 0 


Code: 315 

3· Revision Number 

5 

Code: 0 - Form Dated: 5/63 


Nine-digit number for Pat~ent Identification 


5· IMP (o:e-4) 15-20 

Six-digit number for month (cols. 15-1.6), 

day (cols. 17-18), and year (cols. 19-20) 



6. Number of Ant~artum .Adl!lissions 21 


1-7 - Number reported 

8 - 8 or more reported 

9 -Unknown 

7- Number of OB-l2 Forms 


8. Number of OB-4:Z: Forms 23 


9· No Drusa Taken 24 

Code: 0 - Drugs taken 

1 - No drugs taken 

10. X-Ral Pe1vimet!,"Z 25 

Code: 0 - No 

1 - Yes 

Revised March 1965 

II.A.363 

OB-15 


DEFINITION OF CODES (Continued) FOFM OE-15 

Card 0315 

FIELD 

CARD 

COLUMN 

ll. 

FIRST DRUG 

Fourteen-digit code for: 

D~~g (columns 26-29) 

Code: 

See Attachment "Drugs In Pregnancy" 

pRge OB 15-4 - 6 

Lunar Month of Pregnancy in 

Which Taken 

Four·weets prior to LMP (col. 30) 

First Month (col. 31) 

Second Month (col. 32) 

Third Month (col. 33) 

Fourth Month (col. 34) 

Fifth Month (col. 35) 

Sixth Month (col. 36) 

Seventh Month (col. 37) 

Eighth Month (col. 38) 

Ninth Month (col. 39) 

Tenth Month (col. 4o) 

Eleventh month or more (col. 41) 

Unknown Month -(col. 42) 

Code for each colunm: 

¢ -- Not·-:ta.ken 

A - Taken 1 day only 

B - Taken 1-7 days 

C - Taken more than 7 days 

D - Taken unknown time 

NarE: If No Drugs are reported, card ends in column 25. If more 

than one.drug reported, a card is punched for each drug with 

columns 1-42 same aa above. 

Revised 1-!a.rch l965 

II.A.364 

OB-15 



(08-15) 

Blank 

0010 

0011 

0012 

0013 

0014 

0015 

oafs 

0017 

0018 

0019 

0021 

0022 

0023 

0024 

0025 

0026 

0030 

0031 

0032 

0033 

0034 

0035 

0050 

0051 

0052 

0053 

0054 

0055 

0056 

0057 

0058 

0059 

·ooso 

0061 

0062 

0063 

0070 

0071 

0077 

0078 

0081 

0096 

1000 

1001 

1002 

No drugs 

Dinitrogen Monoxide 

Cyclopropane 

Anesthetic Ether 

Trichloroethylene 

Ethylene 

Bromochlortrifluorethane 

Fluoromar 

Chloroform 

Aethylis Chloridum 

Vinyl Ether 

Somnoform 

Alcofonn 

Anesthol 

GOE 

Oxygen 

Methoxyflurane 

Cyclonal Sodium 

Surital Sodium 

Intraval Sodium 

Brevital Sodium 

Hydroxydione Sodium 

G29-505 

Cyclaine 

Diothane HCl 

Isocaine 

Chloroprocaine HCl 

Dibucaine HC1 

Amethocaine HCl 

Allocaine 

Blockaine 

Xylocaine 

Amylocaine HCl 

Carbocaine 

Oxaine 

Anesthesin 

Butethamine HCl 

Diethyl (Allyl Methox-Phenoxy) 

Acetamide 

Cytamest 

Caine Derivatives, n.o.s. 

L 67 

Nupercaine Lozenge 

Bratacaine 

Antibiotics, n.o.s. 

Chloramphenicol 

Erythrocin 

1003 

1004 

1005 

1006 

1007 

1008 

1009 

1010 

1011 

1012 

1013 

1014 

1015 

1016 

1017 

1018 

1019 

1020 

1021 

1022 

1023 

1024 

1025 

1026 

1027 

1028 

1029 

1030 

1031· 

1032 

1033 

1034 

1035 

1036 

1037 

1038 

1039 

1040 

1041 

1042 

1043 

1044 

1045 

1046 

1047 

1048 

Furadantin 

Penicillin (all derivatives) 

Streptomycin 

Achromycin 

Gantrisin 

Sulfadiazine 

Kynex 

Flagyl 

Griseofulvin 

Isoniazid 

Mandel amine 

Mycostatin 

Para-aminosalicylic Acid 

Quinine 

Sulamyd 

Trisulfapyrimidine 

Sulphadimethoxine · 

Gentian Violet 

Sulfathiazole 

Povan 

Piperazine 

Aspidium 

Azomandelamine 

Azotrex 

Sulfaquanidine 

Sulfanilimide 

Sulfasuxidine 

Succinylsulfathiazole 

Gantanol 

Bacitracin 

Sulfamerazine 

Sulfacetamide 

Crystamycin 

Sulfapyridine 

Altafur 

Aerosporin 

Daraprim 

Pa1udrine 

Diamerazole 

Del vex 

Sonilyn 

Uri sol 

Combiotic 

Panalba 

Plaquenil Sulfate 

Hexol 


II.A.365 

Revised September 1975 

OB-15

Drugs in Pregnancy (cont.) 

1049 

1050 

1051 

1052 

1053 

1054 

1060 

1061 

1062 

1063 

1088 

1101 

1102 

1103 

11 OS 

1106 

1107 

1114 

1115 

1116 

1117 

1121 

1126 

1136 

1140 

1141 

1201 

1202 

1206 

1210 

1211 

1212 

1306 

1307 

1375 

1376 

1603 

1614 

1991 

2001 

2002 

2003 

2004 

2005 

2006 

2007 

2008 

2009 

2010 

2011 

2012 

2013 

Acrotetracyl 

K-Neopasalate 

Primaquine Phosphate 

Sulfathal idine 

Sulfadine 

Azo-Kynex 

Emetine HCl 

Benzapas 

Diodoquin 

Cystex 

Sulfa, (P.O. or Parenteral) 

Neomycin 

Albamycin 

Lincomycin 

Dihydrostreptomycin Sulfate 

Aureomycin 

Cyclamycin 

Amphotericin 8 

Distrycin 

Chloroquine 

Sul fazem 

Thiosul fil-A 

Uri sed 

Azu1fidine 

Diamerzine 

Pansul fa 

Kanamycin 

Spontin 

Oxytetracycline 

Mycelin 

Vancomycin HCl 

Paromomycin 

Declomycin 

Keflin 

Bismarsen 

Mapharsen 

Tricofuron (non-vaginal) 

Declostatin 

Myacin 

Meperidine 

Methadone 

Morphine Sulfate 

Paregoric 

Heroin 

Dilaudid 

Apomorphine 

Leritine 

Lorfan 

Alphaprodine 

Prinadol 

Na 11 ine 

Sedans 

2014 

2015 

2016 

2017 

2018 

2019 

2020 

2022 

2023 

2024 

2025 

2026 

2027 

2028 

2029 

2030 

2031 

2032 

2033 

2034 

2035 

2036 

2037 

2038 

2039 

2040 

2041 

2042 

2043 

2044 

2045 

2046 

2047 

2048 

2049 

2050 

2051 

2052 

2053 

2054 

2055 

2056 

2099 

2101 

2103 

2107 

2116 

2117 

2118 

2122 

2123 

2124 

2127 

Aldadine 

Pylodine 

Phenacetin 

Acetylsalicylic Acid 

Codeine 

Darvon 

Ethoheptazine 

Methocarbamol 

Carisprodol 

Flexin 

Chlora 1 Hydrate 

Dilantin 

Gluthemide 

Methyprylon 

Carbrital 

Phenobarbital 

Ethchl orovynol 

Secobarbital 

Ethinamate 

Magnesium Sulfate 

Barbital 

Mysolin 

Peganone 

Phenurone 

Mesantoin 

~1ephenesin 

Paradione 

Tempra 

Kemadrin 

Metaxalone 

Celontin 

Elipten 

Mercodinone 

Acetanilide 

Tensilon 

Levodromoran 

Tridione 

Valpin P-8 

Numorphan 

Dimethylane 

Marijuana 

Menalgesic 

Barbiturate, n.o.s. 

Dipyrone 

Alvodine 

Colchicine 

Sal fayne 

Butazolidin 

Tandearil 

Cogentin 

Norflex 

Artane 

Propiomazine 



II.A.366 OB-15

Drugs in Pregnancy (cont.} 

2128 Para1dehyde 

2129 Amobarbital 

2130 Papaverine HCl 

2131 Paraflex 

2132 Tuinal 

2133 Flaxedil 

2134 D-Tubocurare 

2135 Curare 

2136 Alurate 

2137 Sedulon 

2138 Lotusate 

2139 Beta Chlor 

2140 Depropanex 

2217 Sodium Salicylate 

2218 Cyclopal w/Aspirin 

2229 Delvinal 

2310 Benemid 

2329 Butabarbital 

2380 Ethyl Alcohol 

2522 Succinylcholine 

2523 Decamethonium 

2524 Isoxsuprine 

2525 Protoveratrine 

2526 Unitensen 

2527 Amyl nitrite 

2528 Peritrate 

2529 Provell Maleate 

2530 Nitranital 

2536 Salutensin 

2925 Sodium Bromide 

2933 Valerian Essence 

3022 Tranquilizer, n.o.s. 

3023 Permital 

3024 Proketazine 

3025 Compoz 

3026 Timovan 

3031 Hydroxyzine Pamoate 

3032 Chlormezanone 

3033 Mellaril 

3034 Prochlorperzine 

3035 Meprobamate 

3036 Chlordiazepoxide 

3037 Promazine 

3038 Chlorpromazine 

3039 Perphenazine 

3040 Dramamine 

3041 Meclizine 

3042 Pipamizine 

3043 Tigan 

3044 Torecan 

3045 Brompheniramine 

3046 Chlor Pheniramine 

3047 Benedryl 

3048 

3049 

3050 

3051 

3052 

3053 

3054 

3055 

3056 

3057 

3058 

3059 

3060 

3061 

3062 

3063 

3099 

3129 

3130 

3131 . 

3134 

3135 

3136 

3137 

3138 

3140 

3141 

3142 

3143 

3144 

3145 

3146 

3147 

3148 

3149 

3150 

3151 

3152 

3153 

3154 

3155 

3156 

3157 

3158 

3159 

3160 

3161 

3162 

3163 

3165 

3166 

3167 

3238 

Phenergan 

Temaril 

Lon tabs 

Methapyrilene 

Chlorcyclizine 

Ambodryl 

Stelazine 

Prolixin 

Groval 

Cholestyramine 

Benzomorphan 

Taractan 

Striatran 

Hydroxyphenamate 

Soft ran 

Probutylin 

Anti nauseant, n.o.s. 

Valium 

Vomex A 

Trepidone 

Dartal 

Deprol 

Phenoglycodal 

Trif1upromazine HCl 

Methoxypromazine HCl 

Daricon 

Cyclizine 

Verazine 

Tigacol 

Allerest 

Polaramine 

Forhistal 

Tacaryl 

Pinex 

Dormadrin 

Histadyl 

Kriptin 

Bristamine 

Asthma Tabs 

Thephoran 

Tagathen 

Anahist 

Pyralamine 

Histacin 

Actide1 

Hispri1 SKF 

Peri actin 

Diamidine 

Tridecamine 

Clistin 

Twiston Tablets 

Anthallan 

Pyrahist 


II.A.367 

00-15

Drugs in Pregnancy (cont.} 

3239 Ursinus 

3240 Emetrol 

3246 Theruhistin 

3247 Pyronil 

3248 Anergex 

4032 Asthmatic Mix 

4033 Neo-Cobefrin 

4034 Otrivin 

4035 Metropine 

4036 Aromatic Spirits of 

Ammonia (orally} 

4037 Cayt~ne 

4038 Aramine 

4039 Levophed 

4040 Elavil 

4041 Niamid 

4042 Naphozoline 

4043 Isoproterenol 

4044 Choledyl 

4045 Ritalin 

4046 Methoxamine 

4047 Mephentermine 

4048 Sudafed 

4049 Caffeine 

4050 Aminophylline 

4051 Amphetamine 

4052 Ephedrine 

4053 Adrenal in 

4054 Phenylephrine 

4055 Phenmetrazine 

4056 Atropine 

4057 Banthine 

4058 Belladonna 

4059 Pro ban thine 

4060 Chlorpropamide 

4061 Cortisone 

4062 Delalutin 

4063 Enovid 

4064 Progesterone 

4065 Propylthiouracil 

4066 Diethyl Stilboestrol 

4067 Orinase 

4068 Aquadiol 

4069 Premarin 

4070 Relaxin 

4071 Testosterone 

4072 Tace 

4073 ACTH 

4074 Lutrexin 

4075 Cytomel 

4076 Depo-Provera 

4077 Equinex 

4078 Medrol 

4079 Pitressin 

4080 

4081 

4082 

4083 

4084 

4085 

4087 

4088 

4089 

4090 

4091 

4092 

4093 

4094 

4095 

4096 

4097 

4098 

4099 

4138 

4139 

4140 

4145 

4146 

4147 

4148 

4149 

4150 

4151 

4152 

4153 

4154 

4155 

4156 

4157 

4158 

4159 

4160 

4161 

4162 

4163 

4164 

4165 

4166 

4167 

4168 

4169 

4171 

4247 

4249 

4250 

4251 

4252 

4254 

Dianabol 

Prolactin 

Nilevar 

Ovulen 

Chorionic Gonadotrophin 

Celestone 

Insulin 

Thyroid 

Norl utate 

Duphaston 

Pranone 

OBI 

Aldosterone 

Dymelor 

Glucagon 

Del estrogen 

Hormone, n.o.s. 

Progynon 

Estrogen, n.o.s. 

Bronkephrine 

Coramine 

Emivan 

Cyclogyl 

Val pin 

Isedrin 

Pamine Bromide 

Theocalcin 

Murel 

Orthoxine 

Tyzine 

Tofranil 

Benizol 

Diethylpropion 

Hyoscine 

Dicyclomine 

Nacton 

Me sop in 

Darbid 

Hydrocortisone 

Robinu1 

Nardil 

Prednisone 

Tapazole 

Parna te 

Marplan 

Hexestrol 

Ha1drone 

Halotestin 

Benzedrix Inhal. 

Camphor 

Theophylline 

Didrex 

Phentermine 

Dextroamphetamine HCl 

Reproduced at the National Archives II.A.368 OB-15

Orugs in Pregnancy (cont.) 

4256 Hyocyamus 

4257 Dacti 1 

4260 Pro-Decadron 

4261 Decadron 

4262 Depo-Medrol 

4263 Medrol-Solu 

4264 Prednisolone 

4265 Medaprin 

4351 Phenylpropanalamine 

4357 Octine 

4358 Benzyl Benzoate 

4361 Triamcinolone 

4362 Clomophine 

4556 Neostigmine 

4557 Mestinon 

4558 Urecholine 

4559 Mytelase 

4568 Ilopan-Chol ine 

4900 Thimecil 

4971 Male Hormone, n.o.s. 

5050 Ansolysen 

5051 Aldomet 

5054 Prisco line 

5055 Ser-ap-es 

5056 Veriloid 

5057 Rauwiloid 

5058 Raudixin 

5059 Singoserp 

5060 Methium Chloride 

5064 Serpasil-Apresoline 1 

5065 Serpasil-Apresoline 2 

5066 Azapetine 

5067 Deserpidine 

5068 Apresoline 

5069 Reserpine 

5070 Acetazolamide 

5071 Amchlor 

5072 Benzylhydroflumethiazide 

5073 Chlorthalidone 

5074 Chlorothiazide 

5075 Hydroch1orthiazide 

5076 Mercuhydrin 

5077 Trichlorimethiazide 

5078 Enduron 

5079 Benzthiazide 

5080 Polythiazide 

5081 Aldactone 

5002 Metamycin· 

5083 Hydromox 

5084 Hydroflumethiazide 

5085 Cream of Tartar 

5086 Dicurin 

5087 Cyclothiazide 

5088 

5089 

5090 

5091 

5092 

5093 

5100 

5150 

5174 

5176 

5276 

6001 

6002 

6003 

6004 

6005 

6006 

6007 

6008 

6009 

6010 

6011 

6012 

6013 

6014 

6015 

6016 

6017 

6018 

. 6019 

6020 

6021 

6022 

6023 

6024 

6025 

6026 

6027 

6028 

6029 

6030 

6031 

6032 

6033 

6035 

6036 

6037 

6038 

6039 

6040 

6041 

6042 

6043 

Hydrodaine 

Mannitol 

Aldactazide A 

Harwoods Diuretic 

Dyrenium 

Dyazide 

Bellvue Cocktail 

Ismelin 

Ademol 

Thiomerin 

Neohydrin 

Milibis (vag.) 

Fl agyl (vag. ) 

Gentersal 

Massengill Powder 

Tricofuron (vag.) 

AVC 

Hyva 

Nylmerate 

Aci -Jel 

Podophyllin (vag.) 

Neosporin 

Douche Powder (lanteen) 

Gentian Violet (vag.) 

Propion {vag.) 

Sterisil 

Lysol (vag.) 

Betadine 

Douche Tabs {Jan) 

Trichotine {vag.) 

Alum Capsule {vag.) 

Metacine 

Quinine and Sulva Cap. (vag.) 

Exceptive Cream {vag.) 

Zeptabs {vag.) 

Zonite {vag.) 

Potassium PermanJanate {vag.) 

San Powder (vag. 

Hy-G Douche Powder 

Terramycin {vag.) 

Triva (vag.) 

Gantrisin {vaJ.) 

!11'11'10 1 in; (vag. 

Vagisec (vag.) 

Vioform 

PMC {vag.) 

Trib (vag.) 

Quinseptikons (vag.) 

Pimafucin (vag.) 

Gynomin 

Ramses (vag.) 

Cardui (vag.) 

Penicillin Cream (vag.) 


II.A.369 

OB-15


6044 

6045 

6046 

6047 

6048 

6049 

6050 

6051 

6052 

6053 

6054 

6055 

6056 

6057 

6058 

6059 

6060 

6061 

6062 

6063 

6064 

6065 

6066 

6067 

6068 

6069 

6070 

6071 

6072 

6073 

6074 

6075 

6076 

6077 

6078 

6079 

6080 

6081 

6082 

6083 

6084 

6085 

6086 

6087 

6088 

6089 

Sulfa Cream (vag.) 6099 

lysette (vag. ) 6101 

lycinate (vag.) 6102 

Baculin (vag.) 6103 

RC-C-122-R (vag.) 6104 

Cooper creme (vag.) 6105 

Contra squares (vag.) 6106 

Mu-col (vag.) 6107 

Furestral Vag. Supp. 6108 

Zestabs Contraceptive 6109 

Rocky Mountain Spotted Fever Vaccine 6110 

BIP 6111 

Paratyphoid Shot 6112 

Vacagen 6158 

Rabies Vaccine 6666 

Bacillus Calmette Guerin 

Poison Ivy Vaccine 7024 

Allergy Shots 7101 

Hypos en 7102 

Poll en Vaccine 7103 

Dust Extract 7104 

Triple Typhoid 7105 

Catarrhalis Vaccine 7106 

Mumps Vaccine 

Staphylococcus Vaccine 

Pertussis Vaccine . 

Black Widow Antitoxin 

Yellow Fever Vaccine 

Cholera Immunization 

Typhus Shots 

Measles n.o.s. 

Po1i o , n . o . s . 

Diphtheria Toxoid 

Typhoid Immunization 

Influenza Shots 

Measles, Killed 

Measles, live-oral 

Polio, Killed 

Polio, live-oral 

Smallpox 

Tetanus Toxoid 

Floraquin 

Furacin 

Mycostatin, vag. 

Sporostacin 

Sultrin Cream 

7107 

7113 

7114 

7115 

7116 

7117 

7118 

7119 

7121 

7122 

7123 

7124 

7125 

7126 

7127 

7128 

7129 

7130 

7133 

7134 

7136 

7143 

7144 

Oral Contraceptives, n.o.s. 

Duraform (vag.) 

Vaseline and vag. 

Kotnex Cream &vag. 

Delta Contraceptive Jelly 

Aquacort Vag. supp. 

Ortho-Cream 

Stoma sept in 

Triform 

Pulsatilla Nigra 

Ora-Jel &Contraceptive 

Blue Seal Vag. Gel 

Conatopins 

Devegan 

Unknown if Phenergan- 

Hasp. SO Only 

General Anesthesia, n.o.s. 

Biomydrin 

Hibitane 

Cycloserine 

Durycin A.S. 

Dicrystacin 

Achrocidin 

V-Kor 

Signemycin 

Glucosamine 

Polymagma 

Triquin 

Azo-Gantrisin 

Azo Gantanol 

Suladyne 

Hydrozet 

Semets 

Cepacol 

Thantis 

Tracinets 

Mysteclin 

Candettes 

6090 Del fen 7145 Pent ids 

6091 Emko 7146 Biosulfa 

6092 Orthogynol 

7147 

6093 Precept in 

7148 

6094 Lorophyn 

7149 

6095 Zonitore 

7150 

6096 Certane 

7151 

Candie ill in 

Pomalin 

Pyridium Tri-Sulfa 

Bradosol 

larylgan 

Urobiotic 

Pen-Tabs 

Pen-Alba 

Gantricill in 

Aldiazol 

Trisulfaminic 

Spectrocin T 

Cosa-Tetrastatin 

6097 Koromex 7152 Achrostatin 

6098 Tetanus Antitoxin 7153 Terracydin 


II.A.370 

OB-15

. 


7154 Sul-Pondets Troches 

7155 Bio-Kets 

7156 Ilosone Sulfa 

7157 Orabiotic 

7158 Neo-Delta-Cortef 

7159 Cremomycin 

7161 Synthaloids 

7162 Mesulfin 

7163 Supronal 

7164 Quintess-N 

7165 Aura1gan 

7170 Dri 1ito1 

7171 Tetraci1lin 

7172 Pentazets 

7174 Syndecon 

7175 Pondets 

7176 Rhinitis Mix 

7177 Co1ymycin 

7203 Opium 

7204 Pantopon 

7205 . Opi urn-Be11 adonna 

7206 Pabi zo1 

7207 Colbenemid 

7208 Parepectolin 

7209 Do1oni 1 

7210 Phelantin Kapseals 

7211 Copaine with Codeine 

7212 Asafen 

7213 A1ysine 

7214 Pabalate 

7215 Phenaphen 

7216 Edrisal 

7217 Anacin 

7218 Percodan 

7219 Darvon Compound 

7220 Daprisa1 

7221 Excedrin 

7222 Fiorina1 

7223 Axoto1 

7224 Trigistic 

7225 Parafon 

7226 Arrestin 

7227 Ethecodene 

7228 Phen #3 

7229 Nebra1in 

7230 Opta1idone 

7231 Emagrin 

7232 Hycodan 

7233 Lumaspirin with Hyocyamus 

7234 #844 

7235 P1exona1 

7241 Tranquil 

7242 Madricidin 

7243 Passiphen 

7244 Copavin 

7245 Trancoprin 

7246 Pentagesic 

7247 Librax 

7248 Triaminicin 

7249 Bladder Sedative Mix 

7250 Mephergan 

7251 Donnozyme 

7252 Aludrox 

7253 Paadon 

7254 Dovacet Capsules 

7255 Rebutal 

7256 Wygraine 

7257 Anadol 

7258 Be1barb 

7259 Hasacode 

7260 Sedaphen 

7261 Hasamal 

7262 Synirin 

7263 Barbidonna 

7264 Acogesic 

7265 Va1octin 

7266 Bellerga1 

7267 Phenocin DA 

7268 Acetylphen 

7269 Nembudeine 

7270 Empiral 

7271 Antispasmodic Elixir 

7272 Midrin 

7274 Sigmagen 

7275 Rotase-Mitte 

7276 Pamine with Phenobarbital 

7278 Defencin 

7279 Robaxisal-Ph 

7280 A1goson 

7281 Trigesic 

7282 Mebaroin 

7283 Aspirin Compound 

7284 Zarumin 

7285 Cofedrine 

7286 4S/8S 

7287 Kamumodic 

7289 Penscope 

7290 Ethobra1 

7291 Phenobell 

7292 Ropad 

7293 Butigetic 

7294 Nembu-Donna 

7236 · Quieta 1 7295 Eskaphen B 

7237 Arcade 7296 Kanulase 

7238 Ch1oranodyne 7326 Citrophen 

7239 Robaxi sa1 7327 Hycomine 

7240 Serenitas 7328 Sinutabs 


II.A.371 

OB-15

Drugs in Pregnancy (cant.) 

7333 Equagesic 7415 All ertonic 

7334 Prozine 7420 Lomoti 1 

7335 Vitonex 7425 Norm in 

7336 Darvo-Tran 7428 Mudrane 

7337 Maredox 7429 Butibe1 

7338 Nausex 7430 Be11adeno1 

7339 Banausea 7431 Mag1yn Magma CPO 

7340 Bendectin 7433 Qui bran 

7341 Prenausen 7434 Combid 

7342 Bucl ad in 7435 Ba11 a fa 1 i ne 

7343 Na1decon 7436 Metreton 

7344 Tuss-Ornade 7437 Kol anty1 

7345 Tro1ar/E1 ixir 7438 Donna1ate 

7346 Novahistine 7439 APE 

7347 Ornade 7440 Syntil 

7348 Triaminic 7441 Monase 

7349 Pyrroxate 7442 Bronkotabs 

7350 Actifed 7443 Natorexic 

7351 Co-Pvroni1 7444 Prelu Vite 

7352 Rhinalgan 7445 Bontri 1 

7353 NTZ 7446 . Bamadex 

7354 Luasmin 7447 Appetro1 

7355 Frano1 7448 Eskatro1 

7356 An to sen 7449 Quadrinal 

7357 Nethaprine 7450 AEA 

7358 Dimetapp 7451 Dexamyl 

7359 Bihistrin 7452 Ambar 

7360 Disophrin 7453 Tedral 

7361 Neo Bronchoid 55 7454 Amodrine 

7362 Rynatan 7455 Amphedase 

7363 Fedrazil 7456 Be lap 

7364 Decotussin 7457 Marax Syrup 

7365 Kolephrin 7458 Donna tal 

7367 Para-Hist 7459 Donna gel 

7369 Hesper C 7460 Cantril 

7370 Synephricol 7461 Ataraxoid 

7371 Syntussin 7462 Deluteval 

7372 C1istanal 7463 Trisocart 

7373 Phenergan Expectorant 7464 Pro-Estrone 

7374 Duadacin 7465 Gestest 

7375 Novahistine DH 7466 Pro-Duosterone 

7376 Tranquil Aid 7467 Tristerone 

7377 Thephorin AC 7468 8ardase 

7378 Hespergesic 7469 Neo-Cortef 

7379 Pharmhistine 7470 Nugestoral 

7380 Mil path 7471 Duo harm 

7382 Tri lamine 7472 Deladumone 

7383 Cafaryl 7473 Gevrestin 

7384 Serpa ti 1 in 7474 Cordex 

7385 Rinohist Syrup 7475 Cytran 

7386 Mil prem 7476 Neo-Hydeltraso1 

7388 Kryl 7477 Desplex 

7389 Covanamine 7479 Dainite 

7401 Cafergot 7480 Cal a trap 

7402 Migral 7481 Nul abort 


II.A.372 

OB-15

1 Drugs in Pregnancy (cont.) 

7482 Ortho-Novum 8225 

7483 Biphetamine T20 8226 

7484 Estrosed 8227 

7485 Bifran 8228 

7486 Dexabarb 8229 

7487 Amvicel 8230 

7488 A M Plus 8232 

7489 Thin-Down 8233 

7490 Reladine 8234 

7491 Calradine #2 8250 

7525 Veralba 8251 

7550 Benedrin 8252 

7555 Rauwidrine 8270 

7556 Diupres 8274 

7568 Miopressin 8275 

7569 Butiserpine 8276 

7570 Serbutal 8277 

7571 Butizide 8331 

7572 Matrite #2 8332 

7575 Hydro pres 8333 

7576 Enduronyl 8334 

7577 Brondecon 8335 

7578 Rautrax 8336 

7910 Medigum 8337 

7930 Vio-Dex 8338 

7990 Anusol 8339 

7991 Wyanoid 8340 

7992 Desitin HC Supp. 8341 

7993 Cardol 8342 

7994 Medicone 8343 

7995 Syppository, Anesthetic n.o.s. 8344 

7996 Nupercainal Suppository 8345 

7997 Anesthesin Suppositories 8346 

7998 PNS Suppositories 8347 

8107 Mycinettes Troches 8348 

8108 Sulfa Lozenge 8349 

8109 Squibbs Lozenges 8350 

8110 Biotroches 8351 

8111 666 Cough Syrup 8352 

8209 Alum Powder-Orally 8353 

8210 Dewitts Kidney Pills 8354 

8211 666 Tablets 8355 

8212 Alka Seltzer 8356 

8213 Bromo Seltzer 8357 

8214 Bromoquinine 8360 

8215 B.C. Powders 8690 

8216 Stanback 8691 

8217 Four Way Cold Tablets 8902 

8218 Miles Nervine 9001 

8219 Midol 9002 

8220 Rem 9003 

8221 Santa Caps 9004 

8222 Rexatuss 9005 

8223 Tetrazets 9006 

8224 Rid-A-Pain 9007 

Isodine 

Diamine 

Phenamid 

Nap 

Pheno-Bromide 

Calmers 

Brochine-Menthol 

Bistrimate 

Trimicin Trokes 

Her Tabs 

Femicin 

Co-A Dec 

Doz-0-Nol 

Dremelon 

Canadian 222 

Coldrex 

Amidophen 

Proquil Capsules 

Sinocap 

Ni-Span 

Cotussin 

Coryban-D 

Nolamine 

Dri-Con 

Contac 

Histotussin 

Coldene 

Azmar 

Primatene 

Allergi Caps 

Haysma 

Dristan 

Coricidin 

Coricidin D 

Inhist 

Sominex 

Sleep-Eze 

Somni Caps 

Emprazil 

No Doz 

Nite-R 

Dohistan 

Sleep Tablet 

Minagest 

Pectrol 

Norforms 

Bropheno-Form 

Midragen 

Digitalis 

Digitoxin 

Quinidine 

Cedilanid 

Sodium Tetradecyl Sulfate 

Digoxin 

Phenol 


II.A.373 

OB-15


9008 Safflor Caps 9115 

9013 Pronestyl 9116 

9015 Bantron 9117 

9050 Heparin 9118 

9051 Dicumarol 9119 

9052 Coumadin 9120 

9055 Axon Throat Spray 9121 

9056 Dobells Solution 

9057 Micrin Lozenges 9122 

9058 Gargle Tablets 9123 

9059 Dr. Tichenors Anti-Septic Gargle 9124 

9060 Anisole 9125 

9061 Hydrogen Peroxide 9126 

9062 Tonsiline 9127 

9063 Sucrets 9128 

9064 Orathricin 9129 

9065 Argyrol Nose Qtts. 9130 

9066 Zephiran Chloride 9131 

9067 Chloroseptic 9132 

9068 Rhinall Nose Drops 9133 

9069 Penetrol Nose Drops 9134 

9070 Efedron Nose Drops 9135 

9071 Nasa Nasal Spray 9136 

9072 Gluco-Fedrin 9137 

9073 Spray R 9138 

9074 Bena Fedrin 9139 

9075 Nefrine 9140 

9076 Spectrocin 9141 

9078 Neohist 9142 

9079 Rhinazine Nose Qtts. 9143 

9080 Nasalaire Inhaler 9144 

9081 Congestaid Nasal Spray 9145 

9082 A1con-Efrin 9146 

9083 Medicated Throat Discs 9147 

9084 Paradrine Nose Drops 9148 

9085 Cocaine Nose Spray 9149 

9086 Phedric Nose Drops 9150 

9090 Lysol 9151 

9094 Eugenol 9152 

9095 Pharycidin Garg 9153 

9100 Brown Co1 d Tab 9154 

9101 Elixir Terpin Hydrate 9155 

9102 Benadry1 Expectorant 9156 

9103 Cheracol 9157 

9104 Robitussin 9158 

9105 Co1ban Cough Medicine 9159 

9106 Pertussin 9160 

9107 Pyraldine 9161 

9108 Tussaminic 9162 

9109 Endotussin 9163 

9110 Vicks Cough Syrup 44 9164 

9111 Prunicodeine 9165 

9112 Creomu1sion 9166 

9113 Levopropoxyphene 9167 

9114 Orthoxicol 9168 


II.A.374 

Chaneys Cough Syrup 

Tussagesic 

Cosadein 

Isodettes 

Romilar 

Sedatole 

Charcoal I Rexall Cherry 

Cough Syrup 

Triaminical 

Romex Cough Syrup 

Tyrozets 

Remcoff 

Hydoden 

Tangro Cough Syrup 

White Pine Syrup 

Be 11 s Co4gh Syrup 

Pee-Kat 

Cobenzil 

Quelidrine 

Thorexin 

Cosanyl 

Creoterpin 

St. Josephs Cough Syrup 

Antipec Cough Syrup 

Ambenyl 

Cherry Flax Cough Syrup 

Vidor Cough Syrup 

Coplexen 

Calcidrine 

Tussionex 

Breocol 

Cocillana 

GI Gin Clear Liquid 

Hydrillin 

Remicol C.ough Syrup 

410 Expectorant 

Santaminic 

Secremol 

Actin 

Ana col 

Codessin 

Mercadol 

Cotussis 

Dicotuss 

Dondri1 

Martussin 

Meditussin 

Tessalon 

Ipecac 

Pinacol 

Pentro Cough Syrup 

Crealy Cough Syrup 

Knock Out Cough Drops 

Sawyers Cough Syrup 

Ipsatol 

--- 

OB-15


9169 

9170 

9171 

9172 

9173 

9174 

9175 

9176 

9177 

9178 

9179 

9180 

9181 

9182 

9183 

9184 

9185 

9186 

9187 

9188 

9189 

9190 

9191 

9192 

9193 

9194 

9195 

9196 

9197 

9198 

9200 

9201 

9004 

9210 

9211 

9212 

9213 

9215 

9217 

9218 

9220 

9304 

9305 

9338 

9345 

9346 

9401 

9402 

9403 

9404 

9405 

9406 

9407 

9408 

Tricodeine 

Sedative Cough Syrup 

Rileys Cough Syrup 

Soltice Cough Syrup 

Vitalix 

Watkins Cough Syrup 

Ward Cough Syrup 

Bristalin Cough Syrup 

Epsidol 

Expectorant Cough Syrup 

Anestin Cough Syrup 

Longserver Cough Syrup 

Pine-O Tar Syrup 

Angells Syrup 

Krey Cough Svrup 

A H Cough Syrup 

Expectina 

Toclase 

Dictorate 

Mistol Mist 

Bayers Inhalant 

Minagest with Codeine 

Certurpin 

Super-Anapac 

Smith Brothers Cough Medicine 

Mathieus Cough Syrup 

Foleys Honey/Tar Cough Syrup 

Dadamos Cough Syrup 

Hays Cough Syrup 

Juniper Tar 

Cerose 

Vi sine 

Robitussin AC 

Go-Kof Cough Syrup 

Hista Cough Syrup 

Seth Cough Compound 

Havens Cough Syrup 

Dilaudid Cough Syrup 

Cothera Cough Syrup 

Buckleys Cough S.vrup 

Tussacaine 

Dramamine Placebo 

Isoxsuprene (Exper. Study) 

Levomepromazine (Mepromazine) 

Anti-Histamine, n.o.s. 

Poisonok 

S.vntocinon 

Oxytocin 

Sparteine Sulphate 

Ergonovine 

Methergine 

Ergoapiol 

Gynergen 

Sansert 

9409 

9425 

9430 

9431 

9432 

9433 

9434 

9435 

9436 

9437 

9438 

9439 

9440 

9441 

9442 

9443 

9444 

9445 

9446 

9447 

9449 

9450 

9451 

9452 

9453 

9454 

9455 

9456 

9457 

9458 

9459 

9460 

9461 

9462 

9463 

9464 

9465 

9466 

9467 

9468 

9469 

9470 

9471 

9472 

9473 

9474 

9475 

9476 

9477 

9478 

9479 

9480 

9481 

9482 

Uteramine 

Nasal ene 

Chlortrimeton- Ephedrin Syrup 

GG Expectorant 

Histadine Cough Syrup 

Tussar Cough Syrup 

Axon Cough Medicine 

Ulominic Syrup 

Bona Tuss Cough Syrup 

Sedative Cough Mixture 

Dulsana Cough Medicine 

Guaiacol Carbonate 

Codeine Cough Syrup 

Dimetane Expectorant 

Scot-Tussin 

Bucal Cough Svrup 

Tussin 

Troutman Cough Syrup 

Jarabe 

Epsatol 

Cosadein Cough Mixture 

F &F Cough Syrup 

Oradex Lozenges 

Guiaphan Cough Syrup 

Organidin 

Honey-Hist 

Hasanone 

Meggezones 

Dover Pills 

Pyribenzamine Expectorant 

Quajani · 

Sweet Spirit of Niter 

Theratuss Tabs 

Cofa1in 

Quinine Cold Tabs 

Slippery Elm Loz. 

Senodin Cough Syrup 

Cees Cough Medicine 

Co1dmaster Cough Syrup 

Supra C 

Diabetic Cough Syrup 

Mothers Friend 

Linden Cough Balsam 

St. Johns Cold Tabs 

Chestinex Cough Syrup 

Medics Throat Lozenges 

Asafoetida 

Lemon/Turpentine Mixture 

Emo-Caps 

Vegavine Compound 

Teek Cough Syrup 

Cough Syrup 1999 

Neohistin 

Super Plenamin Cough Syrup 


II.A.375 

OB-15


9483 Hacks Cough Drops· 

9484 Halks Cough Drops 

9485 Baby Bee Cough Medicine 

9486 Dr. Lyon Cough Medicine 

9487 Narc on 

9488 PID Mixture 

9489 VM Cough Mixture 

9490 ULO 

9491 360 Cough Syrup 

9492 Remilor CF Cough Syrup 

9493 Clemson Cough Syrup 

9494 Big Three Cough Syrup 

9495 Aristal Cough Syrup 

9496 Super Anahist Cough Syrup 

9497 Hydraturbin Cough Mixture 

9498 Downeys Cough Syrup 

9499 Ronmanoff Cough Mixture 

9500 A leva ire 

9501 Tergemist 

9553 Ananase 

9554 Papase 

9555 Protamide 

9557 Chymolase 

9558 Alidase 

9559 Diuretics, n.o.s. 

9560 Decholin 

9561 Depancol 

9600 Benzine 

9608 M Solution 

9610 KCL IV 

9611 NAHCO IV 

9612 Potas~ium Triplex 

9701 Brytylium Tosylate 

9702 Lederkyn 

9703 Stop-Kof 

9705 Imperal T.L. 

9706 Eze Pain 

9707 WY 1359 

9708 Derm-B 

9709 Sandman Sleeping Pill 

9710 P25 25 

9711 Sedative 222 

9712 Group A Pi 11 s 

9713 Group 8 Pi 11 s 

9714 Prexonate 

9715 5029 8 

9716 Ayds 

9717 Free Day 

9718 L icaran AF 

9719 Largan D 

9720 Licaron, n.o.s. 

9721 WY 1359 G 

9725 Tr-Nux Vomica 

9731 Leen Caps 

9735 Rutorbin 

9801 

9802 

9803 

9804 

9805 

9806 

9807 

9808 

9809 

9811 

9812 

9813 

9814 

9834 

9860 

9871 

9888 

9901 

9902 

9903 

9904 

9905 

9906 

9907 

9908 

9909 

9910 

9918 

9919 

9920 

9921 

9922 

9923 

9924 

9925 

9926 

9927 

9928 

9929 

9930 

9931 

9932 

9933 

9934 

9938 

9939 

9940 

9941 

9942 

9943 

9944 

9945 

9946 

9947 

9948 

Jiffy Powder 

Syrup of Black Draught 

Scotts Emulsion 

Browns Mixture 

Honey Pine Tar 

Humphreys II 

Citrahist 

Lydia Pinkham 

Goody Powder 

Nemisis 

Doanes Pills 

Night Caps 

Regimen 

Histo-Plos 

Ami tone 

Horehound Cough Drops 

Drug, Unknown Type 

Vitamin K 

Protamine 

Gestatabs 

Compound of Rhubarb 

Carters Liver Pills 

Distovagal 

Admadion 

Sodium Thiosulfate 

Sodium Fluoride 

Adrenosem Salicylate 

1987 2A 

1991 2A 

Pathilon 

Iodides, n.o.s. 

Radio Active Iodine 

IVP, n.o.s. 

Diodrast 

Renograffin 

Telapaque 

Hypaque 

Carachol 

Iodo-Neacin 

Iodine 

Orenzyme 

Chymar 

Buccal Varidase 

Amanase 

Dilabil 

G.B. Tablet 

Histalog 

Decholine 

SSP 

PSP 

Regitine 

Vitamin 812, labeled 

Pantopaque 

Renovist, Inj. 

Evans Blue 


II.A.376 

OB-15


9949 

9950 

9951 

9952 

9953 

9954 

9955 

9956 

9957 

9958 

9959 

9960 

9961 

9962 

9963 

9964 

9965 

9966 

9967 

9968 

9969 

9970 

9971 

9972 

9973 

9974 

9975 

9976 

9977 

9978 

9979 

9980 

9981 

9982 

9983 

9984 

9985 

9987 

9988 

9989 

9990 

9991 

9992 

9994 

9995 

9996 

9997 

9998 

9999 

Risa 

Hippuran 

Imferon 

Iron, IM/IV 

Co-Liv-One/I.M. 

Conray 

SKF #1340 

960 Pills 

BA 17922 

Control 24 

Methylene Blue 

SKF #5 

SKF 

Win 

Psilocybin 

Base Oxide 

Sau 

SH 735 

A S I 

Sal 7922 

Diazoxide 

Kucin DM-2 

Aminopterin 

Chlorambucil 

Vasopressor A 

Vasopressor C 

Vasopressor B 

Roche #10 

Vasopressor E 

AX 59034 

AN 2095 

Cold Caps, n.o.s. 

Father Johns Medicine 

Coldettes 

Anis 

Dalex Cold Capsules 

Centrine Cold Tablets 

Copoietin 

Pabisal 

Other specified Drugs, 

not elsewhere classified 

SCH 3940 

SCH 3940D 

Methotrexate 

#30 Solution 

Parstellin 

WY 

Dopan 

Drug Unknown Name 

Unknown if any drug 



II.A.377 

OB-15


DIDOS IN PRIDNANCY 

FORM OB-15 

H 

H 

>0 

w 

00 

" 

0 

t8 

~ 

., 

CAlD 

O~li 

,...os 

'I'= ., 

~ 

llliii\R ...... 

Plfillllt'f 

8/.IIAJ~ 

* If no drug taken, card ends in cotumn 25 

** A card exists for each drug reported for a given NINDB number 

8 

I 

...... 

U1

Prenatal Record - National Archives and Records Administration

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