A Illinois Family Planning Clinic Visit Record

Section 635 Section 635.APPENDIX A Illinois Family Planning Clinic Visit Record ILLINOIS FAMILY PLANNING CLINIC VISIT RECORD Name Pt # Address Phone # 1. FORM NUMBER C121002 12. SERVICE PROVIDERS/BCRR ENCOUNTERS SECTION A ALL VISITS Medical (check one) Counseling (check one) 1. Physician 2. SERVICE SITE NUMBER 2. Mid-Level Pract. 3. Nurse 3. PATIENT NUMBER 4. Ed./Counselor 5. Nutritionist 6. Social Worker 4. DATE OF VISIT MO DAY YR 13. METHOD AT END OF THIS VISIT (check one) 1. Oral 7. Natural Method 5. PURPOSE OF VISIT (check one) 2. IUD 8. Cervical Cap 3. Diaphragm 9. Sterilization 1. Initial Visit 5. Supply Visit 4. Foam & Condom 10, Sponge 2. Annual Revisit 6. Education/Counseling Visit 5. Spermicide 11. Other 3. Routine Visit 7. Non F.P. Visit 6. Condom 12. None 4. Problem Visit 6. DATE OF BIRTH MO DAY YR 14. IF NO METHOD, REASON FOR NONE (check one) 1. Pregnant 4. Other Medical Reasons 7. PRIMARY SOURCE OF PAYMENT (Check One) 2. Infertility 5. Relying on Partner's Method 3. Seeking Pregnancy 6. Other 1. Medicaid Only 4. Full Fee 15. REFERRALS MADE (check up to two codes) 2. No Fee (0-100%) 5. FWF Only 1. Sterilization 7. STD 3. Part Fee (101%-250%) 6. Medicaid and FWF 2. Gynecology 8. Other Medical 8. BILLABLE MEDICAL SERVICES 3. Prenatal 9. Other F.P. Clinic 1. Minimal Service 13. Misc. Culture 4. Other Pregnancy 10. Infertility 2. Brief/Int. Exam 14. Sickle Cell 5. Social Service 11. Nutrition 3. Extended Exam 15. PP Blood Gluc. 6. Contraception 12. Other 4. IUD Insertion 16. Cholesterol Level SECTION B INITIAL, ANNUALS 5. Diaphragm Fit 17. SMA-12 ZIP CODE FIPS 6. HGB/HCT 18. Colposcopy 16. RESIDENCE CODES 7. U/A 19. Colposcopy & Biopsy 17. ETHNIC ORGIN/RACE (check one) 8. Pregnancy Test 20. Sonography/Lost IUD 1. White 4. Asian or Pacific Islander 9. VDRL 21. X-Rays/Lost IUD 2. Black 5. Hispanic 10. PAP Smear 22. Chlamydia Test 3. Native American 11. Gonococcal 23. Cervical Cap Fit 18. SEX (check one) 12. Wet Mount 24. None 1. Female 2. Male 9. BILLABLE COUNSELING SERVICES 19. EMPLOYMENT STATUS (check one) 1. Indepth/l Hr. 2. Counseling/15 min. to 1 Hr. 1. Employed 3. Not In The Work Force 1 0. ROUTINE COUNSELING SERVICES 2. Unemployed 1. Sterilization 4. Pregnancy 20. GROSS WEEKLY INCOME 2. Contraception 5. STD 21. FAMILY SIZE 3. Infertility 6. Natural Family Planning 22. SOURCE OF REFERRAL (check one) 11. BILLABLE CONTRACEPTIVE SUPPLIES 1. Other F.P. Clinic 6. Other Patient Qty Brand Qty Brand 2. Hospital/Health Agency 7. Family/Friend 1. Orals 8. Basal T&C 3. Private Doctor 8. Media 2. Creams 9. Contraceptive Sponges 4. Social/Church Agency 9. Hotline 3. Jellies 10. Condoms 5. School 10. Phonebook 4. Suppositories 11. Meds/Vag Inf LOCAL USE SECTION 5. Foams 12. Meds/STD 6. Diaphragms 13. VC-Foam A B C D 7. IUD 14. Cervical Cap