Medical and Social History of the Expectant/Birth Mother Form

Medical and Social History of the Expectant/Birth Mother Form - Adoption Choices of Nevada

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Medical and Social History of the Expectant/Birth Mother Form

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Medical and Social History of the Expectant/Birth Mother Form

Medical and Social History of the Expectant/Birth Mother

You are being asked to provide information about yourself and your medical history at a time that we know is difficult for you. This information will be very important to your child in the future. Much of the information requested will assist doctors in providing medical care to your child. Because many medical conditions can run in families, we are asking for information about your relatives’ health, as well as your own. Please answer the questions as accurately and as thoroughly as you can. Additionally, this information will be provided to the Prospective Adoptive Parent(s) that you select. Thank you for your efforts to provide honest and complete information.

Birth Mother Name:(Required)

First Last Initial

Message to the Birth Mother:

You are being asked to provide information about yourself and your medical history at a time that we know is difficult for you. This information will be very important to your child in the future. Much of the information requested will assist doctors in providing medical care to your child. Because many medical conditions can run in families, we are asking for information about your relatives’ health, as well as your own. Please answer the questions as accurately and as thoroughly as you can. Additionally, this information will be provided to the Prospective Adoptive Parent(s) that you select. Thank you for your efforts to provide honest and complete information.

A. General Information about the Birth Mother:

Place of Birth (city, state, country):(Required)

Race/Ethnic Background:(Required)

Caucasian

African-American

Hispanic

Native American

Asian

Pacific Islander

Multi-Ethnic

Other

Please specify:(Required)

Are you a member of a Native American Indian tribe?(Required)

Yes

If yes, please specify what tribe:(Required)

State in which tribe is located:(Required)

If yes, what is your blood quantum level/degree of Indian blood(Required)

Are either of your parents or grandparents or other relatives members of a Native American tribe?(Required)

Yes

If yes, please specify which person and relationship to you as well as the name of the tribe(s) and blood quantum level/degree of Indian blood (if known):(Required)

Is the child being placed for adoption a member, or eligible to be a member of a Native American tribe?(Required)

Yes

If yes, please specify what tribe:(Required)

B. Medical and Genetic History of Birth Mother and Her Family:

Physical Description of Birth Mother:

Height:(Required)

Weight (before pregnancy):(Required)

Eye Color:(Required)

Natural Hair Color:(Required)

Skin Shade:(Required)

Have you had any serious medical problems?(Required)

Yes

If yes, please explain:(Required)

Are you currently taking any doctor-prescribed medications for a medical problem?(Required)

Yes

If yes, please specify the medication, why it was prescribed, and how long you have been taking it:(Required)

Do you have or have you ever had any mental illness (e.g. schizophrenia, bi-polar disorder, severe depression, etc.)?(Required)

Yes

If yes, please describe:(Required)

Are you currently in treatment for, or have you ever had any psychiatric evaluations, counseling, or treatment? (Include treatment for alcohol or drug addiction):(Required)

Yes

If yes, please discuss these evaluations, including the date of the evaluation, the symptoms/situations that prompted the evaluation, any diagnoses, and give a summary of any psychiatric or psychological findings and treatment:(Required)

Do you have any significant emotional/behavioral history, other than what is indicated in the above discussion (include any known or suspected victimization, including physical or sexual abuse)?(Required)

Yes

If yes, please explain:(Required)

Do you have any chronic physical or mental health problem that requires continuing medication?(Required)

Yes

If yes, please specify the medication, the condition that requires the medication, and how long you have been taking it:(Required)

If you are taking any medication(s), does the physician that is prescribing you any and all medications know that you are pregnant?(Required)

Yes

If yes, have you discussed with your physician any potential problems with taking your medication while pregnant?(Required)

Yes

If yes, has your doctor given you any particular risk factors to you or the baby about continuing on this medication while pregnant? If yes, please describe:(Required)

Are you allergic to any medications?(Required)

Yes

If yes, please list the medication(s) that you are allergic to and describe the allergic reactions you have to the drug:(Required)

Are you:(Required)

Left Handed

Right Handed

Ambidextrous

Have you had any major surgeries?(Required)

Yes

If yes, please describe (including dates and any complications):(Required)

Have you had any of the following childhood/other diseases?:(Required)

Measles

German Measles

Mumps

Rubella (3 days)

Rubella (2 weeks)

Chicken Pox

Whooping Cough

Ear Infections

Roseola

Asthma

Hay fever

Meningitis

Heart Murmur

Encephalitis

Scarlet Fever

Rheumatic Fever

Urinary/bladder infections

Flu (any type)

Other

None of the above

Specify "other":(Required)

Have you had any of the above diseases during this pregnancy?(Required)

Yes

If yes, please specify which one(s) and if you are being treated by a physician:(Required)

During this pregnancy, have you been in any accidents?(Required)

Yes

If yes, please explain:(Required)

During this pregnancy, have you been exposed to any toxic substances?(Required)

Yes

If yes, please explain:(Required)

During this pregnancy, have you had, or do you have any of the following sexually transmitted diseases?(Required)

Syphilis

Gonorrhea

Chlamydia

Herpes

Genital Warts

HIV

None of the above

Have you had an HIV test?(Required)

Yes

If yes, when did you have it and what were the results?(Required)

During this pregnancy, have you had any pregnancy related complications, such as edema, eclampsia, preeclampsia, gestational diabetes, etc.?(Required)

Yes

If yes, please explain:(Required)

Have you had any miscarriages in previous pregnancies?(Required)

Yes

If yes, please specify (please include dates):(Required)

Have you given birth to any other children?(Required)

Yes

Child 1 - Please indicate date of birth:(Required)

Child 1 - Please indicate gender:(Required)

Child 1 - Please indicate relationship to child being placed for adoption (full/half sibling):(Required)

Child 2 - Please indicate date of birth:

Child 2 - Please indicate gender:

Child 2 - Please indicate relationship to child being placed for adoption (full/half sibling):

Child 3 - Please indicate date of birth:

Child 3 - Please indicate gender:

Child 3 - Please indicate relationship to child being placed for adoption (full/half sibling):

Child 4 - Please indicate date of birth:

Child 4 - Please indicate gender:

Child 4 - Please indicate relationship to child being placed for adoption (full/half sibling):

Child 5 - Please indicate date of birth:

Child 5 - Please indicate gender:

Child 5 - Please indicate relationship to child being placed for adoption (full/half sibling):

Have any of the above children had any significant health, learning or psychological problems?(Required)

Yes

If yes, please indicate which one(s) by number and describe such problem(s):(Required)

If any of the above children are deceased, please indicate which child died, state age at death, and cause of death (if known):

Were your previous labor(s) and deliver(ies):(Required)

Vaginal Delivery

Cesarean Section

Birth Mother’s Brothers and Sisters

How many brothers do you have?(Required)

How many sisters do you have?(Required)

Do you have any brothers or sisters who died?(Required)

Yes

If yes, list each below; include full or half sibling, age at death, cause of death, medical problem resulting in death (if known):(Required)

Birth Mother’s Parents

Your Mother

Year of Birth:

Height:

Weight:

Natural Hair Color:

Eye Color:

Skin tone:

Race/Ethnic Background:

Has your mother had any serious health problems, including physical, mental, or learning problems?

Yes

If yes, please explain and include age of onset:

If your mother is deceased, please specify cause of death, and age at death:

Did she receive special education?

Yes

I don't know

Please indicate any significant emotional/behavioral history (include any known or suspected victimization, including physical or sexual abuse, and history of treatment for a mental illness):

Your Father

Year of Birth:

Height:

Weight:

Natural Hair Color:

Skin tone:

Race/Ethnic Background:

Has your father had any serious health problems, including physical, mental, or learning problems?

Yes

If yes, please explain and include age of onset:

If your father is deceased, please specify cause of death, and age at death:

Did he receive special education?

Yes

I don't know

Please indicate any significant emotional/behavioral history (include any known or suspected victimization, including physical or sexual abuse, and history of treatment for a mental illness):

C. Birth Mother’s Genetic Medical History

For the following section, please check any of the medical conditions that YOU have had or now have.

Please check any of the following medical conditions that YOU have had or now have:(Required)

Blindness or other visual problems (ex. cataracts, glaucoma, color blindness)

Corrective glasses or contact lenses

Farsighted or nearsighted

Strabismus (cross-eyed)

Astigmatism (inability to focus)

Deafness or hearing difficulties

Speech problem(s) (delayed speech, stuttering, articulation disorder etc.)

Dental problems (missing or extra teeth, severe malocclusion, etc.)

Braces on teeth or other orthodontic work

Cleft lip (harelip)

Cleft palate

None of the above

Age at which lenses were necessary:(Required)

If deafness or hearing difficulties, were they present from birth?(Required)

Please check any of the following medical conditions that YOU have had or now have:(Required)

Learning disability/slow learner

Mental retardation

Attention deficit disorder and/or hyperactivity

Down Syndrome

Other chromosome abnormality(s)

Mental Illness (manic depression nervous breakdown, schizophrenia, etc.)

Hydrocephalus (water on the brain)

Microcephaly (small head)

Patches of Skin of Different Color

Skin Problems (severe eczema, acne, etc.)

Bleeding Problems or Hemophilia

Sickle Cell Disease/Trait

Thalassemia (Mediterranean anemia, Cooley’s anemia)

Tuberculosis (Specify type and age at onset)

High Blood Pressure (Hypertension)

Stroke

Heart Attack Before Age 50

Born w/ Heart Defect (ex. hole in heart)

Other Heart Disease:

None of the Above

Mental retardation cause (if known) and classify as mild, moderate, or severe:(Required)

Specify other chromosome abnormality(s):(Required)

Specify other heart disease:(Required)

Please check any of the following medical conditions that YOU have had or now have:(Required)

Born with Open Spine (Spina Bifida)

Born with Missing Brain (anencephaly)

Born with Hip Problems (dislocated hips)

Dwarfism or Short Stature

Spinal Curvature (Scoliosis)

Unusually Formed Bones or broken bones (not due to accident)

Unusually Formed Hands (extra/missing/webbed fingers)

Unusually Formed Feet (extra/missing/webbed toes)

Club Foot

Other Birth Defects not listed above:

Other Unusual Characteristics:

None of the Above

Specify other birth defects:(Required)

Specify other unusual characteristics:(Required)

Please check any of the following medical conditions that YOU have had or now have:(Required)

Arthritis, Joint Problems

Muscular Dystrophy

Muscle Weakness

Loss of Muscle Control

Pyloric Stenosis (projectile vomiting)

Breast Cancer

Colon Cancer

Ovarian Cancer

Other Cancers:

Hodgkin’s Disease

Cystic Fibrosis

Alzheimer Disease

Huntington Disease (chorea)

Neurofibromatosis

Multiple Sclerosis

Tay Sachs Disease

Cerebral Palsy

Seizures, Convulsions, Epilepsy.

None of the Above

Specify other type of cancer & site:(Required)

If Cerebral Plasy, was there a history of birth trauma? YES or NO(Required)

If Seizures, Convulsions, or Epilepsy, is medication required? YES or NO(Required)

Please check any of the following medical conditions that YOU have had or now have:(Required)

Childhood Diabetes

Adult Diabetes (insulin or non-insulin dependent)

Thyroid Disorder (underactive/overactive)

Frequent Infections

Infections Necessitating Hospitalization

Kidney Problems

Gastrointestinal Disorders

Hepatitis

Respiratory or Breathing Problems (ex. Emphysema)

Asthma

Allergies/Hay Fever (pollen, mold, dust)

Allergies To Food

Allergies to Medicine/Anesthesia

None of the Above

Specify Frequent Infections:(Required)

Specify Kidney Problems:(Required)

Specify Gastrointestinal Disorder:(Required)

Specify what type of Hepatitis and age at onset:(Required)

Specify Food Allergies:(Required)

Specify Medicine/Anesthesia Allergies:(Required)

Please check any of the following medical conditions that YOU have had or now have:(Required)

Chemical Dependency-Alcohol (any addiction or predisposition to addiction)

Chemical Dependency – Other Drugs (any addition/predisposition to addiction)

Weight Problems (obesity or anorexia)

Infertility

Miscarriages

Stillbirths

Neonatal Deaths (before one year old)

Infant Deaths (before one year old)

Childhood Deaths

HIV Positive (Human Immunodeficiency Virus)

AIDS (Acquired Immunodeficiency Syndrome)

Frequent Infections (immune deficiency)

Other Venereal Diseases

C(2). Birth Mother’s FAMILY Genetic Medical History

For the following section, please check any of the medical conditions that ANY BLOOD RELATIVE have had or now have.

Please check any of the following medical conditions that ANY BLOOD RELATIVE, (e.g., your children, parents, grandparents, aunts, uncles, brothers, sisters, nieces and nephews) have had or now have:(Required)

Blindness or other visual problems (ex. cataracts, glaucoma, color blindness)

Corrective glasses or contact lenses

Farsighted or nearsighted

Strabismus (cross-eyed)

Astigmatism (inability to focus)

Deafness or hearing difficulties

Speech problem(s) (delayed speech, stuttering, articulation disorder etc.)

Dental problems (missing or extra teeth, severe malocclusion, etc.)

Braces on teeth or other orthodontic work

Cleft lip (harelip)

Cleft palate

None of the above

I Don't Know

Age at which lenses were necessary:(Required)

If deafness or hearing difficulties, were they present from birth?(Required)

If you checked any, please specify WHO has/had this medical condition(s):

Learning disability/slow learner

Mental retardation

Attention deficit disorder and/or hyperactivity

Down Syndrome

Other chromosome abnormality(s)

Mental Illness (manic depression nervous breakdown, schizophrenia, etc.)

Hydrocephalus (water on the brain)

Microcephaly (small head)

Patches of Skin of Different Color

Skin Problems (severe eczema, acne, etc.)

Bleeding Problems or Hemophilia

Sickle Cell Disease/Trait

Thalassemia (Mediterranean anemia, Cooley’s anemia)

Tuberculosis (Specify type and age at onset)

High Blood Pressure (Hypertension)

Stroke

Heart Attack Before Age 50

Born w/ Heart Defect (ex. hole in heart)

Other Heart Disease:

None of the Above

Mental retardation cause (if known) and classify as mild, moderate, or severe:(Required)

Specify other chromosome abnormality(s):(Required)

Specify other heart disease:(Required)

If you checked any, please specify WHO has/had this medical condition(s):

Born with Open Spine (Spina Bifida)

Born with Missing Brain (anencephaly)

Born with Hip Problems (dislocated hips)

Dwarfism or Short Stature

Spinal Curvature (Scoliosis)

Unusually Formed Bones or broken bones (not due to accident)

Unusually Formed Hands (extra/missing/webbed fingers)

Unusually Formed Feet (extra/missing/webbed toes)

Club Foot

Other Birth Defects not listed above:

Other Unusual Characteristics:

None of the Above

Specify other birth defects:(Required)

Specify other unusual characteristics:(Required)

If you checked any, please specify WHO has/had this medical condition(s):

Arthritis, Joint Problems

Muscular Dystrophy

Muscle Weakness

Loss of Muscle Control

Pyloric Stenosis (projectile vomiting)

Breast Cancer

Colon Cancer

Ovarian Cancer

Other Cancers:

Hodgkin’s Disease

Cystic Fibrosis

Alzheimer Disease

Huntington Disease (chorea)

Neurofibromatosis

Multiple Sclerosis

Tay Sachs Disease

Cerebral Palsy

Seizures, Convulsions, Epilepsy.

None of the Above

Specify other type of cancer & site:(Required)

If Cerebral Plasy, was there a history of birth trauma? YES or NO(Required)

If Seizures, Convulsions, or Epilepsy, is medication required? YES or NO(Required)

If you checked any, please specify WHO has/had this medical condition(s):

Childhood Diabetes

Adult Diabetes (insulin or non-insulin dependent)

Thyroid Disorder (underactive/overactive)

Frequent Infections

Infections Necessitating Hospitalization

Kidney Problems

Gastrointestinal Disorders

Hepatitis (Specify what type, age at onset

Respiratory or Breathing Problems (ex. Emphysema)

Asthma

Allergies/Hay Fever (pollen, mold, dust)

Allergies To Food

Allergies to Medicine/Anesthesia

None of the Above

Specify Frequent Infections:(Required)

Specify Kidney Problems:(Required)

Specify Gastrointestinal Disorder:(Required)

Specify what type of Hepatitis and age at onset:(Required)

Specify Food Allergies:(Required)

Specify Medicine/Anesthesia Allergies:(Required)

If you checked any, please specify WHO has/had this medical condition(s):

Chemical Dependency-Alcohol (any addiction or predisposition to addiction)

Chemical Dependency – Other Drugs (any addition/predisposition to addiction)

Weight Problems (obesity or anorexia)

Infertility

Miscarriages

Stillbirths

Neonatal Deaths (before one year old)

Infant Deaths (before one year old)

Childhood Deaths

HIV Positive (Human Immunodeficiency Virus)

AIDS (Acquired Immunodeficiency Syndrome)

Frequent Infections (immune deficiency)

Other Venereal Diseases

D. Birth Mother’s Social History

Are you adopted?(Required)

Yes

Were you ever in special education classes (classes designed to provide extra help in learning)?(Required)

Yes

Please explain what special education classes:(Required)

Are you currently employed?(Required)

Yes

What types of things do you like to do in your free time?(Required)

If yes, what type of work do you do?(Required)

Do members of your family know about this adoption?(Required)

Yes

If yes, please identify by relationship (father, mother, etc.) not by name and indicate their reaction to your adoption plan.(Required)

The information contained in this form was provided by:

Birth Mother Name:(Required)

Other (please specify):

ACKNOWLEDMENT

I certify that I have personally completed this Medical and Social History form and certify that the information that I have provided on is true to the best of my knowledge and belief. I am providing this information as part of my adoption plan and in the best interest of my unborn child. I understand that I am swearing or affirming under oath to the truthfulness of the claims made in this affidavit and/or document and any false statements knowingly made herein may be viewed as perjury and in violation of the penal laws of my state and may subject me to criminal and/or civil penalties under the law, which may include fines and/or imprisonment. I acknowledge that the Prospective Adoptive Parent(s) and the Adoption Agencies staff, attorneys, employees and case workers and other parties will rely on this information in making a determination to proceed with the prospective adoption, and the Court will rely on this information during the adoption related proceedings. In my written and verbal communication in connection with the adoption, I have not provided any false or misleading information of any kind. The Adoption Agency has stressed to me the importance of providing full and accurate information in an adoption, particularly as it relates to the biological father, or any way to contact him with regard to this adoption.

Birth Mother Signature:(Required)

Today's Date:(Required)

MM slash DD slash YYYY

Check box to acknowledge:(Required)

By submitting this form, you consent to the transmission of your information over the internet and understand the associated risks.

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