BIRTHPARENT BACKGROUND INFORMATION

 

This Background Information form is designed to provide you and us with a tool for collecting significant social and medical information about your child's heritage. If you plan adoption for your child, the information will be shared with your child's adoptive family.  If you have chosen to parent, you may wish to use a copy of this form to preserve information about yourself for future use.

 

You will notice that various types of information are included in this form. The medical information, in particular, is asked for the purpose of early awareness, identification and treatment of future conditions your child may develop.  We urge you to keep the adoption professional, with whom you work, informed of health problems you, your parents, your brothers or sisters, or your future children might develop.

 

Perhaps the most important purpose of this information will be in the future when your child asks questions about you.  We have tried to include answers to the usual questions of physical appearance, interests, talents, and education.  Questions including the "why" are also included.  If some information that you feel is important has been omitted, please add this.  Some of the specific facts asked may not be available or known.

 

The Background Information is limited in many ways.  It indicates a "snapshot" of you at this time.  Changes that may be of major importance to your child will occur to you in the future.  Therefore, additional information can be added at any time.

 

The accuracy and care that you use in completing this form will be greatly appreciated by your child, the prospective adoptive family, and the adoption professionals who are working with you.  Thank you for your help.

 

 

 

PLEASE SIGN BELOW

 

I give my permission to the following background information shared with the adoptive family and the adopted child/adult.

 

Date:______________                   Signature:_____________________________

 

 

 

 

 

 

 

 

BACKGROUND INFORMATION

 

Background Information Concerning:  Mother ____  Father ____

Information Provided By: ________________________________ Date: ________________

 

IDENTIFYING INFORMATION:                                                        Date of Birth______________________

Name: _______________________________ Telephone Number: (          )__________________________

Social Security #: _____-____-_____  Driver’s License: State:_____ Number:________________________

Present Address:________________________________________________________________________

                                    Number & Street                                       City                          State          Zip

Permanent Address:_____________________________________________________________________

                                    Number & Street                                    City                       State              Zip

Religion:______________________ Name of Church Attended:___________________________________

For your child: Open to Religion ___Yes ___No

Open to the following Religions:_____________________________________________________________

Nationality Background(s):(e.g. French, Italian etc.) _____________________________________________

Racial Background(s): (e.g. Caucasian, Hispanic, African American, etc.)___________________________

______________________________________________________________________________________

If you have any Native American (Indian) Heritage, please specify to the best of your knowledge all tribe(s) :

______________________________________________________________________________________

If you are enrolled, where are you  enrolled?___________________________________________________

 

RELATIVES WITH NATIVE AMERICAN HERITAGE:

Name:____________________________ Date of Birth:_____________ Place of Birth:_________________

Relationship (e.g. mother’s father) __________________________________________________________

Possible Tribes: ________________________________________________________________________

Name:____________________________ Date of Birth:_____________ Place of Birth:_________________

Relationship (e.g. mother’s father) __________________________________________________________

Possible Tribes: ________________________________________________________________________

Name:____________________________ Date of Birth:_____________ Place of Birth:_________________

Relationship (e.g. mother’s father) __________________________________________________________

Possible Tribes: ________________________________________________________________________

If Eskimo:  Villages you are enrolled in or might be eligible to be enrolled in:__________________________

______________________________________________________________________________________

Marital Status:__________________________________________________________________________

            If married, is spouse aware of pregnancy?_______________________________________________

            Name and Address of spouse:________________________________________________________

            In common law marriage state?  Yes____ No ____ Unknown_____

            Occupation of spouse:______________________________________________________________

            Date of Marriage:__________________ Place of Marriage:_________________________________

            If separated, date of separation:_______________________________________________________

            Date of Divorce:___________________  Place of Divorce:__________________________________

If widowed, date of spouse’s death:__________________________________________________________

With whom do you live?___________________________________________________________________

 

PHYSICAL DESCRIPTION:

Height:____________________ Usual Weight:_____________________ Eye Color:___________________

Hair color and Texture:_________________________________ Build:______________________________

Skin Color:_______________________ Complexion:(fair, medium, dark)____________________________

Distinguishing Physical Features:____________________________________________________________

______________________________________________________________________________________

Are you willing to share a photograph?_______________________________________________________

Describe your Personality:_________________________________________________________________
______________________________________________________________________________________
______________________________________________________________________________________
______________________________________________________________________________________

 

EDUCATION:

Completed High School?  Yes____ No____  If no, last grade completed:_____________________________

Name of School:_________________________________________________________________________

Average Grades:_________________________________________________________________________

Subjects you were interested in during high school:______________________________________________
______________________________________________________________________________________

Additional education (e.g. College/Vocational, etc. please specify):_________________________________
______________________________________________________________________________________

Do you have future plans for additional schooling?   Yes____   No ____

If so, what type?___________________________________________________________________

Talents, hobbies, interests, pastime activities:_________________________________________________

______________________________________________________________________________________
______________________________________________________________________________________


MEDICAL

Your present general health:________________________________________________________________

Any accidents, illnesses or other complications during pregnancy?__________________________________
______________________________________________________________________________________

Major surgery - for what condition?___________________________________________________________

            When?___________________________________________________________________________

Any exposure to toxic environmental substances or conditions (e.g.: x-rays, pesticides, changing cat litter etc.)? _________________________________________________________________________________
            When?___________________________________________________________________________

Birthfather a genetic relative of Birth mother?___________________________________________________

 

PREGNANCY

Due date:_______________  Ultrasound done? When?___________________  Gender of child?_________

Pregnancy verified by whom? When?________________________________________________________

Prenatal care began with: Dr.’s Name________________________________________________________

                                           Address___________________________________________________________

                                           Phone___________________________ Date____________________________

 

RECEIVING REGULAR PRENATAL CARE?  YES_____    NO_____

Are you willing to take an HIV+ test? YES____    NO_____  TEST TAKEN_______

            If had HIV+ testing, date completed:______________________ Results:_______________________

 

HEALTH INSURANCE

Do you have insurance coverage? Yes____ No____ Medicaid?_____ Medicaid #:_____________________

Address_________________________________________ Phone of issuing office____________________

Other insurance (including pending or approved Disability Applications):

Name of Company: _________________________________ Policy or card #:________________________

Date of Disability Application: __________________  Date of rejection or approval: ____________________

Phone # of Disability Office: _____________________________

 

DRUGS TAKEN (BEFORE pregnancy for birthmother):

Prescription:___________________________________________________________________________

Non-Prescription (including aspirin, nose drops):_______________________________________________

Alcohol:  When?__________________ Amount:__________________ How often?____________________

Amphetamines (Uppers):  When?___________________________ Kind?___________________________

            Amount:_________________________________________________________________________

Barbiturates (Downers): When?__________________________ Kind?_____________________________

            Amount:________________________________________________________________________

Crack:  When?___________________________________Amount:_______________________________

Cocaine: When? _________________________________Amount:________________________________

Heroin: When? ______________________________Amount:_____________________________________

LSD:  When?__________________________________Amount:__________________________________

Marijuana:  When? _____________________________Amount:___________________________________

Methadone:  When? ____________________________Amount:___________________________________

Tranquilizers: When? ______________________________Amount:________________________________

Anti-Depressants: When? ________________________Amount:__________________________________

Anti-Psychotics: When? ____________________________Amount:________________________________

Were any of these or other drugs taken intravenously (with a needle)?_______________________________

 

DRUGS TAKEN (DURING pregnancy for birthmother, before and/or after you knew you were pregnant):

Prescription:___________________________________________________________________________

Non-Prescription (including aspirin, nose drops):_______________________________________________

Alcohol:  When?__________________ Amount:__________________ How often?____________________

Amphetamines (Uppers):  When?___________________________ Kind?___________________________

            Amount:_________________________________________________________________________

Barbiturates (Downers): When?__________________________ Kind?_____________________________

            Amount:________________________________________________________________________

Crack:  When?___________________________________Amount:_______________________________

Cocaine: When? _________________________________Amount:________________________________

Heroin: When? ______________________________Amount:_____________________________________

LSD:  When?__________________________________Amount:__________________________________

Marijuana:  When? _____________________________Amount:___________________________________

Methadone:  When? ____________________________Amount:___________________________________

Tranquilizers: When? ______________________________Amount:________________________________

Anti-Depressants: When? ________________________Amount:__________________________________

Anti-Psychotics: When? ____________________________Amount:________________________________

Were any of these or other drugs taken intravenously (with a needle)?_______________________________

Have you ever used injected drugs? Yes____  No___ Please Explain_______________________________

______________________________________________________________________________________

Have you ever had a sexual partner who you suspected might have injected drugs? Yes________________

No___ Please explain_____________________________________________________________________

Have you ever received in patient or out patient drug/alcohol or related substance abuse treatment? Yes   No

If yes, please list the dates, facilities and/or health care providers, along with their address and phone numbers.  ______________________________________________________________________________________

______________________________________________________________________________________

______________________________________________________________________________________

Please make sure to sign the specific release noted in the packet of forms providing for substance abuse treatment records.

Have you ever had a sexual partner who had hemophilia? Yes___ No___ Please explain________________

______________________________________________________________________________________

Have you ever had a sexual partner who you knew or suspected was actively bisexual or homosexual? Yes___ No___ Please explain_____________________________________________________________

Cigarettes: When?________________________________ # per/day:______________________________

Other: When?______________________________Amount:______________________________________

Have you had any possible exposure to HIV+ or increased risk due to any event, mishap or circumstance?

 _____________________________________________________________________________________

Have you had any blood transfusions?_______________________________________________________

 

EMPLOYMENT HISTORY

Current Occupation:_____________________________________________________________________

Place of Employment:____________________________________________________________________

Address: _____________________________________________________________________________

            Length of time employed at above:____________  Work Telephone:________________________

Previous Occupation(s): _________________________________________________________________

Previous Place(s) of Employment:__________________________________________________________

Military Service: Yes_____ No____ If yes, which branch of service?________________________________

 

FAMILY HISTORY:

Were you or any member of your immediate family adopted? Yes____No____  If yes, please identify by full name and their relationship to you:___________________________________________________________________
______________________________________________________________________________________

 

 

PEOPLE AWARE OF PREGNANCY OTHER THAN YOUR IMMEDIATE FAMILY

(In case the agency needs to write you and/or for reasons of confidentiality)

 

 

NAME

 

ADDRESS

Place of Employment

 

Relationship

 

CAN CONTACT?

 

 

 

 

 

 

 

 

Yes            No

 

 

 

 

 

 

 

 

Yes            No

 

 

 

 

 

 

 

 

Yes            No

 

 

 

 

 

 

 

 

Yes            No

 

Geographic areas to avoid in placing child for adoption:__________________________________________

Any other agencies, attorneys or adoption professionals with whom you’ve discussed adoption planning:___

 

 

 

PATERNAL

                                                           Your Father                       Grandfather                     Grandmother

Full Name

 

 

 

 

 

Birth date

 

 

 

Place of Birth

 

 

 

 

Present address

 

 

 

 

 

If deceased, date and place of death

 

 

 

Cause of death

 

 

 

 

Height

 

 

 

Weight

 

 

 

Hair color and texture; baldness?

 

 

 

Eye color

 

 

 

Skin color/complexion (eg ruddy, fair, olive)

 

 

 

 

Racial background

 

 

 

Nationality; including Native American Heritage, Irish, French, etc.

 

 

 

Religion

 

 

 

 

Last grade completed

 

 

 

 

Occupation

 

 

 

 

Place of employment

 

 

 

 

Previous occupation(s)

 

 

 

 

Hobbies, talents, interests

 

 

 

 

Aware of adoption plan?

Yes            No

Yes            No

Yes            No

Marital status

 

 

 

Name of spouse (if applicable)

 

 

 

Number of children

 

 

 

 

MATERNAL

                                                            Your Mother                      Grandfather                     Grandmother

Full Name

 

 

 

 

Birth date

 

 

 

 

Place of birth

 

 

 

 

Present address

 

 

 

 

If deceased, date and place of death

 

 

 

 

Cause of death

 

 

 

Height

 

 

 

Weight

 

 

 

Hair color and texture; baldness?

 

 

 

Eye color

 

 

 

Skin color/complexion (e.g. ruddy, fair, olive)

 

 

 

 

Racial background

 

 

 

Nationality; Inc. Native American Heritage, Irish, French, etc.

 

 

 

Religion

 

 

 

 

Last grade completed

 

 

 

 

Occupation

 

 

 

 

 

Place of employment

 

 

 

 

Previous occupation(s)

 

 

 

 

Hobbies, talents, interests

 

 

 

 

Aware of adoption plan?

Yes            No

Yes            No

Yes            No

Marital status

 

 

 

Name of spouse (if applicable)

 

 

 

Number of children

 

 

 

 

YOUR BROTHERS AND SISTERS

Full Name

 

 

 

 

 

Birth date

 

 

 

 

Present address

 

 

 

 

 

If deceased, date and place of death

 

 

 

Cause of death

 

 

 

Height

 

 

 

Weight

 

 

 

Hair color and texture; baldness?

 

 

 

 

Eye color

 

 

 

Skin color/complexion (e.g. ruddy, fair, olive)

 

 

 

 

Racial background

 

 

 

 

 

Nationality

 

 

 

 

Religion

 

 

 

 

Last grade completed

 

 

 

 

Occupation

 

 

 

 

 

Place of employment

 

 

 

 

 

Previous occupation(s)

 

 

 

 

 

Hobbies, talents, interests

 

 

 

Aware of adoption plan?

Yes            No

Yes            No

Yes            No

Marital status

 

 

 

Name of spouse (if applicable)

 

 

 

Number of children

 

 

 

 

 

OTHER CHILDREN BORN TO YOU      

Full Name

 

 

 

 

Sex

 

 

 

Birth date

 

 

 

Was pregnancy and delivery of this child normal?  If not, please describe any problems or complications.

 

 

 

If deceased, date & place of death

 

 

 

Cause of death

 

 

 

Height

 

 

 

Weight

 

 

 

Hair color and texture; baldness?

 

 

 

Eye color

 

 

 

Skin color/complexion (e.g. ruddy, fair, olive)

 

 

 

Racial background

 

 

 

 

 

Nationality

 

 

 

Religion

 

 

 

Who currently cares for.

 

 

 

Physical, mental, emotional health:

 

 

 

 Grade level in school

 

 

 

 Grade average

 

 

 

 Hobbies, talents, interests

 

 

 

Aware of adoption plan?

Yes            No

Yes            No

Yes            No

Reaction to adoption plan?

 

 

 

Receiving counseling?

 

 

 

Relationship w/parent/s

 

 

 

Relationship w/sibling/s

 

 

 

Relationship w/relatives

 

 

 

History of physical or sexual abuse, neglect, violence, etc.

 

 

 

IF HEALTH PROBLEMS ARE PRESENT, COULD THEY BE LINKED GENETICALLY TO THE CHILD WHO IS BEING PLACED FOR ADOPTION (Circle Response)

Yes        No                        Yes        No                      Yes         No

 

If yes, it is very important to indicate which health problems are present on the medical conditions list

       beginning on the next page.

 

      If more than three children please use back of page.


MEDICAL HISTORY

Please indicate by checking “Yes” or “No” if YOU or any GENETIC RELATIVES (i.e. yourself, other children you have given birth to, your mother, father, sisters, brothers, maternal/paternal grandparents, aunts, uncles, nieces, nephews, cousins, great grandparents, great aunts, great uncles, etc.) ever had or now have the following medical conditions.  PLEASE CIRCLE YES OR NO IN THE MEDICAL CONDITIONS SECTIONS, AND INDICATE AGE OF ONSET, TREATMENT, AND SEVERITY.

 

MEDICAL

CONDITIONS

 

WHICH RELATIVES

(including yourself)

 

Age of onset, treatment,

specific diagnosis & severity

 

1.  YES       NO

Glasses (please specify if near/far sighted, astigmatism)

 

 

 

 

 

2.   YES       NO

Visual problems/blindness

(glaucoma, cataracts, etc.)

 

 

 

 

 

3.   YES       NO

Retinitis Pigmentosa

 

 

 

 

 

4.   YES       NO

Strabismus (continual squinting, cross eyes, watering eyes, etc.)

 

 

 

 

 

5.   YES       NO

Color blindness

 

 

 

 

 

6.   YES       NO

“Lazy Eye”

 

 

 

 

 

 

7.   YES       NO

Hearing difficulties/deafness

 

 

 

 

 

8.   YES       NO

Frequent earaches

 

 

 

 

 

9.   YES       NO

Speech problems (Stutter, stammering, lisp, etc.)

 

 

 

 

 

 

10.  YES       NO

Dental problems (Missing or extra teeth, receding chin, protruding jaw or teeth, etc.)

 

 

 

 

 

11.   YES       NO

TMJ (Temporal-mandibular Joint Syndrome)

 

 

 

 

 

 

12.   YES       NO

Corrective orthodontia (Braces for overbite, cross bit, irregular alignment, etc.)

 

 

 

 

 

13.   YES       NO

Cleft lip

 

 

 

 

 

 

14.  YES       NO

Cleft palate

 

 

 

 

 

15.  YES       NO

Facial abnormalities (describe shape of face/nose/ears, etc.)

 

 

 

 

 

16.   YES       NO

Hand abnormalities (extra, missing fingers, curved little finger, etc.)

 

 

 

 

 

17.   YES       NO

Feet Abnormalities (Extra, missing, or webbed toes)

 

 

 

 

 

18.   YES       NO

Hip Abnormalities (Congenital hip, shallow hip socket)

 

 

 

 

 

19.   YES       NO

Physical abnormalities (different length legs, etc.)

 

 

 

 

 

20.   YES       NO

Orthopedic problems (fallen arches, pigeon-toes, feet turning out, etc.)

 

 

 

 

 

21.  YES       NO

Club foot

 

 

 

 

 

22.   YES       NO

Learning disability (Dyslexia, Attention Deficit Disorder, Hyperactivity, etc)

 

 

 

 

 

 

23.   YES       NO

Hyperactivity

 

 

 

 

 

24.   YES       NO

(EBD) Emotional Behavior Disorder

 

 

 

 

 

25.   YES       NO

 (AAD) Active - Alert Disorder

 

 

 

 

 

26.   YES       NO

Autism

 

 

 

 

 

27.   YES       NO

Mental retardation

 

 

 

 

 

28.   YES       NO

Hydrocephalus

 

 

 

 

 

29.  YES       NO

Down’s Syndrome

 

 

 

 

 

30.   YES       NO

Microcephalus (small head circumference)

 

 

 

 

 

31.   YES       NO

Manic Depression (Bipolar Disorder)

 

 

 

 

 

32.  YES       NO

Schizophrenia

 

 

 

 

 

33.   YES       NO

Obsessive-Compulsive disorder

 

 

 

 

 

34.  YES       NO

Clinical depression

 

 

 

 

 

35.   YES       NO

Other mental illness or emotional disorder(please specify)

 

 

 

 

 

36.   YES       NO

Headaches/Migraines

(Frequency, symptoms,

medication, location of pain)

 

 

 

 

 

37.   YES       NO

Brain tumors

 

 

 

 

 

 

38.   YES       NO

Alzheimer’s

 

 

 

 

 

39.    YES       NO

Senility

 

 

 

 

 

40.   YES       NO

Patches of hair of different color

(location)

 

 

 

 

 

41.   YES       NO

Eyes of different color

 

 

 

 

 

42.   YES       NO

Patches of skin of different color

 

 

 

 

 

43.   YES       NO

Birthmarks (Unusual configuration, size, number, and location)

 

 

 

 

 

44.   YES       NO

 Eczema

 

 

 

 

 

45.   YES       NO

 Acne

 

 

 

 

 

46.   YES       NO

  Psoriasis

 

 

 

 

 

47.   YES       NO

Other Skin Problem (Please specify)

 

 

 

 

 

 

48.   YES       NO

Unusual Scarring  (Diagnosed growths or lumps on skin, etc.)

 

 

 

 

 

 

49.   YES       NO

Varicose veins

 

 

 

 

 

50.   YES       NO

Bleeding problems

 

 

 

 

 

51.   YES       NO

 Hemophilia

 

 

 

 

 

52.   YES       NO

Pernicious Anemia

 

 

 

 

 

53.   YES       NO

Sickle Cell Anemia

 

 

 

 

 

54.   YES       NO

Other types of anemia (Please specify)

 

 

 

 

 

55.   YES       NO

Hypertension (high blood pressure)

 

 

 

 

 

56.    YES       NO

High cholesterol

 

 

 

 

 

57.   YES       NO

Aneurysm

 

 

 

 

 

58.   YES       NO

 Stroke

 

 

 

 

 

59.   YES       NO

Angina (heart pain)

 

 

 

 

 

60.   YES       NO

Irregular heart beat

 

 

 

 

 

61.   YES       NO

 Heart murmur

 

 

 

 

 

 

62.    YES       NO

Congenital heart defect

 

 

 

 

 

 

63.   YES       NO

Open spine/Spina Bifida

 

 

 

 

 

65.   YES       NO

Spinal curvature/scoliosis

 

 

 

 

 

66.   YES       NO

Arteriosclerosis (narrowing of the arteries)

 

 

 

 

 

 

 67.   YES       NO

Bone tissue deformities (spurs, bunions, etc.)

 

 

 

 

 

68.    YES       NO

Brittleness of bones

 

 

 

 

 

 

69.   YES       NO

 Osteoporosis

 

 

 

 

 

70.   YES       NO

Arthritis (rheumatoid/osteo/juvenile, etc.)

 

 

 

 

 

 

71.   YES       NO

Neuromuscular Disorder (Myasthenia Gravis, etc.)

 

 

 

 

 

72.   YES       NO

Muscular Dystrophy

 

 

 

 

 

73.   YES       NO

Parkinson’s Disease

 

 

 

 

 

74.  YES       NO

Lou Gehrig’s Disease (Amyotrophic Lateral Sclerosis)

 

 

 

 

 

75.   YES       NO

Multiple Sclerosis

 

 

 

 

 

76.   YES       NO

Muscle weakness (Myasthenia Gravis, etc.)

 

 

 

 

 

77.    YES       NO

Lupus

 

 

 

 

 

78.   YES       NO

Huntington’s Chorea

 

 

 

 

 

79.   YES       NO

Tay-Sachs Disease

 

 

 

 

 

80.   YES       NO

Bulbar Palsy

 

 

 

 

 

 

81.   YES       NO

Bell’s Palsy

 

 

 

 

 

 

82.   YES       NO

Seizures & convulsions

 

 

 

 

 

83.   YES       NO

Epilepsy (Grand Mal, Petit Mal, Jacksonian)

 

 

 

 

 

84.    YES       NO

Narcolepsy (sleep disorder)

 

 

 

 

 

85.   YES       NO

Cerebral Palsy

 

 

 

 

 

86.   YES       NO

Diabetes (indicate if Juvenile or Adult)

 

 

 

 

 

87.   YES       NO

Hypoglycemia (low blood sugar)

 

 

 

 

 

88.   YES       NO

Thyroid disorder (low - overactive)

 

 

 

 

 

89.   YES       NO

Other hormone disorders

 

 

 

 

 

90.    YES       NO

Growth disorder (please specify)

 

 

 

 

 

91.   YES       NO

Irregular growth patterns

 

 

 

 

 

92.   YES       NO

Dwarfism

 

 

 

 

 

93.   YES       NO

Tuberculosis

 

 

 

 

 

94.   YES       NO

Cystic Fibrosis

 

 

 

 

 

95.   YES       NO

Emphysema

 

 

 

 

 

96.   YES       NO

Asthma

 

 

 

 

 

 

97.   YES       NO

Chronic sinusitis

 

 

 

 

 

98.   YES       NO

Chronic rhinitis (runny nose)

 

 

 

 

 

99.   YES       NO

Tonsils/adenoid problems

 

 

 

 

 

 

100.   YES       NO

Frequent colds

 

 

 

 

 

101.   YES       NO

Bronchitis

 

 

 

 

 

102.   YES       NO

Pneumonia

 

 

 

 

 

103.   YES       NO

Other respiratory/breathing problems

 

 

 

 

 

104.   YES       NO

Hay fever (allergic to what?)

 

 

 

 

 

 

105.   YES       NO

Allergies (Inhalant, food, skin, etc; allergic to what?)

 

 

 

 

 

106.   YES       NO

Kidney problems

 

 

 

 

107.   YES       NO

Bladder problems

 

 

 

 

 

108.   YES       NO

Cysts

 

 

 

 

 

109.   YES       NO

Hernias

 

 

 

 

 

110.   YES       NO

Alcoholism

 

 

 

 

 

 

111.   YES       NO

Other chemical abuse (specify substance used)

 

 

 

 

 

112.   YES       NO

Weight problems

 

 

 

 

 

113.   YES       NO

Treatment for overweight (Staples, by-pass, etc.)

 

 

 

 

 

114.   YES       NO

Eating disorders (anorexia, bulimia, overeating)

 

 

 

 

 

115.   YES       NO

Projectile vomiting

 

 

 

 

 

116.   YES       NO

Pyloric stenosis (reflux)

 

 

 

 

 

117.   YES       NO

Ulcers

 

 

 

 

 

118.   YES       NO

Stomach problems (specifics)

 

 

 

 

 

119.   YES       NO

Esophageal problems (throat)

 

 

 

 

 

120.   YES       NO

Intestinal problems (mal-absorption, colitis, Crohn’s Disease)

 

 

 

 

 

121.   YES       NO

Cancer (lung, breast, cervical, prostate, skin, etc.)

 

 

 

 

 

122.   YES       NO

Miscarriages (identify number & cause, if known; do you know if DES was the prescribed treatment?)

 

 

 

 

 

 

123.   YES       NO

Stillbirths (identify cause, if known for each stillbirth)

 

 

 

 

 

124.   YES       NO

Multiple births (identical\ fraternal)

 

 

 

 

 

125.   YES       NO

Pre-term labor

 

 

 

 

 

126.   YES       NO

Delivery problems (breech, Cesarean)

 

 

 

 

 

127.   YES       NO

HIV infection

 

 

 

 

 

128.   YES       NO

Birth defects

 

 

 

 

 

 

129.   YES       NO

PKU (Phenylketonuria)

 

 

 

 

 

130.   YES       NO

Fetal Alcohol Syndrome

 

 

 

 

 

 

131.   YES      NO

Infertility

 

 

 

 

 

132.   YES       NO

Breast growth pattern (any corrective surgeries?)

 

 

 

 

 

133.   YES       NO

Unusual onset of menses (period)

 

 

 

 

 

 

134.   YES       NO

 PMS (Premenstrual stress syndrome)

 

 

 

 

 

 

135.  YES       NO

Unusual onset of menopause

 

 

 

 

 

136.   YES       NO

Undescended testicle

 

 

 

 

 

137 .  YES       NO

Unusual onset of puberty for males

 

 

 

 

138.   YES       NO

Low resistance to infection

 

 

 

 

 

139.   YES        NO

Any psychiatric hospitalizations or treatment? Dates and name of hospital.

 

 

 

 

 

 

 

140.   YES       NO

Any counseling or psychotherapy?

 

 

 

 

141.   YES       NO

Any history of Sudden Infant Death Syndrome(SIDS) or crib death

 

 

 

142.     YES          NO

 

Fetal Alcohol Effects (FEA) or Fetal Alcohol Syndrome (FAS)

 

 

 

143.     YES          NO

Neurofibromatosis

(skin disorder)

 

 

 

144.    YES          NO

Tuberous Sclerosis

 

 

 

145.     YES       NO

 

Marfan Syndrome or homocystinuria

(Dislocated Lenses in the eye)

 

 

 

146.     YES       NO

 

Retinal detachments (connective tissue disorder)