"" 1 Birth Parent Social And Health History Information BirthmotherBirthfather Prenatal Care During this Pregnancy Describe any Complications0 / Description of Self Marital StatusSingleMarriedSeparatedDivorcedWidowed If married or separatedCivil marriageReligious ceremony (Specify) Are youan enrolled member of a Native American tribe, Alaskan Village or affiliated with a tribe? YesNo If yeswhat tribe? Religion Ethnic Background Country or Stateof birth Race(e.g. Black, White, American Indian, Japanese etc) Height Weight Hair Color and Texture Eye Color Unique Physical Featurese.g. freckles, moles, etc. ComplexionFairMediumOliveDark Right HandedLeft Handed Physical Builde.g. big/small boned, long/short limbed, muscular etc. Talents, hobbies and other interests Which of the following describe your personality?check all that applyAggressiveCalmCriticalEmotionalFriendlyFunHappyHelpfulIrresponsibleNervousOutgoingRebeliousSelf-confidentTempermentalShyStubbornSeriousUnhappy Commentsmore details0 / Education Last grade level completed: Average grade recieved or GPA Presently in schoolYesNo Future plans for schooling Subjects you are interested in Any school-related problems or challenges (Tutoring, Special Ed etc.) Additional educational experiences Employment History Current Occupation Military ServiceYesNo If yes, branch of service Vocational Training0 / Work History0 / Family History Was anyone in your family adopted?Yes No If yes, whom? Your order of birthe.g. 1st of 4 Personal relationship with parents, siblings, or extended family members0 / Summarize adjustment to pregnancy. Include you and your parents adjusted to the pregnancy, and if you have peer support.0 / Your Birth Parents Father Age (If deseased, state age at death) Health problems Height/Weight Hair/Eye voloryour full name Buildsmallmediumlargeextra large Complexionfairmediumolivedark Right/Left handed Description of personality, e.g. happy, shy, serious, nervous, stuborn, etc. Talents, hobbies, interests Education Occupation Number of siblings Race (Black, White, American Indian etc.) Country or State of birth Ethnic background (e.g. English, German) Religion Marital StatusSingleMarriedDivorcedWidowed Aware of this pregnancyYesNo Mother Age (If deseased, state age at death) Health problems Height/Weight Hair/Eye voloryour full name Buildsmallmediumlargeextra large Complexionfairmediumolivedark Right/Left handed Description of personality, e.g. happy, shy, serious, nervous, stuborn, etc. Talents, hobbies, interests Education Occupation Number of siblings Race (Black, White, American Indian etc.) Country or State of birth Ethnic background (e.g. English, German) Religion Marital StatusSingleMarriedDivorcedWidowed Aware of this pregnancyYesNo Your Birth Brothers and Sisters (Child's Uncles and Aunts) 1.BrotherSister Age (If deceased, state age at death and cause of death) Health problems Height/Weight Hair/Eye color Buildsmallmediumlargeextra large Complexionfairmediumolivedark Right/Left handed Talents, hobbies, interests Education (last grade completed) Occupation Religion Marital statusSingleMarriedDivorcedWidowed Widowed Health of children (if any) Aware of this pregnancyYesNo 2.BrotherSister Age (if desceased, state age at death and cause of death) Health problems Height/Weight Hair/Eye color Buildsmallmediumlargeextra large Complexionfairmediumolivedark Right/Left handed Talents, hobbies, interests Education (last grade completed) Occupation Religion Marital statusSingleMarriedDivorcedWidowed Health of children (if any) Aware of this pregnancyYesNo 3BrotherSister Age (if desceased, state age at death and cause of death) Health problems Height/Weight Hair/Eye color Buildsmall mediumlargeextra large Complexionfairmediumolivedark Favorite Fruitspick one!AppleOrangeWatermelon Right/Left handed Talents, hobbies, interests Education (last grade completed) Occupation Religion Marital statusSingleMarriedDivorcedWidowed Health of children (if any) Aware of this pregnancyYesNo 4.BrotherSister Age (if desceased, state age at death and cause of death) Health problems Height/Weight Hair/Eye color Buildsmallmediumlargeextra large Complexionfairmediumolivedark Right/Left handed Talents, hobbies, interests Education (last grade completed) Occupation Religion Marital statusSingleMarriedDivorcedWidowed Health of children (if any) Aware of this pregnancyYesNo 5BrotherSister Age (if desceased, state age at death and cause of death) Health problems Height/Weight Hair/Eye color Buildsmallmediumlargeextra large Complexionfairmediumolivedark Talents, hobbies, interests Education (last grade completed) Occupation Religion Marital statusSingleMarriedDivorcedWidowed Health of children (if any) Aware of this pregnancyYesNo 6.BrotherSister Age (if desceased, state age at death and cause of death) Health problems Height/Weight Hair/Eye color Buildsmall medium large extra large Complexionfairmedium olivedark Right/Left handed Talents, hobbies, interests Education (last grade completed) Occupation Religion Marital statusSingleMarriedDivorcedWidowed Health of children (if any) Aware of this pregnancyYesNo Your Children 1.SonDaughter Age (If deceased, state age at death) Height/Weight Hair/Eye color Buildsmallmediumlargeextra large Complexionfair medium olive dark Describe any current and past medical ·. conditions as well as any treatment or medications child is taking: Choose some words to describe this child's personality: Child's personal interests (art, reading, games, animals, etc.): Involvement in sports, teams, or other programs for youth (Baseball, karate, dance, scouts, YWCA, etc.): Special talents or abilities: Last grade completed in school123456789101112 Attending school now?YesNo Which school subjects does this child excel in? Describe any school related problems or challenges Weight at birth Length of pregnancy (weeks) Weaned from breast feeding (weeks) Spoke first word Walked without help (months) Toilet trained (months) First attended pre-school or daycare (age and length of time) 2.SonDaughter Age (If deceased, state age at death) Height/Weight Hair/Eye color Buildsmallmediumlargeextra large Complexionfair medium olive dark Describe any current and past medical ·. conditions as well as any treatment or medications child is taking: Choose some words to describe this child's personality: Child's personal interests (art, reading, games, animals, etc.): Involvement in sports, teams, or other programs for youth (Baseball, karate, dance, scouts, YWCA, etc.): Special talents or abilities: Attending school now?YesNo Which school subjects does this child excel in? Describe any school related problems or challenges Weight at birth Length of pregnancy (weeks) Weaned from breast feeding (weeks) Spoke first word Walked without help (months) Toilet trained (months) First attended pre-school or daycare (age and length of time) Medical History Please indicate by checking "None" or "You" if you or any genetic (birth) relatives (i.e., your mother, father, sisters, brothers, grandparents, uncles, aunts or any other children you have had) ever had or now has any of the medical conditions listed below. Please explain in the comments section. Medical Condidtion BaldnessNoneYou Your RelativeSpecify Relationship Comments Birth DefectsNoneYou Your RelativeSpecify Relationship Comments Club FootNoneYou Your RelativeSpecify Relationship Comments Cleft Palate (hairlip)NoneYou Your RelativeSpecify Relationship Comments Congenital heart diseaseNoneYou Your RelativeSpecify Relationship Comments Cancerspecify typeNoneYou Your RelativeSpecify Relationship CommentsAge at onset? Part of body affected? OtherspecifyNoneYou Your RelativeSpecify Relationship Comments Allergies AnimalsNoneYou Your Relativespecify relationship Comments AsthmaNoneYou Your Relativespecify relationship Comments EczemaNoneYou Your Relativespecify relationship Comments FoodNoneYou Your Relativespecify relationship Comments Hay Fever/PlantsNoneYou Your Relativespecify relatnship Comments Hives!NoneYou Your Relativespecify relationship Comments MedicationsNoneYou Your Relativespecify Relationship Comments Other allergiesNoneYou Your Relativespecify relationship Comments Otherspecify Your Relativespecify relationship Comments Otherspecify Your Relativespecify relationship Comments Visual Impairments AstigmatismNoneYou Your Relativespecify relationship Comments BlindnessNoneYou Your Relativespecify relationship Comments Color blindnessNoneYou Your Relativespecify relationship Comments Otherspecify Your Relativespecify relationship Comments Otherspecify Your Relativespecify relationship Comments Emotional/Mental Illness Bipolar (manic-depressive)NoneYou Your Relativespecify relationship CommentsAge of onset? Treatment? Hospitalization? Bipolar (manic-depressive)NoneYou Your Relativespecify relationship CommentsAge of onset? Treatment? Hospitalization? Bipolar (manic-depressive)NoneYou Your Relativespecify relationship CommentsAge of onset? Treatment? Hospitalization? Bipolar (manic-depressive)NoneYou Your Relativespecify relationship CommentsAge of onset? Treatment? Hospitalization? Bipolar (manic-depressive)NoneYou Your Relativespecify relationship CommentsAge of onset? Treatment? Hospitalization? Bipolar (manic-depressive)NoneYou Your Relativespecify relationship CommentsAge of onset? Treatment? Hospitalization? Bipolar (manic-depressive)NoneYou Your Relativespecify relationship CommentsAge of onset? Treatment? Hospitalization? Otherspecify Your Relativespecify relationship CommentsAge of onset? Treatment? Hospitalization? Otherspecify Your Relativespecify relationship CommentsAge of onset? Treatment? Hospitalization? Hereditary Diseases Cystic FibrosisNoneYou Your Relativespecify relationship CommentsAge of onset? Treatment? Hospitalization? GalactosemiaNoneYou Your Relativespecify relationship CommentsAge of onset? Treatment? Hospitalization? HemophiliaNoneYou Your Relativespecify relationship CommentsAge of onset? Treatment? Hospitalization? Huntington's DiseaseNoneYou Your Relativespecify relationship CommentsAge of onset? Treatment? Hospitalization? Hypothyroidism or hyperthyroidismNoneYou Your Relativespecify relationship CommentsAge of onset? Treatment? Hospitalization? Otherspecify Your Relativespecify relationship CommentsAge of onset? Treatment? Hospitalization? Cardiovascular Disease Heart AttackNoneYou Your Relativespecify relationship CommentsAge of onset? Outcome? Heart MurmurNoneYou Your Relativespecify relationship CommentsAge of onset? Outcome? High Blood PressureNoneYou Your Relativespecify relationship CommentsAge of onset? Treatment? Diabetesspecify typeNoneYou Your Relativespecify relationship CommentsAge of onset? Treatment? Otherspecify Your Relativespecify relationship CommentsAge of onset? Treatment? Otherspecify Your Relativespecify relationship CommentsAge of onset? Treatment? Sexually Transmitted Diseases ChlamydiaNoneYou Your Relativespecify relationship CommentsAge of onset? Treatment? Hospitalization GonorrheaNoneYou Your Relativespecify relationship CommentsAge of onset? Treatment? Hospitalization HerpesNoneYou Your Relativespecify relationship CommentsAge of onset? Treatment? Hospitalization SyphilisNoneYou Your Relativespecify relationship CommentsAge of onset? Treatment? Hospitalization HIV/AIDSNoneYou Your Relativespecify relationship CommentsAge of onset? Treatment? Hospitalization Pelvic inflammatory diseaseNoneYou Your Relativespecify relationship CommentsAge of onset? Treatment? Hospitalization Otherspecify Your Relativespecify relationship CommentsAge of onset? Treatment? Hospitalization Neurological Disorders Cerebral PalsyNoneYou Your Relativespecify relationship CommentsSeverity? Treatment? MusculardystrophyNoneYou Your Relativespecify relationship Multiple sclerosisNoneYou Your Relativespecify relationship Comments Epilepsy/ConvulsionsspecifyNoneYou Your Relativespecify relationship CommentsAge at onset? Frequency? Treatment StrokeNoneYou Your Relativespecify relationship Comments Rheumatic feverNoneYou Your Relativespecify relationship Commentsdid heart murmur result? Otherspecify Your Relativespecify relationship Comments Developmental Disorders Learning disability/Attention deficit (specify)NoneYou Your Relativespecify relationship CommentsType of education? Treatment? Mental Retardationspecify typeNoneYou Your Relativespecify relationship CommentsDiagnosis? Severity? Type of education? Down SyndromeNoneYou Your Relativespecify relationship Comments Speech or hearing problemsNoneYou Your Relativespecify relationship Comments Low birth weightNoneYou Your Relativespecify relationship Comments Otherspecify Your Relativespecify relationship Comments Otherspecify Your Relativespecify relationship Comments Otherspecify Comments Your Relativespecify relationship History of Drug Use Types of Drugs Prescriptionspecify type (e.g. Prozac, accutane, etc.) Dosage or amount and length of time used Date of Last Use When UsedBefore ConceptionAfter Conception Over-the-counterspecify type (e.g., diet pills, antihistamine, etc.) Dosage or amount and length of time used Date of Last Use When UsedBefore ConceptionAfter Conception Other Types of Drugs Used Alcoholspecify type Dosage or amount and length of time used Date of Last Use When UsedBefore ConceptionAfter Conception Methamphetamine "Meth" or "speed"specify type Dosage or amount and length of time used Date of Last Use When UsedBefore ConceptionAfter Conception Downers (i.e. sleeping pills, bensodiazepines, barbiturates, etc)specify type Dosage or amount and length of time used Date of Last Use When UsedBefore ConceptionAfter Conception Cocoaine "Crack"YesNo By Injection?YesNo Dosage or amount and length of time used Date of Last Use When UsedBefore ConceptionAfter Conception Heroin/Pain Killers (codeine, hydrocodone)YesNo By Injection?YesNo Dosage or amount and length of time used Date of Last Use When UsedBefore ConceptionAfter Conception Hallucinogens (i.e.. LSD, Ecstacy or XTC, mushrooms, PCP, etc.)specify type Dosage or amount and length of time used Date of Last Use When UsedBefore ConceptionAfter Conception Cigarettesspecify type Dosage or amount and length of time used Date of Last Use When UsedBefore ConceptionAfter Conception Marijuana Dosage or amount and length of time used Date of Last Use When UsedBefore ConceptionAfter Conception Otherspecify types Dosage or amount and length of time used Date of Last Use When UsedBefore ConceptionAfter Conception Otherspecify types Date of Last Use Dosage or amount and length of time used When UsedBefore ConceptionAfter Conception Otherspecify types Dosage or amount and length of time used Date of Last Use When UsedBefore ConceptionAfter Conception If you wish, please add any additional information that will further describe you and your situation. (Consider your schooling, health work, goals or hopes for the future, relationship history, religious or spiritual beliefs, challenges, strenghts, etc.)0 / Next Previous Next
