"" 1 You Name Your Last Name NON-IDENTIFYING INFORMATION FOR ADOPTION REGISTRY The information in this report has been provided by the birth parent. The Office of Vital Records and Statistics is not responsible for the accuracy of this information. TO BE COMPLETED BY THE PERSON OR AGENCY MAKING PLACEMENT (This information will not be released or shared) 1a. Name of Agency or individual responible for placementno-icon 1b Addressno-icon Cityno-icon Stateno-icon Zip Codeno-icon 2. Name the person to contact for further informationno-icon 3. Placewhere adoption was finalized:Cityno-icon Countryno-icon Stateno-icon 4. Date of finalizationdate_range 5. Adoptee's Date of Birthdate_range 6. Adoptee's place of birthCityno-icon Countryno-icon Stateno-icon 7. Birth Mother ResidenceCityno-icon Countryno-icon Stateno-icon Birth Mother Information (This information should reflect the facts as they were at the time the birth of the adopted child occured) 8. During this pregnancy, were you diagnosed as:(check all that apply)1. Anemic2. Diabetic3. Gestationa Diabetic 9. Did you have X-rays during this pregnancy?if yes, what procedure/type?no-icon 10. Weight gained during this pregnancylbsno-icon 11. Delivery history Weeks Gestationweeksno-icon Length of Laborhoursno-icon APGARS (1/5)no-icon Birth Weight: lbsno-icon ozno-icon 12. This birth:single, twin, triplet specifyno-icon 13. If notsingle birth;born 1st, 2nd, 3rdno-icon 14. Month pregnancy prenatal care beganno-icon 15. Prenatal Visits: total number(if none, so state)no-icon 16. Previous Pregnancies (Complete Each Section) LIVE BIRTHS 16a. Now Livingno-icon None 16b. Now Deadno-icon None OTHER PREGNANCIES 16c. Spontaneous/ Induced Terminationsno-icon None 17. Type of Delivery AnesthesiaNonePericervical blockEpidural spinal blockGeneralLocal 18. Type of DeliveryC-sectionNormal vaginalForceps assistedVacuum assistedOther If Otherspecifyno-icon 19. If C-sectiongive indicationBreech presentationCephalopelvic disproportionFetal distressOther If Otherspecifyno-icon 20. Primary Reason for PlacementLack of support systemsLack of relationship with birth fatherLack of financial resourcesAge (too young/old)Other If Otherspecifyno-icon On a scale of 1 to 5, 5 being the worst, rate your stress levelduring the pregnancy:12345 Birth Father Information (This information should reflect the facts as they were at the time the birth of the adopted child occured) 22. Previous Children (Complete Each Section) LIVE BIRTHS 22a. Now Livingno-icon None 22b. Now Deadno-icon None OTHER PREGNANCIES 22c. Spontaneous/ Induced Terminationsno-icon None 23. Primary Reason for PlacementLack of support systemsLack of relationship with birth fatherLack of financial resourcesAge (too young/old)Other NEXT Previous Next
