Free Medical Information on Birth Parents - New Hampshire

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THE STATE OF NEW HAMPSHIRE

JUDICIAL BRANCH

http://www.courts.state.nh.us

Court Name: Case Name: Case Number:
(if known)

MEDICAL INFORMATION ON BIRTH PARENTS Birth Mother Birth Father (Use separate form for each parent.)
For each of the medical conditions described below, please check the appropriate column indicating whether you or any blood relative (i.e. your mother, father, sisters, brothers, grandparents, aunts, uncles or any other children you have had) ever had, or now have, the condition listed. Complete the "Comments" section as needed using a separate sheet of paper if additional space is required.

MEDICAL CONDITION 1. Club Foot 2. Harelip, cleft lip, or cleft palate 3. Congenital heart defect 4. Any other malformations 5. Muscular Dystrophy

NO

NOT KNOWN

YES
(SELF)

YES
(RELATIVE)

COMMENTS

Part of body involved? Age at onset?

6. Multiple Sclerosis 7. Cerebral Palsy 8. Other paralysis or crippling disorder 9. Seizures, convulsions or epilepsy 10. Blindness, glaucoma or other visual problems 11. Deafness or other ear problems 12. Speech problem Age at onset? Cause? Special Education? Age at onset? What Treatment? Frequency?

Age at onset? Cause? Special Education?

13. Learning disability 14. Retardation: mental or physical Any diagnosis or cause? Hospitalized?

15. Diabetes

Age at onset? Treatment?

16. Thyroid disorder
NHJB-2193-FP (10/01/2006) (formerly AOC-200-003) Page 1 of 4

Case Name: Case Number:
MEDICAL INFORMATION ON BIRTH PARENTS


MEDICAL CONDITION 17. Other hormone disorder 18. Eczema or other skin conditions

NO

NOT KNOWN

YES
(SELF)

YES
(RELATIVE)

COMMENTS

Any cause known? What treatment? Medication?

19. Asthma 20. Hay fever or other allergy 21. Schizophrenia 22. Manic depressive 23. Other mental or emotional illness 24. Hypertension (high blood pressure) 25. Stroke 26. Heart attack (Coronary) 27. Other cardiovascular problems 28. Cancer 29. Tumors 30. Cystic Fibrosis 31. Huntington's Disease 32. Tuberculosis 33. Kidney disease 34. Alcoholism or heavy drinking 35. Drug abuse 36. Hospitalization, operation, or injury 37. Any other conditions you or others in your family might have
NHJB-2193-FP (10/01/2006) (formerly AOC-200-003) Page 2 of 4

Age at onset? Treatment? Hospitalization?

What kind? Age at onset? What part of body?

Age of onset? Treatment?

Kind, amount and when taken.

Case Name: Case Number:
MEDICAL INFORMATION ON BIRTH PARENTS


OTHER INFORMATION ON BIRTH PARENTS
Information given should be as of the time of the child's birth. Do not include any identifying information.

Height Eye color Age Ethnic background Future education goals General field of occupation Talents, hobbies and special interests Future aspirations Relationship between parents Number of other female children born to you Number of other male children born to you

Weight Hair color Race Religion

Body build Skin color Nationality (citizenship) No. of school years completed

Ages Ages BIRTH MOTHER ONLY


MENSTRUAL AND PREGNANCY HISTORY
Age at onset of menses Are periods regular? Usual length of period No. of days between periods List all pregnancies in order. Use one line for each child, miscarriage, abortion or still-birth. CHILDREN (Write baby girl, baby boy, miscarriage, still-birth or
abortion.)
HOW MANY MONTHS DID YOU CARRY THIS PREGNANCY? YEAR IN WHICH PREGNANCY ENDED IF MISCARRIAGE OR ABORTION,
WAS IT NATURAL OR INDUCED?


NHJB-2193-FP (10/01/2006) (formerly AOC-200-003)

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Case Name: Case Number: MEDICAL INFORMATION ON BIRTH PARENTS

INFORMATION ON THIS PREGNANCY

Is the baby's father aware of this pregnancy? Is the baby's father a genetic relative of yours? If yes, how is he related?
Month prenatal care began for this pregnancy
Complications, if any
Exposure during pregnancy: Prescription drugs taken during pregnancy
Kind X-Ray When Electrocardiogram Radiation Amount and frequency
Yes Yes No No

Non-prescription drugs taken during pregnancy Kind

When

Amount and frequency

Did you use alcohol during pregnancy? Amphetamines (Uppers) used during pregnancy Kind

Yes

No

Amount and frequency

When

Amount and frequency

Barbiturates (Downers, cocaine, heroin, LSD, marijuana, cigarettes) used during pregnancy Kind When

Amount of frequency

CHILD'S BIRTH HISTORY

Child's first name Time of birth Length Complexion Physical appearance including abnormalities Sex Place of birth Eye color Head circumference Date of birth Weight Hair color Chest circumference

Term Mother's blood type Type of delivery

Premature

weeks RH factor

Postmature

weeks

Full term Baby's blood type Duration of labor

weeks

Anesthesia used Apgar score at 5 minutes

Apgar score at 1 minute Condition of child at birth

NHJB-2193-FP (10/01/2006) (formerly AOC-200-003)

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