Free Instructions - New Hampshire

Instructions for completing MEDICAL INFORMATION ON BIRTH PARENTS
(NHJB-2193-FP)

Form use. This form is to be completed by the birth mother and birth father each using a separate form. Top part of form ·COURT NAME: Enter the name of the county probate court where the document will be filed. (example: Belknap County Probate Court; Rockingham County Probate Court). ·CASE NAME: Enter the birth name of the child (example: Adoption of John Adams; Adoption of Susan Jones). ·CASE NUMBER: Leave blank if not yet assigned by court OR fill in case number if it is known. Top section of form Check off the box Birth Mother to indicate the person completing this form is the birth mother of the child. Check off the box Birth Father to indicate the person completing this form is the birth father of the child. Pages 1 and 2 Read each of the Medical Conditions listed in the left column numbered 1 through 37. For each condition, check off the box that indicates if you or any blood relative (mother, father, sisters, brothers, grandparents, aunts, uncles or any other children you have had) ever had, or now have the condition. Complete the Comments section as needed attaching a separate sheet of paper if additional space is needed. Page 3. Top section Other Information On Birth Parents is to be completed by each parent. Enter information as of the time of the child's birth. No identifying information should be included. Page 3. Bottom section and Page 4 Menstrual and Pregnancy History, Information on this Pregnancy, Child's Birth History sections are to be completed by Birth Mother Only.

Review the completed form for accuracy prior to filing it with the court. If completing this form on-line, some fields may be filled in automatically based on entries in other fields. If more space is needed for any question, please attach additional sheets of paper.

NHJB-2193-FP Instructions (10/01/06)

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