Medical Information on Birth Parents

In order to provide health-related information about the biological parents in an adoption case, the following for has to be completed and submitted.

Extracted Text for Proper Search

NHJB-2193-FP (10/01/2006) Page 1 of 4 	
 
 	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 rel ative 	
(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  NO NOT 
KNOWN  YES 	
(SELF)
 	
YES 	
(RELATIVE) 	
COMMENTS 	
 1.  Club Foot 	 	 	 	  	
 2.  Harelip, cleft lip, or cleft palate 	 	 	 	  	
 3.  Congenital heart defect 	 	 	 	  	
 4.  Any other malformations 	 	 	 	  	
 5.  Muscular Dystrophy 	 	 	 	 Part of body involved?  Age at onset? 	
 6.  Multiple Sclerosis 	 	 	 	  	
 7.  Cerebral Palsy 	 	 	 	  	
8.  Other paralysis or crippling 
 disorder 	 	 	 	  	
9.   Seizures, convulsions or 
 epilepsy 	 	 	 	  Age at onset?   What Treatment?  Frequency? 	
10. Blindness, glaucoma or other  
 visual problems 	 	 	 	  Age at onset?  Cause?  Special Education?  	
11. Deafness or other ear problems 	 	 	 	  	
12. Speech problem 	 	 	 	  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

Case Name:   
Case Number:   
MEDICAL INFORMATION ON BIRTH PARENTS  
NHJB-2193-FP (10/01/2006) Page 2 of 4 	
MEDICAL CONDITION NO NOT 
KNOWN  YES 	
(SELF) 	
YES 	
(RELATIVE) 	
COMMENTS 	
17.  Other hormone disorder 	 	 	 	 
 	
18. Eczema or other skin 
conditions 	 	 	 	 
Any cause known? What treatment? 
Medication? 	
19. Asthma 	 	 	 	  	
20.  Hay fever or other allergy 	 	 	 	  	
21. Schizophrenia 	 	 	 	 Age at onset?  Treatment?  Hospitalization? 	
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 	 	 	 	 What kind?  Age at onset?  What part of body? 	
29. Tumors 	 	 	 	 
 	
30. Cystic Fibrosis 	 	 	 	  	
31. Huntington's Disease 	 	 	 	  	
32.  Tuberculosis 	 	 	 	  	
33. Kidney disease 	 	 	 	 Age of onset?  Treatment? 	
34.  Alcoholism or heavy drinking 	 	 	 	 
 	
35. Drug abuse 	 	 	 	 Kind, amount and when taken. 	
36. Hospitalization, operation, or 
injury 	 	 	 	   	
37. Any other conditions you or 
others in your family might have

Case Name:   
Case Number:   
MEDICAL INFORMATION ON BIRTH PARENTS  
NHJB-2193-FP (10/01/2006) Page 3 of 4 	
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 Weight Body build 
Eye color  Hair color Skin color 
Age Race  Nationality (citizenship) 
Ethnic background  Religion No. of school years completed 
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    Ages 
Number of other male children born to you   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  HOW MANY MONTHS DID YOU  YEAR IN WHICH  IF MISCARRIAGE OR ABORTION,  
(Write baby girl, baby boy,  CARRY THIS PREGNANCY? PREGNANCY ENDED  WAS IT NATURAL OR INDUCED?  
miscarriage, still-birth or 
abortion.)

Case Name:   
Case Number:   
MEDICAL INFORMATION ON BIRTH PARENTS  
NHJB-2193-FP (10/01/2006) Page 4 of 4 	
INFORMATION ON THIS PREGNANCY 	
Is the baby's father aware of this pregnancy? 	  Yes 	  No 
Is the baby's father a genetic relative of yours?  	
  Yes 	  No 
If yes, how is he related?        	
Month prenatal care began for this pregnancy   
Complications, if any      
Exposure during pregnancy: 	  X-Ray 	  Electrocardiogram 	  Radiation 	
Prescription drugs taken during pregnancy 
     Kind      When  Amount and frequency  
 
 
Non-prescription drugs taken during pregnancy 
     Kind      When  Amount and frequency  
 
 
Did  you use alcohol during pregnancy?  	  Yes 	  No  Amount and frequency  
 	
Amphetamines (Uppers) used during pregnancy 
     Kind      When  Amount and frequency 
 
 
Barbiturates (Downers, cocaine, heroin, LS D, marijuana, cigarettes) used during pregnancy 
     Kind      When  Amount of frequency 
 
 	
CHILD'S BIRTH HISTORY 	
Child's first name  Sex  Date of birth 
Time of birth Place of birth  Weight 
Length Eye color  Hair color 
Complexion Head circumference  Chest circumference 
Physical appearance including abnormalities 
 
 
Term  Premature    weeks  Postmature    weeks  Full term    weeks   
Mother's blood type  RH factor   Baby's blood type 
Type of delivery   Anesthesia used   Duration of labor 
Apgar score at 1 minute  Apgar score at 5 minutes   
Condition of child at birth