Dorothy Brown, Clerk of the Circuit Court of Cook County, Illinoiscookcountyclerkofcourt.orgPage 1 of 3 Birth Parent Medical Information þ (02/05/19) CCCO 0062 A en-USIN THE CIRCUIT COURT OF COOK COUNTY, ILLINOISen-USBIRTH PARENT MEDICAL INFORMATION Birth parent name: þ Signature: þ þ Date: þ en-US þ Yes þ No I agree to release my full name on this form to the adoptive family. If NO is en-USselected then the birth parent222s name shall be redacted on this form.Eyes: þ þ Hair: þ þ Complexion: þ þ Height: þ þ Weight: en-US Body build: þ þ Race: þ en-US Nationality/Descent: þ þ Blood type: þ Rh factor: en-US Eye glasses or contact lenses? þ þ Yes þ þ No Handedness: þ þ Right þ þ Left þ þ Ambidextrous Age: þ þ Date of birth: þ þ Religion: þ en-USen-USPlease list your highest education level, occupation, hobbies, interests, and talents: Existence of any disabilities? þ þ Yes þ þ No en-USIf yes, explain: Dorothy Brown, Clerk of the Circuit Court of Cook County, Illinoiscookcountyclerkofcourt.orgPage 2 of 3 Birth Parent Medical Information þ (02/05/19) CCCO 0062 B en-USIf you have other children, list them below. Include any children previously placed for adoption.en-USDescribe your relationship with the birth father:en-USFATHER222S PHYSICAL CHARACTERISTICS: Eyes: þ þ Hair: þ þ Complexion: þ þ Height: þ þ Weight: en-US Body build: þ þ Race: þ en-US Nationality/Descent: þ þ Blood type: þ þ Rh factor: þ en-US Eye glasses or contact lenses? þ þ Yes þ þ No Handedness: þ þ Right þ þ Left þ þ Ambidextrous Age: þ þ Date of birth: þ þ Religion: þ en-USen-USPlease list your highest education level, occupation, hobbies, interests, and talents: Existence of any disabilities? þ þ Yes þ þ No en-USIf yes, explain:en-USIf you have other children, list them below. Include any children previously placed for adoption.en-USPREGNANCY HISTORY INVOLVING THIS CHILD Month prenatal care began during this pregnancy: þ en-US Complications during pregnancy: þ þ Yes þ þ No þ If yes, explain: Dorothy Brown, Clerk of the Circuit Court of Cook County, Illinoiscookcountyclerkofcourt.orgPage 3 of 3en-USMEDICATION AND OTHER SUBSTANCES USED DURING PREGNANCY OR YEAR PRIOR TO en-USPREGNANCY en-USYes/Noen-USFrequency/Amount During en-USPregnancyen-USFrequency/Amount Prior to en-USPregnancyen-USAlcohol þ Yes þ þ No en-USAmphetamines þ Yes þ þ No en-USBarbiturates þ Yes þ þ No en-USCocaine þ Yes þ þ No en-USHeroin þ Yes þ þ No en-USLSD þ Yes þ þ No en-USMarijuana þ Yes þ þ No en-USCaffeine (Coffee, tea, etc) þ Yes þ þ No en-USPrescription drugs þ Yes þ þ No en-USNon-Prescription drugs þ Yes þ þ No en-USOther þ Yes þ þ No Birth Parent Medical Information þ (02/05/19) CCCO 0062 C