BIRTH FAMILY AND CHILD HISTORY (MATERNAL) Child's Birth Name: ____________________________________________________________________________ Birth Date _______________ City ________________ County _________________ State ___________________ Time of Birth __________ Hospital _____________________ Gender ___________ Birth Weight_____________ Apgar Scores ____________ Hair Color____________ Eye Color __________ Complexion __________ Pediatrician ________________________ Contact Info _______________________________________________ Immunizations______ Shots and Dates_____________________________________________________________ Child's General Health Status ____________________________________________________________________ Child's Progress: Physical, Emotional, Developmental ________________________________________________ ____________________________________________________________________________________________ PREGNANCY INFORMATION: Prenatal Care? _____________ If yes, how many visits ______________ Month of the First Visit _____________ Length of Pregnancy _______ Complications during Pregnancy ________________________________________ ____________________________________________________________________________________________ Type of Delivery _____________ Length of Labor ____________ Birth Mother's Blood Type _______________ Have you had other pregnancies? No Yes if yes, please explain: ___________________________________ ____________________________________________________________________________________________ No Yes Have you had any miscarriages? if yes, please explain: ___________________________________________________________________________________________ ___________________________________________________________________________________________ Do you have any children not residing with you? Yes No _________________________________________ ___________________________________________________________________________________________ Yes No Have you previously released a child and/or had rights terminated on a child? __________________________________________________________________________________________ __________________________________________________________________________________________ Information Provided By: ________________________________________________ Date: ____________________ 1. Indicate how the birth family feels about the plan being made for the child(ren): ________________________________________________________________________________________ ________________________________________________________________________________________ Birth Family and Child History.docx Oakland County Family Court, 2014 American LegalNet, Inc. www.FormsWorkFlow.com Page 1 2. What do you want your child (ren) to know about why placement for adoption or foster care was necessary? ________________________________________________________________________________________ ________________________________________________________________________________________ 3. Is the birth father of the child (ren) aware of the adoption/foster plan in place? ________________________________________________________________________________________ ________________________________________________________________________________________ 4. Is there a genetic relationship between the birth parents? Yes No 5. If yes, how were they related? Has the birth mother or birth father expressed any feelings regarding this child and the placement plan that is being made? ________________________________________________________________________________________ ________________________________________________________________________________________ ________________________________________________________________________________________ 6. What is the relationship between the birth mother and or birth father of this child at this time? ________________________________________________________________________________________ ________________________________________________________________________________________ 7. Were you married to someone else at the time of conception? Yes No DRUGS TAKEN DURING AND BEFORE PREGNANCY Indicate in the appropriate space medications/drugs taken during this pregnancy involving this child and/or medications/drugs taken prior to this pregnancy. Name of Drug/Medication * ADD/ADHD Medications Alcohol Anticonvulsant Antidepressants Antihistamines Aspirin/Other Pain Killers Cancer Medications Cigarettes Cocaine/Crack Cortisone Diet Pills Birth Family and Child History.docx Oakland County Family Court, 2014 YES NO MONTH(S) YEARS TYPE, FREQUENCY, AMOUNT American LegalNet, Inc. www.FormsWorkFlow.com Page 2 Heart/Blood Pressure Heroin Hormones Inhalants LSD Marijuana Nausea Meds/Tranquilizers/ Anti-Anxiety Medications Prenatal or Other Vitamins Nose Drops Sleeping Pills/Barbiturates Thalidomides Herbs/Supplements If any others, please list here: ______________________________________________________________________________________________ ______________________________________________________________________________________________ To the best of your knowledge, is the birth father on medications or has he used any non-prescription drugs? If yes, please list here: ______________________________________________________________________________________________ ______________________________________________________________________________________________ Birth Mother History: Identifying Information: ( ) Name: ____________________________________________________ Phone Number: (_____) Maiden Name Area Code Address:_______________________________________________________________________________________ Number & Street Name City State / Zip Code Age: ________________ Date of Birth: __________________ Place of Birth: _______________________________ Social Security No.: _______________________ Driver's License No.: ____________________________________ Marital Status: Never Married Married Separated Divorced Widowed Number of Previous Marriages: __________ Name of Spouse: __________________________________________________________________________ Address of Spouse: ________________________________________________________________________ Street No. and Name City State Zip Code Date of Marriage: ________________________ Place of Marriage: _________________________________ Date of Separation: _____________ Date of Divorce: ____________ Place of Divorce: _________________ Date of Death of Spouse: _________