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. NO NOT YES YES KNOWN MEDICAL CONDITION (SELF) (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 NHJB-2193-FP (10/01/2006) (formerly AOC-200-003) Page 1 of 4 American LegalNet, Inc. www.FormsWorkflow.com Case Name: Case Number: MEDICAL INFORMATION ON BIRTH PARENTS NO NOT YES YES KNOWN MEDICAL CONDITION (SELF) (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 NHJB-2193-FP (10/01/2006) (formerly AOC-200-003) Page 2 of 4 American LegalNet, Inc. www.FormsWorkflow.com 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 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 (Write baby girl, baby boy, miscarriage, still-birth or abortion.) NHJB-2193-FP (10/01/2006) (formerly AOC-200-003) HOW MANY MONTHS DID YOU CARRY THIS PREGNANCY? YEAR IN WHICH PREGNANCY ENDED Page 3 of 4 IF MISCARRIAGE OR ABORTION, WAS IT NATURAL OR INDUCED? American LegalNet, Inc. www.FormsWorkflow.com Case Name: Case Number: MEDICAL INFORMATION ON BIRTH PARENTS 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 Amphetamines (Uppers) used during pregnancy Kind Amount and frequency No 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 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 Mother's blood type RH factor Baby's blood type Type of delivery Anesthesia used Duration of labor Apgar score at 1 minute weeks Apgar score at 5 minutes Condition of child at birth NHJB-2193-FP (10/01/2006) (formerly AOC-200-003) Page 4 of 4 American LegalNet, Inc. www.FormsWorkflow.com