D.R.L. §§112(3)(6) S.S.L. §373-a Form 1-D (Child's Medical History - Agency or Private-Placement) 12/97 COURT OF THE STATE OF NEW YORK COUNTY OF In the Matter of the Adoption of A Child whose First Name is (Docket)(File) No. Child's Medical History (Agency or Private-Placement) 1. Age and date of birth of child: 2. Has the child had any of the following illnesses or health problems: on additional sheet). ___ (AIDS Infection) (HIV positive status)1 ___ Allergy to foods/other substances ___ Allergy to medications (prescription or overthe-counter) ___ Asthma ___ Chicken Pox ___ Circulatory system disorders (specify): ___ Diabetes ___ Diphtheria ___ German Measles (Rubella) ___ Measles (Rubeola) ___ Hay Fever ___ Heart problems (specify): (Where indicated, specify below or ___ Hepatitis ___ Kidney disease ___ Malaria ___ Mental/Behavioral disorders (specify): ___ Mumps ___ Parasites in stool ___ Rheumatic Fever ___ Scarlet Fever ___ Sickle Cell Anemia/Trait ___ Tuberculosis ___ Typhoid Fever ___ Urinary tract infection ___ Whooping Cough (Pertussis) ___ Other (specify): ___ Operations/Accidents/Fractures (specify): 3. Immunizations: give dates of the following: D.P.T/D.T. _____________________________________________ Polio (oral) _____________________________________________ Measles _________ Mumps __________ Rubella _______________ Hemophilus Influenza B. (H.I.B.) _________________________ Heptavax/Hepatitis Immune Globulin _______________________ Influenza (Flu) __________________________________________ Pneumonia vaccine ________________________________________ 1 Delete inapplicable provision. 2001 © American LegalNet, Inc. Form 1-D page 2 Other (specify) __________________________________________ Tuberculosis test (most recent/result) ____________________ 4. List Pre-natal History: ___ First trimester bleeding ___ Toxemia (high blood pressure or protein in the urine) ___ Medications (other than vitamins or iron) ___ Diabetes or thyroid problem (specify): Birth: Birth weight _________________ length ______________ Apgar score: 1 min. _________ 5 mins. ____________ Date baby was due ____________________ Date baby was born ___________________ Complications of delivery: ___ Premature rupture of membranes ___ Caesarian: routine _______ emergency ____________ ___ Excessive bleeding: abruption _________ placenta previa ______ Newborn: ___ Resuscitation required ___ Yellow jaundice: lights _______ exchange transfusion ____________ ___ Infection (specify): ___ Breathing problem (specify): ___ Other (specify): 5. List congenital impairments, including physical defects, if any. ___ Drugs (such as marijuana, heroin, methadone or amphetamines) (specify): ___ Alcohol (occasional)(moderate)(heavy)2 (specify): 6. State present health or cause of death (give ages), if known, of: 2 Delete inapplicable provision. 2001 © American LegalNet, Inc. Form 1-D page 3 Birth father: Birth mother: Siblings: full: half: 7. If known, indicate whether birth mother had any of the following: ___ Tuberculosis ___ Diabetes ___ Mental or nervous disorder e.g., schizophrenia, depression, manic depressive illness (specify): ___ Thyroid disease ___ Stroke ___ Sickle cell anemia ___ (Aids infection) (HIV positive status)* ___ High blood pressure ___ Bleeding tendency ___ Eye or ear disorder ___ Retardation: mental ___ Physical disability (specify): ___ Circulatory or blood disorders (specify): ___ Obesity ___ Asthma ___ Gastrointestinal disease, (e.g., gall bladder, ulcer, irritable bowel disorder) (specify): ___ Breast cancer ___ Colon cancer ___ Cancer, other (specify): ___ Arthritis or rheumatism ___ Kidney disease (specify): ___ Alcoholism or other substance abuse (specify): ___ Developmental disorder (e.g., learning disability, (attention deficit)(specify): ___ Other (specify): 8. If known, indicate whether birth father had any of the following: ___ Tuberculosis ___ Diabetes ___ Mental or nervous schizophrenia, depression, manic depressive illness (specify): ___ Thyroid disease ___ Stroke ___ Sickle cell anemia ___ Asthma ___ Gastrointestinal disease (e.g., gall bladder, ulcer, irritable bowel disorder) (specify): ___ Colon cancer ___ Cancer, other (specify): 2001 © American LegalNet, Inc. Form 1-D page 4 ___ (AIDS infection) (HIV positive status)* ___ Arthritis or rheumatism ___ Kidney disease (specify): _________________ *Delete inapplicable provision. ___ High blood pressure ___ Bleeding tendency ___ Eye or ear disorders ___ Retardation: mental ___ Physical disability (specify) ___ Circulatory or blood disorders (specify): ___ Obesity ___ Alcoholism or other substance abuse (specify): ___ Developmental disorder (e.g., learning disability, attention deficit disorder) (specify): ___ Other (specify): Indicate source for information about child's medical history and the source(s) for information about medical history of birth father and birth mother and whether from direct or indirect source: Completed by (state official title, if any): _______________________________________ ___________________________________ Petitioner ___________________________________ Print or type name ___________________________________ Signature of Attorney, if any ___________________________________ Attorney's Name (Print or Type) ___________________________________ ___________________________________ ___________________________________ Attorney's Address and Telephone Number 2001 © American LegalNet, Inc.