700-00126 Information About Birth Family (0) Page 1 of 9 STATE OF VERMONT SUPERIOR COURT PROBATE DIVISION Unit Docket No. In r e Adoption of : INFORMATION ABOUT BIRTH FAMILY Each Birth Parent should complete a separate form. Today's Date: Name of person completing form: If not parent, relationship to parent: Child's Full Name: Date of Birth: Time of Birth: Place of Birth (town, state, country): BIRTH PARENT BACKGROUND (first, middle, last): Maiden or previous name(s), if applicable: Date of Birth: Place of Birth: Social Security Number: State: Race: Ethnic Background: If you attend religious services, what kind? Physical Address Mailing Address Please provide the name and address of a person who is likely to know where you are if you move: American LegalNet, Inc. www.FormsWorkFlow.com 700-00126 Information About Birth Family Page 2 of 9 PHYSICAL DESCRIPTION Height: Weight: Complexion: Hair Color: Eye Color: General Build: PERSONAL BACKGROUND Where did you grow up? What is the highest grade you have completed? How did you do in school? What were your favorite subjects? If you had learning problems in school, what were they? If you have had other training, what kind? What kind of jobs have you had? Present occupation: Briefly describe your personality: What are your interests and talents? (examples of talents: artistic, mechanical, athletic, like science, musical, etc.) Have you been in the military? Yes No If Yes, what branch? What was your rank and serial number? What are your plans for the future? BIRTH PARENT'S FAMILY Your m name (first, middle, maiden): Height: Weight: Age: Race: Hair Color: Eye Color: General Build: General Health: Level of Education: Occupation: Is she aware of the birth of this child? Yes No If deceased, age and cause of death: American LegalNet, Inc. www.FormsWorkFlow.com 700-00126 Information About Birth Family Page 3 of 9 BIRTH PARENT'S FAMILY (continued) Your name): Height: Weight: Age: Race: Hair Color: Eye Color: General Build: General Health: Level of Education: Occupation: Is he aware of the birth of this child? Yes No If deceased, age and cause of death: BROTHERS AND SISTERS Full Name Male / Female Date of Birth Last Grade Completed Occupation M / F M / F M / F M / F M / F MARRIAGES Name of Spouse Year Married Year Divorced BROTHERS AND SISTERS OF YOUR CHILD (Include brothers and sisters living at home or elsewhere including children who were adopted, step-brothers and sisters and any children who may have lived in the child's home for an extended period of time.) Full Name Male / Female Date of Birth Relationship to Child Who is Caring for this Child? M / F M / F M / F M / F M / F American LegalNet, Inc. www.FormsWorkFlow.com 700-00126 Information About Birth Family Page 4 of 9 Does your child have a relationship with these brothers and sisters? Please describe. PREGNANCY (for birthmothers only) In what month did you begin pre-natal care? Did you drink alcohol during this pregnancy? When during your pregnancy? How much at one time and how often? What prescription drugs, over-the-counter medications or street drugs did you take during your pregnancy? What kind, how often, and when during the pregnancy? Did you smoke? If so, how much? Did you have any special problems during pregnancy? (for example: high blood pressure, diabetes, excessive bleeding, kidney or bladder infections, German or Three Day Measles, operations, convulsions, x-rays, sexually transmitted diseases or others): At what age did you get your period? Where was your child born? Was this child born earlier or later than expected? Earlier Later If so, how much earlier or later? How long was your labor? If drugs were used during your labor, what kind? Were forceps used? YesNo If you had a Caesarian Section (C-section), why? If your child had any problems during the labor or soon after birth, please describe: Birth length: Did your child have special problems at birth? Please describe: What s doctor? American LegalNet, Inc. www.FormsWorkFlow.com 700-00126 Information About Birth Family Page 5 of 9 FOR CHILDREN WHO ARE NOT NEWBORNS Wmmunization records? What illnesses has your child had? Chicken PoxBladder or Kidney InfectionMumpsEar infectionsWhooping CoughHepatitisFrequent nausea or vomitingMeningitis RedMeaslesFrequent diarrhea or constipation Sore throatAllergiesSeizures or convulsionsHeadachesDizzinessRash/Skin problemsAsthmaHay FeverBroken bonesFaintingDental cavitiesPneumoniaFrequent swollen glandsRheumatic FeverTrouble urinatingFrequent bruises or bleedingHospitalizationsMajor operations, illnesses or accidentsAnemia If you checked any of the above, please describe: If your child has special educational needs, what are they? If your child has been formally evaluated for any special problems, what was the evaluation for? Medical problemDental or orthodonticLearning/school problemsEmotional disturbance or mental illnessOther: what kind? If so, you may be asked to sign releases so that copies of the evaluations can be obtained. Has your child been abused or neglected in the past? Physical abuseEmotional or verbal abuseSexual abuse NeglectIf so, you may be asked to provide more information about the abuse or neglect. If your child has ever lived with relatives, foster parents or other place away from home, please describe: American LegalNet, Inc. www.FormsWorkFlow.com 700-00126 Information About Birth Family Page 6 of 9 FAMILY MEDICAL HISTORY Instructions: If you have any of the problems listed below, or have had any problem in the past, please place a check in the box. If another family member has had the problem, place a check in the box and then list that mples: aunt, brother, grandmother). If you have more information about the particular problem, please provide it at the end of this section. Acne or pimples MyselfOther family member: HIV infection or AIDS MyselfOther family member: Alcohol Abuse MyselfOther family member: Allergy to Food MyselfOther family member: What kind? Allergy to Other Things MyselfOther family member: What kind? Alzheim MyselfOther family member: Anemia MyselfOther family member: Anencephaly MyselfOther family member: (born with no brain) Arthritis MyselfOther family member: Where? Bedwetting MyselfOther family member: Bipolar illness MyselfOther family member: (manic depression) Birth defects MyselfOther family member: What kind? Blindness or very poor sight Myself Other family member: Braces on teeth Myself Other family member: Breast cancer MyselfOther family member: Bronchitis MyselfOther family member: Hodgkin MyselfOther family member: Cancer MyselfOther family member: What kind? Chlamydia MyselfOther family member: Cleft lip or palate MyselfOther family member: Club foot MyselfOther family member: American LegalNet, Inc. www.FormsWorkFlow.com 700-00126 Information About Birth Family Page 7 of 9 Colitis MyselfOther family member: Color blindness MyselfOther family member: Cystic Fibrosis MyselfOther family member: Dental Problems Myself Other family member: What kind? Deafness/hearing problems MyselfOther family member: Diabetes in childhood MyselfOther family member: Diabetes adulthood onset MyselfOther family member: me MyselfOther family member: Drug Abuse MyselfOther family member: Dwarfism/very short height MyselfOther family member: Ear infections MyselfOther family member: Eczema MyselfOther family member: Emphysema MyselfOther family member: Epilepsy or seizures MyselfOther family member: Eye problems MyselfOther family member: Genital Warts MyselfOther family member: Very tall height MyselfOther family member: Glasses MyselfOther family member: What kind? Glaucoma MyselfOther family member: Gynecological Problems MyselfOther family member: (female) What kind? Gonorrhea Myself Other family member: Headaches or migraines Myself Other family member: Heart attack/heart problems Myself Other family member: Hemochromatosis Myself Other family member: Hemophilia or bleeding Myself Other family member: Hepatitis Myself Other family member: Herpes Myself Other family member: American LegalNet, Inc. www.FormsWorkFlow.com 00126 Information About Birth Family Page 8 of 9 Hives MyselfOther family member: High b