Medical Information On Birth Parents {NHJB-2193-FP}

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. MEDICAL CONDITION 1. Club Foot 2. Harelip, cleft lip, or cleft palate 3. Congenital heart defect 4. Any other malformations 5. Muscular Dystrophy NO NOT KNOWN YES (SELF) YES (RELATIVE) COMMENTS Part of body involved? Age at onset? 6. Multiple Sclerosis 7. Cerebral Palsy 8. Other paralysis or crippling disorder 9. Seizures, convulsions or epilepsy 10. Blindness, glaucoma or other visual problems 11. Deafness or other ear problems 12. Speech problem Age at onset? Cause? Special Education? Age at onset? What Treatment? Frequency? 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 American LegalNet, Inc. www.FormsWorkFlow.com NHJB-2193-FP (10/01/2006) Page 1 of 4 Case Name: Case Number: MEDICAL INFORMATION ON BIRTH PARENTS MEDICAL CONDITION 17. Other hormone disorder 18. Eczema or other skin conditions NO NOT KNOWN YES (SELF) YES (RELATIVE) COMMENTS Any cause known? What treatment? Medication? 19. Asthma 20. Hay fever or other allergy 21. Schizophrenia 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 29. Tumors 30. Cystic Fibrosis 31. Huntington's Disease 32. Tuberculosis 33. Kidney disease 34. Alcoholism or heavy drinking 35. Drug abuse 36. Hospitalization, operation, or injury 37. Any other conditions you or others in your family might have American LegalNet, Inc. www.FormsWorkFlow.com Age at onset? Treatment? Hospitalization? What kind? Age at onset? What part of body? Age of onset? Treatment? Kind, amount and when taken. NHJB-2193-FP (10/01/2006) Page 2 of 4 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 Eye color Age Ethnic background 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 Number of other male children born to you Weight Hair color Race Religion Body build Skin color Nationality (citizenship) No. of school years completed Ages 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.) HOW MANY MONTHS DID YOU CARRY THIS PREGNANCY? YEAR IN WHICH PREGNANCY ENDED IF MISCARRIAGE OR ABORTION, WAS IT NATURAL OR INDUCED? NHJB-2193-FP (10/01/2006) Page 3 of 4 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? Is the baby's father a genetic relative of yours? If yes, how is he related? Month prenatal care began for this pregnancy Complications, if any Exposure during pregnancy: Prescription drugs taken during pregnancy Kind X-Ray When Electrocardiogram Radiation Amount and frequency Yes Yes No No Non-prescription drugs taken during pregnancy Kind When Amount and frequency Did you use alcohol during pregnancy? Amphetamines (Uppers) used during pregnancy Kind Yes No Amount and frequency 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 Time of birth Length Complexion Physical appearance including abnormalities Sex Place of birth Eye color Head circumference Date of birth Weight Hair color Chest circumference Term Mother's blood type Type of delivery Premature weeks RH factor Postmature weeks Full term Baby's blood type Duration of labor weeks Anesthesia used Apgar score at 5 minutes Apgar score at 1 minute Condition of child at birth NHJB-2193-FP (10/01/2006) Page 4 of 4 American LegalNet, Inc. www.FormsWorkFlow.com