BIRTH MOTHER MEDICAL HISTORYPlease answer these questions to your best ability. All information you share is confidential. Name First Last INITIAL QUESTIONSPlease indicate what month of your pregnancy you first received prenatal care: Have you experienced any complications during pregnancy? Yes No If Yes, please explain:Have you ever been tested for HIV/ AIDS? Yes No Date of Test? Results of HIV/AIDS Test Positive Negative Any other type of sexual health related issues?GENERAL HEALTH INFORMATIONBy checking the appropriate box, please indicate if you or any of your relatives have had any of the medical conditions listed below. For any medical condition that you check ‘YES,’ please provide specific information regarding the condition in the column marked ‘ADDITIONAL INFORMATION.’Mental HealthAlcoholism or heavy drinking No Yes, Self Yes, Relative Specify Relationship Additional Information Anxiety No Yes, Self Yes, Relative Specify Relationship Additional Information Suicidal No Yes, Self Yes, Relative Specify Relationship Additional Information Psychosis No Yes, Self Yes, Relative Specify Relationship Additional Information Diagnosed Schizophrenia No Yes, Self Yes, Relative Specify Relationship Additional Information Manic Depressive / Bipolar No Yes, Self Yes, Relative Specify Relationship Additional Information Eating Disorder (anorexia, bulimia, please specify) No Yes, Self Yes, Relative Specify Relationship Additional Information Depression No Yes, Self Yes, Relative Specify Relationship Additional Information PTSD No Yes, Self Yes, Relative Specify Relationship Additional Information OCD No Yes, Self Yes, Relative Specify Relationship Additional Information Drug Abuse (legal/illegal) No Yes, Self Yes, Relative Specify Relationship Additional Information Others (please explain) No Yes, Self Yes, Relative Specify Relationship Additional Information AllergiesHay fever or other seasonal allergy No Yes, Self Yes, Relative Specify Relationship Additional Information Drug Allergy (specify) No Yes, Self Yes, Relative Specify Relationship Additional Information Food Allergy (specify) No Yes, Self Yes, Relative Specify Relationship Additional Information Other Allergy (specify) No Yes, Self Yes, Relative Specify Relationship Additional Information Developmental DisordersSpeech Problems No Yes, Self Yes, Relative Specify Relationship Additional Information Learning Disability No Yes, Self Yes, Relative Specify Relationship Additional Information Retardation (mental or physical) No Yes, Self Yes, Relative Specify Relationship Additional Information Special Education No Yes, Self Yes, Relative Specify Relationship Additional Information Autism No Yes, Self Yes, Relative Specify Relationship Additional Information Other Developmental Disorders No Yes, Self Yes, Relative Specify Relationship Additional Information Psychological Counseling HistoryHave you ever gone to a psychologist, psychiatrist, clinical social worker, mental health or behavioral health therapist for any emotional or psychological or behavioral problems you may have had? Yes No Dates and reasons for treatment:Medications prescribed during your treatment:Reason(s) for discontinuance if no longer under treatment:Additional Medical / Family HistoryDid you experience any childhood illnesses (ear infections, meningitis, etc.):Have you been in any accidents or been hospitalized due to an illness or injury (please indicate nature of the event and date):Please note any other conditions not listed above which you are aware of in either yourself of any of your family members: Δ ADDITIONAL BIRTH PARENT FORMS CHOOSING AN ADOPTIVE FAMILY START SOCIAL PROFILE INFORMATION START HOSPITAL PREFERENCES START BIRTH FATHER INFORMATION START BIRTH PARENT LIVING EXPENSES START BIRTH MOTHER APPLICATION START
