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 RelationshipAdditional InformationAnxiety No Yes, Self Yes, Relative Specify RelationshipAdditional InformationSuicidal No Yes, Self Yes, Relative Specify RelationshipAdditional InformationPsychosis No Yes, Self Yes, Relative Specify RelationshipAdditional InformationDiagnosed Schizophrenia No Yes, Self Yes, Relative Specify RelationshipAdditional InformationManic Depressive / Bipolar No Yes, Self Yes, Relative Specify RelationshipAdditional InformationEating Disorder (anorexia, bulimia, please specify) No Yes, Self Yes, Relative Specify RelationshipAdditional InformationDepression No Yes, Self Yes, Relative Specify RelationshipAdditional InformationPTSD No Yes, Self Yes, Relative Specify RelationshipAdditional InformationOCD No Yes, Self Yes, Relative Specify RelationshipAdditional InformationDrug Abuse (legal/illegal) No Yes, Self Yes, Relative Specify RelationshipAdditional InformationOthers (please explain) No Yes, Self Yes, Relative Specify RelationshipAdditional InformationAllergiesHay fever or other seasonal allergy No Yes, Self Yes, Relative Specify RelationshipAdditional InformationDrug Allergy (specify) No Yes, Self Yes, Relative Specify RelationshipAdditional InformationFood Allergy (specify) No Yes, Self Yes, Relative Specify RelationshipAdditional InformationOther Allergy (specify) No Yes, Self Yes, Relative Specify RelationshipAdditional InformationDevelopmental DisordersSpeech Problems No Yes, Self Yes, Relative Specify RelationshipAdditional InformationLearning Disability No Yes, Self Yes, Relative Specify RelationshipAdditional InformationRetardation (mental or physical) No Yes, Self Yes, Relative Specify RelationshipAdditional InformationSpecial Education No Yes, Self Yes, Relative Specify RelationshipAdditional InformationAutism No Yes, Self Yes, Relative Specify RelationshipAdditional InformationOther Developmental Disorders No Yes, Self Yes, Relative Specify RelationshipAdditional InformationPsychological 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