Birth Mother Medical History

Name

First Last

INITIAL QUESTIONS

Have you received prenatal care?

Yes
No

Please indicate what month of your pregnancy you first received prenatal care.

Have you experienced any complications during pregnancy?

Yes
No

If Yes, please explain:

Results of HIV/AIDS Test

Positive
Negative

GENERAL HEALTH INFORMATION

By 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.’

Allergies

Hay 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 Disorders

Speech 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 History

Have 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:

Mental Health

Alcoholism or heavy drinking

No
Yes, Self
Yes, Relative

Specify Relationship

Additional Information

Anxiety

No
Yes, Self
Yes, Relative

Specify Relationship

Suicidal

No
Yes, Self
Yes, Relative

Additional Information

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

Additional Medical / Family History

Have you ever been tested for HIV/ AIDS?

Yes
No

Date of Test?

Did 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: