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Congratulations! You have made a hard decision,
but it is surely the best decision for you and very
importantlyfor your baby. Let's get you started!
Michelle is waiting to help you find the right home
for your baby!
Michelle will need information from you and your
agreement for her to be your legal representative. Her form is
printed below. You can highlight and print the form,
then mail it in. If you need help with any questions,
call 1-800-806-2010!
BIRTHMOTHER INFORMATION
Date __________________ Referred by ____________________
Due date _____________ Child's Sex _________________
Full name ______________________________________________
Other names used ________________________________________
Home address ____________________________________________
______________________________________________________
Phone numbers_________________________________________
Represented by attorney ( ) yes ( ) no
Name, address, phone ___________________________________
____________________________________________________
Live with parents? _______________ Others - Who?____________
Live-with the baby's father during past year? ________ Dates _______
Family aware of Adoption plan? ____ Do they agree/support? _____
Social Security No. ._____________ Drivers Lic. _______________
American Indian? _____ Registered? _____
If yes: What tribe(s)? ________________ Degree? __________%
Date of birth _____________________ Place of birth ___________
Age _____ Race ______________ Religion _________________
Hair ______ Eyes _____ Complexion ______ Height ______ Weight _____
Marital status ( ) Single ( ) Divorced ( ) Separated ( ) Married
Are you married but your husband is not the father of the child? _______
If yes, is husband aware of pregnancy? ____ Agree to adoption plan? ____
Willing to Consent? ______
Marital History
Husband's name, Date and Place of Marriage,
Date and Place of Divorce ( A certified copy of both
the marriage certifiicate and dissolution decree will be needed.)
_____________________________________________________
Your other children : Provide name, age, address, father's name
1. _____________________________________________________
2. _____________________________________________________
Highest education ______________________
Present Occupation ____________________
Employer _________________________________________
Phone_______________________________
Work address __________________________________________
_____________________________________________________
Pregnancy history
Your Health: (1-10 scale) _______
Any conditions/illnesses? __________________
First Pregnancy ( ) yes ( ) no How many priors? _______
To term? ______
C-sections? _________
Miscarriages? _____________
Abortions? ________________
Any problems with this pregnancy? __________________________
List medications taken during this pregnancy ___________________
Any accidents during this pregnancy? _________________________
Smoke? ____ During this pregnancy? _______
How much? _____________________________
Drink alcohol? ____ During this pregnancy? _____
How much/ how often? _________________
Drug use? ____ During this pregnancy? _____
What?/How much?/ How often? ____________________________
Problems with prior pregnancies or deliveries? _________________
Medical information
Doctor's name, address, phone _____________________________
____________________________________________________
Hospital name, address, phone ____________________________
____________________________________________________
Pre-registered? _________________________________
General information
Any criminal convictions? You? _______________/the father? _______
Drug arrests/convictions? You? _______________/the father? _______
Any accusations of child abuse/neglect? You? __________ the father? ____
Church affiliation: Provide name, address, phone, pastor/priest's name
_________________________________________________________
Previous adoptionplacments: Brief description with date(s)
_________________________________________________________
Why have you chosen adoption for this child?
_________________________________________________________
Criteria (if any) for adopting parents
Married ____ Age ____ Race ______ Religion _________
Education ___ Number of other children __________
Health conditions _________________________________________
Other _________________________________________________
Expectations/preferences regarding open adoption arrangements
______________________________________________________
Describe yourself, i.e. hobbies, activities,
talents, training, sports, family/church/
community involvements, goals/plans__________________________
_______________________________________________________
_____________________________________________________
____________________________________________________
Child's Father's Full Name_______________________________
Other names used _______________________________________
Address ____________________________________________
Phones ___________________________________________
Live-together during past year? ___________
Dates ___________________________________
His Age __________ Race _____________
Religion ______________________
Hair ______ Eyes _____
Complexion ______ Height _____
Weight __________
Date of birth _____________________
Place of birth ____________________________________
Social Security No. ________________
Drivers Lic. _____________________
American Indian? _____ Registered? _____
What tribe(s)? _____________________________
Degree? __________%
His Marital Status ( ) Single ( ) Divorced ( )
Separated ( ) Married
His Marital History: Wife's name, Date and Place of Marriage,
Date and Place of Divorce
_______________________________________________________
Other children : Provide name, age, address, parentage
1._____________________________________________________
2.____________________________________________________
Ishe current on all child support? _________
His Education _________________
Occupation______________________________________________
Employer_______________________________________________
Workaddress___________________________________________
Phone ______________________________________
Aware of pregnancy? ______ Aware adoption plan? _______________
Agree to adoption plan _____
Will he sign a Waiver or Consent? ______________________________
Has he filed with the court to establish parental rights? _______________
MEDICAL INFORMATION
Date ___________________________
Due date ___________
Child¿s Sex _____________
Full name ________________________________________________________
Indicate by checking appropriate box if either birth parent or
any relative ( i.e., mother, father, sisters or brothers) have had,
or now have, the medical conditions listed below.
Indicate relative¿s relationship to child. On a separate attachment,
indicate for each positive response the cause, treatment, specific medications,
parts of body involved, age at onset, and any other explanatory information.
If more than one condition or relative is indicated, specify clearly.
Medical Condition You Your family Father's family
Club foot or any `
orthopedic problem.
2. Harelip (cleft lip)
or cleft plate.
3. Chromosome
abnormality.
4. Congenital heart
defect.
5. Down¿s Syndrome.
6. Hydrocephalus.
7. Muscular Dystrophy.
8. Spina Bifida.
9. Tay-Sachs.
10. Multiple Sclerosis
11. Cerebral Palsy.
12. Seizures, convulsions
or epilepsy.
13. Anemia.
Medical Condition You Your Family Father¿s family.
14. AIDS.
15. Blood disorders.
16. Cancer.
17. Tumors.
18. Cystic Fibrosis
19. Huntington¿s
disease.
20. Hodgkin¿s
disease.
21. Alzheimer¿s
disease.
22. Blindness,
Glaucoma or other
visual problems.
23. Deafness or
other ear problems.
24. Speech problems.
25. Learning disability.
26. Retardation:
Mental or physical
27. Hemophilia.
28. Diabetes.
29. Thyroid disorder.
30. Sickle Cell
Anemia or trait
31. Hypertension
(high blood pressure
or low blood
pressure)
32. Stroke.
33. Heart attack.
34. Asthma.
35. Arthritis.
36. Kidney disease.
37. Tuberculosis
38. Mental illness.
39. Schizophrenia
40. Manic Depressive
(Bipolar disorder)
41. Alcoholism
42. Drug usage.
43. Any other
malformations.
44. Other Paralysis
or crippling disorder.
45. Other hormone
disorder.
46. Other
cardiovascular
problems.
47. Repeated attacks
of fever with no
infection.
48. Hospitalization:
operation or injury.
49. Allergies:
Hay fever
Food
Local
Anesthetic
Penicillin
Antibiotics
Sulfa Drop
Codeine
Aspirin
Iodine
Other.
50. Eczema or
other skin condition.
51. Any other family
medical information. ___________________________________________________
_____________________________________________________________________
____________________________________________________________________
Indicate medications/drugs taken during this pregnancy;
medication/drugs taken during the five years prior to this pregnancy.
YES NO When taken What, When , How much FREQUENCY
1. Aspirin
2. Antibiotics
3. Antihistamines
Types __________
4. Hormones
Types __________
5. Cortisone
(ACTH, etc.)
6. Diet pills
Types __________
7. Sleeping pills
Types __________
8. Nerve pills/
tranquilizers
9. Medicine for
cancer
Type _________
10. Heart/blood
pressure pills
Type _________
11. Thalidomides
12. Medicine for
nausea
Type _________
13. Medicine for
convulsions
14. Nose drops
15. Alcohol
16. Amphetamines
Type _________
17. Barbiturates
18. Cocaine
19. Heroin
20. LSD
21. Marijuana
22. Cigarettes
23. Folic acid
24. Other vitamins
and dietary
supplements
Indicate Yes or No before each question.
____________ Are you and the father of this pregnancy blood relatives?
_____________ Will you be age 35 or older when the baby is due?
_____________ Are you willing to have an amniocentesis?
_____________ Do you or the baby's father have a birth defect,
or have you had a child born dead or alive with a birth defect?
Please describe birth defect: ________________________________
_________________________________________________________
_________________________________________________________
____________ Are there other known inherited or chromosomal
disorders in either your family or the father¿s family?
Describe the disorder: _____________________________________
_________________________________________________________
_________________________________________________________
_________________ Have you taken any of the following drugs
during this pregnancy: seizure medications, alcohol
(more than two drinks/glasses daily), anti- cancer drugs,
anticoagulants, lithium, or tobacco?
Please list which drugs; when during the pregnancy; amount; frequency:
_________________________________________________
___________________________________________________________
___________________________________________________________
___________________________________________________________
_________________ Have you had any X-ray exposure since your
last menstrual period?
Describe: ___________________________________________________
____________________________________________________________
_________________ Have you been exposed to any chemicals
or noxious agents since your last menstrual period?
Describe: ___________________________________________________
____________________________________________________________
_________________ Have you taken any medications or
any abusive substances (¿drugs¿) since your last menstrual period?
List which drugs; when during the pregnancy; amount; frequency:
____________________________________________________________
____________________________________________________________
____________________________________________________________
____________________________________________________________
______ Have you ever had genital herpes?
_______ Have you had diabetes?
________ Have you had measles? Please provide date: _____________
_________ Have you had a blood disease or blood clotting problems?
Describe: ___________________________________________________
____________________________________________________________
________________ Have you had syphilis or other venereal disease?
Give dates & disease & treatment completed ____________________
____________________________________________________________
________________ Do you have cats?
________________ Do you clean the litter box?
BIRTH PARENT ACKNOWLEDGMENT
I, the undersigned, represent that the information contained
in the Adoption Information
Application and Medical Information forms is true and accurate.
I acknowledge that the adoptive parents and other parties will
rely on this information in making a determination to proceed
with the anticipated adoption.
I further understand that any false statement herein is perjury
and in violation of penal laws of my state and may subject me to
criminal and/or civil penalties under the law.
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