Child's Medical History, Agency or Private Placement, [FormDRL 112(3)(6), Social Services Law 373a]
SURROGATE'S COURT OF THE STATE OF NEW YORK
COUNTY OF BRONX
..................................
In the Matter of the Adoption of ) CHILD'S MEDICAL HISTORY
A Child Whose First Name Is )
JANE DOE ) (Agency or Private Placement)
(Docket) (File) No...................................
1. Age and date of birth of child:
2. Has the child had any of the following illnesses or health problems: (Where indicated, specify below or on additional sheet).
____ (AIDS Infection)
(HIV positive status) [FN*MV]
____ Allergy to foods/other substances
____ Allergy to medications (prescription or overthecounter)
____ Asthma
____ Chicken Pox
____ Circulatory system disorders (specify):
____ Diabetes
____ Diphtheria
____ German Measles (Rubella)
____ Measles (Rubeola)
____ Hay Fever
____ Heart problems (specify):
____ Hepatitis
____ Kidney disease
____ Malaria
____ Mental/Behavioral disorders (specify):
____ Mumps
____ Parasites in stool
____ Rheumatic Fever
____ Scarlet Fever
____ Sickle Cell Anemia/Trait
____ Tuberculosis
____ Typhoid Fever
____ Urinary tract infection
____ Whooping Cough (Pertussis)
____ Other (specify):
____ Operations/Accidents/Fractures (specify):
3. Immunizations: give dates of the following:
D.P.T/D.T. _____________________________________
Polio (oral) ___________________________________
Measles __________ Mumps __________ Rubella ____
Hemophilus Influenza B. (H.I.B.) _______________
Heptavax/Hepatitis Immune Globulin _____________
Influenza (Flu) ________________________________
Pneumonia vaccine ______________________________
Other (specify) ________________________________
Tuberculosis test (most recent/result) _________
4. List Prenatal History:
____ First trimester bleeding
____ Toxemia (high blood pressure or protein in the urine)
____ Medications (other than vitamins or iron) (specify):
____ Diabetes or thyroid problem (specify):
____ Drugs (such as marijuana, heroin, methadone or amphetamines) (specify):
____ Alcohol (occasional) (moderate) (heavy) *
Birth:
Birth weight __________ length __________
Apgar score: 1 min. __________ 5 mins. __________
Date baby was due __________
Date baby was born __________
Complications of delivery:
____ Premature rupture of membranes
____ Caesarian: routine __________ emergency __________
____ Excessive bleeding: abruption __________ placenta previa __________
Newborn:
____ Resuscitation required
____ Yellow jaundice: lights __________ exchange transfusion __________
____ Infection (specify):
____ Breathing problem (specify):
____ Other (specify):
5. List congenital impairments, including physical defects, if any.
6. State present health or cause of death (give ages), if known, of:
Birth father:
Birth mother:
Siblings: full:
half:
7. If known, indicate whether birth mother had any of the following:
____ Tuberculosis
____ Diabetes
____ Mental or nervous disorder e.g., schizophrenia, depression, manic
depressive illness (specify):
____ Thyroid disease
____ Stroke
____ Sickle cell anemia
____ (Aids infection) (HIV positive status) *
____ High blood pressure
____ Bleeding tendency
____ Eye or ear disorder
____ Retardation: mental
____ Physical disability (specify):
____ Circulatory or blood disorders (specify):
____ Obesity
____ Asthma
____ Gastrointestinal disease, (e.g.gall bladder, ulcer, irritable bowel
disorder) (specify):
____ Breast cancer
____ Colon cancer
____ Cancer, other (specify):
____ Arthritis or rheumatism
____ Kidney disease (specify):
____ Alcoholism or other substance abuse (specify):
____ Developmental disorder (e.g.learning disability, attention deficit)
(specify):
____ Other (specify):
8. If known, indicate whether birth father had any of the following:
____ Tuberculosis
____ Diabetes
____ Mental or nervous schizophrenia,depression,manic depressive illness
(specify):
____ Thyroid disease
____ Stroke
____ Sickle cell anemia
____ (AIDS infection)
(HIV positive status) *
____ High blood pressure
____ Bleeding tendency
____ Eye or ear disorders
____ Retardation: mental
____ Physical disability (specify)
____ Circulatory or blood disorders (specify):
____ Obesity
____ Asthma
____ Gastrointestinal disease (e.g.,gall bladder, ulcer, irritable bowel
disorder) (specify):
____ Colon cancer
____ Cancer, other (specify):
____ Arthritis or rheumatism
____ Kidney disease (specify):
____ Alcoholism or other substance abuse (specify):
____ Developmental disorder (e.g.,learning disability, attention deficit
disorder) (specify):
____ Other (specify):
Indicate source for information about child's medical history and the source(s) for information about medical history of birth father and birth mother and whether from direct or indirect source:
Completed by (state official title, if any): ____
* Delete inapplicable provision.
DOCTOR'S CERTIFICATE OF HEALTH
Adoptive Parents
I ______________,M.D., have examined JOHN DOE on MARCH ___, 1999 and have found the proposed adoptive parent to be in good physical and mental health and in my opinion is without any disabilities which might affect his suitability as adoptive parent of the child.
Dated: ______, 1999.
____________________________________
Doctor's Signature Address
Tel. No.
DOCTOR'S CERTIFICATE OF HEALTH
Adoptive Child
I ______, M.D., have examined JANEY DOE on ______, 1999 and have found the proposed adoptive child to be in good physical and mental health:
Dated: ______, 1999.
____________________________________
Doctor's Signature Address
Tel. No.