Fill and Sign the Birth Father Use Separate Form for Each Parent

THE ST A TE O F NEW H A M PSHIRE JUDI CI AL BR AN C H Cour t Na m e: Ca se Nam e: Ca se Num ber: (if k now n) MEDI CAL I NFO RM ATION ON BI RT H P AREN TS Bir th M other Bir th Fa ther (Use s epara te form f or ea ch parent.) For eac h of the med ica l co ndit ions d escribed be low , pleas e che ck th e appr opria te co lumn indi cat ing w hether y ou or any blood r elative (i.e. your m other , fath er, s isters, brot hers , gran dpar ents , aun ts, uncle s or a ny other c hildre n you hav e had) ev er h ad, or now hav e, the cond itio n listed. Comp lete the "C om ment s" section a s ne eded u sing a separ ate she et of paper i f ad diti ona l spac e is req uired. MEDI CAL CO NDI TION NO NO T KNO WN YES (SEL F) YES (RELAT IVE) CO MM ENT S 1. Club Foot 2. Harelip, c left lip, or cle ft pal ate 3. Congenita l heart defe ct 4. Any other malfor mati ons 5. Musc ular Dy stroph y Part of bod y in volv ed? Age at onset? 6. Multip le S cleros is 7. Cerebral Pal sy 8. Other par aly sis or cri ppli ng disorder 9. Seizure s, con vulsion s or epilep sy Age at on set? What Treat me nt? Freque ncy ? 10. Blindne ss, g laucoma or other visua l prob lem s Age at on set? Cau se? Sp eci al Educa tion? 11. Deafness or other ear pro blem s 12. Speech pro ble m Age at on set? Cau se? Sp eci al Educa tion? 13. Learning dis abil ity 14. Retardation: ment al or p hys ica l Any diag nos is or caus e? Hos pitali zed? 15. Diabetes Age at on set? Tre atmen t? 16. Thyroid dis order NHJB-2193-FP (10/01/2006) Page 1 of 4 (formerly AOC-200 -003) Case Name: Case Nu mber: MEDIC AL INFORM ATION ON BIRT H P ARE NTS MEDI CAL CO NDI TION NO NO T KNO WN YES (SEL F) YES (RELAT IVE) CO MM ENT S 17. Other hor mone dis order 18. Eczema or other sk in condit ions Any cau se k nown? Wha t treat ment? Medic ation ? 19. Asthma 20. Hay fever or other aller gy 21. Schizo phreni a Age at on set? Tre atmen t? Hospita lization ? 22. Manic depre ssi ve 23. Other m ental or em otiona l illne ss 24. Hypertens ion (h igh b lood pressur e) 25. Stroke 26. Heart attac k (Coronar y) 27. Other cardio vas cular probl em s 28. Cancer What ki nd? Age at on set? What part of body ? 29. Tumors 30. Cystic Fibro sis 31. Huntington' s Disea se 32. Tubercu losi s 33. Kidney disease Age of on set? Tre atmen t? 34. Alcohol ism or hea vy drink ing 35. Drug abuse Kind, am ount an d when ta ken. 36. Hospital izat ion, o perati on, or injury 37. Any other cond ition s yo u or others i n yo ur fam ily migh t hav e NHJB-2193-FP (10/01/2006) Page 2 of 4 (formerly AOC-200 -003) Case Name: Case Nu mber: MEDIC AL INFORM ATION ON BIRT H P ARE NTS OTHER I NFO RM ATION O N BI RT H P AREN TS Information given should be as of the time of the child 's birth. Do n ot include any identify ing information. Height Weight Body bui ld Eye col or Hair color Skin co lor Age Race National ity (citizens hip) Ethnic b ack ground Religion No. of sc hool years co mplete d Future edu cati on goa ls Genera l fie ld of o ccu patio n Talents , hobb ies and s pec ial i nterest s Future as pirati ons Relation ship between parent s Number of ot her fe male chi ldren born to you Ages Number of ot her ma le c hildr en born to you Ages BI RT H M OTHER O NLY MENST RUAL AND PRE GNANCY HI STORY Age at on set of mens es Are period s regu lar? Usual le ngth of perio d No. of day s betwee n peri ods List a ll pre gnan cies in ord er. Use one l ine for eac h ch ild, miscarria ge, ab ortion or st ill-b irth . CHILDREN HO W M ANY M ONTHS DID YO U YEAR IN WHICH IF M ISCARRIAG E O R ABO RTIO N, (Write bab y gir l, bab y bo y, CARRY THIS P REG NANCY? PREG NANCY EN DED WAS IT NATURAL O R INDU CED? misc arriag e, sti ll-b irth or abortion.) NHJB-2193-FP (10/01/2006) Page 3 of 4 (formerly AOC-200 -003) Case Name: Case Nu mb er: MEDIC AL INFORM ATION ON BIRT H P ARE NT S IN FOR MATION ON THIS P REGNA NCY Is the baby's father aware of this pregnancy? Ye s No Is the baby's father a genetic rela tive of yours? Ye s No If yes, how is he related? Month prenatal care began for this pregnancy Complications, if an y Exposure during pregnancy : X -Ra y El ec troc ardiogr am Rad iation Prescription drugs taken during p regnancy Kind When Amount and frequency Non-prescription drugs taken during pregnancy Kind When Amount and frequency Did you u se alcohol during preg nancy? No Amount and frequency Ye s Amphetamines (Uppers) used du ring pregnancy Kind When Amount and frequency Barbiturates (Downers, cocaine, heroin, LS D, marijuana, cigarette s) used during pregnancy Amount of frequency Kind When CHI LD' S BI RT H HI ST ORY Child's first name Sex Date of birth Time of birth Place of birth Weight Length Eye color Hair color Complexion Head circumfer ence Chest circumference Physical appearance including ab normalities Term Premature weeks P ostmature weeks Full term weeks Mother's blood type RH factor Baby's blood type Type of delivery Anesthesia used Duration of labor Apgar score at 1 minute Apgar score at 5 minutes Condition of child at birth NHJB-2193-FP (10/01/2006) Page 4 of 4 (formerly AOC-200 -003)