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1 Delete inapplicable provision. D.R.L. §§112(3)(6)Form 1-D S.S.L. §373-a(Child's Medical History - Agency or Private-Placement) 12/97 SURROGATE'S COURT OF THE STATE OF NEW YORK COUNTY OF In the Matter of the Adoption of (Docket)(File) No. A Child whose First Name is Child's Medical History (Agency or Private-Placement) 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) ___ Hepatitis (HIV positive status)1 __ Kidney disease __ Allergy to foods/other ___ Malaria substances__ Mental/Behavioral disorders (specify): ___ Allergy to medications ___ Mumps (prescription or over-___ Parasites in stool the-counter)__ Rheumatic Fever ___ Asthma___ Scarlet Fever ___ Chicken Pox__ Sickle Cell Anemia/Trait ___ Circulatory system___ Tuberculosis disorders (specify):___ Typhoid Fever ___ Diabetes___ Urinary tract infection ___ Diphtheria__ Whooping Cough (Pertussis) ___ German Measles (Rubella)___ Other (specify): ___ Measles (Rubeola)___ Operations/Accidents/Fractures __ Hay Fever (specify): ___ Heart problems (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) _____________________ Form 1-D page 22 Delete inapplicable provision. Pneumonia vaccine _________________ Other (specify) ___________ Tuberculosis test (most recent/result) _____ 4.List Pre-natal History: __ First trimester bleeding __ Drugs (such as marijuana, __ Toxemia (high blood pressureheroin, methadone or or protein in the urine)amphetamines) (specify): ___ Medications (other than vitamins or iron)__ Alcohol (occasional)(moderate)(heavy)2 (specify): ___ Diabetes or thyroid problem (specify): 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: Form 1-D page 3 Birth father: Birth mother: Siblings: full: half: 7. If known, indicate whether birth mother had any of the following: ___ Tuberculosis__ Asthma ___ Diabetes__ Gastrointestinal disease, ___ Mental or nervous(e.g., gall bladder, ulcer, disorder e.g.,irritable bowel disorder) schizophrenia,(specify): depression, manic depressive illness (specify): ___ Breast cancer ___ Thyroid disease___ Colon cancer ___ Stroke__ Cancer, other (specify): ___ Sickle cell anemia ___ (Aids infection)__ Arthritis or rheumatism (HIV positive status)*__ Kidney disease ___ High blood pressure(specify): __ Bleeding tendency___ Alcoholism or other substance ___ Eye or ear disorderabuse (specify): ___ Retardation: mental___ Developmental disorder ___ Physical disability (specify):(e.g., learning disability, ___ Circulatory or blood(attention deficit)(specify): disorders (specify): ___ Obesity___ Other (specify): 8. If known, indicate whether birth father had any of the following: ___ Tuberculosis__ Asthma ___ Diabetes___ Gastrointestinal disease ___ Mental or nervous(e.g., gall bladder, ulcer, schizophrenia,irritable bowel disorder) depression, manic(specify): depressive illness (specify): ___ Thyroid disease___ Colon cancer ___ Stroke___ Cancer, other ___ Sickle cell anemia(specify): Form 1-D page 4 ___ (AIDS infection) (HIV positive status)* ___ Arthritis or rheumatism ___ Kidney disease (specify): ________________ *Delete inapplicable provision. ___ High blood pressure__ Alcoholism or other substance ___ Bleeding tendencyabuse (specify): __ Eye or ear disorders ___ Retardation: mental ___ Physical disability__ Developmental disorder (specify)(e.g., learning disability, __ Circulatory or blood attention deficit disorder) disorders (specify): (specify): __ Obesity___ 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):________________________ ____________________ Petitioner _____________________ Print or type name ___________________ Signature of Attorney, if any ___________________ Attorney’s Name (Print or Type) ___________________ ___________________ ___________________ Attorney’s Address and Telephone Number