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STATE OF VERMONT SUPERIOR COURT PROBATE DIVISION Unit Docket No. In re Adoption of : INFORMATION ABOUT BIRTH FAMILY Each Birth Parent should complete a separate form. Today's Date: ____________________________ Name of person completing form: ______________________________________ If not parent, relationship to parent: ______________________________________ Child's Full Name: ______________________________________ Date of Birth: _____________________________ Time of Birth: ____________________________ Place of Birth (town, state, country): _____________________________________________________________ BIRTH PARENT BACKGROUND Parent’s Full Name (first, middle, last): ___________________________________________________________________ Maiden or previous name(s), if applicable: __________________________________________________ Date of Birth: __________________ Place of Birth: _____________________________________ Social Security Number: ______________ Driver’s License Number: ______________ State: ______ Race: _____________________________ Ethnic Background: _________________________________ If you attend religious services, what kind? __________________________________________________ Physical Address Mailing Address __________________________________ __________________________________ __________________________________ __________________________________ __________________________________ __________________________________ Please provide the name and address of a person who is likely to know where you are if you move: __________________________________ __________________________________ __________________________________ 700-00126 – Information About Birth Family (06/2019) Page 1 of 9 PHYSICAL DESCRIPTION Height: _____________ Weight: _____________ Complexion: ______________ Hair Color: __________ Eye Color: ___________ General Build: ____________ PERSONAL BACKGROUND Where did you grow up? ____________________________________________________________ What is the highest grade you have completed? ________ How did you do in school? __________ What were your favorite subjects? ____________________________________________________ If you had learning problems in school, what were they? ________________________________ _________________________________________________________________________________ If you have had other training, what kind? _______________________________________________ What kind of jobs have you had? ______________________________________________________ Present occupation: ________________________________________________________________ Briefly describe your personality: ___________________________________________________________________________________ ___________________________________________________________________________________ ___________________________________________________________________________________ What are your interests and talents? (examples of talents: artistic, mechanical, athletic, like science, musical, etc.) ___________________________________________________________________________________ ___________________________________________________________________________________ ___________________________________________________________________________________ Have you been in the military? ☐ Yes ☐ No If Yes, what branch? ____________________ What was your rank and serial number? __________________________________________________ What are your plans for the future? ___________________________________________________________________________________ ___________________________________________________________________________________ ___________________________________________________________________________________ ___________________________________________________________________________________ ___________________________________________________________________________________ BIRTH PARENT'S FAMILY Your mother’s name (first, middle, maiden): _____________________________________________________ Height: _____________ Weight: _____________ Age: __________ Race: _________ Hair Color: __________ Eye Color: ___________ General Build: _______________________ General Health: ______________________________________________________________________ Level of Education: ___________________________ Occupation: _________________________ Is she aware of the birth of this child? ☐ Yes ☐ No If deceased, age and cause of death: _____________________________________________________ 700-00126 – Information About Birth Family (06/2019) Page 2 of 9 BIRTH PARENT'S FAMILY (continued) Your father’s name): _____________________________________________________________________ Height: _____________ Weight: _____________ Age: ___________ Race: _________ Hair Color: __________ Eye Color: ___________ General Build: _______________________ General Health: ______________________________________________________________________ Level of Education: ___________________________ Occupation: _________________________ Is he aware of the birth of this child? ☐ Yes ☐ No If deceased, age and cause of death: _____________________________________________________ BROTHERS AND SISTERS Full Name Male / Female Date of Birth Last Grade Completed Occupation ☐M/☐F ☐M/☐F ☐M/☐F ☐M/☐F ☐M/☐F MARRIAGES Name of Spouse Year Married Year Divorced BROTHERS AND SISTERS OF YOUR CHILD (Include brothers and sisters living at home or elsewhere including children who were adopted, step-brothers and sisters and any children who may have lived in the child's home for an extended period of time.) Full Name Male / Female Date of Birth Relationship to Child Who is Caring for this Child? ☐M/☐F ☐M/☐F ☐M/☐F ☐M/☐F ☐M/☐F 700-00126 – Information About Birth Family (06/2019) Page 3 of 9 Does your child have a relationship with these brothers and sisters? Please describe. _________________________________________________________________________________ _________________________________________________________________________________ _________________________________________________________________________________ _________________________________________________________________________________ _________________________________________________________________________________ _________________________________________________________________________________ PREGNANCY (for birthmothers only) In what month did you begin pre-natal care? ___________________ Did you drink alcohol during this pregnancy? When during your pregnancy? How much at one time and how often? __________________________________________________________________________________ __________________________________________________________________________________ What prescription drugs, over-the-counter medications or street drugs did you take during your pregnancy? What kind, how often, and when during the pregnancy? __________________________________________________________________________________ __________________________________________________________________________________ Did you smoke? If so, how much? _____________________________________________________ Did you have any special problems during pregnancy? (for example: high blood pressure, diabetes, excessive bleeding, kidney or bladder infections, German or Three Day Measles, operations, convulsions, x-rays, sexually transmitted diseases or others):____________________ At what age did you get your period? ____________________________ YOUR CHILD’S HISTORY Where was your child born? ______ Was this child born earlier or later than expected? ☐ Earlier ☐ Later If so, how much earlier or later? ________________ How long was your labor? _____________ If drugs were used during your labor, what kind? _________________________________________ Were forceps used? ☐ Yes ☐ No If you had a Caesarian Section (C-section), why? __________________________________________ If your child had any problems during the labor or soon after birth, please describe: __________________________________________________________________________________ __________________________________________________________________________________ __________________________________________________________________________________ What was your child’s birth weight? _______________ Birth length: ______________ Did your child have special problems at birth? Please describe: __________________________________________________________________________________ __________________________________________________________________________________ What is the name and address of your child’s doctor? __________________________________________________________________________________ 700-00126 – Information About Birth Family (06/2019) Page 4 of 9 FOR CHILDREN WHO ARE NOT NEWBORNS Who has your child’s immunization records? What illnesses has your child had? ☐ Chicken Pox ☐ Bladder or Kidney Infection ☐ Ear infections ☐ Whooping Cough ☐ Frequent nausea or vomiting ☐ Meningitis Red ☐ Frequent diarrhea or constipation ☐ Sore throat ☐ Seizures or convulsions ☐ Headaches ☐ Rash/Skin problems ☐ Asthma ☐ Broken bones ☐ Fainting ☐ Pneumonia ☐ Frequent swollen glands ☐ Trouble urinating ☐ Frequent bruises or bleeding ☐ Major operations, illnesses or accidents _____ ☐ ☐ ☐ ☐ ☐ ☐ ☐ ☐ ☐ ☐ Mumps Hepatitis Measles Allergies Dizziness Hay Fever Dental cavities Rheumatic Fever Hospitalizations Anemia If you checked any of the above, please describe: __________________________________________________________________________________ __________________________________________________________________________________ __________________________________________________________________________________ __________________________________________________________________________________ __________________________________________________________________________________ If your child has special educational needs, what are they? __________________________________________________________________________________ __________________________________________________________________________________ If your child has been formally evaluated for any special problems, what was the evaluation for? ☐ Medical problem ☐ Dental or orthodontic ☐ Emotional disturbance or mental illness ☐ Learning/school problems ☐ Other: what kind? ______________________________________________________________ If so, you may be asked to sign releases so that copies of the evaluations can be obtained. Has your child been abused or neglected in the past? ☐ Physical abuse ☐ Emotional or verbal abuse ☐ Sexual abuse ☐ Neglect If so, you may be asked to provide more information about the abuse or neglect. If your child has ever lived with relatives, foster parents or other place away from home, please describe: ____________________________________________________________________________________ ____________________________________________________________________________________ ____________________________________________________________________________________ ____________________________________________________________________________________ ____________________________________________________________________________________ 700-00126 – Information About Birth Family (06/2019) Page 5 of 9 FAMILY MEDICAL HISTORY Instructions: If you have any of the problems listed below, or have had any problem in the past, please place a check in the box. If another family member has had the problem, place a check in the box and then list that person’s relationship to you (examples: aunt, brother, grandmother). If you have more information about the particular problem, please provide it at the end of this section. Acne or pimples ☐ Myself ☐ Other family member: _______________ HIV infection or AIDS ☐ Myself ☐ Other family member: _______________ Alcohol Abuse ☐ Myself ☐ Other family member: _______________ Allergy to Food What kind? ☐ Myself ☐ Other family member: _______________ ____________________________________________________________________ Allergy to Other Things ☐ Myself ☐ Other family member: _______________ What kind? ____________________________________________________________________ Alzheimer’s ☐ Myself ☐ Other family member: _______________ Anemia ☐ Myself ☐ Other family member: _______________ Anencephaly ☐ Myself ☐ Other family member: _______________ (born with no brain) Arthritis Where? ☐ Myself ☐ Other family member: _______________ ____________________________________________________________________ Bedwetting ☐ Myself ☐ Other family member: _______________ Bipolar illness ☐ Myself ☐ Other family member: _______________ (manic depression) Birth defects What kind? ☐ Myself ☐ Other family member: _______________ ____________________________________________________________________ Blindness or very poor sight ☐ Myself ☐ Other family member: _______________ Braces on teeth ☐ Myself ☐ Other family member: _______________ Breast cancer ☐ Myself ☐ Other family member: _______________ Bronchitis ☐ Myself ☐ Other family member: _______________ Hodgkin’s Disease ☐ Myself ☐ Other family member: _______________ Cancer What kind? ☐ Myself ☐ Other family member: _______________ ____________________________________________________________________ Chlamydia ☐ Myself ☐ Other family member: _______________ Cleft lip or palate ☐ Myself ☐ Other family member: _______________ Club foot ☐ Myself ☐ Other family member: _______________ 700-00126 – Information About Birth Family (06/2019) Page 6 of 9 Colitis ☐ Myself ☐ Other family member: _______________ Color blindness ☐ Myself ☐ Other family member: _______________ Cystic Fibrosis ☐ Myself ☐ Other family member: _______________ Dental Problems ☐ Myself ☐ Other family member: _______________ What kind? ____________________________________________________________________ Deafness/hearing problems ☐ Myself ☐ Other family member: _______________ Diabetes in childhood ☐ Myself ☐ Other family member: _______________ Diabetes adulthood onset ☐ Myself ☐ Other family member: _______________ Down’s Syndrome ☐ Myself ☐ Other family member: _______________ Drug Abuse ☐ Myself ☐ Other family member: _______________ Dwarfism/very short height ☐ Myself ☐ Other family member: _______________ Ear infections ☐ Myself ☐ Other family member: _______________ Eczema ☐ Myself ☐ Other family member: _______________ Emphysema ☐ Myself ☐ Other family member: _______________ Epilepsy or seizures ☐ Myself ☐ Other family member: _______________ Eye problems ☐ Myself ☐ Other family member: _______________ Genital Warts ☐ Myself ☐ Other family member: _______________ Very tall height ☐ Myself ☐ Other family member: _______________ Glasses What kind? ☐ Myself ☐ Other family member: _______________ ____________________________________________________________________ Glaucoma ☐ Myself ☐ Other family member: _______________ Gynecological Problems ☐ Myself ☐ Other family member: _______________ (female) What kind? ____________________________________________________________________ Gonorrhea ☐ Myself ☐ Other family member: _______________ Headaches or migraines ☐ Myself ☐ Other family member: _______________ Heart attack/heart problems ☐ Myself ☐ Other family member: _______________ Hemochromatosis ☐ Myself ☐ Other family member: _______________ Hemophilia or bleeding ☐ Myself ☐ Other family member: _______________ Hepatitis ☐ Myself ☐ Other family member: _______________ Herpes ☐ Myself ☐ Other family member: _______________ 700-00126 – Information About Birth Family (06/2019) Page 7 of 9 Hives ☐ Myself ☐ Other family member: _______________ High blood pressure ☐ Myself ☐ Other family member: _______________ Huntington’s Chorea ☐ Myself ☐ Other family member: _______________ Infertility/difficulty getting pregnant ☐ Myself ☐ Other family member: _______________ Jaundice or yellow skin ☐ Myself ☐ Other family member: _______________ Kidney disease ☐ Myself ☐ Other family member: _______________ Learning problems or disabilities ☐ Myself ☐ Other family member: _______________ Left handed ☐ Myself ☐ Other family member: _______________ Liver disease ☐ Myself ☐ Other family member: _______________ Lung problem ☐ Myself ☐ Other family member: _______________ Lupus ☐ Myself ☐ Other family member: _______________ Mental illness What kind? ☐ Myself ☐ Other family member: _______________ ____________________________________________________________________ Miscarriages ☐ Myself ☐ Other family member: _______________ Muscular Dystrophy ☐ Myself ☐ Other family member: _______________ Obesity/significant overweight ☐ Myself ☐ Other family member: _______________ Osteoporosis ☐ Myself ☐ Other family member: _______________ Paralysis ☐ Myself ☐ Other family member: _______________ Phenylketonuria (PKU) ☐ Myself ☐ Other family member: _______________ Rectal or intestinal polyps ☐ Myself ☐ Other family member: _______________ Rheumatic fever ☐ Myself ☐ Other family member: _______________ Schizophrenia ☐ Myself ☐ Other family member: _______________ Serious depression ☐ Myself ☐ Other family member: _______________ Sickle cell anemia ☐ Myself ☐ Other family member: _______________ Skin disease ☐ Myself ☐ Other family member: _______________ Spina bifida ☐ Myself ☐ Other family member: _______________ Speech problems ☐ Myself ☐ Other family member: _______________ What kind? ____________________________________________________________________ 00126 – Information About Birth Family (07/2016) Page 8 of 9 ☐ Myself Still births ☐ Other family member: _______________ Stomach problems ☐ Myself ☐ Other family member: _______________ What kind? ____________________________________________________________________ Strokes ☐ Myself ☐ Other family member: _______________ Suicide/suicide attempt ☐ Myself ☐ Other family member: _______________ Surgery What kind? ☐ Myself ☐ Other family member: _______________ ____________________________________________________________________ Syphilis ☐ Myself ☐ Other family member: _______________ Sachs Disease ☐ Myself ☐ Other family member: _______________ Thalassemia ☐ Myself ☐ Other family member: _______________ Thyroid problems ☐ Myself ☐ Other family member: _______________ Twins or multiple births ☐ Myself ☐ Other family member: _______________ Ulcers ☐ Myself ☐ Other family member: _______________ Varicose veins ☐ Myself ☐ Other family member: _______________ Wilson’s Disease ☐ Myself ☐ Other family member: _______________ Other: ____________________________________________________________________ Have you ever had a formal evaluation for medical, mental health or educational reasons? ☐ Yes ☐ No Please explain: _______________________________________________________________________________ _______________________________________________________________________________ _______________________________________________________________________________ ADOPTION PLANS FOR YOUR CHILD What led to your decision to plan adoption for your child? _______________________________________________________________________________ _______________________________________________________________________________ _______________________________________________________________________________ _______________________________________________________________________________ _______________________________________________________________________________ _______________________________________________________________________________ _______________________________________________________________________________ 700-00126 – Information About Birth Family (06/2019) Page 9 of 9