5 Broadview Street  Acton, MA  01720
978-263-5400 (phone)
1-877-652-6678 (toll-free for birthparents)
978-266-1909 (fax)
karen@bright-futures.org

 

Birth Family Medical History

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As part of making an adoption plan for your child it is extremely important to provide your child and the adoptive parents of your child with as much information as possible about your medical and health history.  This information will be kept in your files and passed on to the adoptive parents of your child to become part of your child’s medical history.  Since none of us knows what the future may bring and when your child’s life may depend on this information, please take time to indicate whether you or any blood relative (including your mother, father, sisters, brothers, grandparents, aunts, uncles, and children) has had or now has any of the medical conditions listed below.  If you are not sure whether you or your blood relatives have had any of the following conditions, please discuss this form with your doctor or someone in your family who supports your decision to make an adoption plan for your child.

Name: ______________________________       Birthmother             Birthfather
                      (Please Print)                                                   (Please check one)

Medical Condition

 No

Yes
(Self or Relative)

If a relative has this condition, please describe that person’s relationship to you

Details of Medical Condition
(age at onset, treatment, outcome)

Addison’s Disease (adrenal insuffieciency)

       

Alcoholism/Heavy
Drinking

        

Allergies/ Hay Fever

       

Allergies/Food

        

Allergies/Drug

        

Alzheimer’s Disease

        

Anemia

        

Angina (chest pain)

        

Anorexia

        

Anxiety/Panic Attacks

        

Arteriosclerosis (hardening of the arteries)

        

Arthritis

       

Asthma

        

Attention Deficit Disorder

        

Autism

        

Back Problems (including scoliosis, slipped disk, pinched nerve)

        

Birth Defects

        

Blindness

       

Bone Disease

        

Bulimia

        

Cancer – Breast

        

Cancer – Colon

        

Cancer – Hodgkin’s’ Disease

        

Cancer – Leukemia

        

Cancer – Lung

        

Cancer – Melanoma

        

Cancer – Other

        

Cataracts

        

Cerebral Palsy

        

Chlamydia

       

Chrohn’s Disease

        

Cleft Palate/Harelip

        

Club Foot or other orthopedic conditions

        

Colitis

        

Cystic Fibrosis

        

Congenital Heart Defect/Disease

        

Deafness/Hearing Impairment

        

Dental Condition (such as periodontal disease)

        

Depression

        

Diabetes

        

Digestive Problems

        

Down’s Syndrome

        

Drug Use/Abuse

        

Dyslexia

        

Ear Infections (chronic)

        

Emotional Problems

        

Emphysema

        

Endometriosis

        

Epilepsy

        

Fevers (repeated)

        

Gall Stones

        

Glasses (please indicate nearsighted, farsighted)

        

Glaucoma

        

Gonorrhea

        

Gynecological Problems

        

Headaches (migraines)

        

Heart Attack

        

Heart Murmur

        

Hemochromotosis (too much iron in the body causing organ malfunction)

        

Hemophilia

        

Hepatitis

        

Herpes

        

Hiatus Hernia

       

High Blood Pressure

        

High Cholesterol

        

HIV Positive

        

HIV/AIDS

        

Hives

        

Hormone Disorder

        

Huntington’s Chorea (genetic condition of uncontrollable moving of arms/legs)

        

Hydrocephalus (water in the brain causing neurological problems)

        

Hyperactivity

        

Infertility

        

Jaundice

        

Kidney Disease

        

Kidney Stones

        

Learning Disability

        

Liver Disease (Cirrhosis or other liver abnormalities)

        

Lou Gehrig’s Disease (ALS)

        

Lung Problems

        

Lupus

        

Lyme Disease

        

Malformation

        

Malnutrition

        

Mental Illness (schizophrenia, manic depressive, psychosis etc.)

        

Mental Retardation

        

Microcephalus (small brain)

        

Miscarriage

        

Multiple Births

        

Multiple Sclerosis

        

Muscular Dystrophy

        

Obesity

        

Obsessive/Compulsive Disorder

        

Osteoporosis

        

Ovarian Cysts

        

Paralysis (or other crippling disorder)

        

Parkinson’s Disease

        

Pelvic Inflammatory Disease

        

Phenylketonuria (PKU) too much amino acids causing mental retardation and growth problems

        

Premature Births

        

Rectal or Intestinal Polyps

        

Sickle Cell Anemia

        

SIDS (Sudden Infant Death Syndrome)

        

Skeletal Abnormalities (dwarfism, hunchback, malformed or missing limbs)

        

Skin Problems (such as acne, eczema, psoriasis) 

 

 

 

  

Speech Problems (stutters, delayed language development)

        

Spina Bifida

        

Still Birth

        

Stomach Disorder

        

Stroke

        

Suicide

        

Syphilis

        

Tay Sachs Disease

        

Thalassemia Minor

        

Thalassemia Major

        

Thyroid Disorder

        

Tourettes Syndrome

        

Tuberculosis

        

Tumors

        

Turner’s Syndrome

        

Ulcers

        

Urinary Tract Condition

        

Varicose Veins

        

Venereal Disease

        

Wilson’s Disease (mental and visual problems) 

       

Hospitalizations (besides for routine childbirth)

        

Operations

        

Injuries

        

Are there any other conditions you or other members of your family have or have had?

        

Is there any other medical or health information about you or your family that may be helpful to your child in the future?  If so, please write below or attach a separate piece of paper. 

______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________

The information set forth above is the most accurate information knon to me at this time about my and my family’s medical and health history.

                                                                        ________________________________

                                                                        (Signature of Birth Parent)

                                                                        ________________________________

                                                                        (Date)