Michigan > Local County > Oakland > Family Division
Birth Family And Child History - Michigan
| Birth Family And Child History Form. This is a Michigan form and can be used in Family Division Oakland Local County . |
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BIRTH FAMILY AND CHILD HISTORY Child's Birth Name: Birth Date: County: Race: Time of Birth: Hospital: Place of Birth: Birth weight: General Health: Length: State : Sex: INFORMATION ABOUT PREGNANCY: Did Mother Receive Prenatal Care? If Yes, How Many Visits? Date of First Visit: Length of Pregnancy: Complications during Pregnancy: Hair Color and Texture : Eye Color: Complexion: Type of Delivery: Length of Labor: Complications: Current Weight : Current Height : APGAR Scores: Has Child Been Immunized? as of as of Mother's Blood Type: r No q Yes If Yes, Name Shots and Dates Given: Pediatrician's Name Address (City) (State) Phone: ( ) (Zip Code) Are Pictures Available? Child's Progress Physically: Emotionally: Medically: r Yes r No Oakland County Famihly Court, 2001 American LegalNet, Inc. www.USCourtForms.com Page 1 q Adoptive Plan q Foster Care Plan BIRTH FAMILY AND CHILD HISTORY Birth Mother q Birth Father q Social Worker q Other q Filled out by: 1. Indicate how the birth family feels about the plan being made for the child( ren): 2. What do you want the adoptive/foster care parents to tell your child about why he/she was placed for adoption? 3. What qualities would you consider important in the family caring for your child? 4. 5. 6. 7. Is the birth father of this child aware of the adoption/foster plan that was made? q Yes q No q Not Sure Is there a genetic relationship between the birth parents? If yes, how were they related? Has the birth mother/birth father expressed any feelings regarding this child and the placement plan that is being made? q Yes q No 8. What is the relationship with the birth mother/birth father of this child at this time? 9. Were you married to hsomeone else at the time of conception? q Yes q No Oakland County Family Court, 2001 American LegalNet, Inc. www.USCourtForms.com Page 2 BIRTH FAMILY AND CHILD HISTORY 10. Have you had other pregnancies? q No q No q Yes q Yes If yes, please explain: 11. Have you had any miscarriages? If yes, please explain: 12. Age at which you began menstruating? DRUGS TAKEN DURING AND PRIOR TO PREGNANCY Indicate in the appropriate space medications/drugs taken during this pregnancy involving this child and/or medications/drugs taken prior to this pregnancy. Name of Drug/Medication * YES NO MONTH(S) ADD/ADHD Medications Alcohol Anticonvulsant Antidepressants Antihistamines Aspirin / Other Pain Killers Cancer Medications Cigarettes Cocaine/ Crack Cortisone Diet Pills Heart / Blood Pressure Heroin Hormones Inhalants LSD Marijuana Nausea Meds / Tranquilizers/ Anti-Anxiety Medications Prenatal or Other Vitamins Nose Drops Sleeping Pills / Barbiturates Thalidomides Herbs / Supplements * see Page 4 for brand-named drugs for each type listed above. YEARS TYPE, FREQUENCY, AMOUNT If any others, please list here: To the best of your knowledge, is the birth father on medications or has he used any non-prescription drugs? If yes, please list here: Oakland County Family Court, 2001 American LegalNet, Inc. www.USCourtForms.com Page 3 BIRTH FAMILY AND CHILD HISTORY The following is a short list of common medications, both over-the-counter and prescription medications. This is not a comprehensive list and should serve only to aid your memory. If there is any question about prescription medication, a phone call should be made to your regular doctor to check your medical records. ADD/ADHD Antibiotics Anticonvulsants Antidepresssants Antihistamines Amphetamines (Speed) Aspirin/Painkillers Blood Pressure Cancer Medications Diet Aids Heart / Cardiac Herbs / Supplements Hormones Nausea Nerve Meds / Tranquilizers Anti-Anxiety Meds Sleeping Pills / Barbiturates Ritalin, Adderal, Concerta, Cylert Ampicillin, Ceftin, Erythromycin, Penicillin Depakote, Valproate, Dilantin, Phenobarbitol Effexor, Elvavil, Mellaril, Nardil, Prozac, Paxil, Tofranil, Wellbutrin, Zoloft Actifed, Comtrex, Benadryl, Hismanal, Sudafed, Triaminic Dexedrine Aspirin, Codeine, Darvocet, Demerol, Ibuprophen, Motrin, Tylenol Procardia, Prosantin, Accupril Tamoxifen, Megase, Arimidex Dexedrine, Body Solutions, Metabolife Cardizem, Nitroglycerin, Verapamil St. John's Wort, Ginko Biloba, Echinacea ACTH, Estrogen, Levothroid, Premarin, Synthroid, Levoxyl Benadryl, Compazine, Dramamine, Nux Vomica, Thorazine Lithium Carbonate, Neurontin, Xanax, Valium, Ativan, Buspar, Clonadine Excedrin PM, Nytol, Tylenol PM, Unisom, Butisol, Nembutal, Pentothal Oakland County Family Court, 2001 American LegalNet, Inc. www.USCourtForms.com Page 4 BIRTH FAMILY AND CHILD HISTORY (Birth Family History - Maternal) Birth Mother History: Information Provided By: Identifying Information: Name: Address: Number & Street Name City State / Zip Code Date: ( ) Phone Number: ( ) - (Maiden Name) Area Code Age: Social Security No.: Marital Status : Date of Birth: - Place of Birth: Driver's License No.: q Married q Separated q Divorced q Widowed q Never Married Number of Previous Marriages: Name of Spouse: Address of Spouse: Street No. and Name City State Zip Code Date of Marriage : Date of Separation: Date of Death of Spouse: Where is Spouse Employed? Religion: Nationality Background: Racial Background: If Native American (Indian), what Tribes?: Registered: q Yes q No Place of Marriage: Date of Divorce: or , N/A Place of Divorce: Place of Worship: Relationship/Name of Indian Relative : If married, was pregnancy shared with spouse? Physical Description: Height: Eye Color: Complexion / Skin Color: Distinguishing Physical Features: Birth Date: q Yes q No Weight: Hair Color & Texture: Build: Oakland County Family Court, 2001 American LegalNet, Inc. www.USCourtForms.com Page 5 BIRTH FAMILY AND CHILD HISTORY (Birth Family History Maternal - Continued) Birth Mother (Continued) Describe your personality: Describe your sexual orientation: Education: Name of Last School Attended: Last Grade Completed: Average Grades Attained in School: Additional Training Obtained: Do You Have Future Plans for Schooling? Extracurricular activities in which you participated during school years: Subjects you were interested in during school years: Goals and ambitions: Present hobbies, interests and pastime activities: Employment History: Current Occupation: Place of Employment: Address: Length of time employed at above: Previous Occupations : Military Service? q Yes q No If yes, what branch of Service?: Discharge date and highest rank achieved? Oakland County Family Court, 2001 American LegalNet, Inc. www.USCourtForms.com Page 6 BIRTH FAMILY AND
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