Birth Parent Medical History Form
Personal Information
Name
Date of Birth
Phone
Email
Address
Medical History
List any major illnesses or medical conditions
Current Medications (include dosage and frequency)
Allergies (medication, food, etc.)
Mental Health History
Have you ever been diagnosed with a mental health condition?
Family Medical History
Family medical history (parents, siblings, grandparents)
Pregnancy History
Number of Pregnancies
Number of Live Births
Number of Miscarriages
Any complications during pregnancy?
Lifestyle Information
Do you use tobacco products?
Do you consume alcohol?
Use of other substances (specify)
Additional Information
Is there anything else you would like to share regarding your medical history?