Dear Birth Mother:

Thank you for bringing your baby to the hospital. You have taken the first step in assuring that your child will be safe and well taken care of. We know that this has been a difficult decision for you, and we want to assure you that we will do what we can to give your child the best possible care.

We are asking you to help your baby by providing some health information that may be important for your child to know in his or her future. This information is important for your child’s care, and most helpful for their adoptive family. The information will be used only for this purpose. It will not be used to identify you or find you. You may not know all of the answers – that’s OK. Please just provide your baby with as much information as you do know.

What is the baby’s birth date? Was the baby premature? o Yes o No

Were there any problems with the pregnancy or delivery? o Yes o No If yes, what were they?

Did you smoke, use alcohol, drugs or any medication during the pregnancy? o Yes o No

If yes, what were they?

Do you have any medical conditions such as: o Diabetes o Asthma o Allergies o Seizures o Cancer o Heart Disease o High Blood Pressure o Mental Illness

Does the Baby’s Father have any medical conditions such as: o Diabetes o Asthma o Allergies o Seizures o Cancer o Heart Disease o High Blood Pressure o Mental Illness

What is your: Age Race Religion Hair Color Body Build

What is the baby’s father’s: Age Race Religion Hair Color Body Build

Is there anything else you'd like to tell us about your child?

Please feel free to include a note to your baby, or the people who will adopt your child. If you like, you could use the back of this form.

This history is a thoughtful gift for your child. Thank you so much.