Medical Questionnaire

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Baby's Birth Date:________________

Was your Baby born early, before its due date? Yes / No / Unsure

Was there any problems with the pregnancy? Yes / No / Unsure

If yes, what were they?

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

If yes, explain:

 

 

 

Please check any of the medical conditions you have. If you know any of the medical conditions the father might have, please check those as well.

Please list any allergies you have or your baby's father may have:

Are you aware of any health problems that run in your family or your baby's father's family? If yes, please decribe what they are:

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

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