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700-00126 0 H:\Forms\Probateforms\Oct1Forms\Form 126.wpd

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700-00126 – Information About Birth Family (06/2019) Page 1 of 9
STATE OF VERMONT
SUPERIOR COURT
PROBATE DIVISION
Unit
Docket No.
In re Adoption of :
INFORMATION ABOUT BIRTH FAMILY
Each Birth Parent should complete a separate form.
Today's Date: ____________________________
Name of person completing form: ______________________________________
If not parent, relationship to parent: ______________________________________
Child's Full Name: ______________________________________
Date of Birth: _____________________________ Time of Birth: ____________________________
Place of Birth (town, state, country): _____________________________________________________________
BIRTH PARENT BACKGROUND
Parent’s Full Name (first, middle, last): ___________________________________________________________________
Maiden or previous name(s), if applicable: __________________________________________________
Date of Birth: __________________ Place of Birth: _____________________________________
Social Security Number: ______________ Driver’s License Number: ______________ State: ______
Race: _____________________________ Ethnic Background: _________________________________
If you attend religious services, what kind? __________________________________________________
Physical Address Mailing Address
__________________________________ __________________________________
__________________________________ __________________________________
__________________________________ __________________________________
Please provide the name and address of a person who is likely to know where you are if you move:
__________________________________
__________________________________
__________________________________
700-00126 – Information About Birth Family (06/2019) Page 2 of 9
PHYSICAL DESCRIPTION
Height: _____________ Weight: _____________ Complexion: ______________
Hair Color: __________ Eye Color: ___________ General Build: ____________
PERSONAL BACKGROUND
Where did you grow up? ____________________________________________________________
What is the highest grade you have completed? ________ How did you do in school? __________
What were your favorite subjects? ____________________________________________________
If you had learning problems in school, what were they? ________________________________
_________________________________________________________________________________
If you have had other training, what kind? _______________________________________________
What kind of jobs have you had? ______________________________________________________
Present occupation: ________________________________________________________________
Briefly describe your personality:
___________________________________________________________________________________
___________________________________________________________________________________
___________________________________________________________________________________
What are your interests and talents? (examples of talents: artistic, mechanical, athletic, like science, musical, etc.)
___________________________________________________________________________________
___________________________________________________________________________________
___________________________________________________________________________________
Have you been in the military? ☐ Yes ☐ No
If Yes, what branch? ____________________
What was your rank and serial number? __________________________________________________
What are your plans for the future?
___________________________________________________________________________________
___________________________________________________________________________________
___________________________________________________________________________________
___________________________________________________________________________________
___________________________________________________________________________________
BIRTH PARENT'S FAMILY
Your mother’s name (first, middle, maiden): _____________________________________________________
Height: _____________ Weight: _____________ Age: __________ Race: _________
Hair Color: __________ Eye Color: ___________ General Build: _______________________
General Health: ______________________________________________________________________
Level of Education: ___________________________ Occupation: _________________________
Is she aware of the birth of this child? ☐ Yes ☐ No
If deceased, age and cause of death: _____________________________________________________
700-00126 – Information About Birth Family (06/2019) Page 3 of 9
BIRTH PARENT'S FAMILY (continued)
Your father’s name): _____________________________________________________________________
Height: _____________ Weight: _____________ Age: ___________ Race: _________
Hair Color: __________ Eye Color: ___________ General Build: _______________________
General Health: ______________________________________________________________________
Level of Education: ___________________________ Occupation: _________________________
Is he aware of the birth of this child? ☐ Yes ☐ No
If deceased, age and cause of death: _____________________________________________________
BROTHERS AND SISTERS
Full Name
Date of Birth
Last Grade
Completed
Occupation
MARRIAGES
Name of Spouse
Year Married
Year Divorced
BROTHERS AND SISTERS OF YOUR CHILD (Include brothers and sisters living at home or elsewhere including children who
were adopted, step-brothers and sisters and any children who may have lived in the child's home for an extended period of time.)
Full Name
Date of Birth
Relationship
to Child
Who is Caring for
this Child?
700-00126 – Information About Birth Family (06/2019) Page 4 of 9
Does your child have a relationship with these brothers and sisters? Please describe.
_________________________________________________________________________________
_________________________________________________________________________________
_________________________________________________________________________________
_________________________________________________________________________________
_________________________________________________________________________________
_________________________________________________________________________________
PREGNANCY (for birthmothers only)
In what month did you begin pre-natal care? ___________________
Did you drink alcohol during this pregnancy? When during your pregnancy? How much at one time and
how often?
__________________________________________________________________________________
__________________________________________________________________________________
What prescription drugs, over-the-counter medications or street drugs did you take during your
pregnancy? What kind, how often, and when during the pregnancy?
__________________________________________________________________________________
__________________________________________________________________________________
Did you smoke? If so, how much? ____
_________________________________________________
Did you have any special problems during pregnancy? (for example: high blood pressure, diabetes,
excessive bleeding, kidney or bladder infections, German or Three Day Measles, operations, convulsions,
x-rays, sexually transmitted diseases or others):____________________
At what age did you get your period?
____________________________
YOUR CHILD’S HISTORY
Where was your child born? ______
Was this child born earlier or later than expected? ☐ Earlier ☐ Later
If so, how much earlier or later? ________________ How long was your labor? _____________
If drugs were used during your labor, what kind? _________________________________________
Were forceps used? ☐ Yes ☐ No
If you had a Caesarian Section (C-section), why? __________________________________________
If your child had any problems during the labor or soon after birth, please describe:
__________________________________________________________________________________
__________________________________________________________________________________
__________________________________________________________________________________
What was your child’s birth weight? _______________ Birth length: ______________
Did your child have special problems at birth? Please describe:
__________________________________________________________________________________
__________________________________________________________________________________
What is the name and address of your child’s doctor?
__________________________________________________________________________________
700-00126 – Information About Birth Family (06/2019) Page 5 of 9
FOR CHILDREN WHO ARE NOT NEWBORNS
Who has your child’s immunization records? _____
What illnesses has your child had?
☐ Chicken Pox ☐ Bladder or Kidney Infection ☐ Mumps
☐ Ear infections ☐ Whooping Cough ☐ Hepatitis
☐ Frequent nausea or vomiting ☐ Meningitis Red ☐ Measles
☐ Frequent diarrhea or constipation ☐ Sore throat ☐ Allergies
☐ Seizures or convulsions ☐ Headaches ☐ Dizziness
☐ Rash/Skin problems ☐ Asthma ☐ Hay Fever
☐ Broken bones ☐ Fainting ☐ Dental cavities
☐ Pneumonia ☐ Frequent swollen glands ☐ Rheumatic Fever
☐ Trouble urinating ☐ Frequent bruises or bleeding ☐ Hospitalizations
☐ Major operations, illnesses or accidents ☐ Anemia
If you checked any of the above, please describe:
__________________________________________________________________________________
__________________________________________________________________________________
__________________________________________________________________________________
__________________________________________________________________________________
__________________________________________________________________________________
If your child has special educational needs, what are they?
__________________________________________________________________________________
__________________________________________________________________________________
If your child has been formally evaluated for any special problems, what was the evaluation for?
☐ Medical problem ☐ Dental or orthodontic
☐ Learning/school problems ☐ Emotional disturbance or mental illness
☐ Other: what kind? ______________________________________________________________
If so, you may be asked to sign releases so that copies of the evaluations can be obtained.
Has your child been abused or neglected in the past?
☐ Physical abuse ☐ Emotional or verbal abuse
☐ Sexual abuse ☐ Neglect
If so, you may be asked to provide more information about the abuse or neglect.
If your child has ever lived with relatives, foster parents or other place away from home, please describe:
____________________________________________________________________________________
____________________________________________________________________________________
____________________________________________________________________________________
____________________________________________________________________________________
____________________________________________________________________________________
700-00126 – Information About Birth Family (06/2019) Page 6 of 9
FAMILY MEDICAL HISTORY
Instructions:
If you have any of the problems listed below, or have had any problem in the past, please place a check in
the box. If another family member has had the problem, place a check in the box and then list that
person’s relationship to you (examples: aunt, brother, grandmother). If you have more information about
the particular problem, please provide it at the end of this section.
Acne or pimples ☐ Myself ☐ Other family member: _______________
HIV infection or AIDS ☐ Myself ☐ Other family member: _______________
Alcohol Abuse ☐ Myself ☐ Other family member: _______________
Allergy to Food ☐ Myself ☐ Other family member: _______________
What kind? ____________________________________________________________________
Allergy to Other Things ☐ Myself ☐ Other family member: _______________
What kind? ____________________________________________________________________
Alzheimer’s ☐ Myself ☐ Other family member: _______________
Anemia ☐ Myself ☐ Other family member: _______________
Anencephaly ☐ Myself ☐ Other family member: _______________
(born with no brain)
Arthritis ☐ Myself ☐ Other family member: _______________
Where? ____________________________________________________________________
Bedwetting ☐ Myself ☐ Other family member: _______________
Bipolar illness ☐ Myself ☐ Other family member: _______________
(manic depression)
Birth defects ☐ Myself ☐ Other family member: _______________
What kind? ____________________________________________________________________
Blindness or very poor sight ☐ Myself ☐ Other family member: _______________
Braces on teeth ☐ Myself ☐ Other family member: _______________
Breast cancer ☐ Myself ☐ Other family member: _______________
Bronchitis ☐ Myself ☐ Other family member: _______________
Hodgkin’s Disease ☐ Myself ☐ Other family member: _______________
Cancer ☐ Myself ☐ Other family member: _______________
What kind? ____________________________________________________________________
Chlamydia ☐ Myself ☐ Other family member: _______________
Cleft lip or palate ☐ Myself ☐ Other family member: _______________
Club foot ☐ Myself ☐ Other family member: _______________
700-00126 – Information About Birth Family (06/2019) Page 7 of 9
Colitis ☐ Myself ☐ Other family member: _______________
Color blindness ☐ Myself ☐ Other family member: _______________
Cystic Fibrosis ☐ Myself ☐ Other family member: _______________
Dental Problems ☐ Myself ☐ Other family member: _______________
What kind? ____________________________________________________________________
Deafness/hearing problems ☐ Myself ☐ Other family member: _______________
Diabetes in childhood ☐ Myself ☐ Other family member: _______________
Diabetes adulthood onset ☐ Myself ☐ Other family member: _______________
Down’s Syndrome ☐ Myself ☐ Other family member: _______________
Drug Abuse ☐ Myself ☐ Other family member: _______________
Dwarfism/very short height ☐ Myself ☐ Other family member: _______________
Ear infections ☐ Myself ☐ Other family member: _______________
Eczema ☐ Myself ☐ Other family member: _______________
Emphysema ☐ Myself ☐ Other family member: _______________
Epilepsy or seizures ☐ Myself ☐ Other family member: _______________
Eye problems ☐ Myself ☐ Other family member: _______________
Genital Warts ☐ Myself ☐ Other family member: _______________
Very tall height ☐ Myself ☐ Other family member: _______________
Glasses ☐ Myself ☐ Other family member: _______________
What kind? ____________________________________________________________________
Glaucoma ☐ Myself ☐ Other family member: _______________
Gynecological Problems ☐ Myself ☐ Other family member: _______________
(female)
What kind? ____________________________________________________________________
Gonorrhea ☐ Myself ☐ Other family member: _______________
Headaches or migraines ☐ Myself ☐ Other family member: _______________
Heart attack/heart problems ☐ Myself ☐ Other family member: _______________
Hemochromatosis ☐ Myself ☐ Other family member: _______________
Hemophilia or bleeding ☐ Myself ☐ Other family member: _______________
Hepatitis ☐ Myself ☐ Other family member: _______________
Herpes ☐ Myself ☐ Other family member: _______________
00126 – Information About Birth Family (07/2016) Page 8 of 9
Hives ☐ Myself ☐ Other family member: _______________
High blood pressure ☐ Myself ☐ Other family member: _______________
Huntington’s Chorea ☐ Myself ☐ Other family member: _______________
Infertility/difficulty getting pregnant
☐ Myself ☐ Other family member: _______________
Jaundice or yellow skin ☐ Myself ☐ Other family member: _______________
Kidney disease ☐ Myself ☐ Other family member: _______________
Learning problems or disabilities
☐ Myself ☐ Other family member: _______________
Left handed ☐ Myself ☐ Other family member: _______________
Liver disease ☐ Myself ☐ Other family member: _______________
Lung problem ☐ Myself ☐ Other family member: _______________
Lupus ☐ Myself ☐ Other family member: _______________
Mental illness ☐ Myself ☐ Other family member: _______________
What kind? ____________________________________________________________________
Miscarriages ☐ Myself ☐ Other family member: _______________
Muscular Dystrophy ☐ Myself ☐ Other family member: _______________
Obesity/significant overweight
☐ Myself ☐ Other family member: _______________
Osteoporosis ☐ Myself ☐ Other family member: _______________
Paralysis ☐ Myself ☐ Other family member: _______________
Phenylketonuria (PKU) ☐ Myself ☐ Other family member: _______________
Rectal or intestinal polyps ☐ Myself ☐ Other family member: _______________
Rheumatic fever ☐ Myself ☐ Other family member: _______________
Schizophrenia ☐ Myself ☐ Other family member: _______________
Serious depression ☐ Myself ☐ Other family member: _______________
Sickle cell anemia ☐ Myself ☐ Other family member: _______________
Skin disease ☐ Myself ☐ Other family member: _______________
Spina bifida ☐ Myself ☐ Other family member: _______________
Speech problems ☐ Myself ☐ Other family member: _______________
What kind? ____________________________________________________________________
700-00126 – Information About Birth Family (06/2019) Page 9 of 9
Still births ☐ Myself ☐ Other family member: _______________
Stomach problems ☐ Myself ☐ Other family member: _______________
What kind? ____________________________________________________________________
Strokes ☐ Myself ☐ Other family member: _______________
Suicide/suicide attempt ☐ Myself ☐ Other family member: _______________
Surgery ☐ Myself ☐ Other family member: _______________
What kind? ____________________________________________________________________
Syphilis ☐ Myself ☐ Other family member: _______________
Sachs Disease ☐ Myself ☐ Other family member: _______________
Thalassemia ☐ Myself ☐ Other family member: _______________
Thyroid problems ☐ Myself ☐ Other family member: _______________
Twins or multiple births ☐ Myself ☐ Other family member: _______________
Ulcers ☐ Myself ☐ Other family member: _______________
Varicose veins ☐ Myself ☐ Other family member: _______________
Wilson’s Disease ☐ Myself ☐ Other family member: _______________
Other: ____________________________________________________________________
Have you ever had a formal evaluation for medical, mental health or educational reasons?
☐ Yes ☐ No
Please explain:
_______________________________________________________________________________
_______________________________________________________________________________
_______________________________________________________________________________
ADOPTION PLANS FOR YOUR CHILD
What led to your decision to plan adoption for your child?
_______________________________________________________________________________
_______________________________________________________________________________
_______________________________________________________________________________
_______________________________________________________________________________
_______________________________________________________________________________
_______________________________________________________________________________
_______________________________________________________________________________
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Completed 3 July 2020

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