GENERAL
INFORMATION
Today’s Date
Baby’s Due Date
First Name
*
Last Name
*
Complete Address
*
City, State & Zip
*
Home Phone
*
Work Number
Social Security
No
Other Phone
Drivers License
No
State of Issue
Birth Date
Birth place
Maiden Name
Age
Height
Pre-pregnancy
Weight
Current Weight
Hair Color
Eye Color
Complexion
Physical Build
National Ancestry
Race
Religion
Employer
Employer’s
Address
Occupation
Date of
Employment
EDUCATION
Completed High School?
If no, completed what grade?
Years of
College?
Major?
College Degree?
When and Where
Other Training
Military Service
Other
Schooling
Hobbies
REGARDING YOUR
PREGNANCY
Date of your
last period? *
Comments
Have you had
prenatal care? *
When?
*
Last Doctors
Appointment? *
Next
Appointment? *
Have you had an
ultrasound? *
If yes, when? *
OBSTETRICIAN
Doctor’s Name *
Address *
City, State, Zip *
Phone *
Have you told your doctor that you plan to place the child for adoption? *
Yes
No
Are you willing to
allow adoptive parents to speak with your doctor
regarding your pregnancy? *
Yes
No
HOSPITAL
Name of Hospital
you will go to?
Address
City, State, Zip
Phone
Do you have medical insurance?
Yes
No
If yes, Company Name
Policy Number
Phone Number
Do you have Welfare Coverage?
Yes
No
If yes, Contact
PREGNANCY HISTORY
Since you became pregnant, do you or have
you?
Smoked
Cigarettes?
Yes
No
If yes,
quantity?
Consumed
Alcohol?
Yes
No
If yes,
quantity?
Taken Drugs?
Yes
No
If yes,
quantity?
Smoked Pot?
Yes
No
If yes,
quantity?
Have you been
pregnant before?
Yes
No
If yes, dates
Have you had any
complications?
Yes
No
If yes, explain
Have you had any
miscarriages?
Yes
No
If yes, dates
Have you had any
abortions?
Yes
No
If yes, explain
Have you had any
stillborn babies?
Yes
No
If yes, explain
Do you expect a Cesarean Section?
Yes
No
If yes, explain
Are you of
Native American heritage or have any American Indian
relatives?
Yes
No
If yes, explain
FATHER OF THE CHILD
Do you know who
is the birthfather?
Yes
No
If yes, Full
Name
Address
City, State, Zip
Home Phone
Work Phone
Birthfather’s
Employer
Employer’s
Address
Birth date
Birth place
Age
Height
Weight
Hair Color
Eye Color
Nat. Ancestry
Race
Religion
Are you married
to the birthfather?
Yes
No
Have you lived
with him during your pregnancy?
Yes
No
Does he know
that you are pregnant?
Yes
No
Has he helped
you financially during your pregnancy?
Yes
No
Has he
acknowledged that he is the father of the child?
Yes
No
Does he know that you intend to place the child
for adoption?
Yes
No
Does he agree to
the adoption?
Yes
No
Does he wish to
meet or talk with the adoptive parents?
Yes
No
Does he plan on
being named as father on the birth certificate?
Yes
No
Is birthfather willing to sign a
Consent to Adopt
form?
Yes
No
ARRESTS
Have you ever
been arrested?
If yes, explain
Has birthfather
ever been arrested?
If yes, explain
MARRIAGE
Are you now
married?
Yes
No
If yes, answer below
Name of Husband
Phone
Address
City, State, Zip
Date of Marriage
Place of Marriage
Divorced?
Yes
No
If yes, Date of Divorce
Separated?
Yes
No
if yes, Date
Separated
CHILDREN
Do you have any
children?
Yes
No
If yes, How many?
Ages
Where do your
children live?
Have you placed
other children for adoption?
Were you or any
member of your family adopted?
PARENTS
Your Mother’s
Name
Phone
Address
City, State, Zip
Your Father’s
Name
Phone
Address, if
different from above
City, State, Zip
EMERGENCY
CONTACT
Name
Relationship
Address
City, State, Zip
Phone
Comments
Accept my
printed name as an electronic signature. I have provided true and accurate information to the best of my ability.
Print Name
*
Date
Contact Email Address
*