Pregnancy and Birth. Pregnancy/Birth/Delivery Complications? Please Describe: Medications used during pregnancy? Yes No Smoking? How much? Yes No Drug Intake? Type? Yes No Alcohol? How much? How much? Length of pregnancy? (weeks): Birth weight: lbs. oz. Birth length: XXXXX scores: / Type of delivery: spontaneous induced caesarean with instruments breech Any complications for mother or infant after birth? Please explain: At what age did this child first do the following (indicate with year and month of age). Turn over Crawl Walk Upstairs Stand Alone Walk Alone First Words First Phrases Is child toilet Trained? Yes No If yes, Days? Nights? Did bed wetting or soiling occur after training? Wetting Soiling If yes, until what age? Does your child have any speech difficulties? Motor difficulties (e.g. clumsiness)? Does your child have difficulties with hygiene? Please list any other healthcare providers involved in your child’s care (e.g., neurologists, pediatricians or other physicians, psychologists, social workers, therapists, special educators, occupational therapists, etc.)
Pregnancy and Birth. Is your child: □ biological child □ adopted child □ xxxxxx child □ other: Mother’s age at birth? Did mother receive routine medical prenatal care? □Yes □ No Please specify any medications used during pregnancy and the reason used: Pregnancy lasted weeks / months Child’s birth weight: pounds XXXXX score …at 1 minute …at 5 minutes □ Unsure / Don’t know Did child go home from the hospital at the same time as the mother? □Yes □ No If No, explain why: Please check the conditions below that describe the health of the child and mother during… □ No complications □ Normal □ Normal □ Blackouts □ Induced labor □ Lack of oxygen □ Falls □ C-section □ Breathing problem □ Physical injury □ Breech birth □ Birth injury/defect □ Excessive bleeding □ Unusually long labor (>12 hours) □ Jaundice □ Hypertension □ Premature # of weeks □ Newborn ICU # of days □ Diabetes □ Overdue # of weeks □ Other problem (specify) □ Emotional stress □ Other problem (specify) □ Toxemia □ Alcohol and/or drug use □ Use of tobacco B. Health Describe the state of your child’s current health: □ Excellent □ Good □ Fair □ Poor Is your child currently taking any medication? □Yes □ No If yes, please list medications and uses: Has your child ever been identified as having a disability? □Yes □ No If so, by whom, what age, & what disability? Has your child ever received psychological counseling? □Yes □ No If so, by whom (professional/agency) and when: Has your child ever participated in therapy services from a private entity? (i.e., speech, occupational, physical, vision therapy, etc)? □Yes □ No If so, by whom (professional/agency) and when: Has your child ever been evaluated by or participated in educational services from a private entity (i.e., private tutor, Sylvan Learning Center)? □Yes □ No If so, please attach relevant reports. If so, by whom (professional/agency) and when: Has your child ever participated in an early intervention program? □Yes □ No If so, by whom (professional/agency) and when: Has your child had any of the following? Please check all that apply. Please describe and give details, dates, and/or age of onset □ Serious Illnesses □ Head Injuries □ Seizures or convulsions □ Surgery/Hospitalization □ History of Ear Infections □ Allergies and/or Asthma □ Vision Problems Date of last exam: □ Hearing Problems Date of last exam: □ Frequent Nightmares and/or Bedwetting □ Other health problem Is there a family history for the following problems? Biological family member with the history… □ Learn...
Pregnancy and Birth. It is understood and agreed to by all parties that Xxxxxx shall make all medical decisions about the pregnancy and birth of any child(ren) conceived as a result of this insemination;
