State of Connecticut Page 1 of 7 9/12 (Rev.) Department of Children and Families medical information on genetic parent(S)




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DCF-338 State of Connecticut Page 1 of 7

9/12 (Rev.) Department of Children and Families


MEDICAL INFORMATION ON GENETIC PARENT(S)

(Use When Submitting to Superior Court)
0 Mother (Use separate form for each parent) 0 Father

_



Indicate by checking "Yes" or "No" if you or any genetic relatives (i.e. your mother, father, sisters, brothers, grandparents, aunts, uncles, or any other children you have had) ever had, or now have, the medical items listed. Also complete the "Comment" section.


Medical Condition


No


Not

Known


Yes

(Self)

Yes - Relative (Specify which relative)

Comments

(Provide details including, but not limited to, cause, age at onset, treatment and any hospitalizations)

1. Club Foot

















2. Harelip (Cleft Lip) or cleft palate
















  1. Congenital heart defect



















4. Any other malformations

















  1. Muscular dystrophy



















6. Multiple sclerosis

















7. Cerebral palsy

















8. Other paralysis or crippling disorder



















  1. Seizures,

convulsions or

epilepsy
















  1. Blindness, glaucoma or other visual problems
















11. Deafness or other ear problems
















12. Speech problem

















13. Learning
disability




















  1. Developmental

disability: mental or physical
















15. Diabetes

















16. Thyroid disorder

















17. Other hormone disorder

















18. Eczema or other skin conditions
















19. Asthma

















  1. Hay fever or

other allergy

















21. Hemophilia

















22. Sickle cell anemia

















  1. Other blood

disease

(including

anemia)















24. Schizophrenia

















25. Manic depressive

















  1. Other mental or

emotional illness



















  1. Hypertension

(high blood

pressure)

















28. Stroke

















  1. Heart attack

(Coronary)

















  1. Other

cardiovascular

problems

















31. Cancer

















32. Tumors

















33. Cystic fibrosis

















  1. Huntington's

disease

















35. Tuberculosis


















36. Kidney disease

















  1. Alcoholism or

heavy drinking

















38. Drug usage

















  1. Hospitalization,

operation, or

injury
















  1. Any other

condition you or

other in your

family might have
















Initials: Adoptive Father: _________________________ Adoptive Mother: _________________________

For Genetic Mother Only




Menstrual and Pregnancy History

Age at onset of menses


Usual Length of Period

Regular?

0 Yes 0 No

Number of Days Between

Please list all your pregnancies in order. (Use one line for each child or for each miscarriage, abortion, or still birth.)

Children

(Write baby boy, baby girl, miscarriage, abortion, or still-birth)


How Many Months Did You Carry This Pregnancy?



Year in Which Pregnancy Ended


If Miscarriage or Abortion, Was it Natural or Induced?

















































This Pregnancy

Is the baby's father aware of this pregnancy?

0 Yes 0 No 0 Not Sure



Is the baby's father a genetic relative of yours? If yes, how is he related?

0 Yes 0 No



Month prenatal care began for this pregnancy


Complications

Complications (Continued)


Exposure during pregnancy

0 X-Ray 0 Electrocardiogram 0 Radiation



Drugs Taken During Pregnancy

Prescription

and

Non-Prescription

Drugs

Prescription Drugs




Non-Prescription Drugs (including aspirin and/or nose drops)




When During Pregnancy?

Alcohol

0 Yes 0 No

Amount

How Often


Amphetamines

(Uppers)

When During Pregnancy?





Kind


Amount

Barbiturates

(Downers)

Kind

Amount

Cocaine


When

Amount

Heroin


When

Amount

LSD


When

Amount

Marijuana


When

Amount

Cigarettes


When

Amount

Birth History

Child's Name


Date of Birth

Time of Birth

(A.M. or P.M.)

Sex


Weight

Lbs. Oz.

Term

Head Circumference

Chest Circumference

0 Premature

Weeks

0 Postmature

Weeks

0 Full

Weeks







Abnormalities


Mother's Blood Type


RH Factor

Baby's Blood Type

Duration of Labor


Anesthesia Used

Type of Delivery


Apgar Score at 1 and 5 Minutes

/

Condition of Child at Birth


Child's Medical History

First Tooth At (months)


Sat Alone (months)

Walked At (months)

Convulsive Disorder (month and year noted)

Toilet Trained (months)


Diagnosed Medical Conditions (i.e., allergies, bronchitis, etc.)

Attach Medical Passport and Do Not Complete if Immunizations, Diseases and Hospitals Information are Contained on Passport


Immunizations Date Booster Date Booster Date Booster Date
DPT ______/____/______ ______/____/______ ______/____/_____ ______/____/______
Small Pox ______/____/______ ______/____/______ ______/____/_____ ______/____/______
Polio ______/____/______ ______/____/______ ______/____/_____ ______/____/______
Other ______/____/______ ______/____/______ ______/____/_____ ______/____/______


Diseases (Dates)
Measles ______/____/______ Whooping Cough ______/____/______
Mumps ______/____/______ Other (Specify)

__________________________ ______/____/______

Chicken Pox ______/____/______




Hospitalization (Reason, Date(s) and Place)



Complete the Following:
Tests Date Performed by
Psychological Evaluation ______/____/______ ___________________________________________________
Psychiatric Evaluation ______/____/______ ___________________________________________________
Intellectual assessment ______/____/______ ___________________________________________________
Developmental evaluation ______/____/______ ___________________________________________________

(includes, speech, language, and hearing)
Physical examination ______/____/______ ___________________________________________________
Neurological evaluation ______/____/______ ___________________________________________________

I hereby acknowledge receipt of a copy of this form.

Signed (adoptive mother) Date

Signed (adoptive father) Date



Signed (Agency Representative) Date

Agency



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