New York Codes, Rules and Regulations
Title 22 - JUDICIARY
Subtitle D - Forms
Chapter VII - Surrogate's Court Forms
Subchapter B - Adoption Forms Of The Surrogate's Court
Adoption Forms
Form 1-D - Child's medical history (agency or private placement)
D.R.L. § 112(3)(6) Form 1-D
S.S.L. § 373-a (Child's Medical
History - Agency or
Private-Placement)
12/97
SURROGATE'S COURT OF THE STATE OF NEW YORK
COUNTY OF
________
In the Matter of the Adoption of (Docket)(File) No.
A Child Whose First Name is
Child's Medical
History (Agency or
Private-Placement)
________
1. Age and date of birth of child:
2. Has the child had any of the following illnesses or health problems: (Where indicated, specify below or on additional sheet)
________ AIDS(infection)
(b) . The adoptive parent(s) (has)(have) (no) knowledge of any criminal record concerning themselves or any other adult residing in the household (except)
________ Allergy to foods/other
substances
________ Allergy to medications
(prescription or over-
the-counter)
________ Asthma
________ Chicken Pox
________ Circulatory system
disorders (specify):
________ Diabetes
________ Diphtheria
________ German Measles (Rubella)
________ Measles (Rubeola)
________ Hay Fever
________ Heart problems (specify)
________ Hepatitis
________ Kidney disease
________ Malaria
________ Mental/Behavioral disorders
(b) . The adoptive parent(s) (has)(have) (no) knowledge of any criminal record concerning themselves or any other adult residing in the household (except)
________ Mumps
________ Parasites in stool
________ Rheumatic Fever
________ Scarlet Fever
________ Sickle Cell Anemia/Trait
________ Tuberculosis
________ Typhoid Fever
________ Urinary tract infection
________ Whooping Cough (Pertussis)
________ Other (specify):
________ Operations/Accidents/Fractures
(b) . The adoptive parent(s) (has)(have) (no) knowledge of any criminal record concerning themselves or any other adult residing in the household (except)
3. Immunizations: give dates of the following:
D.P.T./D.T. ____________
Polio (oral) ____________
Measles ____________ Mumps ____________ Rubella ____________
Hemophilus Influenza B. (H.I.B.) ____________
Form 1-D page 2
Heptavax/Hepatitis Immune Globulin ____________
Influenza (Flu) ____________
Pneumonia vaccine ____________
Other (specify) ____________
Tuberculosis test (most recent/result ____________
4. List Pre-natal History:
________ First trimester bleeding
________ Toxemia (high blood pressure or protein in the urine)
________ Medications (other than vitamins or iron)
________ Diabetes or thyroid problem (specify):
________ Drugs (such as marijuana, heroin, methadone or amphetamines) (specify):
________ Alcohol (occasional) (moderate) (heavy)[FN2] (specify):
Birth:
Birth weight ________ length ________
Apgar scores: 1 min. ________ 5 mins. ________
Date baby was due ________
Date baby was born ________
Complications of delivery
________ Premature rupture of membranes
________ Caesarian: routine ________ emergency ________
________ Excessive bleeding: abruption ________ placenta previa ________
Newborn:
________Resuscitation required
________ Yellow jaundice:
lights ________ exchange transfusion ________
________ Infection (specify):
________ Breathing problem (specify):
________ Other (specify):
5. List congenital impairments, including physical defects, if any.
Form 1-D page 3
6. State present health or cause of death (give ages), if known, of:
Birth father:
Birth mother:
Siblings: full:
half:
7. If known, indicate whether birth mother had any of the following:
________ Tuberculosis
________ Diabetes
________ Mental or nervous disorder, e.g., schizophrenia, depression, manic depressive illness (specify):
________ Thyroid disease
________ Stroke
________ Sickle cell anemia
________ (AIDS infection)
(b) . The adoptive parent(s) (has)(have) (no) knowledge of any criminal record concerning themselves or any other adult residing in the household (except)
________ High blood pressure
________ Bleeding tendency
________ Eye or ear disorder
________ Retardation: mental
________ Physical disability (specify):
________ Circulatory or blood
disorders (specify):
________ Obesity
________ Asthma
________ Gastrointestinal disease,
e.g., gall bladder, ulcer,
irritable bowel disorder)
(specify)
________ Breast cancer
________ Colon cancer
________ Cancer, other (specify):
________ Arthritis or rheumatism
________ Kidney disease (specify)
________ Alcoholism or other substance
abuse (specify):
________ Developmental disorder,
(e.g., learning disability,
(b) . The adoptive parent(s) (has)(have) (no) knowledge of any criminal record concerning themselves or any other adult residing in the household (except)
________ Other (specify):
8. If known, indicate whether birth father had any of the following:
________ Tuberculosis
________ Diabetes
________ Mental or nervous
disorder, e.g.,
schizophrenia,
depression, manic
depressive illness
(b) . The adoptive parent(s) (has)(have) (no) knowledge of any criminal record concerning themselves or any other adult residing in the household (except)
________ Thyroid disease
________ Asthma
________ Gastrointestinal disease,
e.g., gall bladder, ulcer,
irritable bowel disorder)
(b) . The adoptive parent(s) (has)(have) (no) knowledge of any criminal record concerning themselves or any other adult residing in the household (except)
________ Colon cancer
Form 1-D page 4
________ Stroke
________ Sickle cell anemia
________ (AIDS infection)
(b) . The adoptive parent(s) (has)(have) (no) knowledge of any criminal record concerning themselves or any other adult residing in the household (except)
________ Cancer, other
(b) . The adoptive parent(s) (has)(have) (no) knowledge of any criminal record concerning themselves or any other adult residing in the household (except)
________ Arthritis or rheumatism
________ Kidney disease
(b) . The adoptive parent(s) (has)(have) (no) knowledge of any criminal record concerning themselves or any other adult residing in the household (except)
________ High blood pressure
________ Bleeding tendency
________ Eye or ear disorders
________ Retardation: mental
________ Physical disability
(specify)
________ Circulatory or blood
disorders (specify):
________ Obesity
________ Alcoholism or other substance
abuse (specify):
________ Developmental disorder
(e.g., learning disability,
attention deficit disorder)
(b) . The adoptive parent(s) (has)(have) (no) knowledge of any criminal record concerning themselves or any other adult residing in the household (except)
________ Other (specify):
Indicate source for information about child's medical history and the source(s) for information about medical history of birth father and birth mother and whether from direct or indirect source:
Completed by (state official
title, if any): ________
______________
Petitioner
______________
Print or type name
______________
Signature of Attorney, if any
______________
Attorney's Name (Print or Type)
________
________
______________
Attorney's Address and Telephone Number
[FN1] Delete inapplicable provision.
[FN2] Delete inapplicable provision
[FN*] Delete inapplicable provision.
[FN*] Delete inapplicable provision.
