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-E - Child's medical history (private placement)
Secs. 112(3)(5) D.R.L. Form 1-E
373-a S.S.L (Child's Medical
History
Private-Placement)
12/90
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
(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 reverse side or page)
________AIDS/HIV infection
________Allergy to foods/other
substances
________Allergy to medications
(prescription or over-
the- counter)
________Asthma
________Chicken Pox
________Circulatory system
disorders (specify)
________Diabetes
________Diphtheria
________German Measles (Rube
________Measles (Rubeola)
________Hay Fever
________Heart problems (spec
________Hepatitis
________Malaria
________ Mental/Behavioral disorders
(specify)
________Mumps
________Parasites in stool
________Rheumatic Fever
________Scarlet Fever
________Sickle Cell Anemia/Trait
________Tuberculosis
________Typhoid Fever
________Urinary tract/kidney disease;
infection
________Whooping Cough (Pertussis)
________Other (specify)
________Operations/Accidents/Fractures
specify)
3. Immunizations: give dates of the following:
D.P.T./D.T. ____________
Polio (oral) ____________
Measles ____________ Mumps ____________ Rubella ____________
Hemophilus Influenza B. (H.I.B.) ____________
Heptavax/Hepatitis Immune Globulin ____________
Influenza (Flu) ____________
Pneumonia vaccine ____________
Other (specify) ____________
Tuberculosis test (most recent/result ____________
4. List Perinatal History:
Pregnancy:
/ / First trimester bleeding
/ / Toxemia (high blood pressure
or protein in the urine)
/ / Medications (other than
vitamins or iron)
(specify)
/ / Diabetes or thyroid
problem (specify)
/ / Drugs (such as marijuana,
heroin, methadone or
amphetamines) (specify)
/ / Alcohol (occasional,
moderate, heavy)
(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.
____________
____________
6. State present health or cause of death (give ages), if known, of:
Natural father: ____________
Natural mother: ____________
Siblings: full: ____________
half: ____________
7. If known, indicate whether natural mother had any of the following:
/ / Tuberculosis
/ / Diabetes
/ / Breast cancer
/ / Mental or nervous
disorder, e.g.,
schizophrenia,
depression and manic
depression illness
(specify)
/ / Thyroid disease
/ / Stroke
/ / Sickle cell anemia
/ / AIDS
/ / High blood pressure
/ / Bleeding tendency
/ / Eye or ear disorders
/ / Retardation: mental or physical
/ / Circulatory or blood disorders (specify)
/ / Obesity
/ / Asthma
/ / Gastrointestinal disease, e.g., gall bladder, ulcer, irritable bowel (specify)
/ / Colon cancer
/ / Cancer, other (specify)
/ / Arthritis or rheumatism
/ / Kidney disease
(specify)
/ / Alcoholism or other substance
abuse (specify)
/ / Developmental disorder,
e.g., learning disability,
attention deficit
(specify)
/ / Other (specify)
8. If known, indicate whether natural father had any of the following:
/ / Tuberculosis
/ / Diabetes
/ / Breast cancer
/ / Mental or nervous
disorder, e.g.,
schizophrenia,
depression and manic
depression illness
(specify)
/ / Thyroid disease
/ / Stroke
/ / Sickle cell anemia
/ / AIDS
/ / Asthma
/ / Gastrointestinal disease,
e.g., gall bladder, ulcer,
irritable bowel
(specify)
/ / Colon cancer
/ / Cancer, other
(specify)
/ / Arthritis or rheumatism
/ / Kidney disease
(specify)
/ / High blood pressure
/ / Bleeding tendency
/ / Eye or ear disorders
/ / Retardation: mental
or physical
/ / Circulatory or blood
disorders (specify)
/ / Obesity
/ / Alcoholism or other substance
abuse (specify)
/ / Developmental disorder,
e.g., learning disability,
attention deficit
(specify)
/ / Other (specify)
Indicate source for information about child's medical history and the source(s) for information about medical history of natural father and natural mother and whether from direct or indirect source:
____________
____________
____________
Completed by (state official
title, if any): ________
Dated: ________
See Sec. 373-a S.S.L.
