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What is it
Information related to the family’s history, including medical, can be priceless for the child throughout his life.
It can be used in Session 4 – Child development & medical matters.
Resource
Birth history
Describe anything relevant at the time of the birth of the child.| Biological Mother/ Maternal side of family | Biological Father/ Paternal side of family |
|
|---|---|---|
| Name | ||
| Age at time of child's birth | ||
| Any previous pregnancy? | N/A | |
| Any miscarriages, stillbirths, or elective abortion? | N/A | |
| Name of mother | ||
| Age of grand-mother at child's birth? (Or indicate date and cause of death) | ||
| Name of father | ||
| Age of grand-father at child's birth? (Or indicate date and cause of death) | ||
| Names and ages of siblings at time of child's birth (If half-siblings, indicate parent they have in common) | ||
| Names, ages, dates, and causes of death of any siblings who may have died prior to the time of the child's birth | ||
| Names, and ages of any siblings who may have been relinquished for adoption prior to the time of the child's birth | ||
| How long was the birth mother in labour? Where was she when it began? | ||
| Where there any complication during pregancy? | ||
| Was meconium passed during birth? | ||
| What was the Apgar score at 1 minute? At 5 minutes? | ||
| Was the child born with any medical condition? | ||
| Was the child born with any handicap? |
Medical history
Information that can help manage the child's health, now or in the future.This will also be useful for their own children.
| Biological Mother/ Maternal side of family | Biological Father/ Paternal side of family |
|
|---|---|---|
| Heart disease (age of diagnosis?) | ||
| Anemia | ||
| Arthritis (give type if known) | ||
| Asthma | ||
| Cancer | ||
| Skin disease | ||
| Depression | ||
| Diabetes (give type if known) | ||
| High blood pressure | ||
| Kideney disease | ||
| Mental illness | ||
| Suicide (attempted or successful?) | ||
| Alcoholism | ||
| Chemical dependency | ||
| Sickle-cell diesease or trait, Tay-Sach's disease, thalassemia, or other genetic blood disease | ||
| HIV, AIDS, or other sexually transmitted disease | ||
| Congenital anomalies or conditions | ||
| Stomach ulcers | ||
| Other chronic illness or condition |
Adoption history
Circumstances that led to the child being placed for adoptions.Possibility of contacts with the biological/birth parents.
| Is any of the above medical information available on other siblings or aunts/uncles? ,, |
| To whom did the birth mother turn for support during the pregnancy and birth?,, |
| What was the realtionship between the birth mother and birth father before, during and after the pregnancy? Was he aware of the pregancy and was he part of the decision making?",, |
| If one or more of the birth parents are not the biological parents, expalin the circumstances of the conception.",, |
| Why circumstances and choices led the birth parents to place the child for adoption?,, |
| Did the birth (or biological) parents leave a letter for the adoptive parents or the child?,, |
| Would either birth parents like to hace contact with the child? If so, what type of contact do they prefer ? (Limited, only when child is adult, never in person, written or phone, through a third party, directly, etc.)",, |
Family history
Interesting facts that will help the child build their identity and self-esteem.| Biological mother | Biological father | Maternal Grand Mother | Maternal Grand Father | Paternal Grand Mother | Paternal Grand Father |
|
|---|---|---|---|---|---|---|
| Name(s) | ||||||
| Nick names | ||||||
| Height | ||||||
| Weight | ||||||
| Eye color | ||||||
| Hair color | ||||||
| Sexual orientation (Including experiments) | ||||||
| Biological background/origins | ||||||
| Last year of education completed | ||||||
| Favorite subject at school | ||||||
| Least favourite subject at school | ||||||
| School-age hobbies | ||||||
| School-age sports | ||||||
| School-age arts | ||||||
| School-age clubs | ||||||
| Sociability as a child | ||||||
| Sociability as an adult | ||||||
| Adult hobbies | ||||||
| Legacy (E.g., piece of art, building, books, etc.) | ||||||
| Other talents | ||||||
| Habits (e.g., nail biting) | ||||||
| Personality characters (Shy, outgoing, jovial, talkative, introverted, violent, etc.) | ||||||
| Religion (Formal affiliation and actual practice) | ||||||
| Occupations | ||||||
| Fears | ||||||
| Other interesting facts |
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