Form Hhs-25 - Nebraska Adoption Medical History (Birth Mother)
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12Vital Statistics
Department of Health & Human Services
NEBRASKA ADOPTION MEDICAL HISTORY (BIRTH MOTHER)
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WE WISH TO OBTAIN AS COMPLETE A MEDICAL HISTORY FOR THE CHILD AS POSSIBLE.
PLEASE COMPLETE ALL OF THE SECTIONS. IF THE BIRTH PARENTS, GRANDPARENTS,
SIBLINGS, AUNTS OR UNCLES HAVE HAD OR NOW HAVE ANY OF THE MEDICAL CONDITIONS
LISTED IN SECTION 4, PLACE A CHECK IN THE APPROPRIATE SPACE.
WHEN LISTING INFORMATION PERTINENT TO OTHER FAMILY MEMBERS, DO NOT ENTER
PROPER NAMES. LIST ONLY THE RELATIONSHIP SUCH AS SISTER, UNCLE, AUNT, ETC.
IF ADDITIONAL SPACE IS NEEDED, REFER TO COMMENT SECTION ON PAGES 4 AND 4-A OR
ATTACH AN ADDITIONAL SHEET.
Section 1. Birth name of child
Date of birth
Place of birth
City and State
Mother
Father
Section 2. This form is completed by
, whose relationship to
is_______________________________.
Date
Section 3. General State of Health of Child (Please explain, in brief, the present health of this child).
HHS-25 (66085) Page 1
New form created 7-11
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Parent category: Medical