Form Hhs-25 - Nebraska Adoption Medical History (Birth Mother) Page 4

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BIRTH MOTHER
SELF
FAMILY
COMMENTS
Section 4. Medical History
If yes, specify which family member and indicate the date
Yes
No
Yes
No
Health Condition
of onset, treatment, medication, etc.
COMPLICATIONS OF PREGNANCY/
CHILDBIRTH
Premature births, miscarriage
Stillbirths
Multiple births
Infant deaths and SIDS (crib deaths)
OTHER MISCELLANEOUS
DISORDERS
Speech
Eating(anorexia, bulimia, etc.)
Learning disability
Alcoholism
Chronic drunkenness
Drug dependency
Cerebral palsy
Exposure to poisons or other
chemicals
Food sensitivities
LIST ADDITIONAL COMMENTS BELOW OR ATTACH A STATEMENT
FOR COURT USE ONLY
RELEASE OF MEDICAL HISTORY
Adoption Agency/Agent
Date
Court of Jurisdiction
Date
Adoptive Parents
Date
Adoptee
Date
Bureau of Vital Statistics
Date
HHS-25 (66085) Page 4

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