Filing Of Required Non-Identifying Health, Genetic And Social Histories With The Utah Adoption Registry (Page 3 of 11) in pdf

Filing Of Required Non-Identifying Health, Genetic And Social Histories With The Utah Adoption Registry Page 3

IRTH

ARENT

OCIAL

EALTH

ISTORY

NFORMATION

Birthmother

Birthfather

Page 3

RENATAL

ARE

URING THIS

REGNANCY

Describe any complications:

ESCRIPTION OF

ELF

Marital Status:

If married or separated

Civil marriage

Religious ceremony (Specify)

Single

Married

Separated

Divorced

Widowed

If yes, what tribe?

Religion:

Are you an enrolled member

of a Native American tribe,

Alaskan Village or affiliated

with a tribe?

Yes

Ethnic background (e.g., English, German, etc.):

Country or State of birth:

Race (e.g., Black, White, American Indian, Japanese, etc.):

Height:

Weight:

Hair color & texture:

Eye color:

Unique physical features (e.g., freckles, moles, etc.):

Complexion:

Right-handed

Left-handed

Fair

Medium

Olive

Dark

Physical build (e.g., big/small boned, long/short limbed, muscular, etc.):

Talents, hobbies and other interests:

Which of the following describe your personality? (check all that apply):

Aggressive

Emotional

Happy

Nervous

Self-confident

Stubborn

Calm

Friendly

Helpful

Outgoing

Temperamental

Serious

Critical

Fun

Irresponsible

Rebellious

Shy

Unhappy

Comments:

DUCATION

Last grade level completed:

Average grade received or GPA:

Presently in school:

Yes

Future plans for schooling:

Subjects you are interested in:

Any school-related problems or challenges (Tutoring, Special Ed etc.):

Additional educational experiences :

MPLOYMENT

ISTORY

Current Occupation:

Work History:

Military Service

Yes

If yes, branch of service:

Vocational Training:

Filing Of Required Non-Identifying Health, Genetic And Social Histories With The Utah Adoption Registry Page 3

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