Filing Of Required Non-Identifying Health, Genetic And Social Histories With The Utah Adoption Registry Page 9

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9
9
B
P
S
A
H
H
I
IRTH
ARENT
OCIAL
ND
EALTH
ISTORY
NFORMATION
Birthmother
Birthfather
Page 9
YOUR
DEVELOPMENTAL
RELATIVE
DISORDERS
(SPECIFY
NONE YOU
RELATIONSHIP)
COMMENTS
Learning disability/Attention deficit
Type of education? Treatment?
(specify type):
Mental retardation (specify type):
Diagnosis? Severity? Type of education?
Downs Syndrome:
Speech or hearing problems:
Low Birth Weight:
Other (specify):
Other (specify):
Other (specify):
H
D
U
ISTORY OF
RUG
SE
Dosage or amount and
Date of last use
When used
Types of Drugs
length of time used
9
Before conception
Specify Type (e.g., Prozac, accutane, etc.):
Prescription
9
After conception
9
Before conception
Over-the-counter Specify Type (e.g., diet pills, antihistamine, etc.):
9
After conception
9
Before conception
Specify Type:
Alcohol
9
After conception
9
Before conception
Methamphetamine
Specify Type:
“Meth” or Speed”
9
After conception
Downers
9
Before conception
Specify Type:
(i.e., sleeping pills,
benzodiazepines,
9
After conception
barbiturates, etc.)
By injection?
9
Before conception
Cocaine
“Crack”
Other Types of
9
9
9
After conception
Yes
No
Drugs Used:
By injection?
9
Before conception
Heroin/Pain Killers
(codeine, hydrocodone)
9
9
9
After conception
Yes
No
Hallucinogens
Specify Type:
9
Before conception
(i.e., LSD, Ecstasy or XTC,
mushrooms, PCP, etc.)
9
After conception
9
Before conception
Specify Type:
Cigarettes
9
After conception
9
Before conception
Marijuana
9
After conception
9
Before conception
Specify Type:
Other
9
After conception
9
Before conception
Specify Type:
Other
9
After conception
9
Before conception
Specify Type:
Other
9
After conception

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