Birthfather Application – Part 2

• Expectant/ Birthfather Applications - Part 1
• Expectant/ Birthfather Applications - Part 2

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  The answers to the following questions will be very important to your child in the future. Please answer each question to the best of your ability. All information you provide is completely confidential. The purpose of these questions is solely for the present and future medical wellbeing of your child.

  Name(Required)

  First Middle Last

  Date of Birth(Required)

  MM slash DD slash YYYY

  Have you been tested for HIV?(Required)

  Yes

  No

  HIV date tested:(Required)

  MM slash DD slash YYYY

  HIV test result:(Required)

  Would you be willing to be tested for HIV?(Required)

  Yes

  No

  Have you been tested for Hepatitis C?(Required)

  Yes

  No

  Hepatitis C date tested:(Required)

  MM slash DD slash YYYY

  Hepatitis C test result:(Required)

  Would you be willing to be tested for Hepatitis C?(Required)

  Yes

  No

  Consent(Required)

  THE ABOVE INFORMATION IS CORRECT AND TRUE TO THE BEST OF MY KNOWLEDGE

  Please answer the following questions pertaining to mental health history:

  Anxiety:(Required)

  Expectant Father (you)

  Your other child(ren)

  Your extended family

  No

  Depression:(Required)

  Expectant Father (you)

  Your other child(ren)

  Your extended family

  No

  Bipolar Disorder:(Required)

  Expectant Father (you)

  Your other child(ren)

  Your extended family

  No

  Schizophrenia/Schizoaffective:(Required)

  Expectant Father (you)

  Your other child(ren)

  Your extended family

  No

  Autism/Asperger's:(Required)

  Expectant Father (you)

  Your other child(ren)

  Your extended family

  No

  Other mental health diagnoses in expectant parents or their extended families, that are important to disclose:

  Consent(Required)

  THE ABOVE INFORMATION IS CORRECT AND TRUE TO THE BEST OF MY KNOWLEDGE

  Please answer the following questions pertaining to mental health history:

  Please complete the table below to indicate whether you or any of your immediate family members (mother, father, brother, sister, grandmother, grandfather, aunt, uncle, or children) currently have or have had any of the following medical conditions in the past.

  For any of the following conditions where you select a ‘Yes’ response, please use the fields provided to indicate who currently has (or has had in the past) the specific medical condition, the age of onset for the condition, and whether any medications were prescribed for the condition. Please be as specific as possible. Below are a few examples.

  Examples:

  • I am a carrier of Sickle Cell Disease. I found this out in 2019 when I donated blood.
  • My son has had milk intolerance since birth. He is healthy as long as he maintains a dairy-free diet.
  • My sister has asthma and was diagnosed with it when she was 10. She uses a ProAir Inhaler.
  • My grandfather died of a heart attack at age 75. He smoked 2 packs of cigarettes every day for 30 years.

  Animal Allergies:(Required)

  Yes

  No

  Don't know

  Condition/Disease description:(Required)

  Environmental/seasonal allergies (Required)

  Yes

  No

  Don't know

  Condition/Disease description:(Required)

  Food allergies(Required)

  Yes

  No

  Don't know

  Condition/Disease description:(Required)

  Drug/medicine allergies (e.g. Codeine, Muscle relaxers, Penicillin)(Required)

  Yes

  No

  Don't know

  Condition/Disease description:(Required)

  Milk/dairy intolerance (Required)

  Yes

  No

  Don't know

  Condition/Disease description:(Required)

  Attention Deficit Disorder (ADD)/Attention Defecit Hyperactivity Disorder (ADHD) (Required)

  Yes

  No

  Don't know

  Condition/Disease description:(Required)

  Autism Spectrum Disorder(Required)

  Yes

  No

  Don't know

  Condition/Disease description:(Required)

  Blindness or Vision problems (e.g. Astigmatism, Crossed Eyes, Glaucoma)(Required)

  Yes

  No

  Don't know

  Condition/Disease description:(Required)

  Deafness or Hearing loss(Required)

  Yes

  No

  Don't know

  Condition/Disease description:(Required)

  Down Syndrome(Required)

  Yes

  No

  Don't know

  Condition/Disease description:(Required)

  Dyslexia/reading disability (Required)

  Yes

  No

  Don't know

  Condition/Disease description:(Required)

  Intellectual disability (Required)

  Yes

  No

  Don't know

  Condition/Disease description:(Required)

  Speech Impediment(Required)

  Yes

  No

  Don't know

  Condition/Disease description:(Required)

  Acne(Required)

  Yes

  No

  Don't know

  Condition/Disease description:(Required)

  Alopecia(Required)

  Yes

  No

  Don't know

  Condition/Disease description:(Required)

  Alzheimer's disease(Required)

  Yes

  No

  Don't know

  Condition/Disease description:(Required)

  Anemia(Required)

  Yes

  No

  Don't know

  Condition/Disease description:(Required)

  Arthritis(Required)

  Yes

  No

  Don't know

  Condition/Disease description:(Required)

  Asthma(Required)

  Yes

  No

  Don't know

  Condition/Disease description:(Required)

  Bladder or Urinary Tract Infections(Required)

  Yes

  No

  Don't know

  Condition/Disease description:(Required)

  Cancer(Required)

  Yes

  No

  Don't know

  Condition/Disease description:(Required)

  Dental or Oral health problems(Required)

  Yes

  No

  Don't know

  Condition/Disease description:(Required)

  Diabetes(Required)

  Yes

  No

  Don't know

  Condition/Disease description:(Required)

  Eczema, Psoriasis, or other skin conditions (Required)

  Yes

  No

  Don't know

  Condition/Disease description:(Required)

  Epilepsy or Seizure Disorder(Required)

  Yes

  No

  Don't know

  Condition/Disease description:(Required)

  Heart disease/heart attack(Required)

  Yes

  No

  Don't know

  Condition/Disease description:(Required)

  Hemophilia(Required)

  Yes

  No

  Don't know

  Condition/Disease description:(Required)

  Hepatitis(Required)

  Yes

  No

  Don't know

  Condition/Disease description:(Required)

  Hereditary Hemorrhagic Telangiectasia (HHT)(Required)

  Yes

  No

  Don't know

  Condition/Disease description:(Required)

  High blood pressure(Required)

  Yes

  No

  Don't know

  Condition/Disease description:(Required)

  Hormone/Thyroid disease(Required)

  Yes

  No

  Don't know

  Condition/Disease description:(Required)

  Huntington disease (Required)

  Yes

  No

  Don't know

  Condition/Disease description:(Required)

  Inflammatory bowel disease (e.g. Crohn's disease, Ulcerative Colitis)(Required)

  Yes

  No

  Don't know

  Condition/Disease description:(Required)

  Kidney disease(Required)

  Yes

  No

  Don't know

  Condition/Disease description:(Required)

  Miltiple Sclerosis(Required)

  Yes

  No

  Don't know

  Condition/Disease description:(Required)

  Muscular Dystrophy(Required)

  Yes

  No

  Don't know

  Condition/Disease description:(Required)

  Parkinson's disease(Required)

  Yes

  No

  Don't know

  Condition/Disease description:(Required)

  Scoliosis(Required)

  Yes

  No

  Don't know

  Condition/Disease description:(Required)

  Sickle Cell disease(Required)

  Yes

  No

  Don't know

  Condition/Disease description:(Required)

  Stroke(Required)

  Yes

  No

  Don't know

  Condition/Disease description:(Required)

  Thalassemia(Required)

  Yes

  No

  Don't know

  Condition/Disease description:(Required)

  Toxoplasmosis(Required)

  Yes

  No

  Don't know

  Condition/Disease description:(Required)

  Tremors (head/hand)(Required)

  Yes

  No

  Don't know

  Condition/Disease description:(Required)

  Tuberculosis(Required)

  Yes

  No

  Don't know

  Condition/Disease description:(Required)

  Ulcers(Required)

  Yes

  No

  Don't know

  Condition/Disease description:(Required)

  Venous Thromboembolism (VTE)(Required)

  Yes

  No

  Don't know

  Condition/Disease description:(Required)

  Vitamin K deficiency bleeding (VKDB)(Required)

  Yes

  No

  Don't know

  Condition/Disease description:(Required)

  Von Willebrand disease (VWD)(Required)

  Yes

  No

  Don't know

  Condition/Disease description:(Required)

  Chlamydia(Required)

  Yes

  No

  Don't know

  Condition/Disease description:(Required)

  Genital Herpes(Required)

  Yes

  No

  Don't know

  Condition/Disease description:(Required)

  Gonorrhea(Required)

  Yes

  No

  Don't know

  Condition/Disease description:(Required)

  Trichomoniasis(Required)

  Yes

  No

  Don't know

  Condition/Disease description:(Required)

  Human papilloma virus (HPV)(Required)

  Yes

  No

  Don't know

  Condition/Disease description:(Required)

  Syphilis(Required)

  Yes

  No

  Don't know

  Condition/Disease description:(Required)

  Alcohol or Drug Addiction(Required)

  Yes

  No

  Don't know

  Condition/Disease description:(Required)

  Anorexia Nervosa, Bulemia or other eating disorder(Required)

  Yes

  No

  Don't know

  Condition/Disease description:(Required)

  Attempted Suicide(Required)

  Yes

  No

  Don't know

  Condition/Disease description:(Required)

  Bipolar Disorder (diagnosed by a Psychiatrist)(Required)

  Yes

  No

  Don't know

  Condition/Disease description:(Required)

  Borderline Personality Disorder(Required)

  Yes

  No

  Don't know

  Condition/Disease description:(Required)

  Depression/Anxiety(Required)

  Yes

  No

  Don't know

  Condition/Disease description:(Required)

  Dissociative Identity Disorder(Required)

  Yes

  No

  Don't know

  Condition/Disease description:(Required)

  Psychiatric hospitalizations(Required)

  Yes

  No

  Don't know

  Condition/Disease description:(Required)

  Schizophrenia/Schizoaffective Disorder (diagnosed by a Psychiatrist)(Required)

  Yes

  No

  Don't know

  Condition/Disease description:(Required)

  Birth mark(Required)

  Yes

  No

  Don't know

  Condition/Disease description:(Required)

  Cerebral palsy(Required)

  Yes

  No

  Don't know

  Condition/Disease description:(Required)

  Chromosomal abnormality (Required)

  Yes

  No

  Don't know

  Condition/Disease description:(Required)

  Cleft lip/cleft palate (Required)

  Yes

  No

  Don't know

  Condition/Disease description:(Required)

  Club foot(Required)

  Yes

  No

  Don't know

  Condition/Disease description:(Required)

  Congenital heart defect (Required)

  Yes

  No

  Don't know

  Condition/Disease description:(Required)

  Congenital Hydrocephalus(Required)

  Yes

  No

  Don't know

  Condition/Disease description:(Required)

  Cystic Fibrosis (Required)

  Yes

  No

  Don't know

  Condition/Disease description:(Required)

  Neurofibromatosis(Required)

  Yes

  No

  Don't know

  Condition/Disease description:(Required)

  Spina Bifida (Required)

  Yes

  No

  Don't know

  Condition/Disease description:(Required)

  Tay-Sach’s disease (Required)

  Yes

  No

  Don't know

  Condition/Disease description:(Required)

  Webbed/extra/missing finger(s) or toe(s) (Required)

  Yes

  No

  Don't know

  Condition/Disease description:(Required)

  Additional Question

  If you or any members of your immediate family have any other medical conditions or diseases that are not on this list, please use the space below to let us know what they are.

  Additional information:

  Consent

  THE ABOVE INFORMATION IS CORRECT AND TRUE TO THE BEST OF MY KNOWLEDGE

  Signature