Birthmother Application – Part 3

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Part 1: 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 Last
Date of birth(Required)
MM slash DD slash YYYY

Hospital where you are having the baby:(Required)

Have you had prenatal care during this pregnancy?(Required)

Yes

No
Doctor's Name
First Last
Doctor's Address
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Doctor's Phone
Have you had prenatal care at more than one location during this pregnancy?(Required)

Yes

No

Please provide their information below:

Doctor's Name - additional location 1
First Last
Doctor's Address - additional location 1
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Doctor's Phone - additional location 1
Doctor's Name - additional location 2
First Last
Doctor's Address - additional location 2
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Doctor's Phone - additional location 2
Have you been tested for HIV?(Required)

Yes

No
Date Tested
MM slash DD slash YYYY

Result:

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

Yes

No
Have you been tested for Hepatitis C?(Required)

Yes

No
Date Tested
MM slash DD slash YYYY

Result:

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

Yes

No
Consent(Required)
I have read and understood the above. The information provided is true and correct to the best of my knowledge.(Required)

Part 2: Previous pregnancies
How many previous pregnancies have you had?(Required)
How many living children do you have?(Required)

Have you ever had...

A stillborn child?(Required)

Yes

No
If yes, how many?
An abortion?(Required)

Yes

No
If yes, how many?
A miscarriage?(Required)

Yes

No
If yes, how many?
A baby that died?(Required)

Yes

No
If yes, how many?
A premature baby?(Required)

Yes

No
If yes, how many?
Consent(Required)
I have read and understood the above. The information provided is true and correct to the best of my knowledge.(Required)

Part 3: Medical conditions during this pregnancy or a previous pregnancy
Have you had any illnesses during this or any previous pregnancy?(Required)

Yes

No
If yes, please explain:
What is/was the treatment for this illness or problem?

During this pregnancy, have you had any of the following?

Bacterial or Viral Infection(Required)

Yes

No

I don't know
Diabetes(Required)

Yes

No

I don't know
Heart disease(Required)

Yes

No

I don't know
Hypertension(Required)

Yes

No

I don't know
Kidney disease(Required)

Yes

No

I don't know
Measles(Required)

Yes

No

I don't know
Rh Factor(Required)

Yes

No

I don't know
Thyroid disease(Required)

Yes

No

I don't know
Toxemia(Required)

Yes

No

I don't know
Bacterial Vaginosis(Required)

Yes

No

I don't know
Chlamydia(Required)

Yes

No

I don't know
Genital Herpes(Required)

Yes

No

I don't know
Gonorrhea(Required)

Yes

No

I don't know
Hepatitis(Required)

Yes

No

I don't know
Human Papillomavirus Infection (HPV)(Required)

Yes

No

I don't know
Mycoplasma genitalium (Mgen)(Required)

Yes

No

I don't know
Pelvic Inflammatory Disease (PID)(Required)

Yes

No

I don't know
Syphilis(Required)

Yes

No

I don't know
Trichomonas(Required)

Yes

No

I don't know
Consent(Required)
I have read and understood the above. The information provided is true and correct to the best of my knowledge.(Required)
Part 4: Expectant/Birth Mother Medications/Substances Taken During the Past 5 Years

Please complete the table below to indicate whether you have used any of the following medications or substances during the past 5 years, including during this pregnancy.

For any of the following conditions where you select a ‘Yes’ response, please use the space below to indicate the specific type of medication/substance used, the most recent date when the medication/substance was used, whether it was prescribed, and the frequency of use. Please be as specific as possible. Below are a few examples.

Examples:

I take 3 mg. of Xanax, prescribed by my doctor, twice a day for anxiety.

I drink 3 glasses of wine per week.

I am a recovering heroin addict and am now in a methadone program. I last used IV heroin in April of 2021 and have been in a methadone program since then. My dosage is 30 mg. daily.

I used to smoke one bowl (marijuana) every night but stopped back in October when I found out I was pregnant.

Alcohol(Required)

Yes

No

I don't know
Additional Information
Antibiotics(Required)

Yes

No

I don't know
Additional Information
Antihistamines(Required)

Yes

No

I don't know
Additional Information
Cortisone(Required)

Yes

No

I don't know
Additional Information
Heart/Blood Pressure Pills (Required)

Yes

No

I don't know
Additional Information
Hormone Therapy(Required)

Yes

No

I don't know
Additional Information
Amphetamines(Required)

Yes

No

I don't know
Additional Information
Barbiturates(Required)

Yes

No

I don't know
Additional Information
Benzodiazepines(Required)

Yes

No

I don't know
Additional Information
Cocaine/Crack(Required)

Yes

No

I don't know
Additional Information
Depression/Anxiety Medication(Required)

Yes

No

I don't know
Additional Information
Diet Pills(Required)

Yes

No

I don't know
Additional Information
Ecstasy/Molly(Required)

Yes

No

I don't know
Additional Information
Hallucinogens (LSD, Muschrooms, Acid)(Required)

Yes

No

I don't know
Additional Information
Fentanyl(Required)

Yes

No

I don't know
Additional Information
Heroin(Required)

Yes

No

I don't know
Additional Information
Ketamine/Special K(Required)

Yes

No

I don't know
Additional Information
Inhalants(Required)

Yes

No

I don't know
Additional Information
Marijuana(Required)

Yes

No

I don't know
Additional Information
Methadone(Required)

Yes

No

I don't know
Additional Information
Methamphetamines(Required)

Yes

No

I don't know
Additional Information
Narcotics(Required)

Yes

No

I don't know
Additional Information
Nerve Pills(Required)

Yes

No

I don't know
Additional Information
Oxycodone(Required)

Yes

No

I don't know
Additional Information
Percocet(Required)

Yes

No

I don't know
Additional Information
Sleeping Pills(Required)

Yes

No

I don't know
Additional Information
Subutex or Suboxone(Required)

Yes

No

I don't know
Additional Information
Vicodin(Required)

Yes

No

I don't know
Additional Information
Cancer Medication(Required)

Yes

No

I don't know
Additional Information
Nausea Medication(Required)

Yes

No

I don't know
Additional Information
Thalidomide(Required)

Yes

No

I don't know
Additional Information
Tranquilizers(Required)

Yes

No

I don't know
Additional Information
Chewing Tobacco(Required)

Yes

No

I don't know
Additional Information
Cigarettes(Required)

Yes

No

I don't know
Additional Information
Vape/E-Cigarettes(Required)

Yes

No

I don't know
Additional Information
If you are taking or using any additional medications or substances that are not on this list, please use the space below to let us know what they are.
Consent(Required)
I have read and understood the above. The information provided is true and correct to the best of my knowledge.(Required)
Part 5: Your Family Medical 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 when I was pregnant in 2019.

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

I don't know
Additional information
Environmental/seasonal allergies(Required)

Yes

No

I don't know
Additional information
Food Allergies(Required)

Yes

No

I don't know
Additional information
Drug/medicine allergies (e.g. Codeine, Muscle relaxers, Penicillin)(Required)

Yes

No

I don't know
Additional information
Milk/dairy intolerance (Required)

Yes

No

I don't know
Additional information
Attention Deficit Disorder (ADD)/Attention Defecit Hyperactivity Disorder (ADHD) (Required)

Yes

No

I don't know
Additional information
Autism Spectrum Disorder(Required)

Yes

No

I don't know
Additional information
Blindness or Vision problems (e.g. Astigmatism, Crossed Eyes, Glaucoma)(Required)

Yes

No

I don't know
Additional information
Deafness or Hearing loss(Required)

Yes

No

I don't know
Additional information
Down Syndrome (Required)

Yes

No

I don't know
Additional information
Dyslexia/reading disability (Required)

Yes

No

I don't know
Additional information
Intellectual disability (Required)

Yes

No

I don't know
Additional information
Speech Impediment(Required)

Yes

No

I don't know
Additional information
Acne(Required)

Yes

No

I don't know
Additional information
Alopecia(Required)

Yes

No

I don't know
Additional information
Alzheimer's disease(Required)

Yes

No

I don't know
Additional information
Anemia(Required)

Yes

No

I don't know
Additional information
Arthritis(Required)

Yes

No

I don't know
Additional information
Asthma(Required)

Yes

No

I don't know
Additional information
Cancer(Required)

Yes

No

I don't know
Additional information
Dental or Oral health problems(Required)

Yes

No

I don't know
Additional information
Diabetes(Required)

Yes

No

I don't know
Additional information
Eczema, Psoriasis, or other skin conditions (Required)

Yes

No

I don't know
Additional information
Epilepsy or Seizure Disorder(Required)

Yes

No

I don't know
Additional information
Heart disease/heart attack(Required)

Yes

No

I don't know
Additional information
Hemophilia(Required)

Yes

No

I don't know
Additional information
Hepatitis(Required)

Yes

No

I don't know
Additional information
Hereditary Hemorrhagic Telangiectasia (HHT)(Required)

Yes

No

I don't know
Additional information
High blood pressure(Required)

Yes

No

I don't know
Additional information
Hormone/Thyroid disease(Required)

Yes

No

I don't know
Additional information
Huntington disease(Required)

Yes

No

I don't know
Additional information
Inflammatory bowel disease (e.g. Crohn's disease, Ulcerative Colitis)(Required)

Yes

No

I don't know
Additional information
Kidney disease(Required)

Yes

No

I don't know
Additional information
Multiple Sclerosis (Required)

Yes

No

I don't know
Additional information
Muscular Dystrophy (Required)

Yes

No

I don't know
Additional information
Parkinson's disease(Required)

Yes

No

I don't know
Additional information
Scoliosis(Required)

Yes

No

I don't know
Additional information
Sickle Cell disease(Required)

Yes

No

I don't know
Additional information
Stroke(Required)

Yes

No

I don't know
Additional information
Thalassemia(Required)

Yes

No

I don't know
Additional information
Toxoplasmosis(Required)

Yes

No

I don't know
Additional information
Tremors (head/hand) (Required)

Yes

No

I don't know
Additional information
Tuberculosis(Required)

Yes

No

I don't know
Additional information
Ulcers(Required)

Yes

No

I don't know
Additional information
Venous Thromboembolism (VTE)(Required)

Yes

No

I don't know
Additional information
Vitamin K deficiency bleeding (VKDB)(Required)

Yes

No

I don't know
Additional information
Von Willebrand disease (VWD)(Required)

Yes

No

I don't know
Additional information
Alcohol or Drug Addiction(Required)

Yes

No

I don't know
Additional information
Anorexia Nervosa, Bulemia or other eating disorder(Required)

Yes

No

I don't know
Additional information
Attempted Suicide(Required)

Yes

No

I don't know
Additional information
Bipolar Disorder (diagnosed by a Psychiatrist)(Required)

Yes

No

I don't know
Additional information
Borderline Personality Disorder(Required)

Yes

No

I don't know
Additional information
Depression/Anxiety(Required)

Yes

No

I don't know
Additional information
Dissociative Identity Disorder(Required)

Yes

No

I don't know
Additional information
Psychiatric hospitalizations(Required)

Yes

No

I don't know
Additional information
Schizophrenia/Schizoaffective Disorder (diagnosed by a Psychiatrist)(Required)

Yes

No

I don't know
Additional information
Birth mark(Required)

Yes

No

I don't know
Additional information
Cerebral palsy(Required)

Yes

No

I don't know
Additional information
Chromosomal abnormality (Required)

Yes

No

I don't know
Additional information
Cleft lip/cleft palate (Required)

Yes

No

I don't know
Additional information
Club foot(Required)

Yes

No

I don't know
Additional information
Congenital heart defect (Required)

Yes

No

I don't know
Additional information
Congenital Hydrocephalus(Required)

Yes

No

I don't know
Additional information
Cystic Fibrosis (Required)

Yes

No

I don't know
Additional information
Neurofibromatosis(Required)

Yes

No

I don't know
Additional information
Spina Bifida (Required)

Yes

No

I don't know
Additional information
Tay-Sach’s disease (Required)

Yes

No

I don't know
Additional information
Webbed/extra/missing finger(s) or toe(s)(Required)

Yes

No

I don't know
Additional information
Repeat pelvic infections (e.g. bladder infections, urinary tract infections)(Required)

Yes

No

I don't know
Additional information
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.
Signature(Required)

Consent(Required)
I have read and understood the above. The information provided is true and correct to the best of my knowledge.(Required)

Birthmother Application – Part 3

Part 2: Previous pregnancies

Have you ever had...

Part 3: Medical conditions during this pregnancy or a previous pregnancy

During this pregnancy, have you had any of the following?

Part 4: Expectant/Birth Mother Medications/Substances Taken During the Past 5 Years

Part 5: Your Family Medical History