New York Codes, Rules and Regulations › Title 22 - JUDICIARY › Subtitle D - Forms › Chapter IV - Forms of the Family Court of the State of New York and Adoption Forms of the Family Court of the State of New York (cf. s205.7) › Subchapter B - Adoption Forms Of The Family Court › Adoption Forms › Form 1-D - Child's medical history (agency or private placement)

Current through Register Vol. 46, No. 28, July
					 10, 2024
D.R.L. § 112(3)(6) Form 1-D
S.S.L. § 373-a (Child's
						Medical
History - Agency or
Private-Placement)
12/97
FAMILY COURT OF THE STATE OF NEW
						YORK
COUNTY OF
________
In the Matter of the Adoption of
						(Docket)(File) No.
A Child Whose First Name is
Child's Medical
History (Agency or
Private-Placement)
________
1. Age and date of birth of child:
2. Has the child had any of the following
						illnesses or health problems: (Where indicated, specify below or on additional
						sheet)
________ AIDS(infection)
(d) . Upon information and belief, an
						Order of Protection or Temporary Order of Protection (has)(has not) been issued
						against any of the above adults in any criminal, matrimonial or Family Court
						proceeding(s). If such an order has been issued, specify the adult against whom
						the order was issued, the court that issued the order, docket number, date of
						order, expiration date of order, next court date and status of case to the
						extent known:
________ Allergy to foods/other
						substances
________ Allergy to medications
(prescription or over-the-counter)
________ Asthma
________ Chicken Pox
________ Circulatory system disorders
						(specify):
________ Diabetes
________ Diphtheria
________ German Measles (Rubella)
________ Measles (Rubeola)
________ Hay Fever
________ Heart problems (specify)
________ Hepatitis
________ Kidney disease
________ Malaria
________ Mental/Behavioral
						disorders
(d) . Upon information and belief, an
						Order of Protection or Temporary Order of Protection (has)(has not) been issued
						against any of the above adults in any criminal, matrimonial or Family Court
						proceeding(s). If such an order has been issued, specify the adult against whom
						the order was issued, the court that issued the order, docket number, date of
						order, expiration date of order, next court date and status of case to the
						extent known:
________ Mumps
________ Parasites in stool
________ Rheumatic Fever
________ Scarlet Fever
________ Sickle Cell Anemia/Trait
________ Tuberculosis
________ Typhoid Fever
________ Urinary tract infection
________ Whooping Cough (Pertussis)
________ Other (specify):
________
						Operations/Accidents/Fractures
(d) . Upon information and belief, an
						Order of Protection or Temporary Order of Protection (has)(has not) been issued
						against any of the above adults in any criminal, matrimonial or Family Court
						proceeding(s). If such an order has been issued, specify the adult against whom
						the order was issued, the court that issued the order, docket number, date of
						order, expiration date of order, next court date and status of case to the
						extent known:
3. Immunizations: give dates of the
						following:
D.P.T./D.T. ____________
Polio (oral) ____________
Measles ____________Mumps ____________
						Rubella ____________
Hemophilus Influenza B. (H.I.B.)
						____________
Form 1-D page 2
Heptavax/Hepatitis Immune Globulin
						____________
Influenza (Flu) ____________
Pneumonia vaccine ____________
Other (specify) ____________
Tuberculosis test (most recent/result
						____________
4. List Pre-natal History:
________ First trimester bleeding
________ Toxemia (high blood pressure or
						protein in the urine)
________ Medications (other than vitamins
						or iron)
________ Diabetes or thyroid problem
						(specify):
________ Drugs (such as marijuana, heroin,
						methadone or amphetamines) (specify):
________ Alcohol (occasional) (moderate)
						(heavy)[FN2] (specify):
Birth:
Birth weight ________ length
						________
Apgar scores: 1 min. ________ 5 mins.
						________
Date baby was due ________
Date baby was born ________
Complications of delivery
________ Premature rupture of
						membranes
________ Caesarian: routine ________
						emergency ________
________ Excessive bleeding: abruption
						________ placenta previa ________
Newborn:
________Resuscitation required
________ Yellow jaundice:
lights ________ exchange transfusion
						________
________ Infection (specify):
________ Breathing problem
						(specify):
________ Other (specify):
5. List congenital impairments, including
						physical defects, if any.
Form 1-D page 3
6. State present health or cause of death
						(give ages), if known, of:
Birth father:
Birth mother:
Siblings: full:
half:
7. If known, indicate whether birth mother
						had any of the following:
________ Tuberculosis
________ Diabetes
________ Mental or nervous disorder, e.g.,
						schizophrenia, depression, manic depressive illness (specify):
________ Thyroid disease
________ Stroke
________ Sickle cell anemia
________ (AIDS infection)
(d) . Upon information and belief, an
						Order of Protection or Temporary Order of Protection (has)(has not) been issued
						against any of the above adults in any criminal, matrimonial or Family Court
						proceeding(s). If such an order has been issued, specify the adult against whom
						the order was issued, the court that issued the order, docket number, date of
						order, expiration date of order, next court date and status of case to the
						extent known:
________ High blood pressure
________ Bleeding tendency
________ Eye or ear disorder
________ Retardation: mental
________ Physical disability
						(specify):
________ Circulatory or blood disorders
						(specify):
________ Obesity
________ Asthma
________ Gastrointestinal disease,
e.g., gall bladder, ulcer, irritable bowel
						disorder)
(specify)
________ Breast cancer
________ Colon cancer
________ Cancer, other (specify):
________ Arthritis or rheumatism
________ Kidney disease (specify)
________ Alcoholism or other substance
						abuse (specify):
________ Developmental disorder,
(e.g., learning disability,
(d) . Upon information and belief, an
						Order of Protection or Temporary Order of Protection (has)(has not) been issued
						against any of the above adults in any criminal, matrimonial or Family Court
						proceeding(s). If such an order has been issued, specify the adult against whom
						the order was issued, the court that issued the order, docket number, date of
						order, expiration date of order, next court date and status of case to the
						extent known:
________ Other (specify):
8. If known, indicate whether birth father
						had any of the following:
________ Tuberculosis
________ Diabetes
________ Mental or nervous disorder, e.g.,
						schizophrenia, depression, manic depressive illness
(d) . Upon information and belief, an
						Order of Protection or Temporary Order of Protection (has)(has not) been issued
						against any of the above adults in any criminal, matrimonial or Family Court
						proceeding(s). If such an order has been issued, specify the adult against whom
						the order was issued, the court that issued the order, docket number, date of
						order, expiration date of order, next court date and status of case to the
						extent known:
________ Thyroid disease
________ Asthma
________ Gastrointestinal disease,
e.g., gall bladder, ulcer, irritable bowel
						disorder)
(d) . Upon information and belief, an
						Order of Protection or Temporary Order of Protection (has)(has not) been issued
						against any of the above adults in any criminal, matrimonial or Family Court
						proceeding(s). If such an order has been issued, specify the adult against whom
						the order was issued, the court that issued the order, docket number, date of
						order, expiration date of order, next court date and status of case to the
						extent known:
________ Colon cancer
Form 1-D page 4
________ Stroke
________ Sickle cell anemia
________ (AIDS infection)
(d) . Upon information and belief, an
						Order of Protection or Temporary Order of Protection (has)(has not) been issued
						against any of the above adults in any criminal, matrimonial or Family Court
						proceeding(s). If such an order has been issued, specify the adult against whom
						the order was issued, the court that issued the order, docket number, date of
						order, expiration date of order, next court date and status of case to the
						extent known:
________ Cancer, other
(d) . Upon information and belief, an
						Order of Protection or Temporary Order of Protection (has)(has not) been issued
						against any of the above adults in any criminal, matrimonial or Family Court
						proceeding(s). If such an order has been issued, specify the adult against whom
						the order was issued, the court that issued the order, docket number, date of
						order, expiration date of order, next court date and status of case to the
						extent known:
________ Arthritis or rheumatism
________ Kidney disease
(d) . Upon information and belief, an
						Order of Protection or Temporary Order of Protection (has)(has not) been issued
						against any of the above adults in any criminal, matrimonial or Family Court
						proceeding(s). If such an order has been issued, specify the adult against whom
						the order was issued, the court that issued the order, docket number, date of
						order, expiration date of order, next court date and status of case to the
						extent known:
________ High blood pressure
________ Bleeding tendency
________ Eye or ear disorders
________ Retardation: mental
________ Physical disability
(specify)
________ Circulatory or blood disorders
						(specify):
________ Obesity
________ Alcoholism or other substance
						abuse (specify):
________ Developmental disorder
(e.g., learning disability, attention
						deficit disorder)
(d) . Upon information and belief, an
						Order of Protection or Temporary Order of Protection (has)(has not) been issued
						against any of the above adults in any criminal, matrimonial or Family Court
						proceeding(s). If such an order has been issued, specify the adult against whom
						the order was issued, the court that issued the order, docket number, date of
						order, expiration date of order, next court date and status of case to the
						extent known:
________ Other (specify):
Indicate source for information about
						child's medical history and the source(s) for information about medical history
						of birth father and birth mother and whether from direct or indirect
						source:
Completed by (state official title, if
						any): ________
______________
Petitioner
______________
Print or type name
______________
Signature of Attorney, if any
______________
Attorney's Name (Print or Type)
________
________
______________
Attorney's Address and Telephone
						Number
[FN1] Delete inapplicable
						provision.
[FN2] Delete inapplicable provision
[FN*] Delete inapplicable
						provision.
[FN*] Delete inapplicable
						provision.