Child's Name:
Nicknames:

Child's Birth History:

• Term? Gravida/Para
• Type of Delivery
• Birth Complications
• Apgars
• Documented Maternal Alcohol or Drug use
• Communicable Disease History of Bio Mom/Dad
• How arrived at Orphanage? With Whom? Baby Pictures (Pay)?
• How old when arrived at orphanage? Why Ward of State?
• Does she remember bio family? Who named her?
• What has child been told about adoption process & birth parents?

Medical Histories of Parents:

• Known Mental Illness
• Siblings & Health Status
• Known Congenital Diseases
• Where is family from?

Vaccinations to date:

• Polio
• Diptheria/Tetnus
• Chicken Pox
• Small Pox
• Measles
• Tuberculosis
• BCG
• Others

Childhood Diseases to Date:

• Chicken Pox
• Whooping Cough
• Measles
• RSV
• Fifths Disease
• Others:

Previous Medical History & Diagnosis, Date, Basis of Diagnosis (tests, findings), current status of problem:

• Allergies
• Heart Conditions
• Lung Conditions
• Stomach/Bowel
• Urinary/Bedwetting
• Accidents/Injuries
• Hospitalizations/Surgery
• History of Blood Transfusions/Repeated Parenteral Injections
• Current Illnesses
• Current Medications

Developmental Delays Noted/ Milestones Achieved when:

• Speech- Native language:

  • Began to Speak age
  • Approx Word Vocab
  • Problem Areas

• Growth/ Mobility:

  • Sat Up At
  • Crawled
  • Walked
  • Problems noted

• Social:

  • Consistent with Peers in development?
  • Does she get along well with other children?
  • Prefer younger/older/peer/same gender?
  • How many children in group?
  • Exposed to pets- cats/dogs

• Emotional:

  • Concerns with autism, tourrets, ADHD, Mental Retardation
  • Unexplained Outbursts for no apparent reason?
  • Difficulty keeping direct eye contact or hypervigilant
  • Overly Affectionate to Strangers?
  • Unusual attachment to something? Is child rigid?
  • Signs of Violence/destructiveness
  • Strange behaviors associated with eating, sleeping, cleaning, learning or playtime?
  • Phobias, panic attacks, nightmares or terrors?
  • Known cases of sexual abuse?
  • Grown Attached to any caretakers?
  • How does she express affection?
  • How does she deal with frustration, anger, surprise, change, learning new things?

Schooling:

• If any, does she like it?
• Classes (Music, Art, Dance)
• Best areas
• Problem areas
• What has she learned/does she know about the U.S.?

Daily Activities:

• What time does she usually get up?
• When bathed- am/pm?
• Shower/Bath/Sponge?
• Bath/Shower How Often?
• Sensitivities to soaps/detergents?
• Describe Hair Washing?
• Brushes own teeth?
• Dresses Self?
• Bathroom Times?
• What are daily responsibilities?
• What is/are play times?
• Play Time activities (Toys, outside, favorites)
• When is bedtime?
• Bedtime Routine?

Food Questions:

• Allergies:
• Eating Times?
• Typical Meals/Menus
• Breakfast:
• Lunch:
• Dinner:
• Snacks:
• How much fluids used to drinking?
• Special Treats:
• What were they?
• When or why were they given?
• Food Likes
• Food Dislikes

Life in Children's Home:

• What comforts her when upset?
• What music/songs does she like?
• Have a security item?
• Favorite Toys
• Interests?
• Best Friends?
• How is she disciplined? Response?
• Response when sick?
• How does she show fatigue?
• What does she do when she knows she's done something wrong?

• Special Holidays/Celebrations:

  • Birthdays
  • Easter
  • Christmas
  • Other

-- Kerry