How To Gather the Child's Health History

This is a list of basic health information that is helpful for our staff to have when they are doing your preadoption consultation. You can use this as a guide to information gathering when you travel to meet or visit your referred child. Use this guide in conjunction with the development guide and Denver Developmental Questionnaire

SOCIAL INFORMATION
Name
Sex
Date of birth
Current age (or estimate)
Country of origin
City/orphanage/region
Date entered institution
Length of time spent with birth family
Length of time spent in institution
Length of time spent in foster home
Reason child is being placed for adoption

BIOLOGICAL FAMILY INFO
Bio mother’s name, age
Bio mother’s occupation
# of previous pregnancies, including abortions, miscarriages, premature and full-term births
Bio mother’s health during pregnancy
Bio mother’s history of alcohol use
Father’s name, age
Names and ages of other siblings
Additional notes on family health history

BIRTH INFO
Full term or premature (include # of weeks premature)
Delivery (normal or C-section)
Apgar scores
Diagnoses at birth

HEALTH HISTORY SINCE BIRTH
Hospitalizations
Injuries
Illnesses
Allergies

LABORATORY TESTS
Hepatitis A
Hepatitis B
Hepatitis C
HIV
Syphilis
Other

IMMUNIZATIONS THE CHILD HAS RECEIVED
Name of vaccination
Date(s) administered 

GROWTH

*To measure head circumference, use a device that cannot be stretched (e.g. a plastic or flexible metal tape measure). Wrap the tape measure around the circumference of the child's head from the largest part at the back of the skull to the largest part at the front of the skull.