TM

Safe Place

for Newborns:

Hospitals:

A hospital near you

Helping out:

Start the Program

Be sure to visit:

Links

Articles from the Director

Contact:

Safe Place

for Newborns

Download Medical Questionnaire

Medical Questionnaire
Dear Birth Mother: Thank you for bringing your baby to the hospital.  No matter what difficulties you are going through, you still chose to bring your child to a safe place.  Thank you.  Please know that we will do everything we can to give your beautiful child every best possible care.  Would you do one more thing to help your child’s future?  Would you complete this health form?  You can either bring it in with your child, or if you have already left your child at a hospital and been given this form, please mail it back in.  You may have been given an envelope to do so.  If you weren’t given an envelope, or you lost track of yours, you can mail it in any envelope to the hospital.  If you don’t know the address, you can call the hospital, find it on the Internet, or just write the hospital’s name and city on the envelope – it should find its way to us.  You may not know all of the answers to these questions– that’s OK.  You may not know for sure who the father of your child is.  We are asking only for you to tell us what you do know.  This will help your child’s future health.
Your baby's birth date:		_________
Was your baby premature?
		_____  yes _____  no _____  unsure
Were there any problems with the pregnancy?
		_____  yes _____  no _____  unsure
If yes, what were they?
Did you smoke, use alcohol, drugs or any medication during the pregnancy?
		_____  yes _____  no _____  unsure
If yes, please explain:
Please check any of the following medical conditions that you have.  If you know that your baby's father had any of the medical conditions listed, please check that as well.
		Mother	Father
	Diabetes:	_____	_____
	Asthma:	_____	_____
	Seizures:	_____	_____
	Cancer:	_____	_____
High Blood Pressure:		_____	_____
Heart Disease:		_____	_____
Mental Illness:		_____	_____
Allergies:		_____	_____
Please list any allergies you have, or if you are aware of any that your baby's father has:
Are you aware of any heredity conditions that run in your family, or your baby's father's family?  If yes, please describe:
		Mother	Father
Age:		__________	__________
Race:		__________	__________
Religion:		__________	__________
Hair Color:		__________	__________
Body Build:		__________	__________
Please feel free to include a note to your baby, or the people who will adopt your child.  If you like, you could use the back of this form.
Thank you so much for your help.  This history is a thoughtful gift for your child.

Go to:

Links in your state