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Non-Identifying Health,Genetic and Social HistoryDate :This form is required when a child born in Utah is adopted in Utah. Utah Code 78b-6-143.Adoptions by a step-parent whose spouse is the adoptee's birth parent do not require this form.AGENCY OR INDIVIDUAL MAKING THE PLACEMENT1. Individual, Attorney or Agency:1a. Name of person to contact for further information:2. Mailing Address:3. Email Address:4. Phone:5. Finalized in City/County: 6. Date Finalized:ADOPTEE INFORMATION7. Name(s):8. Date of Birth: 9. City and County of Birth:10. Birth Mother's city and county of residence at time of child's birth:IF UNABLE TO OBTAIN INFOThe agency responsible for the placement of this child was unable to obtain any additional non-identifying health,genetic, and social information relating to the child because: (check all that apply)[ ] The child's birth mother failed / refused to provide any informationYou may turn in page 1[ ] The child's birth father failed / refused to provide any informationalone if unable to[ ] The identity of the child's mother is unknownobtain further info.[ ] The identity of the child's father is unknown[ ] Other. Please explain:Signature of Agency representative:BIRTH MOTHER INFORMATION - facts at the time of the adoptee's birth11. During the pregnancy were you diagnosed as:[ ] Anemic[ ] Hypertension [ ] Toxemia/Eclampsia12. Did you have X-rays during this pregnancy?[ ] Yes [ ] No13. Weight gain during this pregnancy lbs.14. Delivery history:Weeks gestationAPGARS (1/5)15. This birth: single, twin, triplet (specify:)17. Month pregnancy prenatal care began:[ ] Diabetic[ ] Gestational DiabeticIf Yes, what procedure/type?Length of Labor hoursBirth weight lbs. oz.16. If not a single birth, born 1st, 2nd, 3rd?18. Number of prenatal Visits:19. Describe any prenatal complications:20. Previous live births now living21. Previous live births now dead22. Other pregnancies - Number of Miscarriage or induced terminations:23. Type of Delivery Anesthesia: [ ] None [ ] Pericervical block [ ] Epidural Spinal block [ ] General [ ] Local24. Type of Delivery: [ ] C-Section [ ] Normal Vaginal [ ] Forceps Assisted [ ] Vacuum Assisted[ ] Other (Specify:)25. If C-Section, give indication: [ ] Breech presentation [ ] Cephalopelvic disproportion [ ] Fetal distress[ ] Other (Specify:)BIRTH FATHER INFORMATION - facts at the time of the adoptee's birth26. Number of living children27. Number of children not living28. Number Miscarriages or induced terminationsADOPTION REGISTRY ONLINE SUBMISSION: AdoptionRegistry.utah.gov MAILING ADDRESS: PO Box 141012 SLC, UT 84114-1012801-538-6105 Fax 801-538-7012 vrequest@utah.gov vitalrecords.utah.gov UDOH-OVRS-320 July 2021 Page 1
BIRTH PARENT and FAMILY SOCIAL AND HEALTH HISTORY INFORMATIONPlease make additional copies of these pages as needed for each family member you choose to include.[ ] BIRTH MOTHER [ ] BIRTH FATHER[ ] MOTHER OF BIRTH MOTHER [ ] FATHER OF BIRTH MOTHER [ ] MOTHER OF BIRTH FATHER [ ] FATHER OF BIRTH FATHER1. Marital Status:[ ] Married[ ] Single[ ] Married to second birth parent[ ] Separated[ ] Divorced[ ] Widowed4. Country orState of birth:7. Height:8. Weight:2a. Currently living,2b. Cause ofor age at death?Death?3. Enrolled member of a Native American tribe, Alaskan Village or affiliated with a tribe?[ ] Yes [ ] NoIf yes, list Tribe:11. Complexion:fair, olive, dark etc.13. [ ] Right-handed12. Unique physicalfeatures:14. Physical Build:big/small boned, muscular etc:[ ] Left-handed15. Talents, hobbies and other interests:5. Race:9. Eye Color:6. EthnicHeritage:10. Hair Colorand texture:16. Describe personality:17. Was anyone in your family adopted? [ ] Yes [ ] NoIf yes, what relation?19. Other Information:18. Your order of birth:Ex: 1st of 4 or2nd of triplets, 3rd of 5Please make additional copies of these pages as needed for each family member you choose to include.[ ] BIRTH MOTHER [ ] BIRTH FATHER[ ] MOTHER OF BIRTH MOTHER [ ] FATHER OF BIRTH MOTHER [ ] MOTHER OF BIRTH FATHER [ ] FATHER OF BIRTH FATHER1. Marital Status:[ ] Married[ ] Single[ ] Married to second birth parent[ ] Separated[ ] Divorced[ ] Widowed4. Country orState of birth:7. Height:8. Weight:2a. Currently living,2b. Cause ofor age at death?Death?3. Enrolled member of a Native American tribe, Alaskan Village or affiliated with a tribe?[ ] Yes [ ] NoIf yes, list Tribe:11. Complexion:fair, olive, dark etc.13. [ ] Right-handed12. Unique physicalfeatures:14. Physical Build:big/small boned, muscular etc:[ ] Left-handed15. Talents, hobbies and other interests:5. Race:9. Eye Color:6. EthnicHeritage:10. Hair Colorand texture:16. Describe personality:17. Was anyone in this immediate family adopted?[ ] Yes [ ] NoIf yes, what relation?19. Other Information:18. Your order of birth and number of siblings:Ex: 1st of 4 or2nd of triplets, 3rd of 5ADOPTION REGISTRY ONLINE SUBMISSION: AdoptionRegistry.utah.gov MAILING ADDRESS: PO Box 141012 SLC, UT 84114-1012801-538-6105 Fax 801-538-7012 vrequest@utah.gov vitalrecords.utah.gov UDOH-OVRS-320 July 2021 Page 2
BIRTH PARENT and FAMILY SOCIAL AND HEALTH HISTORY INFORMATIONPlease make additional copies of these pages as needed for each family member you choose to include.[ ] SIBLING OF BIRTH MOTHER [ ] SIBLING OF BIRTH FATHER[ ] CHILD OF BIRTH MOTHER [ ] CHILD OF BIRTH FATHER1. Sex: [ ] Male [ ] Female[ ] Unknown/non-binary3. Height:4. Weight:2a. Currently living,or age at death?5. Eye Color:7. Complexion:fair, olive, dark etc.9. [ ] Right-handed8. Unique physicalfeatures:10. Physical Build:big/small boned, muscular etc:[ ] Left-handed11. Talents, hobbies and other interests:2b. Cause ofDeath?6. Hair Colorand texture:12. Describe personality:19. Other Information:Please make additional copies of these pages as needed for each family member you choose to include.[ ] SIBLING OF BIRTH MOTHER [ ] SIBLING OF BIRTH FATHER[ ] CHILD OF BIRTH MOTHER [ ] CHILD OF BIRTH FATHER1. Sex: [ ] Male [ ] Female[ ] Non-binary/Unknown3. Height:4. Weight:2a. Currently living,or age at death?5. Eye Color:7. Complexion:fair, olive, dark etc.9. [ ] Right-handed8. Unique physicalfeatures:10. Physical Build:big/small boned, muscular etc:[ ] Left-handed11. Talents, hobbies and other interests:2b. Cause ofDeath?6. Hair Colorand texture:12. Describe personality:19. Other Information:Please make additional copies of these pages as needed for each family member you choose to include.[ ] SIBLING OF BIRTH MOTHER [ ] SIBLING OF BIRTH FATHER[ ] CHILD OF BIRTH MOTHER [ ] CHILD OF BIRTH FATHER1. Sex: [ ] Male [ ] Female[ ] Non-binary/Unknown3. Height:4. Weight:2a. Currently living,or age at death?5. Eye Color:7. Complexion:fair, olive, dark etc.9. [ ] Right-handed8. Unique physicalfeatures:10. Physical Build:big/small boned, muscular etc:[ ] Left-handed11. Talents, hobbies and other interests:2b. Cause ofDeath?6. Hair Colorand texture:12. Describe personality:19. Other Information:ADOPTION REGISTRY ONLINE SUBMISSION: AdoptionRegistry.utah.gov MAILING ADDRESS: PO Box 141012 SLC, UT 84114-1012801-538-6105 Fax 801-538-7012 vrequest@utah.gov vitalrecords.utah.gov UDOH-OVRS-320 July 2021 Page 3
BIRTH PARENT FAMILY MEDICAL HISTORYCONDITIONNONEYOUYOUR BLOOD RELATIVE(Specify Relationship)[ ] BIRTH MOTHERCOMMENTS[ ] BIRTH FATHERBaldnessBirth DefectsClub footCleft palate (harelip)Congenital heart diseaseCancer (specify type) Age at onset?Part of body affected?AsthmaEczemaOther (specify)ALLERGIES:AnimalsFoodHay fever/plantsMedicationsHivesOther allergiesOther (specify)Other (specify)VISUAL:AstigmatismBlindnessColor blindnessGlaucomaNearsighted/farsightedOther (specify)EMOTIONAL/MENTAL ILLNESS: Age at onset? Treatment? Hospitalization?Biopolar (manic-depressive)SchizophreniaSevere depressionSuicideObsessive-Compulsive disorderPersonality disorderAlcoholism / drug addictionOther (specify)Other (specify)HEREDITARY DISEASE:Cystic fibrosisGalactosemiaHemophiliaHuntington's diseaseOther (specify)ADOPTION REGISTRY ONLINE SUBMISSION: AdoptionRegistry.utah.gov MAILING ADDRESS: PO Box 141012 SLC, UT 84114-1012801-538-6105 Fax 801-538-7012 vrequest@utah.gov vitalrecords.utah.gov UDOH-OVRS-320 July 2021 Page 4
BIRTH PARENT FAMILY MEDICAL HISTORYCONDITIONNONE[ ] BIRTH MOTHERYOUYOUR BLOOD RELATIVE(Specify Relationship)[ ] BIRTH FATHERCOMMENTSCARDIOVASCULAR DISEASE: Age at onset? Outcome?Heart AttackHeart murmurHigh blood pressureDiabetes (specify type)Rheumatic feverDid heart murmur result?Other (specify)Other (specify)SEXUALLY TRANSMITTED DISEASE: Age at onset? Treatment? Hospitalization?SyphilisHIV / AIDSPelvic inflammatory diseaseOther, esp if birth mother infected attime of birth (specify)OTHER DISEASE:Hepatitis (A, B or C?)Hypo or hyper -thyroidismOther (specify)NEUROLOGICAL DISORDER: Severity? Treatment? Age at onset? Frequency of events?Cerebral palsyMuscular dystrophyMultiple sclerosisEpilepsy / Convulsions (specify)StrokeOther (specify)DEVELOPMENTAL DISORDER: Type of education? Treatment?Learning disability/attention deficit(specify type)Mental disorder (specify type)Down SyndromeSpeech or hearing problemsLow birth weightOther (specify)OTHER: Any other condition that may affect the adopteeADOPTION REGISTRY ONLINE SUBMISSION: AdoptionRegistry.utah.gov MAILING ADDRESS: PO Box 141012 SLC, UT 84114-1012801-538-6105 Fax 801-538-7012 vrequest@utah.gov vitalrecords.utah.gov UDOH-OVRS-320 July 2021 Page 5
BIRTH MOTHER HISTORY OF MEDICATION, DRUG, AND SUBSTANCE USEPlease list type of substance, dosage or amount and length of time used.PRESCRIPTION MEDICATIONcheck when applicableUSED BEFORE USED DURINGCONCEPTION PREGNANCYOVER THE COUNTER DRUGOTHER SUBSTANCEAlcoholCigarettesMarijuana - recreationalMethamphetamine ('meth','speed')Downers (sleeping pills,benzodiazepines,barbiturates)Cocaine ('crack')Heroin / pain killers(coedeine, hydrocodone)Hallucinogens (LSD,Ecstasy/XTC, mushrooms,PCP)ADOPTION REGISTRY ONLINE SUBMISSION: AdoptionRegistry.utah.gov MAILING ADDRESS: PO Box 141012 SLC, UT 84114-1012801-538-6105 Fax 801-538-7012 vrequest@utah.gov vitalrecords.utah.gov UDOH-OVRS-320 July 2021 Page 6
BIRTH PARENT SOCIAL AND HEALTH HISTORY INFORMATION[ ] BIRTH MOTHER[ ] BIRTH FATHERIf you wish, please add any additional information that will further describe you and your situation.Consider schooling, health, career interests, military service, goals or hopes for the future, relationship history,religious or spiritual beliefs, challenges, strengths, etc. for you, your parents and your extended family.ADOPTION REGISTRY ONLINE SUBMISSION: AdoptionRegistry.utah.gov MAILING ADDRESS: PO Box 141012 SLC, UT 84114-1012801-538-6105 Fax 801-538-7012 vrequest@utah.gov vitalrecords.utah.gov UDOH-OVRS-320 July 2021 Page 7
801-538-6105 Fax 801-538-7012 vrequest@utah.gov vitalrecords.utah.gov UDOH-OVRS-320 July 2021 Page 1 IF UNABLE TO OBTAIN INFO Non-Identifying Health, Genetic and Social History ADOPTION REGISTRY ONLINE SUBMISSION: AdoptionRegistry.utah.gov MAILING ADDRESS: PO Box 141012 SLC, UT 84114-1012
