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Placing baby for Adoption in Texas
  • I am pregnant
    • Unplanned Pregnancy
    • Put my baby up for adoption
    • Adoption Agencies in Texas
      • Austin Adoption
      • Dallas Adoption
      • Houston Adoption
      • San Antonio Adoption
    • Do I get paid for adoption?
    • Adoption Process in Texas
    • Adoption Plan in Texas
    • Types of Adoption
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  • Just Delivered
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  • En español
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Health, Social, Educational, and Genetic History (HSEGH)

General Information

Race:
Highest Grade Completed:
Were you ever in the military?
Are you adopted?
History of mental health problems?
Have you had any addiction treatment?
Have you ever been in counseling?

Genetic/Medical History

Do you or your family have the following mental or physical health issues?

Do you have any major medical problems?
Autism Spectrum Disorder
Attention Deficit Hyperactivity Disorder (ADHD) Diagnosis
Attention Deficit Disorder (ADD)
Anxiety Disorder Diagnosis
Bi-Polar Disorder
Borderline Personality Disorder
Depression
Dyslexia
Schizoaffective Disorder
Schizophrenia
PTSD
Other Mental Health Diagnoses
AIDS
Acne
Allergies (Food)
Allergies (Medicine)
Allergies (Seasonal)
Allergies (Other)
Alzheimer’s Disease
Arthritis
Asthma
Auto-Immune Disorder
Birth Defects
Birth Marks
Cancer
Cerebral Palsy
Cleft Lip or Palate
Club Foot
Cystic Fibrosis
Deformities
Dental Problems
Diabetes
Downs Syndrome
Dwarfism
Eczema
Epilepsy
Wear Glasses or Contacts (Nearsighted or Farsighted)
Major Eyesight Problems or Blindness
HIV Positive
Hearing Problems or Deafness
Heart Attack
Heart Disease
Heart Murmur
Hemophilia
Hepatitis B
Hepatitis C
Herpes Virus
High Blood Pressure
High Cholesterol
Infertility
Kidney Problems
Learning Disability
Left Handed
Mental Retardation
Miscarriage
Multiple Sclerosis
Obesity
Scoliosis
Seizures
Stillbirth
Sickle Cell
Spina Bifida
Stroke
Stuttering
Sudden Infant Death Syndrome (SIDS)
Thyroid Problems
Tourette Syndrome
Alcohol Use/Addiction
Cocaine Use/Addiction
Fentanyl Use/Addiction
Heroin Use/Addiction
Marijuana Use/Addiction
Methamphetamine Use/Addiction
Prescription Opioids Addiction (morphine, oxycodone, OxyContin, Percocet, Vicodin, Methadone)
Prescription Sedatives Addiction (Lorazepam (Ativan), Diazepam (Valium), Clonazepam (Klonopin), Alprazolam (Xanax)
Prescription Stimulants Addiction (Adderall, Ritalin, Concerta, Daytrana)
Other substance use during this pregnancy:

Other Pregnancies

Have you had any miscarriages?
Have you had any stillbirths?
Have you had any vaginal births?
Have you had any C-Sections?
Have you had any complications during pregnancy before?
How do you plan to deliver this pregnancy?

Parents & Grandparents

Please list your biological family’s information below. If you’re adopted, list any information you may know about your biological parents. The information below is to provide information on what may or may not genetically run in your family.
Mother's Race:
Father's Race:
Mother's Highest Grade Completed:
Father's Highest Grade Completed:
Is mother still alive?
Is father still alive?

Grandparents (Mom's Side)

Grandma's Race:
Grandpa's Race:

Grandparents (Dad's Side)

Grandma's Race:
Grandpa's Race:

Siblings

Have any of your siblings passed away?
MM slash DD slash YYYY
Check box to acknowledge:(Required)

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