DEPARTMENT OF CHILDREN AND FAMILIES Adoption Records Search Program Division of Safety and Permanence PO Box 8916 Madison, WI 53708-8916 (608) 266-7163 Family History Questionnaire Medical / Genetic Use of form: This form is used to collect biological family medical and genetic history for any child whose biological parent has terminated parental rights to that child in Wisconsin. Completion of this form meets the requirements of s. 48.425(1)(am), Wis. Stats. Any biological parent whose parental rights are being terminated in a Wisconsin court is required to complete this form at the time of the termination of parental rights proceeding. If a birth parent is adopted, only biological family information should be included. This form is also used to update medical / genetic history by any birth parent who has terminated their parental rights to a child in Wisconsin at any time. Another individual may complete this form on behalf of a birth parent if the birth parent is unable to do so. Personally identifiable information on this form is confidential and will be used only for identification purposes. The information on this form pertains to: Mother Birth Father SECTION I INFORMATION ABOUT BIRTH PARENT AND CHILD PLACED FOR ADOPTION Name Child (Last, First, Middle) Birthdate (mm/dd/yyyy) Birthplace (City, State) – Name Hospital – Name Attending Physician – Name (Current) Birth Mother (Last, First, Middle) Name Maiden (Last) Birthdate (mm/dd/yyyy) – – Address Permanent (Street, City, State, Zip Code) Telephone Number – Name Birth Father (Last, First, Middle) Birthdate (mm/dd/yyyy) – Address Permanent (Street, City, Zip Code) Telephone Number – Yes No Are the parents related to each other in any way or do they have blood ties? If "Yes", specify relationship: SECTION II PROVIDER OF INFORMATION IF NOT COMPLETED BY BITH PARENT Name Individual Providing Information on Behalf of Birth Parent Address Current (Street, City, State, Zip Code) – – Telephone Number Relationship to Child Name Agency Staff Person Reviewing Questionnaire Name Agency Telephone Number – – SECTION III DESCRIBE PARENT AND HIS / HER PARENTS Birth Parent Your Mother Your Father Name (Last, First, Middle) Birthdate (mm/dd/yyyy) Height and weight Ethnic / national background
DEPARTMENT OF CHILDREN AND FAMILIES Adoption Records Search Program Division of Safety and Permanence PO Box 8916 Madison, WI 53708-8916 (608) 266-7163 Family History Questionnaire Medical / Genetic Use of form: This form is used to collect biological family medical and genetic history for any child whose biological parent has terminated parental rights to that child in Wisconsin. Completion of this form meets the requirements of s. 48.425(1)(am), Wis. Stats. Any biological parent whose parental rights are being terminated in a Wisconsin court is required to complete this form at the time of the termination of parental rights proceeding. If a birth parent is adopted, only biological family information should be included. This form is also used to update medical / genetic history by any birth parent who has terminated their parental rights to a child in Wisconsin at any time. Another individual may complete this form on behalf of a birth parent if the birth parent is unable to do so. Personally identifiable information on this form is confidential and will be used only for identification purposes. The information on this form pertains to: Mother Birth Father SECTION I INFORMATION ABOUT BIRTH PARENT AND CHILD PLACED FOR ADOPTION Name – Child (Last, First, Middle) Birthdate (mm/dd/yyyy) Birthplace (City, State) Name – Hospital Name – Attending Physician Name (Current) – Birth Mother (Last, First, Middle) Name – Maiden (Last) Birthdate (mm/dd/yyyy) Address – Permanent (Street, City, State, Zip Code) Telephone Number Name – Birth Father (Last, First, Middle) Birthdate (mm/dd/yyyy) Address – Permanent (Street, City, Zip Code) Telephone Number Yes No Are the parents related to each other in any way or do they have blood ties? If "Yes", specify relationship: SECTION II PROVIDER OF INFORMATION IF NOT COMPLETED BY BITH PARENT Name – Individual Providing Information on Behalf of Birth Parent Address – Current (Street, City, State, Zip Code) Telephone Number Relationship to Child Name – Agency Staff Person Reviewing Questionnaire Name – Agency Telephone Number SECTION III DESCRIBE PARENT AND HIS / HER PARENTS Birth Parent Your Mother Your Father Name (Last, First, Middle) Birthdate (mm/dd/yyyy) Height and weight Ethnic / national background
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