Form 413 (DHR)

Georgia Department of Human Resources BACKGROUND INFORMATION FOR NON-STATE AGENCY CHILD

For use as attorney-client work product only.


Today's Date:
Responsible Party:	Legal Name of Child:

Telephone No.:

Date:

Date of Birth of Child:

Sex:

Resident County:

Placement County:

Race/Ethnic:

ALL RELATIONSHIPS ARE TO THE CHILD

Child's Name

Maternal

	Mother	Grandmother	Grandfather
Date of Birth:
Race/Ethnic:
National Descent:
Hair Color:
Eye Color:
Complexion:
Weight:
Height:
Occupation:
General Health:
Education:
If Deceased, Age & Cause:
Special Characteristics:

Paternal

	Father	Grandmother	Grandfather
Date of Birth:
Race/Ethnic:
National Descent:
Hair Color:
Eye Color:
Complexion:
Weight:
Height:
Occupation:
General Health:
Education:
If Deceased, Age & Cause:
Special Characteristics:

Maternal Aunts & Uncles

Date of Birth:
Race/Ethnic:
National Descent:
Hair Color:
Eye Color:
Complexion:
Weight:
Height:
Occupation:
General Health:
Education:
If Deceased, Age & Cause:
Special Characteristics:

Paternal Aunts & Uncles

Date of Birth:
Race/Ethnic:
National Descent:
Hair Color:
Eye Color:
Complexion:
Weight:
Height:
Occupation:
General Health:
Education:
If Deceased, Age & Cause:
Special Characteristics:

Reason Child Placed:

ALL RELATIONSHIPS ARE TO THE CHILD

Siblings Maternal

Date of Birth:
Full or Half Sibling:
Sex:
Hair Color:
Eye Color:
Complexion:
General Build:
General Health:
School Grade and Achievement:
Special Characteristics:

Siblings Paternal

Date of Birth:
Full or Half Sibling:
Sex:
Hair Color:
Eye Color:
Complexion:
General Build:
General Health:
School Grade and Achievement:
Special Characteristics:

SOURCE OF INFORMATION:

ALL RELATIONSHIPS ARE TO THE CHILD

Family of Child's Mother Maternal

	Great Grandmother	Great Grandfather
Date of Birth:
Race/Ethnic:
National Descent:
Hair Color:
Eye Color:
Complexion:
Weight:
Height:
Occupation:
General Health:
Education:
If Deceased, Age & Cause:
Special Characteristics:

Paternal

	Great Grandmother	Great Grandfather
Date of Birth:
Race/Ethnic:
National Descent:
Hair Color:
Eye Color:
Complexion:
Weight:
Height:
Occupation:
General Health:
Education:
If Deceased, Age & Cause:
Special Characteristics:

Maternal Great Aunts & Uncles

Date of Birth:
Race/Ethnic:
National Descent:
Hair Color:
Eye Color:
Complexion:
Weight:
Height:
Occupation:
General Health:
Education:
If Deceased, Age & Cause:
Special Characteristics:

Paternal Great Aunts & Uncles

Date of Birth:
Race/Ethnic:
National Descent:
Hair Color:
Eye Color:
Complexion:
Weight:
Height:
Occupation:
General Health:
Education:
If Deceased, Age & Cause:
Special Characteristics:

SOURCE OF INFORMATION:

ALL RELATIONSHIPS ARE TO THE CHILD

Family of Child's Father Maternal

	Great Grandmother	Great Grandfather
Date of Birth:
Race/Ethnic:
National Descent:
Hair Color:
Eye Color:
Complexion:
Weight:
Height:
Occupation:
General Health:
Education:
If Deceased, Age & Cause:
Special Characteristics:

Paternal

	Great Grandmother	Great Grandfather
Date of Birth:
Race/Ethnic:
National Descent:
Hair Color:
Eye Color:
Complexion:
Weight:
Height:
Occupation:
General Health:
Education:
If Deceased, Age & Cause:
Special Characteristics:

Maternal Great Aunts & Uncles

Date of Birth:
Race/Ethnic:
National Descent:
Hair Color:
Eye Color:
Complexion:
Weight:
Height:
Occupation:
General Health:
Education:
If Deceased, Age & Cause:
Special Characteristics:

Paternal Great Aunts & Uncles

Date of Birth:
Race/Ethnic:
National Descent:
Hair Color:
Eye Color:
Complexion:
Weight:
Height:
Occupation:
General Health:
Education:
If Deceased, Age & Cause:
Special Characteristics:

SOURCE OF INFORMATION:

Family Medical Information Maternal

Check YES or NO to each of the following diseases or conditions, if the answer is YES give family member, and brief description of disease, condition, its effect, age of onset, age if cause of death, in the space below.

COMPLETE ONE FORM ON MOTHER'S FAMILY AND ONE FORM ON FATHER'S FAMILY

	Yes	No		Yes	No		Yes	No
1. Allergies			7. Congenital Birth Abnormalities			b) still births
a) drugs			8. Cleft Lip			c) incompetent cervix
b) foods			9. Cleft Palate			d) ectopic pregnancies
c) asthma			10. Cystic Fibrosis			e) eclamptogenic toxemia
d) hay fever			11. Diabetes			f) spontaneous abortion
e) other			12. Dwarfism			g) other
2. Alcoholism-Drug Addiction			13. Epilepsy			29. Respiratory Diseases
3. Blood diseases			14. Hearing Disorders			a) emphysema
a) hemophilia			15. Huntington Disease			b) Bacterial pneumonia
b) Rh disease			16. Hyperactivity			c) tuberculosis
c) sickle cell disease trait			17. Immune System Disease			d) other
d) thalassemia (cooley's amenia)			a) HIV Positive			30. Skin Disorders
e) other			b) AIDS			a) psoriasis
4. Bone diseases			18. Learning Disability (specify)			b) other
a) arthritis						31. Speech Disorders
b) curvature of spine						a) stuttering
c) other structural malformation			19. Liver Disease			b) tongue tie
d) other			20. Mental Illness			c) sound omissions
5. Cancer			a) manic-depressive			d) delayed speech
a) breast			b) schizophrenia			e) other
b) bowel			c) other			32. Sudden Infant Death
c) colon			21. Mental Retardation			33. Systemic Lupus Erythematosis
d) ovarian			a) Downs Syndrome			34. Thyroid Disorders
e) skin			b) PKU			35. Tay-Sachs Disease
f) stomach			c) Lesch-Nyham Syndrome			36. Visual Disorders
g) lungs			d) Hunters			a) cataracts
h) leukemia			e) Tuberous sclerosis			b) dyslexia
i) other			f) other			c) glaucoma
6. Cardiovascular disease			22. Migraine headache			d) retinitis pigmentosa
a) atherosclerosis			23. Multiple Births			e) strabismus
b) congenital heart defects			24. Multiple Sclerosis			f) other
c) heart attack			25. Muscular Dystrophy			37. Any other diseases which have occurred repeatedly in family. (Specify)
d) hyperlipidemia			26. Myasthenia Gravis
e) stroke			27. Obesity
f) other			28. Pregnancy Complications
			a) premature births

Biological mother's age at onset on menses:

Code number and letter when describing disease/ condition.

SOURCE OF INFORMATION:

Family Medical Information Paternal

COMPLETE ONE FORM ON MOTHER'S FAMILY AND ONE FORM ON FATHER'S FAMILY

	Yes	No		Yes	No		Yes	No
1. Allergies			7. Congenital Birth Abnormalities			b) still birthsb
a) drugs			8. Cleft Lip			c) incompetent cervix
b) foods			9. Cleft Palate			d) ectopic pregnancies
c) asthma			10. Cystic Fibrosis			e) eclamptogenic toxemia
d) hay fever			11. Diabetes			f) spontaneous abortion
e) other			12. Dwarfism			g) other
2. Alcoholism-Drug Addiction			13. Epilepsy			29. Respiratory Diseases
3. Blood diseases			14. Hearing Disorders			a) emphysema
a) hemophilia			15. Huntington Disease			b) Bacterial pneumonia
b) Rh disease			16. Hyperactivity			c) tuberculosis
c) sickle cell disease trait			17. Immune System Disease			d) other
d) thalassemia (cooley's amenia)			a) HIV Positive			30. Skin Disorders
e) other			b) AIDS			a) psoriasis
4. Bone diseases			18. Learning Disability (specify)			b) other
a) arthritis						31. Speech Disorders
b) curvature of spine						a) stuttering
c) other structural malformation			19. Liver Disease			b) tongue tie
d) other			20. Mental Illness			c) sound omissions
5. Cancer			a) manic-depressive			d) delayed speech
a) breast			b) schizophrenia			e) other
b) bowel			c) other			32. Sudden Infant Death
c) colon			21. Mental Retardation			33. Systemic Lupus Erythematosis
d) ovarian			a) Downs Syndrome			34. Thyroid Disorders
e) skin			b) PKU			35. Tay-Sachs Disease
f) stomach			c) Lesch-Nyham Syndrome			36. Visual Disorders
g) lungs			d) Hunters			a) cataracts
h) leukemia			e) Tuberous sclerosis			b) dyslexia
i) other			f) other			c) glaucoma
6. Cardiovascular disease			22. Migraine headache			d) retinitis pigmentosa
a) atherosclerosis			23. Multiple Births			e) strabismus
b) congenital heart defects			24. Multiple Sclerosis			f) other
c) heart attack			25. Muscular Dystrophy			37. Any other diseases which have occurred repeatedly in family. (Specify)
d) hyperlipidemia			26. Myasthenia Gravis
e) stroke			27. Obesity
f) other			28. Pregnancy Complications
			a) premature birthsb

Biological mother's age at onset on menses:

Code number and letter when describing disease/ condition.

SOURCE OF INFORMATION:

ALL RELATIONSHIPS ARE TO THE CHILD

NAMES AND ADDRESSES

	Name	Date of Birth	Address
Child:

MATERNAL

	Name	Date of Birth	Address
Mother:
Grandmother:
Grandfather:
Aunts & Uncles:


Siblings:

PATERNAL

Father:
Grandmother:
Grandfather:
Aunts & Uncles:


Siblings:

Is mother aware of the provisions of 19-8-23(f)

Yes

Is father aware of the provisions of 19-8-23(f)

Yes

SOURCE OF INFORMATION:

Please also complete the adoption questionaire.