Birth Parent - Brief Health History 1 Brief Health History2 Medical Provider Information For each of the following, please select Yes, No, or Unknown as appropriate. If you select Yes, please provide more information as requested.Your Name* First Last Do you carry the sickle cell trait?*YesNoUnknownDescribe your situation as it applies to the sickle cell trait.Have you been diagnosed with depression?*YesNoUnknownApproximate Date of Depression Diagnosis* Have you been prescribed medication for depression?*YesNoWhat prescriptions are you taking for depression?Describe your experience with depression.Have you been diagnosed with bipolar disorder?*YesNoUnknownApproximate date of bipolar disorder diagnosis* Have you been prescribed medication for bipolar disorder?*YesNoWhat prescriptions are you taking for bipolar disorder?Describe your experience with bipolar disorder.Have you been diagnosed with schizophrenia?*YesNoUnknownApproximate date of schizophrenia diagnosis* Have you been prescribed medication for schizophrenia?*YesNoWhat prescriptions are you taking for schizophrenia?Describe your experience with schizophrenia.Have you been diagnosed with panic attacks?*YesNoUnknownApproximate date of panic attack diagnosis* Have you been prescribed medication for panic attacks?*YesNoWhat prescriptions are you taking for panic attacks?Describe your experience with panic attacks.Do you have any other mental health conditions that have not been mentioned here?*YesNoUnknownDescribe your mental health conditions.Have you been officially diagnosed?*YesNoMore information about other mental health conditions.What is your diagnosis?Approximate date of diagnosis Have you been prescribed medication for this (these) condition(s)?*YesNoWhat prescriptions are you taking for this (these) condition(s)?Do you have a history of trauma? (optional)YesNoI'd prefer not to sayDescribe your history of traumaDo you have a history of alcohol or drug use? (optional)YesNoI'd prefer not to sayDescribe your history of alcohol or drug usageDo you have any other medical conditions?*YesNoI'd prefer not to sayDescribe your other medical conditions Please complete the following listing information about medical care you have received. Hospital NameHospital PhoneDate of Medical Care Hospital Address Street Address City State / Province / Region ZIP / Postal Code Doctor / Clinic NameDoctor / Clinic PhoneDate of Medical Care Doctor's Office / Clinic Address Street Address City State / Province / Region ZIP / Postal Code If you have Medicaid, please complete the following:Medicaid NumberState of MedicaidAlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces PacificExpiration Date Name on Card First Last I authorize Medicaid in the state listed above to give information about my case to Heart to Heart Adoptions. Your email address* Email PreferencesWe understand that, in some circumstances, it might not be a good idea to have proof of your communication with us in your inbox. So, please let us know your preference below.No. Please DO NOT email me a copy of this document.Yes. Please email me a copy for my records.NameThis field is for validation purposes and should be left unchanged. This iframe contains the logic required to handle Ajax powered Gravity Forms.