1 19 (Rev 2025

1. Click ‘Get Form’ to open the 1 19 (Rev) in the editor.
2. Begin by filling out the parent information section. Indicate whether the mother or father has any genetic medical conditions by checking 'Yes', 'No', or 'Don’t Know' for each listed condition.
3. In the comments section, provide additional details about any conditions marked as 'Yes', including specifics like cause, age at onset, treatment, and hospitalizations.
4. For the genetic mother only section, complete your menstrual and pregnancy history accurately. List all pregnancies and specify if they were natural or induced.
5. Fill out the current pregnancy details, including any complications and prenatal care information. Ensure to answer questions regarding substance exposure during pregnancy.
6. Complete the child’s medical history and immunization sections thoroughly. Attach any necessary documents as indicated.
7. Finally, ensure both adoptive parents sign and date the form before submission.

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