# 1234ABcd

 

OUTREACH RESPONSE FORM

 

Please choose one of the following responses:

___I am not the birth relative who was the object of this search and, therefore, have not completed this response form and am returning the outreach letter unopened.

___Although I may be the birth relative who was the object of this search, I
do not wish to complete this response form at the present time and am returning the outreach letter unopened.

___Although I am unable to consider contact with my birth daughter at the present time, I would like to provide her with the following general, ethnic and medical background information:

My general appearance is as follows:

Height________ Weight__________ Hair Color ___________

Eye color __________ Complexion_________________

Educational background: ______________________________________

My occupation is: ___________________________________________

My hobbies include: _________________________________________

_______________________________________________________

My talents include: _________________________________________

_______________________________________________________

My interests include: ________________________________________

_______________________________________________________

The ethnic origin of the birth motherís family is: ______________________

_______________________________________________________

Birth fatherís name (optional): _________________________________

To the best of my knowledge, the ethnic origin of the birth fatherís family is: _______________________________________________________

 

To the best of my knowledge, the following genetically-inherited diseases and conditions are known to exist in my family. (Check all appropriate entries. Complete birth father information only if known.) If you have any questions about completing this form, please call 312/666-5721 for assistance.

 

Birth Mother

Birth

Father

Birth Motherís Parents

Birth Fatherís Parents

Birth Motherís Siblings/Children

Birth Fatherís Siblings/Children

ADD/ADHD

 

 

 

 

 

 

Alcoholism

 

 

 

 

 

 

Allergies

 

 

 

 

 

 

Alzheimerís

 

 

 

 

 

 

Anemia

 

 

 

 

 

 

Arthritis

 

 

 

 

 

 

Asthma

 

 

 

 

 

 

Bipolar disorder

 

 

 

 

 

 

Blood disorders

 

 

 

 

 

 

Cancer, breast

 

 

 

 

 

 

Cancer, colon

 

 

 

 

 

 

Cancer, ovarian

 

 

 

 

 

 

Cancer, prostate

 

 

 

 

 

 

Cancer, skin

 

 

 

 

 

 

Cystic fibrosis

 

 

 

 

 

 

Diabetes

 

 

 

 

 

 

Dyslexia

 

 

 

 

 

 

Eating disorders

 

 

 

 

 

 

Eczema

 

 

 

 

 

 

Emphysema

 

 

 

 

 

 

Epilepsy

 

 

 

 

 

 

Farsightedness

 

 

 

 

 

 

Gout

 

 

 

 

 

 

Hay fever

 

 

 

 

 

 

Hearing defects

 

 

 

 

 

 

Heart disease

 

 

 

 

 

 

Hemophilia

 

 

 

 

 

 

High blood pressure

 

 

 

 

 

 

Huntingtonsí Disease

 

 

 

 

 

 

Hyper-thyroidism

 

 

 

 

 

 

Hypo-thyroidism

 

 

 

 

 

 

Kidney disease

 

 

 

 

 

 

Leukemia

 

 

 

 

 

 

Lou Gehrigís disease

 

 

 

 

 

 

Mental illness

 

 

 

 

 

 

Mentally challenged

 

 

 

 

 

 

Muscular diseases

 

 

 

 

 

 

Nearsightedness

 

 

 

 

 

 

Obesity

 

 

 

 

 

 

Obsessive-compulsive disorder

 

 

 

 

 

 

Parkinsonís disease

 

 

 

 

 

 

Physically challenged

 

 

 

 

 

 

RH factors

 

 

 

 

 

 

Schizophrenia

 

 

 

 

 

 

Sickle cell anemia

 

 

 

 

 

 

 

 

 

Birth Mother

Birth

Father

Birth Motherís Parents

Birth Fatherís Parents

Birth Motherís Siblings/Children

Birth Fatherís Siblings/Children

Seizures

 

 

 

 

 

 

Speech disabilities

 

 

 

 

 

 

Stroke

 

 

 

 

 

 

Tay Sachs

 

 

 

 

 

 

Tumors (benign)

 

 

 

 

 

 

Tumors (malignant)

 

 

 

 

 

 

Turrettís syndrome

 

 

 

 

 

 

Tuberculosis

 

 

 

 

 

 

Other (specify)

 

 

 

 

 

 

 

 

 

 

 

I also wish to provide the following additional background information : ___________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________