# 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 mother’s family is: ______________________
_______________________________________________________
Birth father’s name (optional): _________________________________
To the best of my knowledge, the ethnic origin of the birth father’s 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.
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Birth Mother |
Birth Father |
Birth Mother’s Parents |
Birth Father’s Parents |
Birth Mother’s Siblings/Children |
Birth Father’s Siblings/Children |
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ADD/ADHD |
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Alcoholism |
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Allergies |
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Alzheimer’s |
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Anemia |
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Arthritis |
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Asthma |
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Bipolar disorder |
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Blood disorders |
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Cancer, breast |
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Cancer, colon |
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Cancer, ovarian |
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Cancer, prostate |
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Cancer, skin |
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Cystic fibrosis |
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Diabetes |
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Dyslexia |
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Eating disorders |
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Eczema |
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Emphysema |
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Epilepsy |
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Farsightedness |
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Gout |
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Hay fever |
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Hearing defects |
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Heart disease |
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Hemophilia |
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High blood pressure |
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Huntingtons’ Disease |
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Hyper-thyroidism |
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Hypo-thyroidism |
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Kidney disease |
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Leukemia |
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Lou Gehrig’s disease |
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Mental illness |
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Mentally challenged |
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Muscular diseases |
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Nearsightedness |
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Obesity |
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Obsessive-compulsive disorder |
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Parkinson’s disease |
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Physically challenged |
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RH factors |
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Schizophrenia |
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Sickle cell anemia |
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Birth Mother |
Birth Father |
Birth Mother’s Parents |
Birth Father’s Parents |
Birth Mother’s Siblings/Children |
Birth Father’s Siblings/Children |
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Seizures |
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Speech disabilities |
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Stroke |
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Tay Sachs |
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Tumors (benign) |
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Tumors (malignant) |
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Turrett’s syndrome |
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Tuberculosis |
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Other (specify)
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I also wish to provide the following additional background information : ___________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________