The Life Story of...

___________________________________________________________________________________

Today's Date_____________________

First Name ___________________________________________________

Middle Name _________________________________________________

Last Name ___________________________________________________

Maiden Name (if applicable) _____________________________________

I was born on __________________________(date) in the town/city of

_______________________________________________________________ (location including hospital if

known)

I was born at _________ am/pm on a _____________ (day of week) LINK

My Birth Weight: _______________ My Birth Length: ____________________

My Current address: _________________________________________________________________

My Father Is: _______________________________________________________________________

My Mother Is: ______________________________________________________________________

Complications at Birth?: ______________________________________________________________

Had I been born the opposite sex, my parents were going to name me ___________________________

My nationality is ____________________ and my ethnic background is ________________________

I was born number ________ of ________ children

I have ________ brother(s) & ________ sister(s) ________ step-brothers _______ step-sisters

My natural hair color is _____________________ My eyes are ________________________ in color

My adult height is _____________ and my weight has ranged between ___________ and _________

I wear glasses for READING EVERYDAY I'VE NEVER WORN GLASSES

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I am RIGHT-HANDED LEFT-HANDED AMBIDEXTROUS

I was named after someone YES NO

I have an interesting story/circumstance to tell about my mother getting to the hospital on time:YES NO

Additional Notes and Comments:

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