Birth Parent Updated Medical History

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Birth Parent Updated Medical History
Name of Child on original birth record:
Date of Birth:
Sex:
Male
Female Hospital:
County:
City:
Mother’s Name (as shown on birth certificate):
Adoption agency involved with adoption (if known):
Today’s Date:
Person completing this form is:
Birth Mother
Birth Father
If information is unknown (“unk”) or not available (“N/A”) please indicate.
MEDICAL CONDITIONS OF CHILD’S BIOLOGICAL FAMILY
Mother’s Family & Father’s Family
Please list relationship to child e.g. parent, grandparent, aunt, uncle,
sibling, etc.
Condition
Mother’s
Father’s
Comments
Family*
Family*
(also list name of person reporting information;
if condition resulted in death, note here)
1. Respiratory
Allergies
Asthma
Bronchitis
Emphysema
Tuberculosis
Cystic Fibrosis
2. Gastrointestinal
Ulcers
Inflammatory
Bowel
Cleft lip or palate
Other
THIS FORM IS AVAILABLE IN ALTERNATE FORMAT UPON REQUEST
CF 246R (8/99) PC 4/02
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