Birth Parent Updated Medical History Page 2
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2
3
4Child’s Name:
*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)
3. Cardiovascular
High Blood
Pressure
Heart Attack
Stroke
Congestive Heart
Failure
Atherosclerosis
Heart Rhythm
Abnormality
Congenital Heart
Defect
4. Condition Immune/Hematologic
Mononucleosis
Hemophilia
Leukemia
Lymphomas
Hodgkin’s Disease
Other Cancer
(type?)
5. Condition Renal
Kidney Failure/
Dialysis/
Transplant
Other Kidney
Problems
THIS FORM IS AVAILABLE IN ALTERNATE FORMAT UPON REQUEST
CF 246R (8/99) PC 4/02
Page 2 of 4
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