Birth Parent Updated Medical History Page 3
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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
Comment
Family*
Family*
(name of person reporting information; if condition
resulted in death, note here)
6. Liver Disease
Hepatitis (specify
type)
Cirrhosis
Other Liver
Disease
7. Condition Central Nervous System
Epilepsy
Hydrocephalus
Multiple Sclerosis
Huntington’s
Chorea
Seizures/
Convulsions
8. Endocrine
Diabetes (Adult or
Juvenile) - list
treatment
Thyroid
(hyper/hypo)
Adrenal
9. Muscular/Skeletal
Club Foot
Scoliosis
(Curvature of the
Spine)
Arthritis (Osteo or
Rheumatoid)
Lupus
*Mother’s Family & Father’s Family Please list relationship to child e.g. parent, grandparent, aunt,
THIS FORM IS AVAILABLE IN ALTERNATE FORMAT UPON REQUEST
CF 246R (8/99) PC 4/02
Page 3 of 4
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