Birth Parent Updated Medical History Page 4
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1
2
3
4Child’s Name:
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)
10. Neuromuscular
Cerebral Palsy
Muscular
Dystrophy
Spina Bifida
11. Visual/Auditory
Blindness
Glaucoma
Cataracts or Other
Eye Problems
(specify)
Deafness or Other
Hearing Problems
(specify)
Other Conditions
12. Mental Illness
List type:(e.g.,
Depression,
Biopolar,
Schizophrena)
13. Alcohol or
Drug Abuse
14. Eating
Disorders
15. Mental
Retardation
16. Give age at
death & cause of
death of child’s
grand-parent,
aunt, uncle, and
siblings:
Human Services Building
nd
Adoptions, 2
Floor South
Please return this completed form to:
500 Summer Street NE, E 71
Salem, Oregon 97301-1068
Or the private agency involved in the adoption.
THIS FORM IS AVAILABLE IN ALTERNATE FORMAT UPON REQUEST
CF 246R (8/99) PC 4/02
Page 4 of 4
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