Vital Records Form (Page 2 of 2) in pdf

Vital Records Form Page 2

Colorado Department of Public Health and Environment

Vital Records

Adoption Specialist

4300 Cherry Creek Drive South

Denver, CO 80246

(303) 692-2227

M E D I C A L

H I S T O R Y

STATEMENT

(

)

This form can be submitted no more frequently than every 3 years unless there is a significant change in medical history

BIRTH PARENT INFORMATION

Birth mother

Birth father

Example of medical history-

List any hereditary diseases, childhood diseases, allergies, adult diseases, and

allergies, asthma, diabetes,

history of cancer, congenital impairments or other significant illnesses:

migraine headaches, eye

disorders, hypertension, heart

problems, depression,

Blood type:

epilepsy, stroke, thyroid.

Significant medical information about biological relatives and state their relationship:

I hereby waive confidentiality of any medical information supplied in this statement with respect to the adoptee, an

adult descendent of an adoptee or legal representative of such person and to the State Registrar and his or her

designees.

________

Signature of birth parent________________________________________________Date___________

_______________________________________________________________________________________________________________________________________________________________________

(Please print full name)

FORM-VR08 Rev. 12/2014

Vital Records Form Page 2

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