Health Report For Foster And Adoptive Parents Page 2
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6C. To be completed by family before visiting health practitioner:
Does any member of your family have a history of any of the following? Check yes or no.
If yes, indicate each affected person’s name.
Yes
No
Name of Person Affected
Anemia
Convulsions
Hepatitis
Hernia
Rheumatic fever
Skin disease
Diabetes
Heart disease
High blood pressure
Kidney disease
Tuberculosis
Ulcers
Other (specify)
Has any member of your family had operations, broken bones, or serious accidents during the
past two years? If so, describe below:
Type of Incident
Person Involved
Approximate Date
I agree that all findings of the examination be submitted to the Iowa Department of Human
Services and
(Name of licensed child placing agency, if appropriate)
Signed
Date
470-0720 (Rev. 7/10)
Original: Department
Copy: Retention and Recruitment Contractor
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