Filing Of Required Non-Identifying Health, Genetic And Social Histories With The Utah Adoption Registry Page 7

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9
9
B
P
S
A
H
H
I
IRTH
ARENT
OCIAL
ND
EALTH
ISTORY
NFORMATION
Birthmother
Birthfather
Page 7
YOUR
RELATIVE
ALLERGIES
(SPECIFY
NONE
YOU
RELATIONSHIP)
COMMENTS
Animals:
Asthma:
Eczema:
Food:
Hay fever/Plants:
Hives:
Medications:
Other allergies:
Other (specify):
Other (specify):
VISUAL IMPAIRMENT
Astigmatism:
Blindness:
Color blindness:
Other (specify):
Other (specify):
Age at onset? Treatment? Hospitalization?
EMOTIONAL/MENTAL ILLNESS
Bipolar (manic-depressive):
Schizophrenia:
Severe depression:
Suicide:
Obsessive-Compulsive disorder:
Personality disorder:
Alcoholism/Drug addiction:
Other (specify):
Other (specify):

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