Form Mc 356 - Medical Questionnaire (Page 2 of 2) in pdf

Form Mc 356 - Medical Questionnaire Page 2

ID number: ____________________

Please tell us if the birth mother, birth father, or any of their relatives had or now have any of the medical conditions listed below.

RELATIONSHIP TO THE CHILD

AGE

TYPE OF ILLNESS

(Mother, Father, Grandparent, Aunt, Uncle)

ILLNESS BEGAN

HIV or AIDS

Sexually transmitted disease

What kind? ____________________________________

Cancer

What kind? ____________________________________

Epilepsy

Mental Illness

What kind? ____________________________________

High blood pressure

Heart disease

Diabetes

Cystic fibrosis

Kidney problems

What kind: ____________________________________

Hearing, vision, or speech problems

What kind? ____________________________________

Asthma

Tuberculosis

Sickle cell disease

Learning delays/special education

What kind? ____________________________________

Allergies

What kind? ____________________________________

Other

What?________________________________________

Please provide any additional information that might help us provide the baby with the best health care now or in the future.

(You may use an additional page.)

MC 356 (05/07)

Form Mc 356 - Medical Questionnaire Page 2