Form Soc 861 - "Safely Surrendered Baby" Medical Questionnaire Page 2

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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY
CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
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.
AGE
TYPE OF ILLNESS
RELATIONSHIP TO THE CHILD
ILLNESS BEGAN
(Mother, Father, Grandparent, Aunt, Uncle)
Please state if relative is mother’s or father’s
■ ■
■ ■
■ ■
HIV or AIDS
Mother’s
Father’s
■ ■
■ ■
■ ■
Sexually Transmitted Disease
Mother’s
Father’s
What kind?
■ ■
■ ■
■ ■
Cancer
Mother’s
Father’s
What kind?
■ ■
■ ■
■ ■
Epilepsy
Mother’s
Father’s
■ ■
■ ■
■ ■
Mental Illness
Mother’s
Father’s
What kind?
■ ■
■ ■
■ ■
High Blood Pressure
Mother’s
Father’s
■ ■
■ ■
■ ■
Heart Disease
Mother’s
Father’s
■ ■
■ ■
■ ■
Diabetes
Mother’s
Father’s
■ ■
■ ■
■ ■
Cystic Fibrosis
Mother’s
Father’s
■ ■
■ ■
■ ■
Kidney Problems
Mother’s
Father’s
What kind?
■ ■
■ ■
■ ■
Hearing, vision, or speech problems
Mother’s
Father’s
What kind?
■ ■
■ ■
■ ■
Asthma
Mother’s
Father’s
■ ■
■ ■
■ ■
Tuberculosis
Mother’s
Father’s
■ ■
■ ■
■ ■
Sickle Cell Disease
Mother’s
Father’s
■ ■
■ ■
■ ■
Learning delay/special education
Mother’s
Father’s
■ ■
■ ■
■ ■
Allergies
Mother’s
Father’s
What kind?
■ ■
■ ■
■ ■
Arthritis
Mother’s
Father’s
What kind?
■ ■
■ ■
■ ■
Other
Mother’s
Father’s
What kind?
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)
PAGE 2 OF 2
SOC 861 (10/10)

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