Form Adph-Hs-86 - Request To Place A Contact Preference And Medical History Form With The Child'S Original Birth Certificate Page 4

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MEDICAL HISTORY SECTION:
DATE OF COMPLETION:
Please give information on the medical history of your family. Indicate if the birth parent,
grandparent(s), brother, sister or other family member had the condition. Give any additional
information that is appropriate such as age at onset, treatment, outcome, etc.
Medical Conditions
Self
Family
Comments (indicate which family member)
Yes No
Yes No
Hypertension or high
blood pressure
Stroke
Heart attack
Cancer
(state what kind)
Leukemia
Intestinal problems
(state what kind)
Renal disease or
kidney disorder
Cirrhosis or Liver
disease
Diabetes
(adult or juvenile)
Thyroid condition
Arthritis
Allergies
(state what kind)
Page 2 of 4 ADPH-HS-87/10/2009

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