Form Adph-Hs-86 - Request To Place A Contact Preference And Medical History Form With The Child'S Original Birth Certificate Page 5

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MEDICAL HISTORY SECTION:
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
Asthma
Tuberculosis
Sexually transmitted
disease
Blindness or other
eye problem
Hearing or speech
problems
Dental problems
(state what kind)
Muscular Dystrophy
Multiple Sclerosis
Cerebral Palsy
Cystic Fibrosis
Sickle Cell Anemia
Huntington’s Disease
Page 3 of 4 ADPH-HS-87/10/2009

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