Form Adph-Hs-86 - Request To Place A Contact Preference And Medical History Form With The Child'S Original Birth Certificate Page 6

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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
Tay-Sachs Disease
Epilepsy or other
seizures
Birth defects
such as: cleft lip, club foot,
congenital heart condition,
hydrocephalus, spina bifida,
etc. (state what kind)
Learning disability
Mental retardation
Severe depression
Mental illness
Alcoholism
Drug abuse
Any other conditions
you wish to describe
Page 4 of 4 ADPH-HS-87/10/2009

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