Birth Parent Medical History printable pdf download

Birth Parent Medical History

Center for Health Statistics

PO Box 47814

Olympia, Washington 98504-7814

360.236.4300

Birth Parent Medical History

Indicate if information is unknown or not available.

For each of the medical conditions described below, please check the appropriate column indicating whether you or any

blood relative, i.e. your mother, father, sister, brother, grandparent, aunt, uncle or any other children, have the condition

listed. Complete the “Comments” section, as needed using a separate sheet of paper if additional space is required.

Person completing this form is: ☐ Birth Mother ☐ Birth Father

COMMENTS

YES

NOT

MEDICAL CONDITION

(SELF)

(RELATIVE)

KNOWN

(indicate which relative in relation to adoptee)

Skeletal/muscular

Club foot

Cleft lip or cleft palate

Arthritis (Osteo or Rheumatoid)

Scoliosis or other malformations

Spina bifida

Neuromuscular/autoimmune

Part of body involved?

Muscular dystrophy

Age at onset?

Multiple sclerosis

Cerebral palsy

Other paralysis or crippling disorder

Age at onset?

What treatment?

10. Seizures, convulsions or epilepsy

Frequency?

11. Huntington’s disease

12. Lupus

Visual/auditory

13. Blindness, glaucoma or other visual

problems

14. Glaucoma

DOH 422-111 August 2013

Birth Parent Medical History