Birth Parent Medical History Page 2
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4Center for Health Statistics
PO Box 47814
Olympia, Washington 98504-7814
360.236.4300
COMMENTS
NO
YES
YES
NOT
MEDICAL CONDITION
(SELF)
(RELATIVE)
KNOWN
(indicate which relative in relation to adoptee)
15. Other visual problems
16. Deafness or other ear problems
Internal organs/conditions
17. Hepatitis
Specify type
18. Cirrhosis or other liver disease
Age at onset?
19. Kidney disease
Treatment?
20. Inflammatory bowel
21. Other intestinal conditions
Age at onset?
22. Diabetes
Treatment?
23. Thyroid disorder (hyper/hypo)
24. Other hormonal disorder
Location?
25. Cancer
Onset?
Heart/circulatory
26. Congenital heart defect
27. Heart attack
28. Stroke
29. Atherosclerosis
30. Congestive heart failure
31. High blood pressure
32. Hemophilia
33. Other cardiovascular problems
DOH 422-111 August 2013
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