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Family Medical History - Birth Father
BIRTH Father - Name:
(Required)
First
Last
Phone
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Email
(Required)
Please provide the following information about your biological family’s medical history. Listed below are a number of medical conditions that might be important to a child. Please go through the list and state whether or not a particular condition exists in your family. Include yourself, biological parents, biological grandparents and biological siblings. If you mark YES for a medical condition, please complete the MORE INFROMATION SECTION at the bottom of each page. Please use another sheet of paper if necessary. If you are unsure what something is, then you probably don’t have that medical condition.
MEDICAL CONDITION
Untitled
Club Foot or any Orthopedic Problem
Chromosome Abnormality
Hydrocephalus
Spinal Bifida
Tay-Sachs Disease
Acne
Hay Fever
Animal Allergies (Please indicate below what animal)
Alcoholism or Heavy Drinking
Leukemia
Hodgkin's Disease
Harelip (Cleft Lip) or Cleft Palate
Down Syndrome
Muscular Dystrophy
Congenital Heart Defect
Hives
Eczema or other Skin Condition
Food Allergies (Please indicate below what food)
Drug Allergies (Please indicate below what drug)
Cancer (Please indicate below what kind)
Cystic Fibrosis
Multiple Sclerosis
List Animal Allergies
List Food Allergies
List Drug Allergies
What Kind of Cancer
MORE INFORMATION
Below please state all information requested for each YES. Who In Your Family - Self, Mother, Father, Brother, Sister, Grandmother or Grandfather (father’s or mother’s side of the family); When the Medical Condition Occurred, the Cause, the Treatment, List Any Medications Given, Part(s) of the Body Affected.
Medical Information
Add
Remove
MEDICAL CONDITION
Huntington's Disease
Seizure or convulsions (Please indicate below the frequency)
Asthma
Blindness
Color Blindness
Deafness or other Ear Problems
Learning Disability
Sickle Cell Anemia or Trait
Low Blood Pressure
Heart Disease
Rheumatism
Kidney Infection
Kidney Disease
Rash or Skin Problems
Anorexia
Headaches
Cerebral Palsy
Epilepsy
Hospitalizations or Operations
Glaucoma
Glasses (Please indicate below near or far sighted)
Speech Problems
Hemophilia
Hypertension (High Blood Pressure)
Stroke
Heart Murmur
Arthritis (Please indicate below what kind)
Urinary Problems
Diabetes
Tuberculosis
Bulimia
Migraines
Frequency of Seizure or convulsions
Near or far sighted)
Near-sighted
Far-sighted
What kind of Arthritis
Below please state all information requested for each YES. Who In Your Family - Self, Mother, Father, Brother, Sister, Grandmother or Grandfather (father’s or mother’s side of the family); When the Medical Condition Occurred, the Cause, the Treatment, List Any Medications Given, Part(s) of the Body Affected.
Medical Information
Add
Remove
MEDICAL CONDITION
Blackouts
Miscarriages
Multiple Births (twins, etc.)
Chronic Coughs
Braces and/or Dental Work
Stomach Ulcers
Scoliosis
Bone or Joint Trouble
Paralysis
Nervous System Disease
Mental Illness (Please indicate below if hospitalized)
Chronic Depression (Please indicate below if hospitalized)
Sexually Transmitted Diseases
Balding
Blood Disorders
Other Malformations, Paralysis, or Crippling Disorders
Dizziness
Stillbirths
Chronic Colds
Chronic Sore Throat
Gallstones
Hernias
Back Injuries
Swelling of Legs
Numbness
Emotional Trouble
Diagnosed Schizophrenia (Please indicate below if hospitalized)
Bi-Polar Disorder (Please indicate below if hospitalized)
Hypoglycemia
Alzheimer’s Disease
Anemia
Other Conditions not previously mentioned
Please indicate if hospitalized with Mental Illness
Please indicate if hospitalized with Chronic Depression
Please indicate if hospitalized with Diagnosed Schizophrenia
Please indicate if hospitalized with Bi-Polar Disorder
Below please state all information requested for each YES. Who In Your Family - Self, Mother, Father, Brother, Sister, Grandmother or Grandfather (father’s or mother’s side of the family); When the Medical Condition Occurred, the Cause, the Treatment, List Any Medications Given, Part(s) of the Body Affected.
Medical Information
Add
Remove
Below please state all information requested for each YES. Who In Your Family - Self, Mother, Father, Brother, Sister, Grandmother or Grandfather (father’s or mother’s side of the family); When the Medical Condition Occurred, the Cause, the Treatment, List Any Medications Given, Part(s) of the Body Affected.
Medical Information
Add
Remove
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