Family Medical History - Birth Mother - Adoption & Beyond

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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

List Animal Allergies

List Food Allergies

List Drug Allergies

What Kind of Cancer

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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.

Frequency of Seizure or convulsions

Near or 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.

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.

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Family Medical History - Birth Mother

MEDICAL CONDITION

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