Health History Form

Where appropriate please indicate yes next to an item. Whenever possible please explain further. (e.g. visual problems yes, nearsighted) Please indicate all history for all family members and note who in the family has this problem/illness.

Acne (severe) ________________________________
Alcoholism ___________________________________

Anemia (sickle cell if black) ________________
Arthritis (type) __________________________
Back problems _______________________
Bladder infections ______________________
Bleeding tendency ______________________
Female abnormalities Bronchitis _________________________
Cancer ______________________________ Cystic Fibrosis ____________________________
Deafness other ear problems ________________
Deformities or birth defects _________________
Depression, mood swings _______________
DES note if taken by mother during pregnancy __________
Diabetes; note severity _____________
Digestive problems ________________
Emotional problems, mental illness ___________ Emphysema __________________
Epilepsy __________________
Gall Bladder _____________
Headaches type etc _______________
Heart Disease including Blood pressure irregularities _______________
Huntington’s Chorea ____________
Learning disability, describe ______________
Liver disease ___________________
Mental deficiency or retardation ___________
Paralysis or muscle weakness ______________
Pleurisy, Pneumonia ________________
Respiratory Disease ________________________
Rheumatic Fever ________________________
Sinus ___________________________
Speech problems _______________________
Stroke _____________________
Thyroid, hormone problems __________
Ulcer ________________________________ Visual problems ____________
Additional health problems not included above____________________________
Surgeries not included above ________________________________________
Female members difficulties in pregnancy, miscarriage or other difficulties in carrying children __________________________
Any family members with multiple births _____
On a scale of one to ten, with ten being the best score, how would you rate What is the average longevity of paternal family relatives? ___
What is the average longevity of maternal family relatives? ___
Causes of death of family members; please state your relationship and their age at death ______________________________________________
Please add anything you feel to be of importance that has not been covered in this form. ____________________________________________

** These relate to the adoptee’s Mother only.

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