Fillable Printable Birth Parent Updated Medical History - Oregon
Fillable Printable Birth Parent Updated Medical History - Oregon
Birth Parent Updated Medical History - Oregon
THIS FORM IS AVAILABLE IN ALTERNATE FORMAT UPON REQUEST
CF 246R (8/99) PC 4/02
Page 1 of 4
Birth Parent Updated Medical History
Name of Child on original birth record:
Date of Birth: Sex: Male Female Hospital:
County: City:
Mother’s Name (as shown on birth certificate):
Adoption agency involved with adoption (if known):
Today’s Date: Person completing this form is: Birth Mother Birth Father
If information is unknown (“unk”) or not available (“N/A”) please indicate.
MEDICAL CONDITIONS OF CHILD’S BIOLOGICAL FAMILY
Mother’s Family & Father’s Family Please list relationship to child e.g. parent, grandparent, aunt, uncle,
sibling, etc.
Condition Mother’s
Family*
Father’s
Family*
Comments
(also list name of person reporting information;
if condition resulted in death, note here)
1. Respiratory
Allergies
Asthma
Bronchitis
Emphysema
Tuberculosis
Cystic Fibrosis
2. Gastrointestinal
Ulcers
Inflammatory
Bowel
Cleft lip or palate
Other
Child’s Name:
THIS FORM IS AVAILABLE IN ALTERNATE FORMAT UPON REQUEST
CF 246R (8/99) PC 4/02
Page 2 of 4
*Mother’s Family & Father’s Family Please list relationship to child e.g. parent, grandparent, aunt,
uncle, sibling, etc.
Condition Mother’s
Family*
Father’s
Family*
Comments
(also list name of person reporting information; if
condition resulted in death, note here)
3. Cardiovascular
High Blood
Pressure
Heart Attack
Stroke
Congestive Heart
Failure
Atherosclerosis
Heart Rhythm
Abnormality
Congenital Heart
Defect
4. Condition Immune/Hematologic
Mononucleosis
Hemophilia
Leukemia
Lymphomas
Hodgkin’s Disease
Other Cancer
(type?)
5. Condition Renal
Kidney Failure/
Dialysis/
Transplant
Other Kidney
Problems
Child’s Name:
THIS FORM IS AVAILABLE IN ALTERNATE FORMAT UPON REQUEST
CF 246R (8/99) PC 4/02
Page 3 of 4
*Mother’s Family & Father’s Family Please list relationship to child e.g. parent, grandparent, aunt,
uncle, sibling, etc.
Condition Mother’s
Family*
Father’s
Family*
Comment
(name of person reporting information; if condition
resulted in death, note here)
6. Liver Disease
Hepatitis (specify
type)
Cirrhosis
Other Liver
Disease
7. Condition Central Nervous System
Epilepsy
Hydrocephalus
Multiple Sclerosis
Huntington’s
Chorea
Seizures/
Convulsions
8. Endocrine
Diabetes (Adult or
Juvenile) - list
treatment
Thyroid
(hyper/hypo)
Adrenal
9. Muscular/Skeletal
Club Foot
Scoliosis
(Curvature of the
Spine)
Arthritis (Osteo or
Rheumatoid)
Lupus
*Mother’s Family & Father’s Family Please list relationship to child e.g. parent, grandparent, aunt,
Child’s Name:
THIS FORM IS AVAILABLE IN ALTERNATE FORMAT UPON REQUEST
CF 246R (8/99) PC 4/02
Page 4 of 4
uncle, sibling, etc.
Condition Mother’s
Family*
Father’s
Family*
Comments
(also list name of person reporting information; if
condition resulted in death, note here)
10. Neuromuscular
Cerebral Palsy
Muscular
Dystrophy
Spina Bifida
11. Visual/Auditory
Blindness
Glaucoma
Cataracts or Other
Eye Problems
(specify)
Deafness or Other
Hearing Problems
(specify)
Other Conditions
12. Mental Illness
List type:(e.g.,
Depression,
Biopolar,
Schizophrena)
13. Alcohol or
Drug Abuse
14. Eating
Disorders
15. Mental
Retardation
16. Give age at
death & cause of
death of child’s
grand-parent,
aunt, uncle, and
siblings:
Please return this completed form to:
Human Services Building
Adoptions, 2
nd
Floor South
500 Summer Street NE, E 71
Salem, Oregon 97301-1068
Or the private agency involved in the adoption.
