Family Health History
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1State of Connecticut
Department of Developmental Services
Family Health History
Name:______________________________________________ D.O.B.:__________________
Address:______________________________________________________________________
Please indicate by checking the appropriate box if any of the person’s blood relatives have been identified
to have any of the following conditions.
Father
Mother
Brother
Sister Grandfather Grandmother
Alcoholism
Anemia
Arthritis
Asthma
Bleeds easily
Cancer (indicate type/ location)
Diabetes
Epilepsy/ Seizures
Glaucoma
Hayfever
Heart Disease
High Blood Pressure
Kidney Disease
Liver Disease
Mental Illness
Migraine Headaches
Osteoporosis
Stroke
Thyroid
Other (describe)
Please indicate if the person’s biological parents are no longer living:
Age at death
Mother_______________________
Father________________________
Cause of death
Mother_______________________
Father________________________
Please indicate the following information regarding the person’s biological siblings:
Gender of Sibling
Age of Sibling if living
Cause of death if deceased
Age at death
Other Pertinent Information:________________________________________________________________
__________________________________________________________________________________
Completed by: _______________________________ Date of Completion:__________________________
Attachment C: DDS Health Standard 09-1
1
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Parent category: Medical