Family Health History

State of Connecticut

Department of Developmental Services

Family Health History
Name

First NameLast Name
Client's Date of Birth

MonthDayYear
Date
Client's Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
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:
Alcoholism

FatherMotherA brotherA sisterA grandfatherA grandmother
Anemia

FatherMotherA brotherA sisterA grandfatherA grandmother
Arthritis

FatherMotherA brotherA sisterA grandfatherA grandmother
Asthma

FatherMotherA brotherA sisterA grandfatherA grandmother
Bleeds Easily

FatherMotherA brotherA sisterA grandfatherA grandmother
Cancer (describe type and location in comments)

FatherMotherA brotherA sisterA grandfatherA grandmother
Diabetes

FatherMotherA brotherA sisterA grandfatherA grandmother
Epilepsy/Seizures

FatherMotherA brotherA sisterA grandfatherA grandmother
Glaucoma

FatherMotherA brotherA sisterA grandfatherA grandmother
Hayfever

FatherMotherA brotherA sisterA grandfatherA grandmother
Heart Disease

FatherMotherA brotherA sisterA grandfatherA grandmother
High Blood Pressure

FatherMotherA brotherA sisterA grandfatherA grandmother
Kidney Disease

FatherMotherA brotherA sisterA grandfatherA grandmother
Liver Disease

FatherMotherA brotherA sisterA grandfatherA grandmother
Mental Illness

FatherMotherA brotherA sisterA grandfatherA grandmother
Migraine Headaches

FatherMotherA brotherA sisterA grandfatherA grandmother
Osteoporosis

FatherMotherA brotherA sisterA grandfatherA grandmother
Stroke

FatherMotherA brotherA sisterA grandfatherA grandmother
Thyroid

FatherMotherA brotherA sisterA grandfatherA grandmother
Other Condition (describe in comments section)

FatherMotherA brotherA sisterA grandfatherA grandmother
Comments for cancer (type and location) and Other Condition
Please indicate if the person's biological parents are no longer living:
Mother (age at death)
Mother (cause of death)
Father (age at death)
Father (cause of death)
Please indicate the following information regarding the person's biological siblings:
Sibling #1 Gender
Sibling #1 Age (if living)
Sibling #1 Cause of Death (if applicable)
Sibling #1 Age at Death (if applicable)
Sibling #2 Gender
Sibling #2 Age (if living)
Sibling #2 Cause of Death (if applicable)
Sibling #2 Age at Death (if applicable)
Sibling #3 Gender
Sibling #3 Age (if living)
Sibling #3 Cause of Death (if applicable)
Sibling #3 Age at Death (if applicable)
Other Pertinent Information:
Completed by:

First NameLast Name
Date of Completion

MonthDayYear
Date
Attachment C: DDS Health Standard 09-1
Should be Empty: