Family Health History

State of Connecticut

Department of Developmental Services

Name

First NameLast Name

Client's Date of Birth

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

Anemia

Arthritis

Asthma

Bleeds Easily

Cancer (describe type and location in comments)

Diabetes

Epilepsy/Seizures

Glaucoma

Hayfever

Heart Disease

High Blood Pressure

Kidney Disease

Liver Disease

Mental Illness

Migraine Headaches

Osteoporosis

Stroke

Thyroid

Other Condition (describe in comments section)

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

Date

Attachment C: DDS Health Standard 09-1