Illinois Department of Public Health

ILLINOIS ADOPTION REGISTRY – MEDICAL QUESTIONNAIRE

(Enter all known information and add explanation/comments as necessary.)

If answering "yes" to any item, specify item number (for example, A2, B4, etc.) and indicate self or family member

A.  CONGENITAL IMPAIRMENTS

Yes

No

1.

Club foot or any other orthopedic problem

q

q

2.

Cleft lip or cleft palate

q

q

3.

Chromosome abnormality (explain)

q

q

4.

Down's syndrome

q

q

5.

Muscular dystrophy

q

q

6.

Spina bifida

q

q

7.

Congenital heart defect

q

q

8.

Tay-Sachs disease

q

q

9.

Fetal alcohol syndrome

q

q

10.

Trisomy 21

q

q

11.

Ambiguous genitalia

q

q

12.

Hydrocephalus

q

q

13.

Macrocephalus

q

q

14.

Amencephalus

q

q

15.

Microcephalus

q

q

16.

Other  (explain)

q

q

B.  ALLERGIES

1.

Eczema or other skin condition

q

q

2.

Hay fever or other allergy

q

q

3.

Drug allergy (to what drugs?)

q

q

4.

Other (explain)

q

q

C.  EYE AND EAR DISORDERS

1.

Blindness, glaucoma, color blindness or

q

q

other  visual problems

2.

Deafness or other ear problems

q

q

3.

Other  (explain)

q

q

D.  BLOOD AND CIRCULATORY DISORDERS

1.

Hemophilia

q

q

2.

Sickle cell anemia or  trait

q

q

3.

Anemia

q

q

4.

Hypertension (high blood pressure)

q

q

5.

Stroke

q

q

6.

Heart attack

q

q

7.

Arthritis

q

q

8.

Kidney disease

q

q

9.

Other (explain)

q

q

E.  RESPIRATORY DISORDERS

1.

Asthma

q

q

2.

Tuberculosis

q

q

3.

Emphysema

q

q

4.

Cystic fibrosis

q

q

5.

Bronchial pulmonary disposia

q

q

6.

Other (explain)

q

q

F.  HORMONAL DISORDERS

Yes

No

1.

Diabetes

q

q

2.

Thyroid disorder

q

q

3.

Other  (explain)

q

q

G.  MENTAL AND BEHAVIORAL DISORDERS

1.

Schizophrenia

q

q

2.

Manic depressive (bi-polar)

q

q

3.

Clinical depression

q

q

4.

Substance abuse (adopted person or birth parent)

q

q

(list type and explain)

5.

Obsessive-compulsive disorders

q

q

6.

Eating disorders

q

q

7.

Drug usage

q

q

8.

Autism

q

q

9.

Other  (explain)

q

q

H.  MALIGNANT DISORDERS

1.

Cancer (specify site)

q

q

2.

Tumors

q

q

3.

Hodgkin's disease

q

q

4.

Other (explain)

q

q

I.  NERVOUS SYSTEM DISORDERS

1.

Multiple sclerosis

q

q

2.

Huntington's disease

q

q

3.

Cerebral palsy

q

q

4.

Seizures or convulsions

q

q

5.

Epilepsy

q

q

6.

Other (explain)

q

q

J.  INFECTIONS AND HOSPITALIZATION  (explain)

1.

Repeated attacks of fever with known infection

q

q

2.

Repeated severe infection requiring

q

q

hospitalization

3.

Hospitalizations or operations, if any

q

q

4.

HIV/STDs (herpes, syphilis, etc.)

q

q

5.

Hepatitis

q

q

6.

Other (explain)

q

q

K.  DEVELOPMENTAL DELAYS

1.

Speech challenged

q

q

2.

Learning challenged

q

q

3.

Mentally challenged

q

q

RELEASE:  On the Information Exchange Authorization Form, the registrant may authorize the release of the information from this medical questionaire.

DISCLAIMER:  The Illinois Department of Public Health cannot guarantee the accuracy of medical information exchanged through the Adoption Registry as the information is submitted by the registrants, not the Department.

4.

Physically challenged

q

q

5.

Other (explain)

q

q

L.  OTHER IMPAIRMENTS, DISEASE OR DISORDERS

q

q

   Illinois Department of Public Health, Division of Vital Records, 605 W. Jefferson St., Springfield, IL  62702-5097

(metabolic, genetic or other)  [including ALS (Lou Gehrig's disease), gout, obesity, etc.]  (list and explain)

VR 161.?  (rev. 05/2000)

Printed by Authority of the State of Illinois  P.O. # 30M 02/00