Personal And Medical Information Form

Probate Court of Lake County, Ohio MARK J. BARTOLOTTA, JUDGE ADOPTION OF _________________________________________________________ CASE NUMBER _____________ PERSONAL AND MEDICAL INFORMATION FORM Name: Address: Date of Birth: Occupation: Have you ever had: Tuberculosis Place of Birth: Work number: Epilepsey Convulsions Asthma _______ Kidney Trouble _______ Rheumatism _______ Pleurisy _______ Syphillis/Gonorrhea _______ Nervous Breakdown _______ Have you undergone any operation? When: Results: Have you ever used narcotics except when prescribed by a physician? Have you ever used, or do you use, alcoholic stimulants to excess? Has any member of your family or household had Tuberculosis or Insanity? What diseases or injuries have you had in the last 10 years other than above mentioned? For what: Mother: Age if living Age at death State of Health Cause State of Health Cause Father: Age if living Age at death Remarks (use another sheet if necessary): Date Signature of petitioner/natural parent Print Reset American LegalNet, Inc. www.FormsWorkFlow.com