Form IL 482-1018 Medical Questionnaire - Illinois Adoption Registry - Illinois

Form IL482-1018 is a Illinois Department of Public Health form also known as the "Medical Questionnaire - Illinois Adoption Registry". The latest edition of the form was released in May 1, 2000 and is available for digital filing.

Download a PDF version of the Form IL482-1018 down below or find it on Illinois Department of Public Health Forms website.

ADVERTISEMENT
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
2. Cleft lip or cleft palate
3. Chromosome abnormality (explain)
4. Down’s syndrome
5. Muscular dystrophy
6. Spina bifida
7. Congenital heart defect
8. Tay-Sachs disease
9. Fetal alcohol syndrome
10. Trisomy 21
11. Ambiguous genitalia
12. Hydrocephalus
13. Macrocephalus
14. Amencephalus
15. Microcephalus
16. Other (explain)
B. ALLERGIES
1. Eczema or other skin condition
2. Hay fever or other allergy
3. Drug allergy (to what drugs?)
4. Other (explain)
C. EYE AND EAR DISORDERS
1. Blindness, glaucoma, color blindness or
other visual problems
2. Deafness or other ear problems
3. Other (explain)
D. BLOOD AND CIRCULATORY DISORDERS
1. Hemophilia
2. Sickle cell anemia or trait
3. Anemia
4. Hypertension (high blood pressure)
5. Stroke
6. Heart attack
7. Arthritis
8. Kidney disease
9. Other (explain)
E. RESPIRATORY DISORDERS
1. Asthma
2. Tuberculosis
3. Emphysema
4. Cystic fibrosis
5. Bronchial pulmonary disposia
Illinois Department of Public Health, Division of Vital Records, 925 East Ridgely Ave., Springfield, IL 62702-2737
6. Other (explain)
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
2. Cleft lip or cleft palate
3. Chromosome abnormality (explain)
4. Down’s syndrome
5. Muscular dystrophy
6. Spina bifida
7. Congenital heart defect
8. Tay-Sachs disease
9. Fetal alcohol syndrome
10. Trisomy 21
11. Ambiguous genitalia
12. Hydrocephalus
13. Macrocephalus
14. Amencephalus
15. Microcephalus
16. Other (explain)
B. ALLERGIES
1. Eczema or other skin condition
2. Hay fever or other allergy
3. Drug allergy (to what drugs?)
4. Other (explain)
C. EYE AND EAR DISORDERS
1. Blindness, glaucoma, color blindness or
other visual problems
2. Deafness or other ear problems
3. Other (explain)
D. BLOOD AND CIRCULATORY DISORDERS
1. Hemophilia
2. Sickle cell anemia or trait
3. Anemia
4. Hypertension (high blood pressure)
5. Stroke
6. Heart attack
7. Arthritis
8. Kidney disease
9. Other (explain)
E. RESPIRATORY DISORDERS
1. Asthma
2. Tuberculosis
3. Emphysema
4. Cystic fibrosis
5. Bronchial pulmonary disposia
Illinois Department of Public Health, Division of Vital Records, 925 East Ridgely Ave., Springfield, IL 62702-2737
6. Other (explain)
Illinois Department of Public Health
ILLINOIS ADOPTION REGISTRY – MEDICAL QUESTIONNAIRE
F. HORMONAL DISORDERS
Yes No
If answering “yes” to any item, specify item number (for example, A2, B4, etc.) and indicate self or family member.
1. Diabetes
2. Thyroid disorder
3. Other (explain)
G. MENTAL AND BEHAVIORAL DISORDERS
1. Schizophrenia
2. Manic depressive (bi-polar)
3. Clinical depression
4. Substance abuse (adopted person or birth parent)
(list type and explain)
5. Obsessive-compulsive disorders
6. Eating disorders
7. Drug usage
8. Autism
9. Other (explain)
H. MALIGNANT DISORDERS
1. Cancer (specify site)
2. Tumors
3. Hodgkin’s disease
4. Other (explain)
I. NERVOUS SYSTEM DISORDERS
1. Multiple sclerosis
2. Huntington’s disease
3. Cerebral palsy
4. Seizures or convulsions
5. Epilepsy
6. Other (explain)
J. INFECTIONS AND HOSPITALIZATION (explain)
1. Repeated attacks of fever with known infection
2. Repeated severe infection requiring
hospitalization
3. Hospitalizations or operations, if any
4. HIV/STDs (herpes, syphillis, etc.)
5. Hepatitis
6. Other (explain)
K. DEVELOPMENTAL DELAYS
1. Speech challenged
2. Learning challenged
3. Mentally challenged
RELEASE: On the Information Exchange Authorization Form, the registrant may authorize the release of the information
from this medical questionaire.
4. Physically challenged
DISCLAIMER: The Illinois Department of Public Health cannot guarantee the accuracy of medical information
5. Other (explain)
exchanged through the Adoption Registry as the information is submitted by the registrants, not the Department.
L. OTHER IMPAIRMENTS, DISEASE OR DISORDERS
Illinois Department of Public Health, Division of Vital Records, 925 East Ridgely Ave., Springfield, IL 62702-2737
(metabolic, genetic or other) [Including ALS (Lou
Gehrig’s disease), gout, obesity, etc.] (list and explain)
VR 161.9 (rev. 05/2000)
IL482-1018
Printed by Authority of the State of Illinois
P.O. #145082
3M
9/04

Download Form IL 482-1018 Medical Questionnaire - Illinois Adoption Registry - Illinois

545 times
Rate
4.3(4.3 / 5) 33 votes
ADVERTISEMENT
Page of 2