Foster Home Medical History Form 

 

Name: 
(Name) 


Home Address: 
(Home Address) 


Phone: 
(Phone) 
Birth date: 
(text) 




Health History 

Any history, past, or present of: 

 Yes
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(text) 
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(text) 
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No
(text) 
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Head or back injuries 
_____ 

Neurological disorders, convulsions, etc. 
_____ 

Heart disease, high blood pressure, or rheumatic fever 
_____ 

Lung disorders, asthma, tuberculosis 
_____ 

Stomach, gall bladder, or other gastro-intestinal disorders 
_____ 

Allergies to food, drug, plant, etc. 
_____ 

Blood disorders, anemia, leukemia, etc. 
_____ 

Kidney trouble 
_____ 

Venereal disease 
_____ 

Diabetes or other glandular disorders 
_____ 

Surgery 
_____ 

Reproductive system problems 
_____ 

Psychological disorders, mental health illness 
_____ 

Physical disabilities 
_____ 

Other chronic illnesses, diseases, or disorders 
_____ 

If any of the above questions were answered yes, please elaborate: 
(text) 
(text) 
(text) 
(If any of the above questions were answered yes, please elaborate [1]) 


 
____________________________________________________________________________ 
____________________________________________________________________________ 

 

What do you consider your state of health: Excellent 
(text) 
Good 
(text) 


Fair 
(text) 
Poor 
(text) 


To the best of my knowledge, the above information is correct. 

 
________________ 
(signature) 


 Signature 
(text) 
Date 

 

 

 

DSS-5017 (Rev. 09-01-07) 

North Carolina Division of Social Services 

Family Support and Child Welfare Services