Bridge Resource Family Health History

              Bridge Resource Parent Health History
Form 04AF017E v.3 08/09/2012 Page 1 of 3
This form is used to obtain complete and accurate information regarding the prospective or current
Bridge resource parent’s health history and is completed by the: (1) Bridge resource applicant as a
component of the application packet; or (2) Bridge resource parent during the re-assessment
process.
Resource Information
Resource name Resource number
Mailing address City
ZIP code County of residence
Bridge applicant or Bridge resource parent's name
Have You Ever Been Treated For:
arthritis
tuberculosis
asthma, emphysema, or other respiratory illnesses
heart disease
ulcers
eating disorders
diabetes
recurrent headaches or migraines
convulsions or epilepsy
cancer
drug abuse
alcohol abuse/alcoholism
other substance abuse
physical handicap, including birth defect or amputation
blood disease
communicable disease
State
Form 04AF017E v.3 08/09/2012 Page 2 of 3
hearing impairment
blindness, eye disease, or significant vision impairment
kidney disease
had surgery
been hospitalized
received psychological or psychiatric counseling or inpatient treatment
received family or marital counseling
Have You Ever:
had surgery
been hospitalized
received psychological or psychiatric counseling or inpatient psychiatric treatment
received family or marital counseling
Provide Information for any Box Checked
Condition Dates Treatment and results
List all Prescribed and Over-the-Counter Medications You Currently Take and the Related
Condition
Medication Dosage Frequency Related condition
Form 04AF017E v.3 08/09/2012 Page 3 of 3
Has a Child in Your Household Other than a Child in OKDHS Custody:
received psychological or psychiatric counseling or substance abuse treatment? Yes No
If yes, child's name:
received treatment for any major health condition? Yes No
If yes, child's name:
Bridge applicant or resource parent signature Date
Bridge applicant or resource parent signature Date
Routing Information
Original - resource record
Copy - resource assessment contractor, when applicable