Washington Birth Parent Medical History (DOH 422-111)
Official state formAdoptionForm DOH 422-111Free downloadLast verified November 10, 2026
A birth parent of an adopted child completes this medical history questionnaire about themselves and their blood relatives. It is filed with the contact preference form at the Center for Health Statistics, Washington State Department of Health.
Who can use this form
- A birth mother or parent, or a birth father or parent, of an adopted child
- The birth parent marks whether they or a blood relative have each listed medical condition, or that it is not known
What to send with it
- The completed medical history form
- The Contact Preference Form for birth parents (DOH 422-110), which it is filed with
Where to send it
- Mail to
- Center for Health Statistics PO Box 47814 Olympia, Washington 98504-7814
- State fee
- Not provided
- Typical processing
- Not provided
- Form revision
- August 2018
- Source
- Official government page