This government document is issued by Child & Family Strengthening Advisory Board for use in San Diego County, CA
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https://www.google.com/url?client=internal-element-cse&cx=015466730696295969998:wokiau6kw8k&q=http://www.sandiegocounty.gov/content/dam/sdc/hr/eBenefits/Documents%2520and%2520Forms/Medical%2520History%2520Statement%2520Form%2520-%2520MetLife%2520Insurance.pdf&sa=U&ved=2ahUKEwir_defgM34AhXySvEDHWGvCLcQFnoECAgQAQ&usg=AOvVaw322BYLz9LyDMp-A0JfSLcG