Art. 1125. Statement of family history; contents; form

A. The Statement of Family History shall contain the following nonidentifying information, if known:

(1) The age of each biological parent.

(2) Descriptive information about each biological parent.

(3) The biological relationship between parents, if applicable.

(4) Explicit and extensive medical genetic history of each biological parent and his parents, siblings, grandparents, great-grandparents, aunts, uncles, and cousins.

(5) If applicable, the child's:

(a) Immunization record.

(b) Illness history.

B. The Statement of Family History form shall be substantially as follows:

STATEMENT OF FAMILY HISTORY

Child's Biological MOTHER

Child's Biological FATHER

Age

Height

Weight

Hair color

Eye color

Complexion

Body build

Education-last grade completed/ degree received

Right/left handed

Occupation

Talents

Religion

Race

Ethnicity/

Nation­ality

Native American/Tribal Affiliation, if applicable

Other

Yes

No

Diseases/conditions

If yes,

•

state relationship to child [biological parent (mother or father), sibling (full or half), grandparent (paternal or maternal), great grandparent (paternal or maternal), aunt/uncle/cousin (paternal or maternal)];

•

state specific condition;

•

age of onset;

•

treatment (medication, surgery, etc.); and

•

outcome.

Cancer

Heart disease

Stroke

High blood pressure

Diabetes

Kidney disease

Liver disease

Digestive disorders

Respiratory disorders

Blood disease (sickle cell, hemophilia, etc.)

Glandular disturbances (thyroid, adrenal, growth, etc.)

Neurological & muscular disorders (multiple sclerosis, muscular dystrophy, Tay-Sachs, etc.)

Arthritis (juvenile, rheumatoid, gout, hammertoe, etc.)

Epilepsy, seizures, convulsions

Allergies (drugs, food, other)

Asthma

Vision problems/blindness

Hearing problems/deafness

Speech disorders

Dental problems/braces

Birth defects (cleft palate, missing digit, club foot, etc.)

Curvature of spine

Headaches/migraines

Alcoholism

Substance abuse

Eating disorders/obesity

Mental illness (schizophrenia, bipolar, depressive, etc.)

Intellectual disability-non-injury (PKU, Down's Syndrome, etc.)

Learning disabilities (ADD, ADHD, etc.)

Multiple births

Miscarriages, stillbirths, neonatal deaths

SIDS

Rh Factor

HIV ( biological mother only)

Venereal disease during pregnancy

(biological mother only)

Other: specify

Other: specify

Other: specify

Prenatal History

Yes

No

If yes,

•

state type;

•

state amount; and

•

state during what months of pregnancy.

Prescription medication

Over the counter medication

Alcohol

Tobacco

Other Drugs

Are the parents of the child biologically related to each other?

Yes_____ No_____

If yes what is the biological relationship? ____________________

Has the minor child had the following immunizations?

YES

NO

YES

NO

( )

( )

Birth-2 mo. Hepatitis (Hep) B

( )

( )

12-15 mo. Hib, MMR # 1

( )

( )

1 - 4 mo. Hep B

( )

( )

12-18 mo. Var (chickenpox)

( )

( )

2 mo. DTaP, IPV, Hib,

( )

( )

15-18 mo. DTaP

( )

( )

4 mo. DTaP, IPV, Hib,

( )

( )

4-6 yrs. MMR # 2, DTaP,

OPV

( )

( )

6 mo. DTaP, Hib,

( )

( )

11-12 yrs. MMR # 2, Var,

Hep B

( )

( )

6-18 mo. Hep B, IPV

( )

( )

11-16 yrs. Td (tetanus,

diphtheria)

Has the minor child had the following illnesses?

YES

NO

YES

NO

( )

( )

Pertussis (P) (Whooping Cough)

( )

( )

Rheumatic Fever

( )

( )

Rubella (R) (Measles)

( )

( )

Tonsillitis

( )

( )

Mumps (M)

( )

( )

Convulsions

( )

( )

Chicken Pox (Var)

( )

( )

Asthma

( )

( )

Rotavirus (Rv)

( )

( )

Polio (IPV)

( )

( )

Scarlet Fever

( )

( )

Allergies, specify

( )

( )

Diphtheria (D)

________________________________

( )

( )

Surgery, operations, specify ________________________________

( )

( )

Glandular Disturbances, specify _______________________________

Does the minor child have or has he had any other serious illnesses or medical conditions?

Acts 1991, No. 235, §11, eff. Jan. 1, 1992; Acts 1992, No. 705, §5, eff. July 6, 1992; Acts 1999, No. 884, §1; Acts 2008, No. 583, §1; Acts 2010, No. 266, §1; Acts 2014, No. 811, §33, eff. June 23, 2014.