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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.)
		Mental retardation-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

( )

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

( )

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.