Louisiana Children's Code Tit. XI, Art. 1125. Statement of family history; contents; form

STATEMENT OF FAMILY HISTORY

Child's Biological MOTHER

Child's Biological FATHER

Age

Height

Weight

Hair color

Eye color

Complexion

Body build

Right/left handed

Occupation

Talents

Religion

Race

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

Asthma

Speech disorders

Curvature of spine

Headaches/migraines

Alcoholism

Substance abuse

Multiple births

SIDS

Rh Factor

Other: specify

Other: specify

Other: specify

Yes

No

If yes,

• state type;

• state amount; and

• state during what months of pregnancy.

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

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