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

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.)

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

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?

___________________________________________________________________________________________________

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