La. Child. Code art. 1125
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 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 child had the following immunizations?
YESNO 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?
YESNO 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?
La. Ch.C. § 1125