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.