LA Chil Code art. 1125 (2021)
2021 Louisiana Laws|Children's Code|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.)       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.