2023 Louisiana Laws › Children's Code › Art. 1125. Statement of family history; contents; form

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.