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
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Child's Biological MOTHER
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Child's Biological FATHER
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Education-last grade
completed/ degree
received
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Native
American/Tribal
Affiliation, if
applicable
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Other
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No
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Diseases/conditions
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If yes,
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•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.
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Cancer
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Heart disease
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Stroke
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High blood pressure
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Diabetes
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Kidney disease
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Liver disease
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Digestive disorders
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Respiratory disorders
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Blood disease (sickle
cell, hemophilia, etc.)
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Glandular disturbances
(thyroid, adrenal,
growth, etc.)
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Neurological &
muscular disorders
(multiple sclerosis,
muscular dystrophy,
Tay-Sachs, etc.)
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Arthritis (juvenile,
rheumatoid, gout,
hammertoe, etc.)
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Epilepsy, seizures,
convulsions
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Allergies (drugs, food,
other)
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Asthma
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Vision
problems/blindness
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Hearing
problems/deafness
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Speech disorders
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Dental
problems/braces
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Birth defects (cleft
palate, missing digit,
club foot, etc.)
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Curvature of spine
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Headaches/migraines
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Alcoholism
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Substance abuse
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Eating
disorders/obesity
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Mental illness
(schizophrenia,
bipolar, depressive,
etc.)
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Intellectual
disability–non-injury
(PKU, Down
Syndrome, etc.)
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Learning disabilities
(ADD, ADHD, etc.)
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Multiple births
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Miscarriages,
stillbirths, neonatal
deaths
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SIDS
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Rh Factor
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HIV ( biological
mother only)
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Venereal disease
during pregnancy
(biological mother
only)
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Other: specify
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Other: specify
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Other: specify
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No
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If yes,
•state type;
•state amount; and
•state during what months of pregnancy.
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Prescription
medication
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Over the counter
medication
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Alcohol
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Tobacco
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Other Drugs
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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?
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 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 child have or has the child 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; Acts 2024, No. 92, §1.