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 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? 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?
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