FA-608, 03/12 Family Medical History Questionnaire 247247767.41(7m) and 767.89(5), Wisconsin Statutes This form shall not be modified. It may be supplemented with additional material. Page 1 of 2 STATE OF WISCONSIN, CIRCUIT COURT, COUNTY Family Medical History Questionnaire Case No. Petitioner: - VS - Respondent: (Parent with sole legal custody completes this section only.) The children subject to the custody order in this case are: Name Date of Birth Name and Address of Child's Primary Physician Parent without legal custody must complete the following medical history questionnaire. The purpose is to record any known medical conditions and medical history information that may affect your child(ren). This information can then be used to diagnose and treat your child(ren) in the future if that becomes necessary. The information must be specific as to you, your parents, your brothers and sisters, and the brothers or sisters of any child(ren) subject to this order. This is a confidential medical history document: The physician or health care provider will retain and release the information in a confidential manner in accordance with statutory requirements. This information is needed for the possible health and safety of your child! Please be accurate and complete. Medical Condition No Do Not Know Yes Comments: Who (what is the relationship of the person with the condition to the child; for example, mother, maternal aunt, paternal grandfather, etc.), when did it occur, specific diagnoses and treatment (attach extra explanation, if needed) 1. Visual problems, glaucoma, lazy eye, cataracts, blindness 2. Hearing problems, deafness, speech problems 3. Dental problems, extra or missing teeth, cleft palate or lip 4. Learning or emotional disability, intellectual disability, attention deficit disorder 5. Mental illness, depression, mania 6. Frequent headaches (tension, migraine), hydrocephalus 7. Skin problems, birthmarks, eczema , acne, different colored patches of hair or skin 8. Bleeding problems, hemophilia, sickle cell anemia 9. Heart attack, stroke, high blood pressure 10. Bone defect, open spine, spinal curvature, arthritis American LegalNet, Inc. www.FormsWorkFlow.com FA-608, 03/12 Family Medical History Questionnaire 247247767.41(7m) and 767.89(5), Wisconsin Statutes This form shall not be modified. It may be supplemented with additional material. Page 2 of 2 11. Muscle weakness, hernias Medical Condition No Do Not Know Yes Comments: Who (what is the relationship of the person with the condition to the child; for example, mother, maternal aunt, paternal grandfather, etc.), when did it occur, specific diagnoses and treatment (attach extra explanation, if needed) 12. Cancer (type, site, age) 13. Birth defects: Downs, Cystic Fibrosis, Huntington's Chorea, cerebral palsy, muscular dystrophy, others 14. Nerve - muscle disorder, multiple sclerosis, myasthenia gravis 15. Seizure disorder 16 Diabetes (juvenile or adult, insulin or noninsulin) 17. Thyroid disorder, other hormone disorder, dwarfism 18. Breathing problems, asthma, emphysema, tuberculosis, allergies 19. Medical or food allergies 20. Kidney or liver problems, hepatit is B or C carrier 21. Chemical dependency - alcohol, tobacco, other substances 22. Stomach problems, ulcer, reflux 23. Weight problems, obesity, anorexia 24. Hand or feet abnormalities, club foot, webbed, extra or missing fingers or toes 25. Miscarriages or stillbirths (number and cause, if known) 26. Multiple births (identical or nonidentical), infertility 27. HIV infection (only if parent of child) 28. AIDS (only if parent of child) 29. Other health problems or concerns 30. During the past year I have not had a medical examination. I have had a medical examination. Explain when, by whom, for what complaints, results of exam, medications or other treatment and present status or condition I certify that the information provided is true, correct and complete to the best of my knowledge, information and belief. Signature Name Printed or Typed Date American LegalNet, Inc. www.FormsWorkFlow.com