FORM SUMMARY Name of Form: Family Medical History Questionnaire Form Number: FA-608 Statutory Reference: Wis. Stats. §§767.24(7m) and 767.51(6) Benchbook Reference: FA 1 Purpose of Form: To comply with §§767.24(7m) and 767.51(6) which require the court to order a noncustodial parent to complete a medical history questionnaire. Who Completes It: Completed by the appropriate parent(s). Distribution of Form: Noncustodial parent sends original to the clerk of court. The clerk then forwards the questionnaire to the physician. The court does not retain a copy. Accompanying Forms: None New Form/Modification: Modification; last update 6/00. Modification to form summary only. Modification: Several changes were made to the form summary to clarify that it is the clerk of court’s responsibility to send the questionnaire to the physician. The Purpose of Form section was revised by removing that last part of previous sentence “for transmittal to the child’s physician in the case of future medical need concerning the child(ren). The Distribution section was revised. Comments: This questionnaire is required in both family and paternity proceedings. The clerk of court is required to send the questionnaire to the physician or other health care provider with primary responsibility for the treatment and care of the child as designated by the parent who is granted legal custody of the child. If there is more than one child, and each child has a different primary physician or medical provider, a separate form should be completed for each child. This form is intended to provide relevant medical information to medical professionals in the future if such is needed to treat the child(ren). This document must be sent by the court to the physician for inclusion in the child's medical records. The physician is required to keep the document confidential. RMC sought input from the State Medical Society of Wisconsin concerning possible revisions on this form to make the information collected as useful as possible to the medical practitioners who would be relying on it in the future. This version uses the wording, format and sequence for medical conditions suggested by the Society. The clerk may wish to retain a transmittal letter in the file for future reference. About this form: This form is the product of the Wisconsin Records Management Committee, a committee of the Director of State Court's Office and a mandate of the Wisconsin Judicial Conference. If you have additional information that does not change the meaning of the form, attach it on a separate page. The form itself shall not be altered. Date: 05/18/01 Date: 05/01/04 (form summary revision only) 1 American LegalNet, Inc. www.USCourtForms.com STATE OF WISCONSIN, CIRCUIT COURT, COUNTY For Official Use Please print or type Family Medical History Questionnaire Petitioner: -VS- Case No. 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. Do Medical Condition No Not Know Comments: Who (what is the relationship of the person with the condition to the es 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, mental retardation, 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 11. Muscle weakness, hernias FA-608, 05/01 Family Medical History Questionnaire §§767.24(7m), 767.51(6), Wisconsin Statutes This form shall not be modified. It may be supplemented with additional material. Page 1 of 2 American LegalNet, Inc. www.USCourtForms.com Family Medical History Questionnaire Page 2 of 2 Do Medical Condition Case No. Comments: Who (what is the relationship of the person with the condition to the No Not Yes child; for example, mother, maternal aunt, paternal grandfather, etc.), when did it Know 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, hepatitis 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 FA-608, 05/01 Family Medical History Questionnaire §§767.24(7m), 767.51(6), Wisconsin Statutes This form shall not be modified. It may be supplemented with additional material. Page 2 of 2 American LegalNet, Inc. www.USCourtForms.com