Child’s social and medical history




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CFS-107 (Part A)

Revised 2/2003


CHILD’S SOCIAL AND MEDICAL HISTORY

General Information:




CHILD’S FULL NAME


Date of Birth


Social Security Number


     


     


     


Birth Place


Ethnicity


Weight at Birth


     


     


     


Length at Birth


Time of Birth


Apgar Scores


     


     


     


Type of Delivery


Duration of Labor


Full-Term Gestation?

 C-Section  Forceps  Vaginal

     


 Yes  No


Complications of Birth


Blood Type


Weight at Discharge


     


     


     


Breast-Fed? Yes 


Circumcised?


Medications Given


 No -- Formula:


 Yes  No


     


Physical Problems Noted at Birth






     






History of Immunizations & Tests:




TYPE


DATE




TYPE


DATE




TYPE


DATE





DPT

     





Smallpox


     





Tuberculosis


     





Measles


     





Tetanus Booster


     





Other (Specify)


     





Polio


     





Other (Specify)


     





Other (Specify)


     


Developmental Milestones:


MILESTONE


AGE


MILESTONE


AGE


MILESTONE


AGE


MILESTONE


AGE


Turned Over


     


Crawled


     


Walked


     


Toilet Trained


     


Sat


     


Stood


     


Fed Self


     


Used Words


     




Childhood Diseases:




Allergies (Specify)




Diabetes



Poliomyelitis



     



Diphtheria




Recurrent Ear Infections



     




Epilepsy



Recurrent Tonsillitis




     



German Measles




Rheumatic Fever



     



Kidney Infection




Scarlet Fever





Bladder Infection




Measles



Tuberculosis





Bronchitis




Mumps



Typhoid Dysentery





Chicken Pox




Pneumonia





Whooping Cough




Child’s Medical Situation at Time of Placement:


     





Child’s History of Surgeries and/or Hospitalizations:


     





Child’s Physically Handicapping Conditions:


     





Child’s History of Psychological or Psychiatric Treatment (reason & current status):


     





Reason for Child’s placement into out-of-home care (attach copy of Affidavit):


     




Physical Description of Child:


Eye Color


Hair Color


Skin Color


Build


 Right-Handed


     


     

     

     


 Left-Handed


Current Child Status Regarding:

Eating Habits

Sleeping Habits

Bath Habits

Toilet Training


     


     


     

     





Child’s Likes


Child’s Dislikes


     

     

Prenatal History With this Child:




Date prenatal care began


     


Mother’s age at time of this pregnancy


     


Number of previous pregnancies


     


Number of live births


     


Weight Gained during pregnancy


     


Blood Type


     





Medication, drugs and/or alcohol used PRIOR to this pregnancy


Medication, drugs and/or alcohol used during this pregnancy


     


     


Complications/accidents during this pregnancy


Congenital defects of mother


     


     


Surgeries performed during pregnancy with this child


Problems with this Delivery -- explain


     


     




Contagious/Infectious Diseases Birth Mother Experienced:

Chicken Pox




Herpes



Rheumatic Fever



Tuberculosis





German Measles




Measles



Scarlet Fever



Other (Specify):      





Gonorrhea




Mumps



Syphilis



Other (Specify):      





Other Complications with Birth Mother:




Allergies:





Convulsions





Diabetes





Sickle-cell Anemia





Allergies:





Elevated Cystic Fibrosis





Blood Pressure





Toxemia





Siblings to this Child:


NAME


BIRTHDATE


WHEREABOUTS


     


     


     


     


     


     


     


     


     


     


     


     


     


     


     


Relationship between Birth Parents (when this child was conceived):

 Married  Divorced  Separated

 Living Together  Widowed  OTHER:      
Relationship between Birth Parents (at the time of child’s out-of-home placement):

 Married  Divorced  Separated

 Living Together  Widowed  OTHER:      

Placement History:


WHEN TO WHEN


WITH WHOM/WHERE


REASON FOR MOVE

     

     

     

     


     

     

     

     

     

     


     

     

     

     

     


     

     

     





Additional Information/Summary:

     
Person Completing this Form:       Date Completed:      
Person Updating this Form:       Date Completed:      
Person Updating this Form:       Date Revised:      
Person Updating this Form:       Date Revised:      




A





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