MISSOURI DEPARTMENT OF SOCIAL SERVICES CHILDREN’S DIVISION CHILD/FAMILY HEALTH AND DEVELOPMENT ASSESSMENT ATTACHMENT A - PARENT INFORMATION
This form contains sensitive and confidential information regarding the child and his family and is protected by the “Health Insurance Portability and Accountability Act.” Neither the form nor its contents may be shared with any person not actively involved in the care and/or treatment of the child.
Child’s Name
MOTHER’S INFORMATION
Mother’s Name:	DOB:
Address:
Race:	Hispanic: Yes No	Nationality Descent:	Religion:
Native American Heritage Yes No	Specify Tribe	Occupation
Eye Color:	Hair: (color/texture)	Complexion:
Height:	Weight:	Body Type:
DESCRIBE PERSONALITY AND APPEARANCE:
EDUCATION:
MOTHER’S REACTION TO PREGNANCY
MEDICAL CARE RECEIVED DURING PREGNANCY
ANY COMPLICATING FACTORS (Health, heredity, legal…etc.)
Hospital	Due Date:

MOTHER’S MARITAL HISTORY
MARRIAGES (LIST CURRENT FIRST AND INCLUDE DATES AND PLACES OF MARRIAGE)
1)
2)
3)
4)
DIVORCES OR DEATH OF A SPOUSE (DATES)
1)
2)
3)
4)
CHILD’S RELATIVES AND FRIENDS OF THE FAMILY
For each of the individuals listed in this section, attach a Child/Family Health and Development Assessment - Relative/Kinship Information (CW-103 Attachment B). Indicate in the attachment section if information is not available.
CHILD’S FULL SIBLINGS (BETWEEN THE CHILD’S BIOLOGICAL PARENTS)
NAME	BIRTHDATE	NAME	BIRTHDATE
CHILD’S HALF SIBLINGS (MOTHER’S CHILDREN WITH OTHER FATHERS)
NAME	BIRTHDATE	NAME	BIRTHDATE
MATERNAL GRANDPARENTS
NAME	ADDRESS	PHONE
OTHER RELATIVES (LIST ALL MATERNAL AUNTS, UNCLES AND COUSINS)
NAME	ADDRESS	PHONE
UNRELATED ADULTS WITH A SIGNIFICANT RELATIONSHIP WITH THE CHILD OR FAMILY
NAME	ADDRESS	PHONE

FATHERS’S INFORMATION
Father’s Name	DOB
Address
Race	Hispanic Yes No	Nationality Descent	Religion
Native American Heritage Yes No	Specify Tribe	Occupation
Eye Color	Hair (color/texture)	Complexion
Height	Weight	Body Type
DESCRIBE PERSONALITY AND APPEARANCE
EDUCATION:
FATHER’S REACTION TO PREGNANCY
FATHER’S MARITAL HISTORY
MARRIAGES (LIST CURRENT FIRST AND INCLUDE DATES AND PLACES OF MARRIAGE)
1)
2)
3)
4)
DIVORCES OR DEATH OF A SPOUSE (DATES)
1)
2)
3)
4)

CHILD’S RELATIVES OR FRIENDS OF THE FAMILY
For each of the individuals listed in this section, use a Child/Family Health and Development Assessment - Relative/Kinship Information (CW-103 Attachment B) to provide additional information.
CHILD’S HALF SIBLINGS (FATHER’S CHILDREN WITH OTHER MOTHERS)
NAME	BIRTHDATE	NAME	BIRTHDATE
CHILD’S PATERNAL GRANDPARENTS
NAME	ADDRESS	PHONE
OTHER RELATIVES (LIST ALL PATERNAL AUNTS, UNCLES AND COUSINS)
NAME	ADDRESS	PHONE
UNRELATED ADULTS WITH A SIGNIFICANT RELATIONSHIP WITH THE CHILD OR FAMILY
NAME	ADDRESS	PHONE
CHILDHOOD DISEASES:
Mother	Father
Asthma
Chicken Pox
Diphtheria
German Measles
Rheumatic Fever
Scarlet Fever
Whooping Cough
Other (please specify)
Other Illnesses:

HEALTH HISTORY
Mother	Father	Blood Relative
Allergy (type)
Epilepsy
Diabetes
Tuberculosis
Venereal Disease (type)
Glandular Disturbance
Blindness
Blood Defects (e.g., Sickle Cell, RH and other Blood types, etc.)
Deafness
Mental Deficiency
Mental Illness
Heart Trouble
Cancer
Arthritis
Alcoholism
Congenital Defects
Neurological (e.g., Huntington’s Chorea, Multiple Sclerosis, Amyotrophic Sclerosis, etc.)
Deaths
Drug usage (prescription and non-prescription)
Other
General Health:
Attached Information