Lynn McNeese Swank
Swanklaw.com
lswank@swanklaw.com

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Form 413 (DHR)

Georgia Department of Human Resources
BACKGROUND INFORMATION FOR NON-STATE AGENCY CHILD
For use as attorney-client work product only.
 
Today's Date: 
Responsible Party: Legal Name of Child:
Telephone No.: Date: Date of Birth of Child: Sex:
Resident County: Placement County: Race/Ethnic:

ALL RELATIONSHIPS ARE TO THE CHILD

Child's Name


Maternal
 MotherGrandmotherGrandfather
Date of Birth:
Race/Ethnic:
National Descent:
Hair Color:
Eye Color:
Complexion:
Weight:
Height:
Occupation:
General Health:
Education:
If Deceased, Age & Cause:
Special Characteristics:

Paternal
 FatherGrandmotherGrandfather
Date of Birth:
Race/Ethnic:
National Descent:
Hair Color:
Eye Color:
Complexion:
Weight:
Height:
Occupation:
General Health:
Education:
If Deceased, Age & Cause:
Special Characteristics:

Maternal Aunts & Uncles
Date of Birth:
Race/Ethnic:
National Descent:
Hair Color:
Eye Color:
Complexion:
Weight:
Height:
Occupation:
General Health:
Education:
If Deceased, Age & Cause:
Special Characteristics:

Paternal Aunts & Uncles

Date of Birth:
Race/Ethnic:
National Descent:
Hair Color:
Eye Color:
Complexion:
Weight:
Height:
Occupation:
General Health:
Education:
If Deceased, Age & Cause:
Special Characteristics:

Reason Child Placed:

ALL RELATIONSHIPS ARE TO THE CHILD

Siblings Maternal
Date of Birth:
Full or Half Sibling:
Sex:
Hair Color:
Eye Color:
Complexion:
General Build:
General Health:
School Grade and Achievement:
Special Characteristics:

Siblings Paternal

Date of Birth:
Full or Half Sibling:
Sex:
Hair Color:
Eye Color:
Complexion:
General Build:
General Health:
School Grade and Achievement:
Special Characteristics:

SOURCE OF INFORMATION:

ALL RELATIONSHIPS ARE TO THE CHILD

Family of Child's Mother
Maternal
 Great GrandmotherGreat Grandfather
Date of Birth:
Race/Ethnic:
National Descent:
Hair Color:
Eye Color:
Complexion:
Weight:
Height:
Occupation:
General Health:
Education:
If Deceased, Age & Cause:
Special Characteristics:

Paternal

 Great GrandmotherGreat Grandfather
Date of Birth:
Race/Ethnic:
National Descent:
Hair Color:
Eye Color:
Complexion:
Weight:
Height:
Occupation:
General Health:
Education:
If Deceased, Age & Cause:
Special Characteristics:

Maternal Great Aunts & Uncles

Date of Birth:
Race/Ethnic:
National Descent:
Hair Color:
Eye Color:
Complexion:
Weight:
Height:
Occupation:
General Health:
Education:
If Deceased, Age & Cause:
Special Characteristics:

Paternal Great Aunts & Uncles

Date of Birth:
Race/Ethnic:
National Descent:
Hair Color:
Eye Color:
Complexion:
Weight:
Height:
Occupation:
General Health:
Education:
If Deceased, Age & Cause:
Special Characteristics:

SOURCE OF INFORMATION:

ALL RELATIONSHIPS ARE TO THE CHILD

Family of Child's Father
Maternal
 Great GrandmotherGreat Grandfather
Date of Birth:
Race/Ethnic:
National Descent:
Hair Color:
Eye Color:
Complexion:
Weight:
Height:
Occupation:
General Health:
Education:
If Deceased, Age & Cause:
Special Characteristics:

Paternal

 Great GrandmotherGreat Grandfather
Date of Birth:
Race/Ethnic:
National Descent:
Hair Color:
Eye Color:
Complexion:
Weight:
Height:
Occupation:
General Health:
Education:
If Deceased, Age & Cause:
Special Characteristics:

Maternal Great Aunts & Uncles

Date of Birth:
Race/Ethnic:
National Descent:
Hair Color:
Eye Color:
Complexion:
Weight:
Height:
Occupation:
General Health:
Education:
If Deceased, Age & Cause:
Special Characteristics:

Paternal Great Aunts & Uncles

Date of Birth:
Race/Ethnic:
National Descent:
Hair Color:
Eye Color:
Complexion:
Weight:
Height:
Occupation:
General Health:
Education:
If Deceased, Age & Cause:
Special Characteristics:

SOURCE OF INFORMATION:

Family Medical Information
Maternal

Check YES or NO to each of the following diseases or conditions, if the answer is YES give family member, and brief description of disease, condition, its effect, age of onset, age if cause of death, in the space below.

COMPLETE ONE FORM ON MOTHER'S FAMILY AND ONE FORM ON FATHER'S FAMILY
 YesNo YesNo YesNo
1. Allergies7. Congenital Birth Abnormalitiesb) still births
a) drugs8. Cleft Lipc) incompetent cervix
b) foods9. Cleft Palated) ectopic pregnancies
c) asthma10. Cystic Fibrosise) eclamptogenic toxemia
d) hay fever11. Diabetesf) spontaneous abortion
e) other12. Dwarfismg) other
2. Alcoholism-Drug Addiction13. Epilepsy29. Respiratory Diseases
3. Blood diseases14. Hearing Disordersa) emphysema
a) hemophilia15. Huntington Diseaseb) Bacterial pneumonia
b) Rh disease16. Hyperactivityc) tuberculosis
c) sickle cell disease trait17. Immune System Diseased) other
d) thalassemia (cooley's amenia)a) HIV Positive30. Skin Disorders
e) otherb) AIDSa) psoriasis
4. Bone diseases18. Learning Disability (specify)b) other
a) arthritis31. Speech Disorders
b) curvature of spinea) stuttering
c) other structural malformation19. Liver Diseaseb) tongue tie
d) other20. Mental Illnessc) sound omissions
5. Cancera) manic-depressived) delayed speech
a) breastb) schizophreniae) other
b) bowelc) other