ADOPTIVE APPLICANT MEDICAL REPORT

 

Patient’s Name: ___________________________________Date of Birth:_________________

Address:_________________________________City:_____________ State:_____Zip:______

To examining physician:

In evaluating the applicant, this agency and the Center of Adoption Affairs must be guided by your medical findings as reported on this form.  Thank you for your assistance.  Please print legibly or type all information.  Please do not leave blanks.  Children’s Hope International

 

CIRCLE ‘No’ or ‘Yes’ ANY MEDICAL HISTORY OF:                                          

Yes  No = Tuberculosis              Yes  No= Sexual Disease             Yes  No= Alcoholism

Yes  No = Tumor             Yes  No= Nervous Disorder                    Yes  No= Substance Abuse

Yes  No = Heart problems           Yes  No= Mental Disease           Yes  No= Genetic Disease

Yes  No = Liver Disease    Yes  No= Other Communicable Disease     Yes  No= Any Surgeries

Any other significant physical problems? __________________________________________________________

Is the patient taking any medications? (List here) ___________________________________________________ _______________________________________________________________________________________________

If ‘Yes’ to any of the above:  use the back of this sheet to describe: dates, course of treatments and final results.

 

CURRENT PHYSICAL CONDITION:

Height:  ________________    Weight:_________________    Blood pressure:________________  

Vision = Normal / Abnormal            Hearing = Normal / Abnormal        Heart = Normal / Abnormal                            

Liver = Normal / Abnormal              Lungs = Normal / Abnormal            Lymphatic System= Normal / Abnormal      

Thyroid = Normal / Abnormal         Nervous system = Normal / Abnormal                          

 

LABORATORY TESTS:                                  Date of  Tests:____________________

Routine Blood Test = Normal / Abnormal                HIV = Negative / Positive                                 

HbsAg = Negative / Positive                                         Liver Function = Normal / Abnormal

Routine Urinalysis  = Normal / Abnormal

 

DO YOU BELIEVE THIS PATIENT IS PHYSICALLY, MENTALLY AND EMOTIONALLY CAPABLE OF ASSUMING THE RESPONSIBILITIES OF ADOPTIVE PARENTHOOD? 

YES______     NO______

 

Date of Report:__________________

 

Name of Physician (Please Print Clearly)_______________________________________________________________

 

Address:______________________________________________________________________________

 

Signature:________________________________________________
Lic. No.                                               

                                                 Examining Physician Name

 

Sworn to and subscribed  before me this _____day of _____________, A.D. 20____

                                                                                                                               

_______________________________________________________

Notary Public

State of_______________________      County of_______________ 
     My commission expires:______________