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Caring Adoption Associates: Medical Examination Report of Prospective Adoptive Parent

This document contains a medical examination report for prospective adoptive parents. It requests information about the applicant's physical health, medical history, current health conditions, medications, history of drug/alcohol abuse and the examining physician's opinion on whether any factors could impact the applicant's ability to care for a child. The examining physician must provide their name, contact information and signature to verify the report.

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587 views1 page

Caring Adoption Associates: Medical Examination Report of Prospective Adoptive Parent

This document contains a medical examination report for prospective adoptive parents. It requests information about the applicant's physical health, medical history, current health conditions, medications, history of drug/alcohol abuse and the examining physician's opinion on whether any factors could impact the applicant's ability to care for a child. The examining physician must provide their name, contact information and signature to verify the report.

Uploaded by

aniketsethi
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
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Download as PDF, TXT or read online on Scribd
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CARING ADOPTION ASSOCIATES

MEDICAL EXAMINATION REPORT OF PROSPECTIVE ADOPTIVE PARENT

To examining physician: Our client has come to you in response to a request for a complete
report on his/her physical condition. It is important for us to know of any health factors which
may interfere with this person’s ability to raise a child from infancy to adulthood. Please fill out
this form completely and state if a category is not applicable.

Name: Date of Exam:

Address: Date of Birth:


Current measurements/evaluation
Height: Vision: Blood pressure:
Pulse: Lungs: Heart:
Weight: If the patient is overweight, is he/she at a health risk?
Is the patient on a weight reduction program? If so, what is the goal?
Medical history of patient and current status (Check and give dates when possible.)
Accidents: Diabetes: Mental Illness:
Allergies: Epilepsy/Seizure dis: Neurological dis:
Anemia: Hearing/Eye disorder: Rheumatic Fever:
Asthma: Heart problems:
Cancer: Hepatitis:
List surgeries and dates:
Other medical conditions:
Comments on prognosis for continued health:
Is patient currently on medication? Name and dosage:
History of alcohol or drug abuse:
Has patient ever participated in a drug or alcohol rehabilitation program?
In your opinion would the applicant’s physical and emotional health be hazardous to the child
and/or impact his/her ability to care for a child until adulthood? If yes,
please explain:

How long have you known this patient?


Additional comments:

I have examined this patient and in my opinion, he/she is free of any communicable and
contagious disease or any physical or mental impairment that could endanger an adoptive child
placed in the same household in which this patient resides. Additionally, in my opinion, the
patient does not have any physical or mental condition which would impair his/her ability to care
for an adoptive child.

Physician’s name: _______________________________Telephone#___________________

Address: _________________________________________________________________

Examining physician’s signature: ________________________________________________

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