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Latvia UKRAINE KYRGYZSTAN MEXICO
MEDICAL SUMMARY – HOST FATHER
(Physician signature required if you have not seen a physician in 3 years or more)
Host Father Full Name: Date: Date of Birth:
This form will aid Project 143 and its governing agencies in determining the physical wellness and capabilities of host parents who are, or may be, caring for children. Please complete the following summary of health problems, conditions, and medication use that may affect his/her ability to maintain alertness, endurance and performance of tasks and responsibilities associated with caring for children ages 4 to 16.
MEDICAL HISTORY:
Define any known health/medical problems:
Will this condition affect their ability to parent a child/ren?:
Are there any condition(s) that are progressive in nature? Yes No
If yes, explain:
Is there a terminal illness that could interfere with this person's ability to care for a child in the next 5 yrs, 10 yrs, 15 yrs?
If yes, explain:
Current medication(s) and reason for medication:
Are there any physical limitations as a result of medication(s)? Yes No
If yes, explain:
Will these medications affect this person’s ability to be a successful parent? Yes No
Explain:
HEALTH HABITS:
Is there a history of substances used by this applicant and what degree of impairment exists, if any, from the substance abuse?
Alcohol Drugs Tobacco Other
Are you aware of this person currently undergoing any personal or family counseling?
If so, comment on the nature of the counseling.
HOST FATHER’s DIGITAL SIGNATURE: DATE: Date last physician visit:
CERTIFICATION/SIGNATURE:
(Required if you have not seen a physician in 3 years or more. If your medical information is up to date, please provide only host parents signatures below. The physician signature will not be needed)
I certify that this individual is found free from symptoms of communicable disease.
Yes No If no, explain:
I certify that the individual has no physical, emotional or cognitive limitations that would prevent her/him from parenting a child/ren.
Yes No If no, explain:
With appropriate signed releases, I am available to discuss this report.
Physician's Name (print): Date:
(this form must be signed by a licensed medical physician and not an LNP, RN, PA, etc….)
______
Physician's Signature: State License Number:
Telephone: Address: Date last physician visit:
LATVIA FAMILIES: Ukraine Please e-mail to:
OR MAIL TO: P143, c/o CCAI, 5825 Glenridge Dr., Bldg., 1 Ste. 126, Atlanta, GA 30328, Attn: Allison Miner
UKRAINE FAMILIES: Latvia Please e-mail to:
OR MAIL TO: P143, c/o CCAI, 5825 Glenridge Dr., Bldg., 1 Ste. 126, Atlanta, GA 30328, Attn: Allison Miner
KYRGYZSTAN FAMILIES: Please e-mail to:
OR MAIL TO: 2916 Waycross Drive, Monroe, NC 28110, Attn: Stephanie Myatt
MEXICO FAMILIES: Please e-mail to:
OR MAIL TO: P143, c/o ICF, 11449 N. Mandarin Lane Tucson, AZ 85737 Attn: Jackie Semar
Latvia UKRAINE Kyrgyzstan MEXICO
MEDICAL SUMMARY – HOST MOTHER
(Physician signature required if you have not seen a physician in 3 years or more)
Host Mother Full Name: Date: Date of Birth:
This form will aid Project 143 and its governing agencies in determining the physical wellness and capabilities of host parents who are, or may be, caring for children. Please complete the following summary of health problems, conditions, and medication use that may affect his/her ability to maintain alertness, endurance and performance of tasks and responsibilities associated with caring for children ages 4 to 16.
MEDICAL HISTORY:
Define any known health/medical problems:
Will this condition affect their ability to parent a child/ren?:
Are there any condition(s) that are progressive in nature? Yes No
If yes, explain:
Is there a terminal illness that could interfere with this person's ability to care for a child in the next 5 years, 10 years, 15 years?
If yes, explain:
Current medication(s) and reason for medication:
Are there any physical limitations as a result of medication(s)? Yes No
If yes, explain:
Will these medications affect this person’s ability to be a successful parent? Yes No
Explain:
HEALTH HABITS:
Is there a history of substances used by this applicant and what degree of impairment exists, if any, from the substance abuse?
Alcohol Drugs Tobacco Other
Are you aware of this person currently undergoing any personal or family counseling? If so, comment on the nature of the counseling.
HOST MOTHER’s DIGITAL SIGNATURE: DATE: Date last physician visit:
CERTIFICATION/SIGNATURE:
(Required if you have not seen a physician in 3 years or more. If your medical information is up to date, please provide parents signatures below. The physician signature will not be needed)
I certify that this individual is found free from symptoms of communicable disease.
Yes No If no, explain:
I certify that the individual has no physical, emotional or cognitive limitations that would prevent her/him from parenting a child/ren.
Yes No If no, explain:
With appropriate signed releases, I am available to discuss this report.
Physician's Name (print): Date:
(this form must be signed by a licensed medical physician and not an LNP, RN, PA, etc….)
______
Physician's Signature: State License Number:
Telephone: Address: Date last physician visit:
LATVIA FAMILIES: Ukraine Please e-mail to:
OR MAIL TO: P143, c/o CCAI, 5825 Glenridge Dr., Bldg., 1 Ste. 126, Atlanta, GA 30328, Attn: Allison Miner
UKRAINE FAMILIES: Latvia Please e-mail to:
OR MAIL TO: P143, c/o CCAI, 5825 Glenridge Dr., Bldg., 1 Ste. 126, Atlanta, GA 30328, Attn: Allison Miner
KYRGYZSTAN FAMILIES: Please e-mail to:
OR MAIL TO: P143, 3038 Proverbs Court, Monroe, NC 28110, Attn: Stephanie Myatt
MEXICO FAMILIES: Please e-mail to:
OR MAIL TO: P143, c/o ICF, 11449 N. Mandarin Lane Tucson, AZ 85737 Attn: Jackie Semar