Date:
RE:
Patient’s Name (Please Print) / Date of Birth
Dear Dr.
(Please Print)
I have applied to Bethany Christian Services of ______to adopt or foster a child. As part of the process, it is necessary that I have a medical evaluation and recommendation regarding each adult in our home.Please complete the questions below and return this form to the agency at the address below. This release to be accompanied by a completed Authorization of Release of Records or Information form.Thank you.
Sincerely,
Signature of Applicant or Adult Household Member
To be completed by Physician:
Length of time physician has known patient: / Height: / Weight:
Date of examination: / Blood pressure: / Pulse:
Acute medical conditions: / Chronic medical conditions:
Treatment/management of conditions: / Treatment Compliance:
Past resolved medical/mental health conditions: / Surgeries:
Present prescriptionmeds, purpose, length of treatment & prescriber: / Significant physical findings:
Significant Personal Health Habits: / Significant family history:
Alcohol use: / Tobacco:
Diet: / OTC meds:
Exercise : / Seatbelt use:
Are there any medications, or physical, emotional, or mental conditions noted that would jeopardize a normal parental role or shorten life expectancy? If yes, please explain. / Laboratory Results
TB testing PPD (if mandated by state):
7 or 10 panel Urine Drug Screening
(non-legal)
I, the undersigned physician, have examined the above mentioned individual and have provided accurate answers to each question to the best of my professional knowledge and judgement.
Physician’s Signature:
License #: / Date Signed:
Please return to: Bethany Christian Services of ______
(Address)
Physician’s Report for Adoption - Child
Date:
RE:
Patient’s Name (Please Print) / Date of Birth
Dear Dr.
(Please Print)
I have applied to Bethany Christian Services of ______to adopt or foster a child. As part of the process, it is necessary to have a medical evaluation and recommendation regarding each child in our home. Please complete the questions below and return this form to the agency at the address below. This release to be accompanied by a completed Authorization of Release of Records or Information form. Thank you.
Sincerely,
Signature of Parent/Legal Guardian of Child
To be completed by Physician:
Length of time physician has known patient: / Height: / Weight:
Date of examination: / Blood pressure: / Pulse:
Immunization History:
(Please attach immunization record)
Acute medical conditions: / Chronic medical conditions:
Present prescription meds/vitamins & purpose: / Significant family history:
Significant household habits (child safety restraints, tobacco exposure, exercise, diet, etc.):
Significant physical findings:
Are there any physical, emotional, or mental conditions of the child which would limit or negatively affect the family’s ability to adopt and care for another child? YES NO
If yes, please explain: / Does this family follow through on treatment recommendations?
I, the undersigned physician, have examined the above mentioned child and have provided accurate answers to each question to the best of my professional knowledge and judgement.
Physician’s Signature:
License #: / Date Signed:
Please return to: / Bethany Christian Services of ______
(Branch Address)
APPROVED: 06/27/2011 by TQM Committee(Combines Adult & Child Reports)
Approved: 8/24/2016 by National Adoption Services Team.
Physician’s Report for AdoptionPage 1 of 2