Questions for the Director/ Caregiver/Doctor

Child’s Name: ______

The child’s birth date: ______
Where was the child born, e.g. town/hospital name: ______
Who named the child: ______
Date the child entered the institution: ______
Length of time the child spent with his/her birth family: ______
Length of time the child spent in the baby house: ______
What is the child’s ethnic background? ______
Reason why the child is placed for adoption: ______

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Does the baby house have the relinquishment paper signed by the parents?______
If the parental rights were terminated, does the baby house have the court papers? ______
What is the birth mother’s name: ______
How old is the child’s mother? ______
How many pregnancies for the mother? ______
What is the mother’s date of birth or just her age: ______
What is the mother’s physical description (her built, color of eyes, color of hair ) ______

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What is the mother’s occupation: ______

What was the mother's health during pregnancy: ______
What is the mother’s history of alcohol abuse: ______
What is the mother’s history of drug abuse: ______
Was the pregnancy full term: ______
Was there any complications with delivery: ______
What is the birth father’s name: ______
What is the birth date of the father or just his age: ______
What is the father’s occupation: ______
What is the father’s physical description: ______
Where are the birthparents from, which city/town: ______
Names and ages of other siblings: ______

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What is known about the health history of the parents and siblings if any: ______

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Was baby premature? ______

Number of weeks premature if applicable: ______
Normal delivery or C-section: ______
What was the child's Apgar scores and at what minute intervals: ______

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Child’s birth weight: ______

Child’s birth height: ______
Child’s head circumference at birth: ______

Range of measurements over time:

Date / Age / Height / Weight / Head Circumference

What antibiotics has the child been given: ______

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Was child hospitalized since birth:______

Reason:______
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Any injuries the child may have endured: ______

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Has the child had any illnesses, and if so how were they treated: ______
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Any allergies the child may have:______

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If child tested positive for syphilis at birth, was he tested again and what was the results: _____

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If child tested positive at birth for HIV, was he tested again afterwards and what were the results: ______
What is the lab results for HIV: ______
What is the lab results for Hepatitis A & B: ______
What is the lab results for syphilis: ______
What is the lab results for tuberculosis: ______
Immunizations the child has received:

Name of vaccination / Date(s) administered

How many children are in the baby house:______
How many care takers in the orphanage: ______
What is the child’s routine: ______

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How does the doctor thinks the child compares to other babies of his/her age at the orphanage:

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Has the child have any convulsions what the doctor knows of: ______
Does the baby house have pictures of the child when younger, if so, may we take a picture of it:

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What food do you feed the child and what is the feeding schedule: ______

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Do you have a difficult time feeding him/her? Is she very picky: ______
How does the child sleep: (good, difficult, fret a lot): ______
Can I see the child with his/her caregiver communicate without him/her seeing us: ______
What is the personality of the child: ______

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Is there a caregiver the child is very attached to? If so, what is her name: ______

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Ask the doctor if she can do the following physical assessment of the child in front of you:

Are the muscle mass and fat on arms and legs approximately equal?(indicating the baby is equally coordinated and developed on both sides)
Any deformities or birthmarks?
With baby on his/her tummy; are the creases at the back of the legs where the knees bend and at the buttocks the same on both legs
While on the tummy, does the doctor feels any unusual curvature while running her thumbs up the baby's spine
With baby lying on his/her back, does he/she have painless full range of motion with arms and legs
Can baby turn his neck painlessly
Can the baby clenches and unclenches his/her fist
When the doctor shines a flashlight into one eye of the baby, does the pupil constricts and delates? Should be the same for both eyes
When the doctor holds a light 45 cm(18 inches) away from the baby, slowly moving it across from left to right and back. Does the baby’s eyes follow it together without crossing or drifting
If the doctor clap her hands on one side of the child once, does the baby turn his/her eyes and face towards the direction of the clapping? Must be the same for both sides.
If the white part of the baby's eyes is not white, ask the doctor if she have any idea why its not?
Is the ear canals properly located inside the ear and are they unobstructed?
Is the results within the normal range?