Files.dcs.tn.gov



|[pic] |Tennessee Department of Children’s Services |

| |Foster Parent/Other Adult Medical Report |

Foster Parent Other Household Adult

|      |      |

|Last Name |First Name |

|SMOKING | | | |

|Do you smoke? |Yes No |Number/packs of cigarettes per day |      |

| |

|MEDICAL | |

|Are you currently seeing a specialist? |Yes No |

|If yes, name of medical provider |      |Date of last physical |      |

| |

|MENTAL HEALTH | |

|Have you ever been treated or hospitalized for a mental illness or suicide thoughts/attempt |Yes No |

|If yes, list dates and treatment |      |

| |

|TB Risk Assessment Date/Results |      |

|and/or TB (PPD) Date/Results |      |

|or Not at Risk Low Risk |

| | |

|Special needs or disabilities |      |

| |

|Current Medical Problem |      |

| |

|Current Medications |      |

|Date of Last Influenza Immunization |      |

|Pertussis Vaccine Date (Adult Inoculation) |      |

Specify any physical, mental or emotional problems which would affect this person’s ability to care for a child. If the person is identified as other adult living in the home, indicate conditions detrimental to a child’s placement in the home.

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|      |

On the basis of this examination and my knowledge of this patient, I recommend do not recommend this person as a foster or adoptive parent for children.

This is not a foster parent applicant. On the basis of this examination and my knowledge of this patient, I have no concerns with this person residing with children.

|Comments |      |

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| | | |

|Physician Name/NP/PA Name | |Patient’s primary care physician Yes No |

|Physician/NP/PA Signature | |Date | |

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