GENERAL PHYSICAL EXAMINATION FOR ADOPTIVE APPLICANT
GENERAL PHYSICAL EXAMINATION FOR ADOPTIVE APPLICANT
A NOTE TO THE EXAMINING PHYSICIAN: Please print clearly or type all information. Do not leave any question blank. Incomplete or illegible forms will need to be re-done. NO WHITE OUT PLEASE!
Applicant's Name: _____________________________________________ DOB: ________________________________
By signing on this form below, I give permission for my physician or health agency representative to release information about my physical and mental condition to CCAI as it pertains to my adoption.
**Please note: Applicant should sign this form AFTER the physician, but prior to submission to CCAI. MEDICAL HISTORY--Please check "No" or "Yes" and indicate Type:
NO YES TYPE
NO YES TYPE
Tuberculosis ____ ____ _______
Tumors
____ ____ _______
Heart Disease ____ ____ _______
(if "yes" please specify benign or malignant tumor)
Sexual Disease ____ ____ _______
Liver Disease
____ ____ _______
Mental Illness ____ ____ _______
Nervous Disorder
____ ____ _______
Lupus
____ ____ _______
Epilepsy
____ ____ _______
Any Operations ____ ____ __________________ Genetic Disease
____ ____ _______
(date & reason)
Alcohol/Drug Abuse
____ ____ _______
_____________________ Other Communicable Diseases ____ ____ _______
PHYSICAL EXAMINATION ?Please check, fill-in, or circle one of the following:
Date of Exam: __________ Height (inches): _______ Weight (lbs): _______ BMI: _______ Blood Pressure: ________
Right Eye Left Eye Right Hearing Left Hearing Heart Kidneys
HBsAntigen:
HIV Test:
Blood Count:
Urinalysis:
NORMAL _____ _____ _____ _____ _____ _____
ABNORMAL _____ _____ _____ _____ _____ _____
Liver Lungs Lymph Thyroid Nervous System Liver Function
NORMAL _____ _____ _____ _____ _____ _____
Date: _______________ Results: Neg. or Pos (circle one)
Date: _______________ Results: Neg. or Pos. (circle one)
Date: _______________ Hb:_____________ Hct:_________________
Date: _______________ S.G:_____________ Alb:_________________
ABNORMAL _____ _____ _____ _____ _____ _____
WBC:________________ Sug:_________________
MEDICATIONS--Please indicate the following:
Is the patient taking any medications?
(please circle)
Yes or
No
If yes, name of medication(s) and dosage amount: ___________________________________________________________
Purpose of medication(s) ________________________________________________________________________________
Has the treatment been successful? ________________________________________________________________________
PHYSICIAN'S STATEMENT: It is my opinion that the applicant is in good and stable physical and mental condition necessary to provide responsible care for an adopted child.
Signed: _________________________________________, M.D. / D.O (circle) Doctor's Printed Name: _____________________________________________
Date: _________________ License No._____________
I, __________________________________________ (Applicant's name) attest that this is a true original, unaltered document. Signature of Applicant: _________________________________________________________ Date:_________________
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