Annexure -IX
MEDICAL REPORT OF THE PROSPECTIVE ADOPTIVE PARENTS
ADDRESS OF THE AGENCY:
Name:_______________________________________________________________________
Sex: Male / Female
Date of Birth:_________________
NOTE: Pl. fill the form completely Write Nil or N.A. (not applicable) under the items that do not apply.
PRESENT HEALTH STATUS
NOTE: Please indicate if medication is being taken for maintaining status under the following items. The back side of this form may be used if extra space is needed.
- Cardiovascular Status:
- Gastro Intestinal System:
- Genito Urinary System:
- Respiratory System Status:
- Neurological Condition:
- Psychological Status:
- Any condition other than those mentioned above:
HEALTH HISTORY
Please describe illnesses/ major surgeries or accidents, if any and the course of treatment during the last five years. If any permanent handicaps resulted say to what extent they affect normal functioning.
FAMILY HISTORY:
Please indicate the history of physical or mental illness in the family. (Indicate tendencies for Blood Pressure, Diabetes etc.)
TEST FINDINGS
Blood Group:____________ Pulse:____________ Blood Pressure:____________
HIV-I: __________________ HIV-II: ______________________
Hepatitis - ‘B’
REMARKS ON PHYSICAL EXAMINATION & MEDICAL HISTORY:
I am satisfied that the health of the parents does not disqualify the parent/s in parenting the child in anyway.
Date:_________________ Examining Physician _________________
Registration No. _________________
Address:___________________________________________________________________