Georgia Department Of Human Resources Medical Evaluation Of An Adult In A Foster Or Adoptive Home

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GEORGIA DEPARTMENT OF HUMAN RESOURCES
Medical Evaluation of an Adult in a Foster or Adoptive Home
Name of Person Examined:
Date:
Date of Birth:
Foster Care Applicant
Adoption Applicant
This form will aid the Department in determining the physical wellness and capabilities of foster
and/or adoptive parents who are or may be caring for children. Please complete the following
summary of health problems, conditions, and medication use that may affect his/her ability to
maintain alertness, endurance, and performance of tasks and responsibilities associated with
caring for up to six children, ages 0 to 18 now and for the foreseeable future (five to ten years).
I. HISTORY
1. Check any health problems:
Heart Problems
Arthritis
Depression
Mental Illness
Lung Problems
Obesity
Sleep Disorder
Hepatitis
Diabetes
Poor Ambulation
Confusion
Allergies
High Blood Pressure
Weak/Frail
Dementia
Other
Asthma
Vision
Epilepsy/Seizures
Kidney Disease
Hearing
Strokes/Paralysis
Explain all medical condition(s) checked and any other chronic conditions:
2. Are there any condition(s) that are progressive in nature? Yes
No
If yes, explain:
3. Is there a terminal illness that could interfere with this person’s ability to care for a child in the next ___5 years,
___10 years ___15 years? If yes, explain:
4. Medication(s):
Are there any physical limitations as a result of medication(s)? Yes
No
If yes, explain:
5. Illness/Injuries, Operations or Hospitalizations during the last 5 years:
Illness/Injury
Operation
Hospitalization
Date
Outcome
FORM 36 Medical Report (Rev. 8-04)
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