Georgia Department Of Human Resources Medical Evaluation Of An Adult In A Foster Or Adoptive Home Page 2

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6. Health Habits
Is there a history of substances used by the applicant and what degree of impairment exists, if any, from the
substance use?
Alcohol
Drugs
Tobacco
Other
II. PHYSICAL EXAMINATION
HEIGHT
WEIGHT
TEMPERATURE
PULSE
BLOOD PRESSURE (INDICATE IF NORMAL)
HEART
LUNGS (INCLUDING TUBERCULIN (TB) SKIN TEST
OR CHEST X-RAY RESULTS)
EYES
VISION
EARS
NOSE/THROAT
TEETH/GUMS
ABDOMEN
ENDOCRINE
PELVIS
NERVOUS SYSTEM
EXTREMITIES
CURRENT LABORATORY RESULTS:
URINALYSIS: SPECIFIC GRAVITY
ALBUMIN
MICROSCOPIC
GLUCOSE
OTHER LABORATORY TEST (NAME, DATE
AND RESULTS)
Summary of abnormal physical findings that would affect caring for a child:
III. PHYSICAL CAPABILITIES
In your medical opinion could your patient physically be able to:
FORM 36 Medical Report (Rev. 8-04)
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