Georgia Department Of Human Resources Medical Evaluation Of An Adult In A Foster Or Adoptive Home Page 3
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31. Lift a child:
Under 6 months
Yes
No
6 months to 3 years
Yes
No
2. Walk/maneuver 50-100 feet without major difficulties: Yes
No
3. Bend/stoop, kneel, reach:
Yes
No
4. Is an assistive device needed to walk, bend/stoop, kneel, or reach? Yes
No
If Yes, what type?
5. Are there any medical conditions which limit this person’s physical ability to care for a medically complex
child which may include the ability to:
Lift from a bed to chair, etc.
Yes
No
Don’t Know
Frequent Feedings
Yes
No
Don’t Know
Frequent Suctions
Yes
No
Don’t Know
Frequent Monitoring
Yes
No
Don’t Know
Frequent Medication
Yes
No
Don’t Know
Frequent Nebulizations
Yes
No
Don’t Know
Frequent Treatments
Yes
No
Don’t Know
Are any limiting conditions temporary? Yes
No
If yes, which condition(s):
For each condition, how long will the limitation exist?
IV. CERTIFICATION/SIGNATURE
I certify that this individual is found free from symptoms of communicable disease.
Yes
No
If No, explain:
-PPD (All household members unless contraindicated for children 5 years and younger) TB skin test or chest x-ray
– Attach a statement of test date and date of findings, signed by the medical provider
•RPR (age 13 years and older) Attach a copy of the lab report findings.
I certify that the individual has no physical or cognitive limitations that would prevent her/him from parenting.
Yes
No
If No, explain:
With appropriate signed releases, I am available to discuss this report.
Physician’s Signature:
Date:
State License Number:
Telephone:
Address:
FORM 36 Medical Report (Rev. 8-04)
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