Form Ldss 0571 - Medical Report Of Prospective Adoptive Parent printable pdf download

Form Ldss 0571 - Medical Report Of Prospective Adoptive Parent

LDSS 0571 (Rev. 5/2004)

NEW YORK STATE

OFFICE OF CHILDREN AND FAMILY SERVICES

MEDICAL REPORT OF PROSPECTIVE ADOPTIVE PARENT

AGENCY:

TELEPHONE NUMBER:

DATE ISSUED:

NAME OF PROSPECTIVE ADOPTIVE PARENT:

ADDRESS OF PROSPECTIVE ADOPTIVE PARENT:

I hereby request and authorize my physician to release the following information to the agency named above.

SIGNATURE OF ADOPTIVE APPLICANT:

TO PHYSICIAN:

The above-named parent has applied to adopt a child. A medical report and your interpretation of it are needed by the adoptive staff

and the agency’s medical advisors. Our serious responsibility is to select adoptive parents whose general health and emotional

stability would enable them to give the child a satisfying life.

Section A. MEDICAL HISTORY

Past History of Illness – Diagnosis and Date

Surgery – Specify and Indicate Date:

Accidents:

Hospital or Sanitarium Care – Other than above:

Section B. PHYSICAL EXAMINATION

Temperature:

Pulse:

Weight:

Height:

Blood Pressure:

Eyes:

Vision:

Hearing:

Lungs:

Date of X-ray:

Results of X-ray:

Teeth and Gums:

Nose and Throat:

Neck:

Heart:

Lymph Gland System:

Pelvis:

Abdomen:

Extremities:

Nervous System:

Endocrine:

Skin:

Rectal Examination:

Form Ldss 0571 - Medical Report Of Prospective Adoptive Parent

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