Dss Form 30202 - Medical Statement For Child - South Carolina Department Of Social Services
Download a blank fillable Dss Form 30202 - Medical Statement For Child - South Carolina Department Of Social Services in PDF format just by clicking the "DOWNLOAD PDF" button.
Open the file in any PDF-viewing software. Adobe Reader or any alternative for Windows or MacOS are required to access and complete fillable content.
Complete Dss Form 30202 - Medical Statement For Child - South Carolina Department Of Social Services with your personal data - all interactive fields are highlighted in places where you should type, access drop-down lists or select multiple-choice options.
Some fillable PDF-files have the option of saving the completed form that contains your own data for later use or sending it out straight away.
ADVERTISEMENT
1South Carolina Department of Social Services
Reset
MEDICAL STATEMENT FOR CHILD
Name of Child:
Date of Birth:
I give permission for
to share information about my child with the
(Name of Licensed Medical Practitioner)
Department of Social Services for the purpose of a foster/adoptive home study.
Signature of Parent(s):
Date:
Comprehensive Health and Developmental History:
(Document any known chronic health problems, medications, allergies, significant
acute illnesses and prenatal history of the child.)
Are immunizations up to date?
If not, which immunizations are needed?
Immunizations administered at:
Physical Assessment:
Height:
Weight:
Blood Pressure:
Temperature:
(Over age 3)
Assessment of Nutritional Adequacy and Overall Well-Being:
Behavior/Developmental Assessment:
(include an assessment of behavior, language, social and psychomotor skills)
Significant Findings/Recommendations:
Licensed Medical Practitioner’s Signature:
Date:
Please print/type name and address of Licensed
Please return form to:
Medical Practitioner:
DSS Form 30202 (OCT 03) Edition of OCT 01 is obsolete.
ADVERTISEMENT
0 votes
Related Articles
Related forms
Form 30237 - Invoice For Youth Graduation Award - South Carolina Department Of Social Services
Legal
Dss Form 1613-1 - Internal Controls - South Carolina Department Of Social Services - Child And Adult Care Food Program
Legal
Dss Form 1905 - Referral For Iv-e Eligibility Determination - South Carolina Department Of Social Services
Legal
Dss Form 30254 - Monthly Nytd Services Tracking Form - South Carolina Department Of Social Services
Legal
Dss Form 1548 - Responsible Father Registry Notice Of Change - South Carolina Department Of Social Services
Legal
Related Categories
Parent category: Legal