Certificate Of General Physical Examination For Adoption Applicant - Madison Adoption Associates
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1CERTIFICATE OF GENERAL PHYSICAL EXAMINATION
FOR ADOPTION APPLICANT
TO EXAMINING PHYSICIAN:
Your medical report is of paramount importance to the adoption authorities in its
examination of the adoption qualification of the applicant. Thank you for your cooperation.
Applicant's Name:
DOB:
Address:
MEDICAL HISTORY:
Have you ever had Tuberculosis?
No / Yes
Tumors?
No / Yes
Heart disease?
No / Yes
Liver disease?
No / Yes
Sexual disease?
No / Yes
Neuropathy?
No / Yes
Mental disease?
No / Yes
Other communicable disease?
No / Yes
Alcoholism/Substance abuse history?
No / Yes
Any genetic disease?
No / Yes
Any surgical operations?
No / Yes
If yes to any, please explain:
PHYSICAL EXAMINATION:
Height:
Inches
Weight:
Lbs
Blood pressure:
Vision: L
R
Hearing: L: Normal / Abnormal
R: Normal / Abnormal
Heart:
Normal / Abnormal
Liver:
Normal / Abnormal
Lungs:
Normal / Abnormal
Lymph:
Normal / Abnormal
Thyroid:
Normal / Abnormal
Nerve system:
Normal / Abnormal
HbsAg:
Negative / Positive
Routine Blood Test:
Normal / Abnormal
Blood test (Date of Test):
Liver Function:
Normal / Abnormal
Urinalysis (Date of Test):
Routine Urine Test:
Normal / Abnormal
HIV Test (Date of Test):
HIV Test:
Negative / Positive
Is the patient taking any medication?
For what purpose:
PHYSICAL TEST RESULT:
1) Are there any physical, mental, or psychological unfavorable elements of the adoption applicant, which will affect the
upbringing of the child?
Yes / No
2) Does the adoption applicant have any disability that would affect the applicant's ability to care for a child? Yes / No
3) Is the adoption applicant’s state of health suitable for raising a child? Yes / No
Physician’s Signature:
Date:
Physician's name
:
License No.
(print clearly)
Subscribed and sworn to before me this _____ day of ____________________, 20____ by
who is:
personally known to me
produced their ____________________________ as identification.
OR
__________________________
____________
______________
___________________________
Notary Public
State
County
My Commission Expires
Medical Exam Form.doc updated February 2017
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