SAMPLE MEDICAL FORM
To Whom it May Concern:
I understand that Applicant 1 and Applicant 2 have initiated the process of adopting a child or children in Ukraine and a complete medical review is required for this purpose. They each underwent extensive testing and the following results indicate that they are both healthy. The medical testing included the following:
All of the results from these medical tests certify and confirm that there are no medical reasons which may affect Applicant 1s ability to be an adoptive parent or to subsequently raise and care for the child or children.
Applicant 1 and Applicant 2 have a very healthy and strong relationship and in my professional opinion, I am confident that their children will grow up in a stable, nurturing, and loving home. I wish them well in their efforts and look forward to meeting the new member(s) of their family.
I, Dr. Your Doctors Name M.D., have examined Applicant 1 and find him/her to be in very good health.
With Best Regards,
Your Doctors Name M.D.
MEDICAL REPORT ON PROSPECTIVE ADOPTING APPLICANTS
The subject of this report is applying to become an adoptive parent. He/she has provided consent for the release of information. We are interested in identifying any and all medical reasons that might compromise his/her ability now, or in the future, to act as parent or provide appropriate care and parenting for adoptive children.
I, Dr. Your Doctors name M.D., last examined Applicant 1 on Date.
Heart - Normal
Blood Pressure (reading) (Normal)
Abdomen and Gastrointestinal Tract Normal
G.U. Abnormalities None
Nervous System Normal
Mental Status Normal
Emotional Stability Normal
Height ___ cm
Pulse __ per minute (Normal)
There are no other abnormalities or infirmities.
Has Applicant 1 ever suffered from emotional or physical illness or medical disorder?
Applicant 1 is currently in very good health.
Elaborate on good relationship and a statement that the child or children would grow up in a good home.
I wish them all the best in their endeavor to adopt a child or children from Ukraine.
Your Doctors Name, M.D.
Address of Practice