SAMPLE MEDICAL FORM

Today’s Date

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:

• HIV Negative
• STD (including Syphilis) Negative
• Tuberculosis Negative
• Mental Disorder Negative
• Substance Abuse Negative

All of the results from these medical tests certify and confirm that there are no medical reasons which may affect Applicant 1’s 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 Doctor’s Name M.D., have examined Applicant 1 and find him/her to be in very good health.

With Best Regards,

Your Doctor’s Name M.D.

__________________________________M.D.

MEDICAL REPORT ON PROSPECTIVE ADOPTING APPLICANTS

Applicant 1

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 Doctor’s name M.D., last examined Applicant 1 on Date.

1. PHYSICAL EXAMINATION:

Skin – Normal

Eyes – Normal

Ears – Normal

Lumps – None

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

Endocrinopathy – Normal

Sight – Normal

Hearing – Normal

Pulse – __ per minute (Normal)

Reflexes – Normal

Urine – Normal

There are no other abnormalities or infirmities.

• HISTORY OF PAST ILLNESS:

• Has Applicant 1 ever suffered from emotional or physical illness or medical disorder?

  YES______ NO______

   

   

• PRESENT MEDICAL STATUS

Applicant 1 is currently in very good health.

• Do you know of any reasons that make it unlikely or impossible that a child will be born of this applicant’s marriage?

• To your knowledge, are there any other contra-indications to the applicant’s ability to parent a child (eg. Marital problems, alcoholism, drug abuse)? No.

• 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.

  Sincerely,

   

  Your Doctor’s Name, M.D.

  Address of Practice