ࡱ>  @ bjbj *5Flllllllggg8hllh,jFo\o\o\o7pqrx$$ވR0߆l/s7p7p/s/s߆ll\o\olwww/s"l\ol\ow/swwllw\oj PHgQsjwSxD 0wƋsƋwllllƋlwt/s/sw/s/s/s/s/s߆߆19.w9PHYSICIAN S STATEMENT FOR ADOPTION(For Applicant and all Household members)Department of Human ServicesAdoptive Family NameDate FORMTEXT       FORMTEXT      Patient Information (to be completed by patient or responsible adult)NameRelationship to ApplicantDate of Birth FORMTEXT       FORMTEXT       FORMTEXT      Address (Street, City, State, Zip) FORMTEXT      Are you currently taking any medication? If yes, please list medications and purpose for use. FORMTEXT       FORMTEXT       FORMTEXT      Have you ever been treated for any of the following? (Check all that apply) FORMCHECKBOX Heart Disease FORMCHECKBOX Kidney Disease FORMCHECKBOX Cancer FORMCHECKBOX Diabetes FORMCHECKBOX Emphysema FORMCHECKBOX Epilepsy FORMCHECKBOX Tuberculosis FORMCHECKBOX Alcohol Abuse FORMCHECKBOX Substance Abuse FORMCHECKBOX Mental Health Issues FORMCHECKBOX Current Communicable Disease FORMCHECKBOX Other serious or chronic illnessIf any are checked, please explain: FORMTEXT       FORMTEXT       FORMTEXT      If you have checked any of the above, please have page 2 of this form completed by your physician, physician s assistant or nurse practitioner.If you have not checked any above please have your physician, physicians assistant or nurse practitioner read and sign the following statement:PHYSICIANS STATEMENTIn your opinion, are there any physical or mental factors that would jeopardize the physical or mental welfare of any child placed in this family for adoption?  FORMCHECKBOX  Yes  FORMCHECKBOX  NoPractitioners SignatureDatePractitioners printed name FORMTEXT       FORMTEXT      AddressTelephone Number FORMTEXT      ( FORMTEXT    )  FORMTEXT      AUTHORIZATION FOR RELEASE OF INFORMATIONI hereby authorize my health care professional to release to Department of Human Services or its agents information regarding my physical condition, mental health, and/or substance abuse services. I understand that completion of this form is required for the agency to proceed with the adoption process.Patient or Responsible Adult Signature and Date PHYSICAL EXAMINATIONDepartment of Human ServicesNameDate of Birth FORMTEXT       FORMTEXT      TO BE COMPLETED BY PHYSICIAN, PHYSICIAN S ASSISTANT OR NURSE PRACTITIONERDate of physical examinationDo you provide medical services to this individual: FORMTEXT       FORMCHECKBOX Regularly FORMCHECKBOX Occasionally FORMCHECKBOX First timePlease respond to the following to the best of your knowledge:1.Does this individual suffer from an illness including a communicable disease that would be detrimentalto the care of an adoptive child placed in his/her home? FORMCHECKBOX Yes FORMCHECKBOX No2.Are there any chronic or serious disorders for which this individual has or is receiving treatment? FORMCHECKBOX Yes FORMCHECKBOX No3.Is this individual currently taking medication? 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FORMCHECKBOX Yes FORMCHECKBOX No7.Have you ever referred this individual to other medical services, mental health services or treatment ofalcohol/substance abuse? FORMCHECKBOX Yes FORMCHECKBOX NoIf the answer to any of the above questions is YES, please explain:Height FORMTEXT      Weight FORMTEXT      Heart FORMTEXT      Blood Pressure FORMTEXT      Lungs FORMTEXT      Vision FORMTEXT      Hearing FORMTEXT      General Appearance FORMTEXT      LABORATORY TESTS:Tuberculin Test and/or X-RayDate FORMTEXT      Results FORMTEXT      HemoglobinDate FORMTEXT      Results FORMTEXT      UrinalysisDate FORMTEXT      Results FORMTEXT      PHYSICIAN S REMARKS ON HISTORY FORMTEXT       FORMTEXT      PHYSICIAN S STATEMENTIn your opinion, are there any physical or mental factors that would jeopardize the physical or mental welfare of any child placed in this family for adoption? FORMCHECKBOX Yes FORMCHECKBOX NoWould you like to be contacted by the adoption worker regarding your recommendation? FORMCHECKBOX Yes FORMCHECKBOX NoPhysician s SignaturePhysician s Printed Name FORMTEXT      AddressTelephone Number FORMTEXT       FORMTEXT      FORMTEXT       DHS-3190 (Rev. 11-08) Previous edition obsolete. 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