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Guidelines for Health Evaluation Form

1.     Answers must be based an a medical examination performed by your physician no more than 6 months prior to the date of the report.  Results of basic blood tests, urinalysis and AIDS test, should be included.

2.     Have this form printed onto your doctor’s letterhead, if possible.  If not possible, have the doctor’s office type in the name and address of the doctor or the practice at the top, or leave the top of the form blank.

3.     Make sure there are no blanks.  Write in N/A for an answer that needs to be left blank.  Have your doctor fill in something, even if the answer is vague or incomplete.

4.     Under “Physician’s Statement”, your doctor should write a general statement about your ability to raise a child, health and life expectancy.  Use the following wording or something similar:

(adoptive parent) is in good health and has a normal life expectancy.  (adoptive parent) is free of all infectious diseases, and is capable, physically and emotionally, to adopt and raise a child.

5.     All results and statement should be either typed or neatly printed, including the name, address and signature of the physician.

6.     The form can be filled out at the discretion of your physician as long as it is based upon a medical exam performed no more than 6 months prior to the report.

7.     No need for any invasive testing (other than the blood, urine, and AIDS tests)  unless your doctor feels it is necessary.  Most of the report can be filled out with knowledge of your medical history and some tests such as blood pressure, vision, hearing, etc.

8.     This form is a new requirement.  There may be some changes of which we will inform you as we learn of them.