Two Step Adoption Process...

 
For those families who need to make two steps prior to adopting their child, we have created this medical intake sheet that can be used to collect medical data and brought back for review along with the video. This type of information can be obtained from anyone who cared for the child, (nurse, doctor, Medical Director of Orphanage, social worker, facilitator)

Remember the more data the easier the decision.

Two Step Adoption Process

This medical intake form can be used by parents adopting from a country where a two visit process is required. This intake form has many pieces of medical information that the adopting parents can try to obtain when visiting their child. At the request of the parent, we can provide a Russian, Romanian, or Spanish translation of this document that the local professionals may be able to fill out.

Name of child

Date of Birth

Place of Birth

Home Birth or Hospital Birth
Pregnancy history (number of pregnancies, births, health issues during pregnancy)

Apgar scores
Type of delivery (vaginal or cesarean section)
Health at time of delivery.

Birth weight, height, head circumference

Date of admission to infant hospital:
Date of admission to orphanage:

Family History
Mother (age, profession,)
Father (age, profession,.)
Siblings (at home, in orphanages,)

Social History
Alcohol, drugs, smoking history for parents

Growth Parameters
Weight, height, head circumference at 3 months, 6 months, 9 months, one year,
 

Physical Exam of Child


Health issues while in the orphanage
(Bronchitis, asthma, anemia, vomiting, diarrhea, allergies, heart murmur, urinary tract infection, skin rashes, chronic medical issues)

Hospitalizations

Medical interventions

Medications &Transfusions

Diagnoses given to the child:

Ultrasound evaluations of organ systems (commonly done in Russia)

Blood tests (results and dates of tests)
HIV, Hepatitis B, syphilis

Developmental commentary (what age did the child do each of the following):

Developmental Milestones by age
Reach for objects
Sitting independently
Creep & Crawled
Pulled to stand
Stand alone
Walking
Understands simple commands
Vocalizes vowel sounds, consonants, single words, puts two words together, etc.

Immunization status (names and dates) :