MISSOURI DEPARTMENT OF SOCIAL SERVICES CHILDREN’S DIVISION FOSTER/ADOPTIVE HOUSEHOLD MEMBER PHYSICAL AND MENTAL HEALTH REPORT
To the Examining Physician:
From:
Children’s Division
In evaluating the individual identified on this form, this agency must be guided by your medical findings, as reported on this form. To meet requirements of being a foster and /or adoptive parent, the applicant(s), as well as all household members, must be in good physical and mental health. It is necessary to determine that the applicant has no communicable diseases, has a reasonable life expectancy and is capable, physically and emotionally, of carrying out the responsibilities of parenthood. With this in mind, please complete the following. The individual’s permission for release of medical information is given below. The patient must have been examined by the physician within the past twelve (12) months per 13 CSR 35-60.030(A).
Name of examining physician (please print)
Physician’s Address
Physician’s Telephone Number:

APPLICANT’S RELEASE FOR INFORMATION

I, ________________________________________, hereby give my permission for release of my complete (SIGNATURE OF APPLICANT). physical and mental condition and any past or current substance abuse treatment to ___________________ County Children’s Division (CD) Office
Patient’s Name	Date of Birth

1. Past medical history (where applicable) – please check all that apply

DIABETES	ULCER	TUBERCULOSIS	MAJOR SURGERY (DATE)
HEPATITIS	CANCER	CARDIAC PROBLEMS	OTHER INFECTIOUS DISEASE

2. Note history of major illnesses and hospitalizations

3. Date of last physical exam: __________________

4. Present medical conditions – check all that apply (note that tuberculosis testing should be completed for foster family applicants should the physician note specific concerns)

DIABETES	ULCER	TUBERCULOSIS	MAJOR SURGERY (DATE)
HEPATITIS	CANCER	CARDIAC PROBLEMS	OTHER INFECTIOUS DISEASE

5. Is patient under treatment for chronic illness? Yes No

If yes, what illness?

6. Is the patient following a treatment plan for a chronic illness?

Yes No
If yes, what treatment?

7. What medication(s) prescribed?

8. Immunizations current?

Yes No
If no, what immunizations are required?

9. Past substance abuse treatment?

Yes No
If yes, what treatment and outcome?

10. Current substance abuse treatment?

Yes No
If yes, what treatment and outcome?

11. Describe any specific factors for this patient that should be considered if care is given to children

10. Impression of general physical health

Superior Good Poor

11. Impression of general mental health

Superior Good Poor

12. How long have you known the patient? _____________________________________________________

13. From your knowledge, would you recommend this patient as a foster parent?

Yes No Not applicable, child or household member

14. From your knowledge, would you recommend this patient as an adoptive parent?

Yes No Not applicable, child or household member

15. I verify that the patient identified on this form is free from communicable diseases.

Yes No
If no, will this pose a medical threat to the household members Yes No
Date of Physical Examination
Signature of physician

PLEASE MAIL COMPLETED FORM IN AN ENVELOPE MARKED “CONFIDENTIAL” TO:

County Children’s Division

Attention:

Address: