Patient Intake Internet Form

Child's Current Given Name:

Child's Birth Name or Name given in country of origin:

Adoptive parents name(s):

Who else lives at home (names, ages):

Date of Birth (if estimated please indicate):

Country of Origin:

City, Province, District or State?:

Orphanage or Foster Care?

Date of Arrival in US:

Date Adoption Completed (if incomplete estimate date):

Current residence (city, state):

Which physicians have already seen your child?

Any medical information from birth parents (including medical family history, social situation, drug/alcohol history etc.):

Birth History:

Caeserean section or vaginal delivery?

Premature?

Yes No Unknown

If so, how early?

Birth weight:

Birth height/length:

Birth head circumference (or OFC):

Age at separation from birth parents & reasons (if known):

Immunizations documented:

Polio (dates):

Diphtheria, Pertussis, Tetanus (dates):

Measles (dates):

Measles/Mumps/Rubella (MMR) (dates):

H. influenza B (HIB) (dates):

Hepatitis B (dates):

BCG (tuberculosis) (date):

Others (type & date):

Past Medical History:

Hospitalizations (dates & reason):

Any surgeries (dates & reason):

Other documented medical problems (whether they appear to be real or not) and treatments if known:

Has any testing been done since arriving in the US?
If so please list results if known:

Currently taking any medications? (please list with dose):

Allergies:

Diet (including likes & dislikes):

Have you noticed anything concerning your child's appearence, or skills? (also use this space to list questions you may need answered):