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Please fill in as much information as possible and bring copies of any original records and any x-rays (copies or originals) that have been provided. If possible, please fax or mail particularly complex records, or those requiring translation, ahead of time. (FAX (317) 278-0860)
Although necessary blood and urine samples will be obtained for testing at the time of your clinic visit, stool samples can be difficult to produce on demand for many children! A fresh (preferably <2 hours old) stool sample can be brought in and processed for parasite and bacterial exams. A sample in a diaper (preferably in a plastic bag) is acceptable. If stools are very loose, a piece of 'Saran Wrap' inside the diaper will keep the sample from being absorbed too much.
Call with other questions: (317) 274-7260. Thank you!
Child's Current Given Name:
_____________________________________________________________
Child's Birth Name or Name given in country of origin:
_____________________________________________________________
Date of Birth:
_____________________________________________________________
Adoptive parents name(s):
_____________________________________________________________
Who else lives at home (names, ages):
_____________________________________________________________
Country of Origin:
_____________________________________________________________
City, Province, District or State?:
_____________________________________________________________
Orphanage or Foster Care?:
_____________________________________________________________
Adoption Agency used?:
_____________________________________________________________
Date of Arrival in US:
_____________________________________________________________
Date Adoption Completed (if incomplete estimate date):
_____________________________________________________________
Current residence (city, state):
_____________________________________________________________
Which physicians have already seen your child?:
_____________________________________________________________
_____________________________________________________________
_____________________________________________________________
_____________________________________________________________
_____________________________________________________________
What lab will you be using for your child's blood work? If not Clarian, please
provide name and number:
_____________________________________________________________
_____________________________________________________________
Any medical information from birth parents (including medical history, family
history, social situation, drug/alcohol history etc.):
_____________________________________________________________
_____________________________________________________________
_____________________________________________________________
_____________________________________________________________
Birth History:
Birth weight:_________ Height:_________ Head circumference:_________
Age at separation from birth parents & reasons (if known):
_____________________________________________________________
Past Medical History:
Hospitalizations (dates and reason):
_____________________________________________________________
_____________________________________________________________
_____________________________________________________________
_____________________________________________________________
_____________________________________________________________
Any surgeries (dates and reason):
_____________________________________________________________
_____________________________________________________________
_____________________________________________________________
_____________________________________________________________
Other documented medical problems (whether they appear to be real or not)
and treatments if known:_________________________________________
_____________________________________________________________
_____________________________________________________________
_____________________________________________________________
_____________________________________________________________
Review of Systems:
What medications is your child taking?:
_____________________________________________________________
_____________________________________________________________
_____________________________________________________________
Does your child have allergies to medicine?:
_____________________________________________________________
_____________________________________________________________
_____________________________________________________________
What laboratory testing has been done since arriving in the US?:
_____________________________________________________________
_____________________________________________________________
_____________________________________________________________
Any smokers living in your home?:
_____________________________________________________________
_____________________________________________________________
_____________________________________________________________
updated 4/07
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