Accept Not Accept

Intercountry Adoption Board

TYPE OF CHILD ACCEPTABLE TO FAMILY
FAMILY NAME: DATE
I. CHILD'S STATUS AND HEALTH CONDITION
25 - 48 months old
49 - 72 months old
73 - 96 months old
8 and above
Others (please idicate)
1. AGE:
Please Indicate Range
0 - 24 months old
3. BIRTH CONDITION:
Premature
Undescended Testicle
Umbilical Hernia
Physical Abnormalities
Cleft lip
2. SIBLING STATUS:
Single Child
Sibling Group of Two
Sibling Group of More Than Two (Please specify)
Strabismus (roving eye, surgically correctable)
5. EAR CONDITION:
Hearing impairment
6. HEART PROBLEMS:
Heart murmur
7. HEMATOLOGIC DISORDER:
Cleft Palate
Visual acuity abnormalities (sight in one eye, partially blind)
4. EYE CONDITION:
Heart Defect (May require surgery)
Ear deformity
G6PD
Thalasemia
Others
____________________________
Date:_______________
8. INFECTIOUS DISEASES:
Positive for hepatitis B
First degree infection, under medication
9. ORTHOPEDIC PROBLEMS:
Hand anomalies
11. DEVELOPMENTAL DELAYS
Cerebral palsy
Seizures
Speech related problems (stuttering, lisps, etc.)
Gross motor delay
II. PARENTAL BACKGROUND:
Leg anomalies (bowed legged)
Foot anomalies (requiring cane, leg braces, or splint)
10. EMOTIONAL AND SOCIAL DEVELOPMENT
Autism
ADHD
Known history of physical / sexual abuse
Facial feature anomalies
Hyperactivity
Slight developmental delay
Global developmental delay
Speech delay
Mental retardation (mild)
Mentally challenged
With criminal record
Child of incest
OTHER SPECIFIC CONDITION/S YOU MAY CONSIDER RELEVANT:
Lactose intolerance
Skin condition - Eczema
A. No known information
(if with information proceed to B)
B. History of drug use
History of alcohol
History of emotional illness (e.g. depressionm etc.)
History of mental illness (e.g. schizophrenia, psychosis)
Child of rape
- Dermatitis
Bronchial asthma
Hypo / Hyperthyroidism
Needing surgical procedure / s
Dental carries
Large Hemangioma (which will disappear over time)
Accomplished by:
_______________________
Under the guidance of: ______________________
Date:___________