PHYSICIAN’S REPORT FOR A CHILD 6th Judicial Circuit-Family Division Oakland County Adoption Services 1200 North Telegraph Road Pontiac, Michigan 48341 Dear Dr. Re: DOB: , I hereby authorize you to release to Oakland County Adoption Services information regarding my current and past physical and mental health. Sincerely, TO BE COMPLETED BY THE PHYSICIAN Date of physical examination Length of time know to physician Diseases or illnesses known or treated by you in the last five years: CURRENT HEALTH STATUS: Height Weight Medications currently prescribed; dosage and purpose: ANY HISTORY OF: Allergies Other Asthma Childhood Diseases: Hospitalizations, operations, or injuries: HIV information (optional): IMMUNIZATIONS DATES OF ORIGINAL SERIES BOOSTERS DPT Polio MMR HIB Hepatitis B Chicken Pox Remarks on medical examination (on the basis of the medial history and present physical condition, please state any medical concerns you may have regarding this child): Would you like to discuss this information with a Social Worker: Yes No PLEASE PRINT OR TYPE PHYSICIAN’S SIGNATURE Physician’s Name Address City, State, Zip Code Physician’s Report for a Child Telephone Number Rev. August, 2006 American LegalNet, Inc. www.FormsWorkflow.com