PHYSICIAN'S REPORT FOR ADOPTIVE APPLICANT 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 ANY HISTORY OF: Alcohol or Drug Dependency Cardiac Disease Cancer Epilepsy Diabetes Mental Illness Depression Allergies Length of time know to physician Diseases, injuries, surgeries, disabilities, or medical conditions not referred to above: Remarks on health history: CURRENT HEALTH STATUS: Height Weight Heart Lungs Medication currently prescribed; dosage and purpose: Essential findings that are deviations from normal: HIV information (optional): Remarks on medical examination (on the basis of the medical history and present physical condition, please state any medical concerns you may have regarding this adoptive applicant): Blood Pressure Vision Hearing Abdomen Would you like to discuss this information with a Social Worker? PLEASE PRINT OR TYPE Yes No Physician's Name Address City, State, Zip Code Telephone Number PHYSICIAN'S SIGNATURE Physician's Report for Adoptive Applicant.doc American LegalNet, Inc. www.FormsWorkFlow.com Rev. March 2014