Physicians Report For An Infant Under The Age Of One Year
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Physicians Report For An Infant Under The Age Of One Year Form. This is a Michigan form and can be use in Oakland Local County.
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Tags: Physicians Report For An Infant Under The Age Of One Year, 667, Michigan Local County, Oakland
PHYSICIAN’S REPORT FOR AN INFANT
UNDER THE AGE OF ONE YEAR
6th Judicial Circuit-Family Division Oakland County
Adoption Services
1200 North Telegraph Road
Pontiac, MI 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
BIRTH HISTORY INFORMATION
Weight
Head Circumference
Results of PKU Test
Height
Chest Circumference
APGAR Source
Complications at Birth:
Abnormalities Noted at Birth:
CURRENT HEALTH STATUS
Weight
Head Circumference
Head, Neck
Eyes
Nose
Lungs
Abdomen
Extremities
Height
Chest Circumference
Skin (rash, birth marks)
Ears
Mouth
Heart
Genitals
Reflexes
Formula and Diet:
HIV Information (Optional):
Immunizations:
Medications Prescribed:
Remarks on Medical Examination:
PLEASE PRINT OR TYPE
PHYSICIAN’S SIGNATURE
Physician’s Name
Address
City, State, Zip Code
Telephone Number
Physician’s Report for an Infant under the Age of One Year.doc
DATE OF EXAMINATION
Rev. August, 2006
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